Ebola index: Virology Down Under posts...

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.

1. 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
   
2. 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
   
3. 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
   
4. 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
   
5. 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
   
6. 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
   
7. 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
   
8. 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
   
9. 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
   
10. 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
    
11. 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
    
12. 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
    
13. 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
    
14. 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
    
15. 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
    
16. 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
    
17. 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
    
18. 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
    
19. 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
    
20. 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
    
21. 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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What words would you use to separate influenza spread from Ebola virus disease spread?

I need your help.

I have spent umpteen hours on trying to make this message simple. None of that has been aided by the way that the CDC, the WHO and now the UN use the terms and words confusingly to convey messages to the public. The message is often delivered as if they were sitting around their meeting rooms talking to other health and science professionals. In my opinion, we all look to these guys for simple clear and consistent messages. Right now they need to do much better to convey complex concepts, simply, quickly and more often. Education helps prevent panic, mistakes and conspiracy theories (well-as much as anything can anyway).

So here is another attempt by me to get this wording into line with what the rest of world can make sense of. 

I could also really use your input to make this work - so leave a comment below, or Tweet me @MackayIM or email me or send me a carrier pigeon - with how to make this message simpler for you and your kids and your grandparents and that weird uncle you stay clear of at Christmas, to understand. 

Let's crowdsource a solution to this confusion, help out others and then see if the major public health bodies can come on board.

Propelled droplets versus a cloud of suspended.

This post and issue have been fuelled most recently by the Ebola virus disease (EVD) epidemic but is also fuelled by my experiences in talking to people about the MERS-CoV and influenza A(H7N9) virus outbreaks. They are respiratory viruses while ebolaviruses are not. Different viruses yes, but common concerns for people and to the issues around trying to understand overly technical terms when they are used differently in everyday life. 

Public health speaking is very public.

Public health issues are spoken about on a global stage, more now than ever. It is up to us to better define the right words and use them consistently. That has definitely not happened for "aerosol" and "airborne". 

We professionals can't just sit back and expect our stakeholders to come along with us for the ride - they will get confused when imagery conflicts with lingo and official statements, and when different public organizations disagree with each other or use tiny but significant differences in their language to communicate risks. 

People are not stupid and deserve more respect than they are currently getting from those who should know much, much better about how to work alongside the public (public health and all).  

So what is the problem here? 

Droplets would probably be an ideal word to differentiate from airborne - and it has been used to differentiate the level of precautions of personal protective equipment (PPE) to prevent infections - droplet precautions and airborne precautions - but the evil physicist types have ruined the use of that word for us by introducing droplet nuclei (the part of the aerosol that lingers in the air and can convey those viruses that survive in it, to a new person to infect them). Physicists like technicalities.

So the problem is trying to define a name for that other process that can simply and clearly describe infectious disease transmission of viruses & bacteria that are propelled from/by the sick person, across the gap between them and an uninfected person, measurably infecting the recipient. The name should make clear that it is a different process to the one that sees a person get sick by inhaling infectious viruses or bacteria held aloft by the air, in a cloud, made by a previously ill person, that has been hanging around for perhaps an hour or more. That one is an airborne route of transmission. 

Some people have berated me for talking technicalities and semantics in recent days while I try to better define this. Tough! Water off an influenza-host's back. Words have meaning and impact and useful words are needed. Especially when everyone is freaking out over a disease they have only read about in dramatized books or seen in Hollywood blockbusters. The two processes listed above are distinct and different for some viruses & bacteria. But it is biology and nothing is 100%, except death. 

Some infections, like those leading to influenza, could result from both processes. Some, like Ebola virus disease have never been observed in humans via one route (airborne), whereas there is a defined risk of them occurring by the other (direct contact between a range of virus-laden body fluids propelled onto a mucous membrane). Yes, coughing a tiny barely visible droplet onto someone else's mouth is direct contact between the wet fluids and the mucous membrane.

They two processes are battled differently. We protect ourselves from them differently. And names can tell us about the different levels of risk. But what is that other route to be called? 

I have an idea. First some perspective.

Ways to think of the differences.

