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The bad the worse and the over-interpreted...

case accumulation, Ebola virus, Ebola virus disease, EVD, explainer

EVD case numbers between WHO reports.

The World Health Organization (WHO) Ebola virus disease (EVD)case numbers that came out on 29-Oct were pretty big (see graph on the left). As if there weren't already enough new cases and deaths every 2-5 days, now there is this bolus of 3,562 cases added to the total. And a net change in deaths of -2? What the heck?

Let's see if we can add some context.

According to a number of past WHO reports, a lot of effort has been going in to trying to collect data more effectively including improving the linkage of lab results to cases, cases to deaths, lab data to deaths and probably a million other things.

Dr Bruce Aylward
http://www.who.int/dg/adg/aylward/en/

In the previous Roadmap SitRep and Roadmap update, the Liberian numbers did not move - they even had the same date. That was new and it was concerning because it suggested that reporting had been stopped or collapsed entirely. However this new large download of cases is in some way good news because it suggests reporting is working and the systems and processes are coping - although undoubtedly still stressed - again.

The thing to be aware of is that these are not cases that have all been detected or all occurred since the last report 5 days previously. According to Dr Bruce Aylward, WHO Assistant Director-General, Polio and Emergencies, during a preceding media conference (and my thanks Martin Enserink for asking the important question; underlining is mine)..

In terms of the jump in the number of cases, one of things that we've talked about in the past on this is that with the huge surge in cases in certain countries, particularly in September and October, people got behind on their data.

They ended up with huge piles of paper in terms of cases, etc, and we knew and I actually said to you the last time, we are going to see jumps in cases at certain times that are going to be associated more with new data coming in but it's actually on old cases.

And a couple of days there were about 2,000 additional cases in, if I remember correctly, it was actually the Liberia case report but most of these were old cases because remember they got swamped a couple of months ago with a lot of new cases and just got behind on their data, so a lot of that is about reconciling new data.

If we look at sort of a seven day rolling average number of cases which have been around 1,000, just under that, about 900, there hasn't been a big change in that in the recent weeks.

So the 3,562 cases come largely from the past as well as the present. It's not that the sky has fallen in the past 5 days. Which is good news. But of course, that puts us back to "just" 1,000 or so Ebola virus disease cases a week. In other words, in just 1 week there are more cases than in any individual outbreak since 1976.

The cumulative EVD case curve at 29-Oct

However, this week has seen a few articles and comments noting that the number of new cases in parts of Liberia seem to have fallen slightly.

This seems to be a real trend in that there are fewer burials and more empty treatment beds and fewer cases found when sought in the community. Why there are fewer is not precisely known and it is far to early to rely on this yet. But we do know that there are better numbers of safe burials, better education, more experience with the disease, more help and facilities and more PPE comapred to when this started.

The three countries with intense transmission still require a lot of help from us though - that urgency must not let up. Remember that cases had dropped a lot back in May - and now look where we are.

If you can't get there in person to offer specialist help, and most of us cannot, keep bringing the issue to the attention of your country's leaders, learn about the virus and the disease from trusted sources and help teach others and head off ignorant comments, and donate some (some more) money to those groups who can make a real difference on your behalf (I've listed some great options here).

Fighting the fire at its source is still the best way to help save lives in Guinea, Sierra Leone and Liberia and to stop new outbreaks from occurring in other countries.

References..

WHO Ebola Roadmap SitRep#10
http://apps.who.int/iris/bitstream/10665/137376/1/roadmapsitrep_29Oct2014_eng.pdf?ua=1
Virtual Press Conference transcript
http://www.who.int/mediacentre/multimedia/vpc-29-october-2014.pdf?ua=1

Point-of-Care Ultrasound Training for Emergency Medicine Residents in Kigali Rwanda

Emergency Medicine, Medical Education, Rwanda, Ultrasound

October 30, 2014

I am so grateful to have had the opportunity to join the PURE Team here in Rwanda and thank the Center of Expertise in Global and Humanitarian Health for making it happen. PURE stands for Point-of -Care Ultrasound in Resource limited Environments and was created by a rock star former Harvard Emergency Medicine resident Dr. Henwood. When Dr. Henwood gave a presentation on the impact of Ultrasound in resource limited settings her senior year, I knew that I wanted to not only perfect my ultrasound skills, but to also provide a useful skill to the practitioner abroad who sometimes may feel helpless when CT or Xray is not readily available.

