IamA RAND global health / health security researcher and 20-year vet of the CDC. AMA about Ebola, flu, etc. !

Given your research focus on public health preparedness and biosurveillance, how do you think the West, and other countries in general, should respond to limit the international spread of the West African ebola outbreak? Do you agree with airport screening of passengers, or should other tactics be adopted?

Great question, wcrp73!

We need a package of interventions to stop the outbreak in Africa, limit international spread of disease, and protect Americans. These aims are obviously linked to one another. And we are already implementing a package of interventions.

Those interventions include airport exit screening, new airport screening at 5 US airports where 94 percent of people from those 3 countries arrive, and stepped-up measures in our medical and public health system to identify cases, manage them medically, and trace their contacts to limit spread here.

What, we don't need to protect those of us who aren't American? ;)
Seriously, though, thanks for the reply!

OMG! Of course we do! We are a global community. Not only are problems sometimes global, but so are the solutions, and the people who benefit from them. That is what we mean by global health security!

What do you think about the CDC anti-infection protocols for Ebola, in place since August? They appear to be based on the broad 2007 guidelines for infection control. Are they concise enough, clear enough, adequate?

I gather from the news that we have a solid foundation for infection control but we are evolving in the specifics of it based on lessons learned from our experiences with the Dallas cases. Basically, my understanding is that we may be rethinking the exact nature of appropriate protection (PPE - personal protective equipment) and protocols for their use - information, training, practical hands-on drills, rigorous implementation through checklists and buddies, etc.

I believe CDC is doing its best to provide clear, user-friendly information that can be used practically by hospitals as they step up their preparedness.

Percentage wise. How much does a flu shot actually reduce my odds of getting flu?

How many flu cases happen in a year?

Vaccines are just about the most cost effective intervention in public health!

In the case of flu vaccines, they are typically at least 90 percent "efficacious" in preventing disease altogether, and certainly in limiting the severity of flu infection.

Every year, hundreds of thousands if not millions of persons around the world are infected by flu. In the US, up to 49,000 or so flu deaths occur each year. You can find more details here: http://www.rand.org/pubs/research_briefs/RB9572/index1.html ... including reasons why some people choose not to get vaccinated.

Have you all gotten your flu shot/mist yet?

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My impression, though no one has said as much, is that this may be an interim measure until hospitals around the country ramp up to be fully prepared to manage an Ebola patient safely and effectively.

In the case of the two nurses moved from the Dallas hospital, I believe that the staffing levels have been compromised because so many medical personnel who cared for Mr. Duncan are under quarantine.

How overblown are the reactions by Americans about Ebola?

It's my understanding that unless you have the equivalent of fluid-swapping contact with an ebola patient, you're perfectly fine and have absolutely nothing to fear. Is that correct?

Hi rohlinxeg! Thanks for your great questions. The answer to your second question is yes. We have a lot of experience with Ebola over the past 30+ years, and all the evidence to date suggests that direct contact with the bodily fluids of a sick person is how the virus is spread.

On your first question, we really do need Americans (and everyone) to understand how Ebola is and is not spread. That way, the reactions will not be overblown.

Do you find it a bit careless that it is a disease that is here since the 1970's but we still don't have a vaccination against it?

That's a really great, but difficult, question. Why? Because there are so many diseases and other health problems out there.... plus new "emerging" infectious diseases that pop up every year.

I gather from Dr. Fauci's testimony yesterday that research has been underway for at least a decade (probably more, assuming DoD might be working on this for military biodefense purposes).... but we still do not have a vaccine today.

We also don't have a vaccine yet for malaria, though we have been researching that since the 1960s or before; nor for HIV. So there are a lot of important vaccine targets out there. We are trying!

apart from the obvious(washing hands, clean environment, etc) what is another tip that will help with staying healthy for most of the year?

What a great question, EazyCheez!

There are lots of ways to stay healthy, and Ebola is just a very tiny piece of that equation. In the broadest sense, we need to have healthy lifestyles in terms of diet, exercise, risk behaviors, etc.