A word cloud of ways to think of the
two different processes of spreading viruses
or bacteria that result in infection and disease
in humans.
v2 Thanks to Nina West for good analogy (Fog/Rain)

The idea.

How about we call the process of relatively short (up to about 3m) distance, coughed/sneezed/vomited wet droplet transfer of disease-causing doses of viruses or bacteria, "Propelled"?

Over to you, world.

Some greats from the comments below...

• "void the spray and live another day"
• Only touched by air, no need to care. Where it splatters, that's where it matters

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Evaluating a traveller being considered for Ebola virus disease

From http://www.cdc.gov/vhf/ebola/pdf/ebola-algorithm.pdf

A lot of other content from the United States Centers for Disease Control and Prevention can be found at: http://www.cdc.gov/vhf/ebola/

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The richer end of the world finds creative ways to spread Ebola virus... [UPDATED x2]

ProMED MODERATOR JW SUGGESTED SOME ASPECT OF THIS WAS A HOAX (HEADLINE). 
http://promedmail.org/direct.php?id=20141004.2832236

Amendment: It has been quite correctly noted below, by the moderator in a personal communication (or 4) and by others, that this image was posted or taken from a Dallas/Fort Worth TV (WFAA) station's chopper on 2-Oct. The infected man vomited 28-Sept, as he headed to hospital. 

So let's say about 72-hours had passed while the vomit sat outside on a non-ceramic/steel surface (these are used in controlled lab experiments to show virus stability-perfect world stuff) through multiple cycles of Texan day/night, high/low temperatures. Okay. The power-washing process is thus extremely unlikely to have generated infectious droplets. Risky and ridiculously long period to leave potentially Ebola-laden vomit out in the open of course, but extremely unlikely to be a source of infection during the power-spraying (water-blasting/gurneying). Apologies for adding to the fear-mongering.  -IanM

This from a Tweet sent to me by @LonnieRhea thanks) 

.@kksheld WFFA-8 photo of crew w/ no PPE's spray washing #Ebola vomit off sidewalk. Via @wfaachannel8: pic.twitter.com/9TJzrkJJKQ cc: @fordvox
� Lonnie Rhea (@LonnieRhea) October 2, 2014

So far the Dallas Ebola virus disease case has been a great learning experience for the United States. 

It really does serve to highlight that humans are what make virus outbreaks...become outbreaks. 

Viruses are nothing without us. And we are so eager to oblige in spreading them around.

Hopefully the virus in that vomit had been inactivated by heat, or the nature of the surface it was on or by drying out before being stirred up by a high pressure water blaster. And hopefully they sterilized their shoes and clothes and...sigh.

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It's what falls out of the aerosol that matters....

v2 031014

"Aerosol" is a messy word. It means different things to different people. So does "airborne".

What's in an aerosol?
Here we're talking about a mixture of different sized stuff. Think  of the size range in a handful the sand from a shelly beach.

A cough/sneeze includes big, wet, heavy propelled droplets that quickly fall to the ground or hit your windscreen (hate it when that happens) or your friend's face (they hate it when that happens) down to dried or gel-like "droplet nuclei" that can float in the air for hours, travelling where the wind blows them; and every size in between.

I've also talked about this before, here.

The public rightly get confused about aerosols. And science and physics and medicine have their own defined meanings - sometimes at odds with each other - that may well be out of step with what the public think.

I do wish the the big public health entities would settle on some definitions for these and other words. It would make everyone's life a lot easier.

Direct contact.

When we talk about "direct contact" and Ebola virus transmission, we do include the bigger wetter heavier droplets that might be propelled from of a sick person during vomiting, or coughing as a risk for transmitting virus. 

Even though that is not physical direct contact, and even though the droplets travel across a gap between people - through the air - it is still a direct line from person A (red in the graphic below) to B (blue). If B is too far away, then those droplets fall to the ground before they hit B. The droplets may remain infectious on the ground. That depends on temperature, humidity, surface type and the type and amount of virus.

The airborne route.