Day 1
I survived a long trip to Kigali, Rwanda. The view from the plane was amazing. The landscape reminded me of my days as a child living in Swaziland. I was picked up from the airport by one of the team members and given a short tour of the city before going home and crashing. The people were wonderful and I even learnt a few greetings in the local language.

Day 2 We packed up the rental car to go to a district hospital about 2.5 hours away to give a training on Cardiac ultrasounds, FAST, and DVT ultrasound. We drove up a windy road on a mountain ( mountains are very common here) where my heart literally wanted to jump out of my chest. The view was amazing.

Unfortunately, the car broke down some where near the top of the mountain. Within 30 minutes we had the local people call for the local mechanic. The mechanic came on bike from Lord knows where and he diagnosed our car with an "engine problem" and called for the local tow truck to tow the car back to Kigali.

We paid about 300 US dollars to be taken back to Kigali Rwanda and to have the car towed-my pockets hurt still. It ended up being quite the experience, but somehow we had a wonderful day. We met new people, saw a new place and broke bread together in the car.

After working in a few places in Sub-Saharan Africa one must be super flexible and adaptable, things happen and you must make the most of it. I honestly had no complaints about this day.

Day 3
Okay finally work!! We arrived at the University teaching hospital of Kigali at 8 am. Our work is performed in the emergency and accident ward mostly, but other internal medicine, surgical and pediatric wards have requested to have scanning sessions for their residents.

This ward serves a slightly different purpose than the emergency room in the US. Most patients present from referring district hospitals and this can even be a matter of several days before arriving here. I was told the role of the ED, is changing though with new emergency residents training in the hospital. Our job is to teach and help facilitate scans with them and internal medicine, and surgical residents. We in no way are here to take any role in patient care.

This day was busy, but apparently it gets more busy than this. We had a number of scans in the morning. For example, we performed an ultrasound on pt who had known cardiomyopathy who presented to the hospital with shortness of breath.

The staff only had an xray from 1 month ago that they continued to refer to the size of the pt's heart. For whatever reason, xray could not be performed that day. We had the residents grab the US machine and look at the pt's lungs and heart. He had bilateral pleural effusions, and diffuse B-lines likely representing interstitial edema. His heart was globally dilated and had extremely reduced function. The residents performed the scans and proceeded to treat the pt for a CHF exacerbation.

We also had a trauma come in from the scene with GCS of 3. One of the stellar training Emergency residents, ran the trauma. A-B-C's initiated. Pt airway was secured with ETT, He had a flail chest and decreased Breath sounds on the right and had a chest tube placed, and he was hypotensive and bradycardic. His Pelvis was unstable. The Emergency resident immediately called out for the US. This was not typical in the past as part of the initial trauma evaluation, but the residents who are so excited about ultrasound have been incorporating it in most trauma pt's. The FAST was positive excellent...now lets go to the OR?? or not...pt pressures were still in the 60s even with resuscitation. Blood was not readily available. Typically this would result in immediate OR intervention in the US, but the team felt that his head injury was too severe, and his quality of life would have been poor...watching resuscitation efforts/interventions stopped in this pt was a bit unsettling.

I have been trying to understand the scenario from the Rwandan physicians point of view. A part of me understands, but still a very difficult pill to swallow.

Until next time...

~Phindile Erika Chowa,MD
PGY 3
Emergency Medicine Resident, BWH/MGH

Why Ebola virus is not human immunodeficiency virus (HIV)

Ebola virus, HIV

I'm not an HIV expert and only an Ebola virus hobbyist but let's see if we can list some things that are similar and different about these two viruses.

Some ways that Ebola virus and HIV are similar...

