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I work for Doctors Without Borders - ask me anything about Ebola.

Sep 12th 2014 by ELasry • 24 Questions • 2579 Points

This thread is now closed. Thank you all for your questions and interest.

Here are a couple of links that may answer some of the questions I didn't get to:

http://www.pbs.org/wgbh/pages/frontline/ebola-outbreak/

http://www.pbs.org/wgbh/pages/frontline/health-science-technology/ebola-outbreak/msf-on-ebola-this-is-the-biggest-outbreak-weve-ever-known/

Hi, I’m Estrella Lasry, MD, MSc, DTMH, Tropical Medicine Advisor for Doctors Without Borders/Médecins Sans Frontières (MSF). Ask me anything about Ebola and the current outbreak in West Africa.

This is me: https://twitter.com/MSF_USA/status/510429565605646336

Some background: Since the Ebola outbreak began in March in Guinea, it has claimed more than 1,800 lives. The outbreak has spread far beyond Guinea, and is now raging unabated. A total of four countries are now affected: Guinea, Liberia, Nigeria, and Sierra Leone.

The World Health Organization has declared the largest-recorded Ebola epidemic an “international public health emergency,” yet the international effort to stem the outbreak is dangerously inadequate. MSF teams on the ground are seeing critical gaps in all aspects of the response: medical care, training of health staff, infection control, contact tracing, epidemiological surveillance, alert and referral systems, community education, and mobilization. All countries require an immediate and massive mobilization of resources.

See the latest updated information from MSF on our Ebola issue page: https://www.doctorswithoutborders.org/our-work/medical-issues/ebola

You can follow us on Flipboard, where we are collecting the most relevant MSF and news articles on the outbreak: https://flipboard.com/section/ebola-outbreak--bYByyy

Thanks to the Doctors Without Borders subreddit for their support: http://www.reddit.com/r/doctorswithoutborders/

Q:

Without an adequate response from the rest of the world, what are the implications for these African countries and their neighbors? How far could the Ebola outbreak spread?

A:

The implications are huge. A deconstructed health system with half of the medical population decimated, a lack of trust in health facilities from the population, and apart from all of the Ebola cases and deaths, all of the non-Ebola cases and deaths that are not being managed, and that are probably in the 10s of thousands.


Q:

What can someone who is not able to be hands on do to actually help in this epidemic?

What should be done that isn't being done by the western world?

A:

A lot of people have been asking that. You can help create awareness, you can put pressure on your governments to act, you can donate to one of the organizations responding to the outbreak...


Q:

Is there an end in sight?

A:

Not if the response is not substantially upscaled


Q:

Hey Doc.

For simple minds like me, in the bluntest terms: how fucked are we?

A:

An outbreak that has been ongoing for over 6 months and has infected over 4000 people and killed over 2000 is not only having devastating consequences on the patients and their families, but is already leaving the health systems of Liberia, Sierra Leone and Guinea shattered, and in need of a complete reconstruction.


Q:

The medical staff that contracted ebola and then were evacuated and received ZMapp got better. How closely are they being monitored to ensure ebola doesn't 'come back' in them? Is the ebola virus known to hang out in lymph nodes, dormant? Thanks

A:

Not all of the people who have received ZMapp have survived, and we don't know, for those who did survive if it was an effect of the drug or if they would've survived anyway. Unfortunately too early to know.

The virus disappears from the blood and has been found for longer periods in semen and breast milk (up to about 3 months in semen), but not in lymph nodes.


Q:

I have heard that MSF's request for support from the US military in responding to the Ebola crisis is unprecedented. Have there historically been any requests by MSF for US military support in response to other crises? Also, what is your perception of the utility of the proposed 24-bed treatment facility for healthcare workers offered by the US government, in comparison to the overall need?

A:

In non-conflict settings, MSF has at various times worked with the militaries of different countries that had logistical capabilities beneficial to the overall response--the 2005 earthquake in Kashmir and the 2010 earthquake in Haiti are examples--and we understand that militaries are at times equipped to provide logistical support on a scale few other organizations can match. That is the case today regarding the ebola crisis.

On the 25 bed Ebola Treatment Center, other than being insufficient, there is a need to isolate and treat the population. Of course it's important to manage healthworkers who get infected, but this should not be the focus of the response, albeit an important part of it.


Q:

Hi Estrella, thanks for taking the time to answer questions on Ebola today.

Here is a list of questions from our community on reddit, /r/doctorswithoutborders.

EDIT: We are also working with reddit to organise a fundraiser for MSF's Emergency Funding. We need help from our fellow redditors! If anyone is good at design then please get involved. We want to use a something created by the community for the community. Maybe a GTA inspired MSF T-Shirt or poster? We want to see all the cool shit redditors can come up with. Also reddit HQ is helping us with free promotion and sorting out the supply. This is a great opportunity to turn the collective interest in this issue into a tangible change on the ground. So please, please check out our thread and get creating!

