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admin 09.08.2014

Given that the World Health Organization (WHO) just concluded a meeting in Geneva to discuss experimental therapy use in Ebola Hemorrhagic Fever I thought it would be a good time to review the current state of therapy for this. Ebola belongs to the family of viruses that cause viral hemorrhagic fevers and a subfamily of that called filoviruses which includes the Marburg and Ebola families that are RNA viruses.
The Ebola virus at 0.8 microns (1) is relatively large and only has 7 genes responsible for all its lethality and contagion. Once a person is infected it takes a 3-21 day incubation period before a patient becomes symptomatic.
This cytokine storm causes massive and widespread organ damage, interferes with the body’s clotting mechanism leading to the features of bloody diarrhea, widespread uncontrollable bleeding, multisystem organ failure, shock and often death.
If your body can survive this onslaught, you’re officially a survivor and hopefully can help other prospective patients unless they’re fortunate enough to receive other experimental therapies I’ll detail in part 2. In that paper the authors also state that EBOV is endemic in the region and predicted the likelihood of an epidemic outbreak. This variant is responsible for the current epidemic and has been isolated in all 4 currently affected countries. As I’ve previously stated we cannot make assumptions on the behavior of this variant based on that of the Zaire strain, neither can we rule out a higher predilection for airborne droplet spread. The United States Citizenship and Immigration Service has announced several immigration relief measures for citizens of Guinea, Liberia and Sierra Leone affected by the Ebola outbreak.  Details  can  be found here.
Not being a virologist I could only keep these suspicions to myself, family and friends plus the occasional tweet. Secondly this excellent interview of Professor Sunday Omilani Consultant virologist at University of Lagos, Nigeria by Sahara Reporters  added additional crucial information (watch from 2:54 but entire interview is highly informative). In the interview Professor Omilani states that patients with high levels of viremia especially in the late stages of the disease will shed the virus in droplets that can become dry and spread by air.
To conclude based on today’s information from the above experts this proves beyond a doubt that Ebola can be transmitted via airborne droplets.
So if you were placed in charge of Ebola disaster preparedness (we can dream, right?) what would be on your wish list with your share of $300m* to spend? The World Health Organization (WHO) recently convened an ethics panel to create guidelines for use of experimental drugs in the current Ebola outbreak.
Current traditional epidemiological methods of contact tracing, quarantining are ineffective due to the size of the epidemic. No particular experimental therapy was promoted but they think 3 drugs and 2 vaccines may be helpful in this crisis.
WHO will not distribute drugs, only act as an intermediary between the requesting country and pharmaceutical industry. In regards to  convalescent blood, Dr  Kieny stated that WHO is currently studying ways to assist the affected countries blood banks to process and provide convalescent serum and produce hyper immune IgG for disease prevention in post exposure individuals. The event concluded with WHO stating another meeting would be convened at the end of the month. In my opinion amongst the therapies discussed, convalescent serum should be prioritized, it’s an established mode of treatment; the Argentinians use it routinely and effectively in their treatment of outbreaks of the Junin hemorrhagic fever that has a comparatively lower 20-30% mortality rate. Let’s wait to hear from our trusted global health leaders after they receive their next paycheck.
While making hospital rounds a few days ago a colleague stopped me to talk about the Ebola epidemic. In 1995 at the height of the Kikwit Ebola outbreak in the Democratic Republic of Congo as described in the PBS documentary “Ebola-The Plague Fighters”, the Congolese doctors were faced with an unthinkable scenario.
The human body fights against infection with foreign organism like viruses and bacteria by producing antibodies called IgM (acute) and IgG (delayed) that kill the foreign organism. Recently Newsweek referred to this treatment by the Congolese doctors in reference to Kent Brantly receiving similar treatment in Liberia prior to receiving Zmapp.
This makes me wonder why haven’t the current countries affected reach out to the Congolese doctors for advice? Well now there’s more than enough potential plasma for anyone who wants it, in Sierra Leone alone there are at least 161 survivors according to official statistics, that’s more than enough donors to conclusively demonstrate that this therapy works.
The world is facing a public health emergency, populations have started panicking and desperation is setting in. At this point, populations have to be offered some treatment that can improve their survival; we can’t wait on scarce experimental therapy that has obviously been prioritized for use in the western hemisphere. In 1995 Doctors in the Congo were faced with a similar dilemma and took the bold step of passive immunotherapy. These bats become infected with Ebola but do not succumb to the disease essentially becoming carriers. Symptoms could be something as innocuous as a fever, however the patient instantly becomes infectious to other people at this time. Ebola goes to work like this: Once the Ebola virus comes in contact with a cell it disguises itself as a friendly molecule to the cell.