Both are harder to catch than a cold. They do not spread through an airborne route.
Both have lipid envelopes - Ebola virus is about 904-
1,100nm long x 80nm wide whereas HIV is about 120nm around
Both can be transmitted in blood, breast milk, and through sexual contact, being present in seminal fluid (HIV also in female genital secretions). For HIV the extent of the frequency of exposure and the viral load play during that exposure, play a role in the likelihood of infection; this is not well defined for Ebola virus.[1]

Some ways that Ebola virus and HIV differ...

HIV is an RNA virus that goes through a DNA phase which allows it to hide in our cells while Ebola virus is strictly an RNA virus
Ebola virus infects dendritic cells, monocytes, macrophages, endothelial cells, endocardium, kidney and liver cells but not peripheral lymphocytes while HIV primarily infects CD4+ lymphocytes and also dendritic cells
They differ in the mechanics underpinning the way that they replicate themselves
Ebola virus disease occurs very quickly whereas acquired immunodeficiency syndrome (AIDS) has a long latent period (although there is an earlier more acute disease)
At writing, no antiviral or vaccines exist on the market for Ebola virus or Ebola virus disease; a range of drugs exist to slow or suppress HIV
Ebola virus acutely kills cells, causes coagulation, organ damage and disrupts the immune response without lingering; HIV eventually becomes latent in the cells it infects, integrating with the genome
Ebola virus has 7 genes, HIV has 9 and overlapping reading frames.

References...

Principles of virology. Flint SJ, Enquist LW, Racaniello VR, Skalka AM.3rd Edition. Vol 2. Chap 6.

Mali makes it 6 countries in the West African Ebola virus disease epidemic

Ebola virus, Ebola virus disease, EBOV, Mali, Zaire ebolavirus

v2 251014

The 6th country in the West African outbreak to host a case of Ebola virus disease (EVD) in 2014, is Mali.

The case was a 2-year old girl who was symptomatic while still in Guinea.

She travelled with her grandmother >1,000km by public transport to Bamako (Capital city of Mali), setting out 19-Oct. WHO are treating the situation as an emergency; there were multiple opportunities for exposure. The case's mother may have died of EVD in Guinea and her grandmother may have travelled from Mali to Guinea to attend the funeral.

The case had contact with health services in Kayes, western Mali, on 20-Oct. She was referred and admitted to a paediatric ward of Fousseyni Daou Hospital 21-Oct with a fever of 39�C, cough, bleeding from nose and blood in her stool). Tests were negative for malaria but positive for typhoid fever. Pain relief was given but there was no improvement.

Further tests confirmed EBOV 23-Oct at the SEREFO (Center for TB and AIDS Research) laboratory in Mali.

Samples are being sent to a WHO-approved laboratory for confirmation.

The girl has since died.[2]

The 2014 West African epidemic and Central African outbreak of EVD.
Click on image to enlarge. Feel free to use and share this map
(please attribute to this blog).
NB: Nigeria (19-Oct) and Senegal (17-Oct) were declared EVD free.

References..

Ebola double vision....

Ebola virus, Ebola virus disease, Editor's Rant

A quick post to crudely highlight that total (suspected+probable+laboratory confirmed) Ebola virus disease case numbers have been doubling approximately every month since June (as far back as I went).

Click on image to enlarge.

The reality is that the most recent reports from the World Health Organization (WHO) may be even less accurate than the underestimated numbers we have become used to during the epidemiological fog-of-war that surrounds any outbreak, epidemic or pandemic.

Apart from the most recent update, WHO Situation Reports (SitReps) of late have made a point of highlighting that the numbers have been lower than what those in the field expect is real.

"It should be emphasized that the reported fall in the number of new cases in Liberia over the past three weeks is unlikely to be genuine. Rather, it reflects a deterioration in the ability of overwhelmed responders to record accurate epidemiological data. It is clear from field reports and first responders that EVD cases are being under-reported from several key locations, and laboratory data that have not yet been integrated into official estimates indicate an increase in the number of new cases in Liberia."