/u/Spacetyrant:

Many of us are following this epidemic very closely -- and it is looking pretty dire. I have no infectious disease background whatsoever; I see the epidemic and the interconnected urban and rural environments it's attacking as an unpredictable complex system with a thousand ways to evade containment. To me this outbreak is starting to look like it may already be unstoppable in west Africa -- if not in all of sub-saharan Africa.

My question: Do you think it's still possible that a world response could conceivably be big enough, quick enough, and west Africa-savvy enough to have a chance to contain it within west Africa?

And, if so, how could that be done?

/u/Assfire:

Can Ebola be spread through the air (regardless of droplet size)? Can it be spread through the contamination of currency?

If someone with Ebola (symptomatic) touches a door knob and I touch that door knob 1 day later and than scratch my eye what is the probability that I contract the virus?

/u/chakalakasp:

What do you think the potential end game scenarios look like for the current EVD outbreak? Even if this is controlled, will it be endemic in West Africa? Can it be controlled (or is this an unknown?) Is this a global pandemic threat?

I have been privately communicating with several respected epidemiologists; what I've been hearing back has really concerned me. None of them want to have their name attached to their thoughts (for what I can assume are professional reasons), but their line of thinking at the moment is that the epidemic in West Africa is too late to contain and that only when the susceptible population decreases (via infection immunity or death) sufficiently will the virus slow down and peter out -- but that this would literally involve millions of cases. The analog used by one epidemiologist I have privately communicated with was the Black Death plague from 1346 to 1353 in Europe.

My second question, if you have time, revolves around CFR (or PFC, or however you want to slice it). In the PBS Frontline documentary, MSF was quoted as saying observed CFR in the clinics is in the 80% range (putting it in line with typical Ebola Zaire CFR). Is this true? Do the WHO figures of ~50% CFR for this epidemic mesh with your on the ground observations? Does the CFR data suffer from a lag effect, or is there some other reason for the discrepancy?

Thank you very much for your time. What you are doing is some of the bravest, most self sacrificing work imaginable.

/u/woody121

If EVD mutates into an airborne virus, what sort of protective gear might be useful for someone to have in their home?

Good luck in all you do, you lead a life so far from mine that I can only say thank you.

A:

To chakalakasp: It's difficult to predict what the evolution of this outbreak will be like as it is very different in terms of spread and settings (more urban settings) than the outbreaks we've seen in the past. People still hide in the villages when they see the MSF ambulances arrive, and some of the ones who arrive at the treatment centers, cannot be admitted because we're so overwhelmed. We have started doing home-based treatment, but it's a difficult choice and we have to trust that the families will treat their relatives appropriately and not expose themselves to the disease. I'm not sure this can be compared to the black plague, but it is certain that without a larger and more substantial response to ensure containment, it will continue to spread in the area.

The CFR we're seeing is of around 60%, and for EBola Zaire we've seen CFR of 30-80%.

We definitely don't have all the information on cases and deaths


Q:

Hello Dr. Lasry, I'm currently finishing up medical school this year and very interested in international health. I have three questions.

  1. In what way can future healthcare professionals best get involved?

  2. Regarding infection control; what do you see as the most fundamental barriers to effective exposure prevention? My understanding is that this virus is spread through contaminated body fluids, correct? Or does an animal vector remain a significant source of new infections?

  3. How optimistic are you regarding the new monoclonal antibody infusion (ZMapp)?

A:

Right now, create awareness. MSF accepts medical volunteers with a minimum of 2 years of experience. We cannot send people to the field who have not been exposed and developed some clinical expertise.

On infection control, awareness, barrier nursing and safe burials are the main ways to prevent the spread. It is now human-to human transmission that is causing the spread of the disease, although the start seems to have been from a human contact with a fruit bat.

About ZMapp we have to wait and see, difficult to make predictions at this stage.


Q:

Hi, thanks for answering questions. I have two: 1. What sort of response do you wish to see from the international community? What do you think of the int'l response so far? 2. Has MSF considered releasing any epidemiological or geo data? I haven't seen any estimates of incubation period, attack rate, time to death, etc for this outbreak. Having that information would be really helpful for logistics and outbreak response.

A:

What we need to see are more people being deployed to do the hands-on work. Right now, we cannot provide all the appropriate treatment to our patients because of a lack of human resources. The international response has been slow and weak, even after Dr. Joanne Liu (president of MSF) plea at the UN briefing.
It is WHO who is releasing the epidemiological data as it is part of their mandate. We do some epidemiological surveillance, but are completely overwhelmed with the response itself and trying to contain the spread of the epidemic. Incubation period is 2-21 days, attack rate is difficult to know since there's a lot of information lacking and many cases and deaths we are missing. Time of death since the start of symptoms is extremely variable according to the previous state of the patients. But all that said, we are concentrating on containing this epidemic, so unfortunately don't have the time and resources to be able to answer all these questions using appropriate research methodology


Q:

Most of the discussion originally was how difficult it was to infect others as it has to be through bodily fluids and that it would soon peter out. Why is this specific outbreak not stopping and actually growing in scope?