In the infectious disease sense, washing our hands always makes sense! And it certainly does for flu, for example, as we now enter flu season. Good personal hygiene is a good rule of thumb to protect against any infectious disease!

Frequent hand-washing is an obvious practice that everyone should be implementing, but I read something recently that I want to ask you about. I work in healthcare so I wash my hands quite a bit during the day, but what if you touch a surface that appears to be dry and then inadvertently touch your nose, eyes or mouth. Is it possible for the Ebola virus to survive and then spread in this way? I'm concerned if bodily fluids aren't cleaned up properly and then that surface dries...am I being too paranoid? Thanks so much for being here to discuss.

Yes, I have also heard experts note that Ebola virus can survive, though not very long, on surfaces as you suggest. It's better to wash your hands after touching surfaces and before touching your eyes/nose/mouth, rather than touching the surfaces, then your E/N/M and then washing your hands!

I believe the survival time of Ebola virus on such surfaces is pretty short, however.

How long do you think will it take for a fully-proven vaccine to be available to the public?

In normal times, it might take years. However, the FDA has the authority to issue "Emergency Use Authorizations" for products that have not completed all the trials and steps required for full licensure. The timeline for EUAs is much shorter -- like days to weeks or months. It's hard to know for sure at what point people would seek EUA for a potential vaccine. There are definitely sensitivities to be perceived (by some) as human guinea pigs for such products.

How accurate was the film Contagion in depicting the response to a catastrophic pandemic? What is your favourite movie?

What other diseases do you think pose a threat to global safety? Have you ever been in a fistfight?

Do you think obese people should pay more taxes because their self-destructive behaviour will likely cost taxpayers money to take care of them? Do you think so or not so for other reasons? What is your favourite dish?

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    What can reddit do to curb the spread of ebola? What are your favourite subreddits?

I actually wrote about this movie when it first came out. Take a look at http://www.rand.org/blog/2011/12/heed-film-lessons-on-outbreak.html

Just a couple points from that:

Mother Nature can be as dangerous as a bioterrorist. Laurence Fishburne, who plays the CDC director, has one of the most important lines in the movie. When asked if the new virus could be a "weaponized version of bird flu," he snaps: "We don't need to 'weaponize' bird flu. The birds are doing that.”

Panic can be as deadly as disease. The movie's depiction of roadblocks at state lines, and the widespread societal breakdown that follows, could easily happen. This was precisely the scenario public health officials feared during the first days of the 2009 flu pandemic.

What other illnesses or health issues should we be more concerned about, if not Ebola?

We are entering flu season. As you probably know, flu is spread through airborne transmission, and even asymptomatic people can spread the virus without knowing it. But we know what to do to minimize the impact of flu: get vaccinated and practice good "respiratory etiquette" as well as hand washing.

And then, of course, we still have the major causes of disease and death in this country, and worldwide, such as heart disease, cancer, road traffic injuries, etc..... so lots of concerns, all of which we should tackle (and are tackling) through research, medicine, and public health.

I think it's safe to say there have been some failures in hospital protocol in treating Ebola patients. What are these failures in your opinion and how can they be corrected?

In particular, are there bureaucratic or organizational hurdles that we need to address?

These are really important points! I believe we need to LEARN from both successes and failures. Certainly, the experiences in Dallas have offered important opportunities on the second front, and I believe we are making progress.

For example, it sounds like CDC is reconsidering tweaking its recommendations for PPE (protection for health workers), as well as modalities for training workers in the protocols for their use. They are also reconsidering the temperature threshold for screening and quarantine.

How likely will the Ebola vaccine be able to be altered to be effective on humans as well?

Hi orchestralcello, and thanks for your question about Ebola vaccines.

As I understand it, there are at least a couple vaccines that are now entering the earliest human testing phases. .... So it's perhaps more a matter of those trials proceeding well than altering an animal vaccine, or a prototype human vaccine tested in animals. But maybe I didn't quite understand your question in the way you meant it.

No, you answered my question. Thank you. I have another!
So if there are more vaccines that are in test phases, then what would be needed to further tests done on those that are being produced? Wouldn't the government want to fund more projects so there isn't a rising death toll should Ebola actually spread throughout more countries, in particular the US?