8-Oct-2014 WHO Ebola Response Roadmap SitRep

So, if you are a senior influencer or a decision-maker in your country and if that country, in which you are a citizen, has offered only limited, financial, or non-existent support to this unprecedented outbreak of infectious disease, I suggest the following: Stop disproportionately worrying about the few sporadic but simply controlled EVD cases that your already-straining healthcare budget has to look forward to. Stop worrying about how those budgets will cope with the unnecessary burden of your feel-good but near-pointless rollout of temperature monitoring resources at entry ports. Stop thinking that by blocking flights out of West Africa you will somehow protect your country and the rest of the world from exported cases.

Think about this instead: If you are not doing your damnedest to insist that your country has put people and equipment on the ground in Liberia, Sierra Leone or Guinea, then you do a disservice to humanity, and on your shoulders be the burden of the many deaths to come.

We individual citizens can't do this. You and our governments can.

Complain about and hide behind who didn't react fast enough if you must, but do be very, very clear in your own mind that now, right this minute, if you are not acting, calling someone, pleading a humanitarian case, then it is you and those like you who are to blame for some of our global villages burning out of control.

I don't care a damn if the currency for today's political action is "security" - you find a way to bring it back to being about humanity.

We live in an interconnected world and some of those country's citizens are your constituents.

The global calls have gone out, the Resolution has been passed, the pleas have been made, the situation is clear to all. And you are failing.

Get up and do something. Now.

References..

Ebola Virus Disease in West Africa � The First 9 Months of the Epidemic and Forward Projections.
New England Journal of Medicine. 23-Sept. WHO Ebola Response Team
http://www.nejm.org/doi/full/10.1056/NEJMoa1411100

Ebola index: Virology Down Under posts...

Ebola virus, Ebola virus disease, Index

To make it a little easier for me to keep up, I thought an index of my key posts - some of which address your most pressing concerns about Ebola virus, ebolaviruses and Ebola virus disease (EVD) - would be useful.