A:

People are hiding and not coming to health facilities, and when they come, not all can be admitted as we are completely overwhelmed and there are not enough people responding on the ground.

Not all burials are being managed in a safe way, as sometimes the families bury their deceased before the burial teams can get there.


Q:

Hey there Doc. Ok so in my microbiology class we have been studying Ebola on and off since the semester started. We came across this one article that talked about people who had survived Ebola and seemed to be doing well then it just comes back. What are your thoughts on the chance of a relapse with Ebola after surviving it?

A:

We don't know of anyone who has relapsed.


Q:

I have two questions:

  • The literature has very little on whether plasma transfer has been effective in protecting patients, or whether surviving Ebola confers long-term immunity. What are your thoughts?

  • How can communications about this epidemic be more effective in generating support? What we're seeing IMO in the U.S. is ~90% of people ignoring the situation (just another overblown "crisis"/African issue) and ~10% of people in a full-out panic. What message can be used to create urgency without panic, and which is the best organization to get that message out? (It seems like the WHO has been unsuccessful and the CDC is hesitant to step up since it's not a U.S. issue...)

A:

It seems that surviving Ebola does confer immunity although we don't know for how long. However, we don't know of any patients who have been infected twice.

Transfer of plasma from convalescent patients is actually being tested.

Awareness is definitely a way of generating support. The WHO has been slow to react but they are now speeding up, and the CDC has been at the outbreak almost since the beginning and has deployed more people on the ground than it ever has, as well as contributed to the awareness. The outbreak has been declared an international humanitarian emergency by the WHO.


Q:

Hello Dr., thank you for all your hard work. Am I to understand that Ebola has the same kind of stigma and it's countries of origin that aids had when it first arrived on the scene here in America?

A:

Yes, it is similar, except it has a faster evolution than HIV/AIDS did at the start of the epidemic, and although some health facilities did contribute to the transmission through transfusions and poor aseptic practices, it is in a lesser magnitude than EBola, since HIV has different forms of contagion.

However, there is a larger stigma in the communities, who sometimes will shun patients (even cured patients) and their families. At the rate that the outbreak is spreading though, it seems like almost everyone has unfortunately had someone in their family/friends affected which may reduce the stigma in a paradoxical way.


Q:

From the perspective of somebody who's on the ground, what do you need to help combat this outbreak properly?

A:

More people on the ground and more Ebola Treatment Centers appropriately staffed.


Q:

How can a private individual donate to help fight the outbreak?

A:

You can donate to any of the organizations that are responding to the outbreak as an individual. Thank you


Q:

How many different strains of the ebola virus are there? or is it just one strain? Also if there are different strains of this virus which strain is the deadliest?

A:

There are 5 different strains that we know of, Zaire and Bundibugyo are the 2 with the highest case fatality rate.


Q:

When do you think that the first cure for Ebola will be available? What formulation will it be based upon?

Would one sick person flying in from Nigeria be enough to start an epidemic in Europe for example?

A:

The infection control facilities in Europe and the capacity of response, isolation and the number of health workers is so much higher that it is highly unlikely that the disease would spread in a similar way.


Q:

Hi Doc.

If you catch Ebola and survive, are you then immune?

Thanks!

A:

Yes, as far as we know


Q:

I read somewhere (almost definitely reddit) that western doctors were seen by some locals as causing the disease, as they were always in places of outbreaks. This, in turn, meant victims were less likely to seek medical help from westerners, like those working for MSF.

Is there any truth to this? If so, have you experienced this?

A:

Yes, this is definitely one of the things happening in the outbreak context and it is not new or specific to this outbreak, since people automatically associate the medical staff or the medical cars with Ebola, and have difficulties understanding what came first, the disease or the Western doctors, as we are responding in all areas where the outbreak has spread to.


Q:

Hi Estrella, Can you get ebola again if you survive it the first time? Thanks!

A:

Not that we know of


Q:

Does surviving one strain confer immunity to the other strains? How separate are they?

A:

We've got some questions on Twitter and FB that I will answer


Q:

How do you regard to speed and response of other agencies, reacting to the ebola outbreak. For instance, I know one large NGO is only recruiting now to put staff on the ground for Ebola response in Liberia, sierra Leone etc...

Has it been a case of too little too late?

A:

Late, but better late than never. There are still enormous needs to respond to the outbreak, and we need people now.


Q:

Now I know the survival rate for Ebola in developing countries can be less than half, even as low as 10%... what would be one's chances if they caught Ebola in the West, and received quick access to the proper medical care?

A:

Difficult to know, but the survival rate would be higher if we had more personnel on the ground able to manage these patients.


Q:

Hey doc, is it true that there's a vaccination for ebola but its just not being made because pharmaceutical giants see no profit in this?

A:

There are 2 vaccines in the pipeline, and funding for this has been upscaled.