Ebola also singles out endothelial cells for attack which are cells that line the surface of organs like your bowel and your blood vessels.
Ebola also depletes the body of a key protein called Protein C that helps prevent blood clots.
I’m using the layman’s interpretation of the word not the virologists’ as I previously stated here. For the difference between Ebola strain, vs variant vs isolate you can decipher this here, once again courtesy of Dr. Khan recently published a paper where he described the Ebola virus (EBOV) present in the Mano River area (triborder area of Sierra Leone, Liberia, and Guinea) as being a genetic variant of the Zaire strain.


As Dr McKay illustrates above this may only occur when in relative close proximity to the patient but it still happens. However we don’t know if they were respirator N95 masks or if they were properly fitted for these masks.
Workers in the field are reusing PPE instead of single use as recommended and this has contributed to high infection rate of healthcare workers. Plasma is required to treat EBV induced DIC and increase survival as EBV patients often bleed to death. Duration of care per patient would increase, per media reports medical professionals can only spend an hour at a time rounding on patients. I believe Kenema, one of the epicenters of the epidemic only has one functioning ambulance currently.
MSF has not lost a single healthcare worker to Ebola, they obviously know what they’re doing. Notably the panel didn’t have a single citizen from any of the currently affected countries (Sierra Leone, Liberia, Guinea and Nigeria) on board. Yes, end of the month, not tomorrow not later this week; this just shows how high they prioritize this outbreak.
In this outbreak, pregnant women and children will probably be excluded from receiving experimental therapy and would most likely be candidates for passive immunotherapy. Their head nurse had become infected and they could see her rapidly dwindling in front of their eyes.
This therapy works and the “magic serum” that was used to treat the American Aid workers is a more expensive and sophisticated form of this simple treatment the Congolese doctors had the vision to use. The Kikwit outbreak had a 20% survival rate, we have a 45% survival rate so there’s obviously enough circulating antibodies to handle Ebola.
Currently a patient diagnosed with Ebola has two choices: a) Go to an isolation ward, receive non curative supportive care and most likely die alone or b) die anyway but in the comfort of your own home and with your loved ones, transmission of disease be damned. The confidence of infected people in medical institutions has to be increased so that they’ll seek medical care immediately and lessen exposure to the community.
Personally I would demand this treatment if in a position to require it and will demand it for anyone I know personally afflicted with Ebola.
It literally rips holes in your gut lining and blood vessel walls leading to the massive bloody diarrhea and vomiting so characteristic of this disease. This can lead to increased clot formation in crucial areas like the lungs and heart leading to sudden death. The official term for this mode of transmission is still “direct contact” but that’s not helpful to healthcare workers in close proximity to patients. Sheik H Khan et al in this scientific paper has been formally named the Mano River variant. Genetic variations can be either benign or dangerous but  future study will determine the effects of this mutation. I personally just underwent my annual N95 respiratory fitting test and not only do the sizes differ but I underwent 20 minutes of testing to ensure the seal was tight enough. I recommend that anyone in contact with symptomatic patients should wear an N95 respirator mask in addition to PPE.
Unless you’re Mr Fantastic you cannot establish direct contact with anyone 3 feet away. I would request lab techs, better kits and the means to store them under the correct conditions.
Helicopters would facilitate speed of diagnosis and delivery of therapeutics, convalescent serum, PPE and needed medical staff.
Healthcare workers don’t need to bake in PPE, this leads to loss of concentration and mistakes with resulting infections.
Ebola victims are currently dying at a rate of around 100 per week I think a higher sense of urgency is in order. They then decided to do something unprecedented in Ebola treatment; they found Ebola survivors drew their blood, screened it for hepatitis and HIV and transfused it into the nurse and 7 other patients. In fact last Thursday the FDA partially released the hold on one of the drugs currently in research development named TKM-Ebola by Tekmira pharmaceuticals. Brantly was diagnosed with Ebola on July 25th, the same day Nancy Writebol was diagnosed according to media reports. Some doctors on the ground I’ve spoken to are hesitant to use blood transfusions due to the risk of transfusion transmissible infections (TTI’s). Unfortunately too many people are choosing the latter option that is leading to the continued spread of the disease.
This will hopefully reduce the rate of spread and stabilize the outbreak which continues to grow exponentially as we speak. I exhort medical professionals in Sierra Leone to implement this therapy, desperate times require desperate measures. Ebola burst onto the global scene in the Yambuku outbreak in Zaire (Now Democratic Republic of the Congo) in 1976.