The tallies and graphs from the major countries that have hosted Ebola virus disease cases in West Africa. Updated as soon after the World Health Organization (WHO) releases their figures as I can manage.
Ebola Virus Disease (EVD) 2014 West African outbreak..
http://newsmedicalnet.blogspot.com.au/2014/07/ebola-virus-disease-evd-2014-west.html
The partner post to #1 but in maps and historical numbers.
Ebolavirus disease (EVD) cases, clusters and outbreaks mapped out...
http://newsmedicalnet.blogspot.com.au/2014/07/ebolavirus-disease-evd-cases-clusters.html
A summary of what we know about how the Ebola virus is transmitted between humans.
Ebola virus may be spread by droplets, but not by an airborne route: what that means
http://newsmedicalnet.blogspot.com.au/2014/08/ebola-virus-may-be-spread-by-droplets.html
The companion piece to #3 - highlights that we can force Ebola virus into an aerosols in non-human primates (not hiding this), and that pigs also seem to produce aerosols...but that this is not the same as natural human virus acquisition/disease which is due to direct contact between body fluids and mucous membranes/broken skin (includes physical touch and propelled).
Ebola, pigs, primates and people
http://newsmedicalnet.blogspot.com.au/2014/08/ebola-pigs-primates-and-people.html
Why this epidemic is extremely unlikely to produce a variant of Ebola virus that changes so much (accompanied by changes in the host), that it becomes an "airborne virus".
The wind beneath my Ebola virus....
http://newsmedicalnet.blogspot.com.au/2014/09/the-wind-beneath-my-ebola-virus.html
Some scientific literature to underscore the risks of acquiring Ebola virus from a very ill person's blood, sweat, spit and tears.
Ebola: Blood, sweat and tears...
http://newsmedicalnet.blogspot.com.au/2014/08/ebola-blood-sweat-and-tears.html
Some scientific literature and discussion to highlight the chronic risk of acquiring Ebola virus infection from the semen of a convalescent male.
Ebola virus in semen is the real deal....
http://newsmedicalnet.blogspot.com.au/2014/08/ebola-virus-in-semen-is-real-deal.html
A post about the many things that lead to healthcare worker (HCW) Ebola virus infections. This was in response to a CIDRAP article and to the increasing narrative that because of a high toll among HCWs, there must be something changed about this virus making it "easier to catch than what we have been told". Which has to date not been backed up laboratory science, epidemiology or the observations of those working in West Africa.
Ebola virus, HCWs infections and personal protective equipment..
http://newsmedicalnet.blogspot.com.au/2014/09/ebola-virus-hcws-infections-and.html
A new graphic to even more simply explain the differences between an airborne transmission route and a short-distance wet droplet/cough route of transmitting viruses like Ebola virus.
It's what falls out of the aerosol that matters....
http://newsmedicalnet.blogspot.com.au/2014/10/its-what-falls-out-of-aerosol-that.html
A thought-provoking post about what to call the way in which viruses like Ebola virus may be transmitted since they are not truly airborne but may be coughed or vomited across short distances as big wet droplets. Airborne vs Propelled.
What words would you use to separate influenza spread from Ebola virus disease spread?
http://newsmedicalnet.blogspot.com.au/2014/10/what-words-would-you-use-to-separate.html
A short brief on the different variant, still from the Zaire ebolavirus species (same species as that ravaging West Africa), concurrently circulating in the Democratic Republic of Congo (DRC).
The battle of Ebola gains a second front...the Democratic Republic of Congo (DRC; formerly Zaire)
http://newsmedicalnet.blogspot.com.au/2014/08/the-battel-of-ebola-gains-second.html
Some of the many fake or non-Ebola virus disease images circulating on the interwebs. Help enlarge this or solve the unknowns, if you can.
Fake/wrong Ebola virus disease images...
http://newsmedicalnet.blogspot.com.au/2014/08/fake-ebola-virus-disease-images.html
How to use the perfect terms to discuss Ebola virus. How does Ebola virus differ from EBOV, differ from ebolaviruses, differ from Ebola virus disease? A primer on the lingo and how it compares to cars.
Behind the naming of ebolaviruses...
http://newsmedicalnet.blogspot.com.au/2014/08/behind-naming-of-ebola-virusesnot-yet.html
How can you help? Donate money and help provide protective equipment for the heroic efforts of those willing to face down Ebola locally in West Africa or after driving/flying in.
Protect the healthcare giver>>save lives>>stop Ebola virus disease
http://newsmedicalnet.blogspot.com.au/2014/08/protect-healthcare-workerssave.html
Application of Prof David Fisman's predictive Ebola modelling.
Updating a model of a modern Ebola epidemic...
http://newsmedicalnet.blogspot.com.au/2014/09/updating-model-of-modern-ebola-epidemic.html
A term to better explain the crude ratio of people who have died in the midst of a chaotic epidemic.
The proportion of fatal cases (PFC)...
http://newsmedicalnet.blogspot.com.au/2014/09/the-proportion-of-fatal-cases-pfc.html
Some hints and tips on how to get the most from commonly used graphs on Virology Down Under.
How to read a VDU graph...
http://newsmedicalnet.blogspot.com.au/2014/08/how-to-read-vdu-graph.html
How to read my graph depicting Ebola virus case numbers between reports.
Case number changes between Ebola virus disease reports...
http://newsmedicalnet.blogspot.com.au/2014/09/case-number-changes-between-ebola-virus.html
An idea that could be used by Australia to more safely allow it to provide/encourage/permit the sending of human help, not just money, to West Africa.
Australia's response to Ebola virus disease in West Africa: is too little enough?
http://newsmedicalnet.blogspot.com.au/2014/10/australias-response-to-ebola-virus.html
A ranty reminder the outbreaks, epidemics and pandemics are chaotic things driven by chaotic humans. Numbers of cases never account for every case..because chaotic. Don't expect them too.
The numbers are underestimates...
http://newsmedicalnet.blogspot.com.au/2014/09/the-numbers-are-underestimates.html
A theory about the cumulative case and death graphs that suggests a possibly useful predictor of things beginning to run out of control.
The control gap...
http://newsmedicalnet.blogspot.com.au/2014/09/the-control-gap.html

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