HI again! The timeline for vaccine development and testing is much longer than the timeline for this Ebola epidemic, though vaccine development does and should continue. As per a response to another question, FDA can issue an Emergency Use Authorization for a vaccine product before it meets the full licensure requirements. We don't know when that might be, or for which vaccine.

In the meantime, we also need to take all the nearer-term actions to limit the outbreak in Africa and ensure proper medical and public health measures here at home.

What can I do as a citizen to be aware? Are there good sites and/or health tips to follow?

Stay tuned to www.cdc.gov.

You might also want to look at my earlier blog post on "putting the public back in public health".... http://www.rand.org/blog/2014/10/ebola-outbreak-putting-the-public-back-in-public-health.html

Assuming your number one priority was survival, where would you go and what would you do if there was an Ebola pandemic?

That is a very sobering question, bradkohl, and one I hope we will not have to face. That is, we really do need to stem the current epidemic before it reaches pandemic proportions.

We need to make sure that there is enough good medical care to take care of people in the three currently affected countries, and also make sure our systems step up their plans, protocols, training, and drills -- i.e., preparedness -- so that we can be confident of good medical care at any hospital where we may need care for this.

There has been uproar about whether or not we should cancel flights coming from areas infected with high amounts of Ebola. What is your take on the matter? Would that help in anyway or would it be pointless?

That is a question that is on the minds of many these days!

My own take is that we should consider our current and any potential new interventions in terms of: what it aims to achieve, how it would actually be carried out, how feasible it is, how effective it is likely to be, how acceptable it is to those involved, any potential unintended negative consequences, etc.

Based on those criteria, I think the travel ban doesn't score well on the details of what it actually means, how it would be carried out, the important negative consequences, etc.

It might be better to focus on scaling up and hunkering down on the package of interventions that are mostly in place now, in Africa and the USA.

The Ebola virus had been discovered in fruit bats and primates. Antibodies had been discovered in dogs. Are there any concerns that rats, which are also mammals, could get infected by Ebola?

I am not aware of any studies that have either confirmed antibody presence in rats or "confirmed" that rats are not an animal reservoir.

There is a very good ongoing project, formerly called Global Viral Forecasting and now called Metabiota, which examines animals in the wild around the world (especially in infectious disease hot spots) and looks for all sorts of viruses.... even new ones. We can take a look at their site or reports to see what has been discovered, if anything, re Ebola in rats.

Is Ebola the biggest threat to the US at this moment in regards to your work?

Well, it is certainly high on the list in terms of acute threats that could get worse if we don't effectively do everything we can and should do.

It looks like all the responsible parties are taking Ebola as seriously as they should -- from CDC to NIH to DHS, the White House, Congress, our medical and public health establishment, etc. That's the best way to make sure we win this battle, and soon!

I have heard a massive amount of differences in the media about how Ebola is spread from the air, to only coughing, to only bodily fluids. Is there any concrete evidence to how it is spread?

Yes. All the concrete evidence to date points to direct contact with bodily fluids as the way Ebola is spread. There is no evidence, as of yet anyway, that Ebola is spread via the air .... however, there is discussion under way, I believe, about aerosolization of bodily fluids.

If you were forced to guess how far Ebola would spread and about how many lives it will take before it's eradicated, what would you say?

I would actually prefer to have us focus all-out on the three currently affected countries, so that it does not become epidemic in other countries. What that will take is more medical care capacity, more public health capacity, and probably also better harnessing of community leadership and community engagement in these African countries where communities are typically so strong.

My question is about weaponization.

I understand that Ebola has a difficult time surviving outside of a host and therefore would be near impossible to extract to aerosalize without a lot of money and an expensive laboratory. I also understand that Ebola "burns quickly" and that the characteristics that make it so deadly are also its limitations.

Knowing this, do you know of any other ways an individual or group could weaponize Ebola without the expensive laboratory or a human host? Any dispersal methods?