Even though it involves a short period of travel through the air, coughing wet droplets directly onto someone's mucous membranes is not an airborne thing. The term "airborne" is reserved for floaty clouds of droplet nuclei. In humans droplet nuclei have not, to the very best of our knowledge and observations and tests, been found to contain doses of Ebola virus that cause disease in humans. Too little virus coughed into the cloud perhaps or too little that survives..it's not known why, but it is pretty clear that in households where a case of Ebola virus disease was residing, only those household members who had direct contact developed disease, and those that breathed the same air but did not have direct contact, did not develop disease. 

While Ebola viruses may be present in floaty clouds of droplet nuclei, or forced to be in a floaty clouds of droplet nuclei under lab conditions with lab viruses at lab virus concentrations, a floaty cloud of droplet nuclei has not been shown to act as a source of acquisition for Ebola virus and resulting disease among humans. Sorry, did I just repeat myself?

Rest in peace.

Please don't say Reston ebolavirus or the Hot Zone. That (by all accounts riveting) book was not a scientific work, it is a dramatized work and the language is colourful and emotive and scary. The Reston ebolavirus event in non-human primates was never proven to be airborne.

Lastly and most recently, an airborne route was not found to play any role in causing disease or infection when Ebola virus infected and uninfected non-human primates were caged near each other. I've written about this and other non-human primate studies here.

To summarize.

Healthcare workers wear face protection(masks and goggles) to prevent their eyes and mouth being hit by wet droplets of virus-laden body fluids while they are in close contact with ill Ebola virus diseases patients. The also wear all-over gowns so that they don't have to sterilize their clothes between each room they move between. Use of protective equipment doesn't need to convey confusing messages about the type of route Ebola virus uses to spread but it's just lacking in enough public discussion via forums the public attend/view. Knowledge is a bit like vaccination - when coverage reaches a certain level, the community is safe (or it's understanding is complete anyway).

And why wouldn't healthcare workers protect themselves from ill patient fluids-however they come into contact with them? For a healthcare worker, body fluids from ill people they are in close and often prolonged contact with, should generally be considered infectious. This is the case whether we're talking about Ebola virus disease, HIV, measles, influenza or something else. Some of those are caused by airborne viruses, some, like Ebola virus and HIV, not.

Below is my latest attempt at trying to make all those words into a picture. 

If you have ways that can help me make this even simpler - please pass them along (thanks @chrisfharvey).

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Australia's response to Ebola virus disease in West Africa: is too little enough?

Written by Dr. Katherine E. Arden and Dr. Ian M. Mackay

The outbreak of Ebola virus disease (EVD) began in December 2013 in Guinea. It spread to Sierra Leone, Liberia, Nigeria and Senegal. The last two countries on that list were able to contain EVD because they had functioning healthcare systems with doctors and nurses, protective equipment and hospitals that work. The United States of America (US) had its first imported cases arrive 30th September. To some extent, these final three countries could �see it coming�. None of these preparations were in place or possible in Guinea, Sierra Leone or Liberia. They are hosting the largest EVD outbreak in recorded history.

Help wanted.

On August 8th, this epidemic was labelled by the World Health Organization (WHO) as a Public Health Emergency of International Concern (PHEIC). The time for help to arrive and be effective is now. Before 70% of the predicted hundreds of thousands of cases to become infected by this variant of Zaire ebolavirus die. Money is required, and Australia has now donated eight million dollars. Three weeks ago a one billion dollar cost was forecast; a ten-fold increase in a month.[6] But what is really needed urgently are people. People to create beds through the building of treatment facilities, people to staff those facilities to provide the best supportive care possible under the circumstances, people to be trained to safely care for the sick and dying and to trains others, people to track cases, people to help educate family members in how to care for a sick loved one, people to help the psychologically traumatised try and deal with the loss of their children, their parents, siblings, cousins and friends. People are what�s needed. The United Nations (UN), which includes Australia, unanimously adopted Resolution 2177(2014) on the 18th of September within which it provided some instructions to member states. One of those is:

�8.   Urges Member States, as well as bilateral partners and multilateral organizations, including the AU, ECOWAS, and European Union, to mobilize and provide immediately technical expertise and additional medical capacity, including for rapid diagnosis and training of health workers at the national and international level, to the affected countries, and those providing assistance to the affected countries, and to continue to exchange expertise, lessons learned and best practices, as well as to maximize synergies to respond effectively and immediately to the Ebola outbreak, to provide essential resources, supplies and coordinated assistance to the affected countries and implementing partners and calls on all relevant actors to cooperate closely with the Secretary-General on response assistance efforts;�

Australian Prime Minster Tony Abbott noted to the UN that �We were one of the first countries to arrive with help in Japan after the 2011 earthquake; and in the Philippines after the 2013 typhoon.�[5] Why haven�t we arrived in West Africa yet?