A human can come into contact with this directly or indirectly by eating fruit contaminated with their saliva or droppings or preparing infected bats for consumption. It takes over the cell and erects a bullet proof shield around itself by manufacturing certain molecules. I routinely screen patients who suffer unexplained blood clots for Protein C deficiency in my clinical practice.
If you know another descriptive word for: ”particles suspended in the air invisible to the naked eye that lie within 3 foot of an individual and can infect someone” other than airborne please write it in the comments below so I can consider updating my article with it.


Why this outbreak took the respective nations completely by surprise is a puzzle to me and I’m sure many other people. Khan, media reports described how meticulously he wore his PPE and would check himself in the mirror to ensure zero skin exposure.
It is much higher than described in previous outbreaks and is difficult to explain solely by direct contact. This entailed me talking, standing and assuming other positions to ensure that there was no risk of pathogen infiltration while interacting with a patient. In the nurse and six patients their symptoms reversed despite initially showing signs of advanced disease and they completely recovered. Their blood thus contained large amounts of antibodies which when injected into another patient killed the virus and the patient survived. Although this was a positive development the reality of widespread availability of medication in this Ebola epidemic seems unlikely. The family of the unfortunate nurse in Nigeria is currently on the run, emphasizing point b).
In this case the Sierra Leone government should obtain blood screening, type and cross matching equipment in the Ebola afflicted regions and implement this therapy immediately.
It was later identified and named by Professors Piot and Heymann as the Zaire Ebolavirus (death rate 83%).
Monkeys can also become infected with Ebola and become severely ill like humans with similarly high death rates. These molecules make the cell resistant to the body’s silver bullets namely interferon produced by immune cells that recognize and attack an infected cell. The liver is akin to a factory and sewage system rolled into one, processing the food you eat into molecules like proteins and glucose that are beneficial to you and responsible for detoxifying all poisonous chemicals in your body.
In this current outbreak there have been anecdotal reports of increased incidence of sudden death relatively early in the disease process (before widespread bleeding and other signs of advanced disease) which could be attributed to either heart attacks or pulmonary emboli. Anecdotally the deceased nurse who cared for Mr Sawyerr stated on her Facebook page prior to her demise that she had not come into direct contact with him, only that she served him food.
Whether Drs Brantly and Khan underwent such fitting and extensive testing is unknown to me. Several experimental drugs and alternative treatments were discussed in addition to convalescent blood. In West Africa 40% of people are surviving so the potential pool of candidates is quite large. This is based on the fact that TKM-Ebola was only in phase 1 trials and we’re yet to determine if it’s effective in diseased individuals.
We can’t wait for the international bureaucrats to fiddle while the world burns from Ebola. Subsequently discovered strains include Sudan (death rate 53%), Bundibugyo (death rate 34%), Reston, Tai Forest and most recently Mano River Strain variant (2)official death rate 55% real death rate close to 80%) which is responsible for this current outbreak. In fact in hyperendemic Ebola regions like the Congo, indigenes there now recognize that sudden mass deaths of monkeys signals a possible Ebola outbreak. Between 3-21 days after infection following its multiplication in peace, it then leaves the cell and starts to attack and kill the body’s other defensive T cells that normally handle viral infections easily. I can leave unsaid what the combination of protein and calorie deficiency with backup of toxic chemicals in your blood stream will do to you. This gave the doctors an 87.5 percent success rate, a rate that has not been matched in any other outbreak and certainly not in the current outbreak. Even if clinical field trials were started today, I doubt there’d be a large enough quantity to use in this epidemic. Incidentally Ebola virus had actually been identified in Liberia as far back as 1973 before anyone knew what disease if any it could cause. Ebola is spread from person to person by direct contact and airborne droplets (3) within close proximity of a patient. This attack on the liver leads to many patients complaining of upper right belly pain and eventually leads to liver failure.
That led me to wonder is this variant of Ebola airborne despite all the proclamations by the media? Their scientific findings were later published in the Oxford Journal of Infectious Disease. Zmapp had never been used in humans prior to 2 weeks ago and has many practical short term hurdles for widespread use. Ebola protects itself even further outside the cell by hypnotizing other T cells not to produce the body’s other silver bullet namely antiviral interferon- ?2, ensuring it’s continued survival. Fast tracking is to ensure we have drugs for the next Ebola epidemic not necessarily this one.
Brantly walked in to the hospital while 2 days later Writebol was wheeled in on a stretcher.
Brantly received convalescent blood, one fewer dose of Zmapp and is doing much better according to media reports. The conclusion I draw is that he benefited from convalescent blood most likely more than from Zmapp.



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