I wish I could answer this great question, but it is a bit beyond my expertise. You might take a look at work others from RAND have done, at http://www.rand.org/topics/bioterrorism.html

Please compare Ebola to HIV in terms of how it might destabilize countries. Should we be concerned about failed states due to this epidemic?

A disease, or any condition, that overwhelms and breaks down the medical system is not good for families, communities, livelihoods, local to national economies, economic development, etc. Some of the "big" infectious diseases like HIV and malaria have been documented (or at least estimated) to have decreased GDPs in some of the hardest hit countries. We need to get Ebola under control so that it does not rise to this macro level of impact.

Given that Ebola usually presents as flu like symptoms and we are entering flu season. Short of triaging in a hazmat suit. How can ED staff stay safe? How can we keep patients safe in a waiting room with 10 patients half of which have flu symptoms and a 3 hour wait?

By the numbers alone, flu season is a large concern, but a mostly predictable one.

Some doctors' offices and medical departments already "triage" persons with fever to a separate waiting room.

In terms of protecting the healthcare personnel, I believe they are very aware of and practice universal precautions, respiratory etiquette, hand washing, etc. No hazmat suits required!

I am an RN in an ICU in one of the largest hospitals in the nation. Why have I not been trained for Ebola?

You need to be! I am hoping that both the CDC Public Health Emergency Preparedness program and the HHS (Assistant Secretary for Preparedness and Response) Hospital Preparedness Program are stepping up their efforts to help ensure that all hospitals and the appropriate personnel (like you!) are trained, have practiced/drilled, and are competent and confident they can care for an Ebola patient safely and effectively.

Thank you doing the AMA! Is Ebola as transmittable as the flu?

I think a peak misconception (that is still unclear to me) about Ebola is just what it means for a virus to spread via "direct contact with bodily fluids" vs. "airborne". I recently read a nurse's perspective who claims that Ebola is actually transmittable as the flu (i.e. the flu is also spread via "direct contact with bodily fluids" and is not "airborne". The droplets from a cough a sneeze, though, are).

http://dtolar.wordpress.com/2014/10/01/ebola-a-nurses-perspective/

Thanks again for the AMA!

You are right! Ebola is not as transmissible as flu.

Flu spreads via the air ("airborne transmission") when someone breathes in invisible aerosolized flu virus or droplets, such as from an uncovered cough or sneeze.

Ebola spreads when someone contacts one of these "bodily fluids" from a patient who is sick, and then introduces it into their own body through mucus membranes (touching their eyes, nose, mouth), open cuts, or inapparent "microabrasions" That is harder than breathing in flu viruses.

I have been very interested in diseases and their spread so I would like to pursue a career in epidemiology. Do you have any suggestions on what I should major in or focus on to reach this job? ( Oh and I am a total CDC nerd ever since it was featured in The Walking Dead.)

Great! We need good people in public health. And epidemiology is FUN! I was one of those disease detectives myself, back when. You could major in public health. Local, state and federal government agencies have and need epidemiologists.

I'm a CDC nerd, too! I assume that you have seen this great CDC piece on emergency preparedness: http://www.cdc.gov/phpr/zombies_novella.htm

good luck!

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My understanding is that Ebola is one of many/many "emerging" pathogens that arose from animals. Fruit bats, for example.

Thanks for doing this AMA.
What has been/is your biggest frustration concerning Ebola in the past few days?

I would really like to see us take a responsible, analytic approach in thinking about and making decisions regarding interventions. We are doing that in many ways, such as quickly evolving in the specifics of PPE for Ebola, screening and quarantine. It will be a very positive thing if the debate on new interventions such as travel bans takes a similar measured tack.

Hi, what are the chances of the virus evolving to the point where it becomes airborne? Is there any testing being done now to determine that, considering the two nurses who have become infected even though they were supposedly in hazmat suits and taking all precautions?

That's another really great question, and certainly on the minds of many!

We always need to keep an open mind to new biological events or situations. In the case of Ebola, we have more than 30 years of information, and nothing in that body of information suggests airborne spread of Ebola. But further investigation, such as the cases of the two US nurses, may uncover new information, and we need to be able to recognize and deal with that if it happens.