Australian Foreign Minister Julie Bishop said on 29th of September, that Australia has not been specifically asked by the WHO to provide healthcare professionals to help.[2] But we a member state of the UN and the WHO is the United Nations� public health arm. In that article the Minister was quoted as saying that we were unable to repatriate infected Australians safely, with this being an integral reason behind our limited response to the Resolution. 

Lightbulb Moment.

Until the Foreign Minister�s comment, the importance of the US concept of building a smaller, healthcare worker-specific treatment facility in West Africa was perhaps lost on the two of us. Such an elitist construction looked bad to the people of the region and, without sufficient background, to others outside it. However, if such a facility reduces or removes the need to spend tens to hundreds of thousands of dollars per person [3] to send them home for treatment, then it seems like a brilliant plan. That money could be better spent, and the added healthcare should help attract more international healthcare workers to the region. In fact, why doesn�t Australia assemble the components and airlift a similar facility, flat-packed, to one of the regions in need of our help? This could be done in a jiffy with Australian military precision. Once built, this facility may well remove the need to repatriate any Australian healthcare professional who may get infected. This may be a better and faster solution than us trying to use British or US facilities or doing a deal with them to evacuate our people. 

A good global citizen.

Prime Minister Abbott noted �That is what you�d expect from a country such as Australia which always wants to be the best global citizen�.[4] We are currently not being the best global citizens that we could be.

Let�s not hide behind excuses. Do we want our national character to be stingy and afraid or strong, generous and willing to give a fair go to those in need? We pride ourselves on our innovative character. We can use this to find a way around problems, real or perceived, in answering the UN�s call for help. Help we are able to provide. 

It would be difficult, heartbreaking, hard work. We know that Aussies are more than capable of doing that. In fact, the more people on the ground, helping, the easier the burden would be. There may be some problems, and it would be naive to expect otherwise. That is why the UN has called for help. If there were no risk, and everything was simple and easy, this situation would not exist in the first place. Should a healthcare worker fall ill, there is a high chance they would die. A tragedy for their family, friends and workmates. And let�s be real, there are more risks to healthcare workers than just Ebola virus disease in these countries. There are scared and sometimes violent villagers, as well as plenty of other diseases like malaria to contend with. 

The lucky country.

Australians have the wealth, the innovation, the ability, the equipment and the skills in our excellent health care workers, engineers, keepers of the peace and logistical organisers. We have the willing volunteers. 

How much of our global village has to burn down before we do more than buy a bucket? Why must we focus on security threats, economic impact, terrorism and political stability when it is the humanitarian aspects that should our priority? Yes, this seems to be the only way to communicate with politicians. But is the way forward for us as a nation that something has to be become a direct threat to us and our lucky country way of life before we lend a hand? Is that who we want to be? Can we not expect a more human perspective from our leaders and ourselves? We think we can. 

References

1. http://www.who.int/mediacentre/news/statements/2014/ebola-20140808/en/
2. http://www.theguardian.com/world/2014/sep/29/australia-cannot-bring-health-workers-home-from-african-ebola-zones
3. http://www.cidrap.umn.edu/news-perspective/2014/09/very-few-aircraft-equipped-evacuate-ebola-patients
4. http://www.news.com.au/national/medecins-sans-frontieres-slams-australias-ebola-response/story-fncynjr2-1227061379772
5. http://www.pm.gov.au/media/2014-09-25/address-united-nations-general-assembly-united-nations-new-york
6. http://www.unmultimedia.org/radio/english/2014/09/one-billion-dollars-needed-to-contain-ebola-outbreak/#.VCv3i_na6-0

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