Ep 11 Ebola: The New Kid on the Block

00:00:08
Speaker 1: When the ebola treatment center in Sierra Leone that the diagnostic lab that I was working in was adjacent to when it first opened, a first ebola patient was an eight year old girl who was very very ill. She actually only survived for a week after that, but she made a special request that she would like some coconut uist. It was very easy to get hold of this and it was all arranged. But one lasting image that's like forever burned in my mind of my time in Sierione is a doctor all kitted out in their full ebola ppe, carrying two coconuts into the high containment ebola treatment tents.

00:00:45
Speaker 2: One of the stories that really really struck me was one of survivor health advocates, Colaco Coroma. She had several children, she was married, and they ended up contracting ebola from a couple traveling into their village from a different village that was affected already, and so they got sick and died. And the couple had a baby, and Colocco had a baby also, and so she took the baby whose mother had succumb to the disease and breastend a baby to keep the baby alive, and so the baby unfortunately had gotten EBuLa from his mother and passed it on to Colocco, and then she passed it on to her baby, and so she ended up losing four of her children, including her infants, as well as her husband. And it's incredible to hear someone tell that story and all of the emotion, but then also see how strong she is afterwards and how she's showing up every day. She wants to be a part of her community, she wants to rebuild her family, and just had like so much hope for the future. And so that was pretty incredible. There's a lot of like heartbreak, but there's also a lot of hope that came out of it. People caring for people that they loved were the ones who getting this disease, and it's like crazy thing.

00:02:03
Speaker 3: Yeah, it's vicious. It's vicious. Like passing along this deadly disease through acts of love is really really hard to imagine. I mean, can you imagine being told that you can't comfort your infant or your toddler, your spouse. Weelthern and like exquisite pain. Just incredible.

00:02:37
Speaker 4: Hi, Hi, and welcome to episode eleven.

00:02:41
Speaker 5: Of this podcast Will Kill You.

00:02:42
Speaker 4: Wow, that's exciting. I know, I'm Aaron Alman update and I'm Aaron Welsh.

00:02:48
Speaker 6: In case you haven't figured it out, this episode is all about Ebola. What you just heard were first hand accounts of the twenty fourteen a Bola epidemic told by three badass swimming Lauren Crowley, Nell Bond and Sarah Page. We're going to let them introduce themselves.

00:03:08
Speaker 1: So my name is Lauren Cowley, and I'm a post talk to a research fellow at Harvard pH Chwan School of Public Health.

00:03:14
Speaker 3: So I'm Sarah Page. I'm had a circuitous pathway to my current field, so i work for as a Global Health Fellow and I'm based at us AID, So I'm a senior Infectious Disease Advisor sitting on the Health Team and the African Bureau. So i work really closely with the Global Health team that's dealing with the Emersion Threat's division and Global Health security.

00:03:39
Speaker 2: Yeah, so I'm new Bond and so I first went to Cyrili own part of like a loss of fever lab, which is really interesting and exciting, and then now I'm working on AIDS pathogenesis in an immunology lab.

00:03:52
Speaker 4: So we'll get back to them. And some of their stories a little bit later in the episode, So what are we drinking today?

00:04:00
Speaker 6: You're drinking the spillover the spillover?

00:04:05
Speaker 5: What is in the spillover eron today?

00:04:07
Speaker 4: It's tequila, kombucha, some lemon juice, and some honey.

00:04:12
Speaker 6: And don't forget the rim, which is a salt and sugar rim.

00:04:14
Speaker 4: But the most important part of the spillover you could really make any drink that you want.

00:04:18
Speaker 5: Anything, beer, yeah, wine, water, juice.

00:04:22
Speaker 4: La croix for example. Just make sure you fill it all the way to the brim of the glass, so that it's about to spill over. Yeah, we're hilarious. Our most clever quarantine yet.

00:05:00
Speaker 6: So let's let's dive right into the biology of ebola.

00:05:04
Speaker 5: Absolutely one of the scariest.

00:05:06
Speaker 4: So Ebola virus is, of course a virus, what shocking. I know. Specifically, it's in the family known as philoviruses. I think that's how you say it. They're called this because they're filamentous viruses. Under a very very high powered microscope, they look like worms. Right. All the viruses in the pilovirus family cause hemorrhagic fevers, all of them. Did you know that?

00:05:31
Speaker 6: I don't know all the viruses in the virus.

00:05:34
Speaker 4: There's only two. Ah, I mean, it seem really dramatic, but there's only two viruses in this family. It's Ebola virus and Marburg virus.

00:05:43
Speaker 6: Oh okay, okay, yeah, I didn't know it was just so limited.

00:05:46
Speaker 4: I didn't either. So ebolavirus is an RNA virus, which we've seen before, YadA YadA. It has a fast replication rate and makes lots of mistakes, et cetera, et.

00:05:54
Speaker 6: Cetera, which means faster evolution.

00:05:57
Speaker 4: Exactly right. There are at least five known species of a Bola virus, sudan of Ebolavirus zayeir restin, which is a very interesting Are you gonna talk about it? I am, yes, I'm excited. And then Thai Forest, which was formerly known as Ivory Coast or kotivoir ebolavirus, and finally Bundy Bougio I think is how you say that, which actually wasn't discovered until two thousand and eight, which that's crazy, an entire new species of virus, except that, well, it's not that crazy since like we basically know nothing about microbes and even less about viruses, not just the ones that infect humans, but overall right, Okay, So there are five strains of a bola, and they differ in their pathogenicity. So the Zayere strain is the most virulent, with fatality rates of up to ninety percent. Yep, it's really that's terrible, fine, and then the Sudan strain, which is probably the one that we know. Zyere and Sudan we've known about for the longest, so we know the most about them.

00:07:07
Speaker 6: They've caused the most outbraks exactly.

00:07:09
Speaker 4: That one has a case fatality rate of usually about fifty percent, and then the other ones tend to be lower. We don't entirely understand the pathophysiology of ebolavirus.

00:07:20
Speaker 5: Meaning the way in the way it causes disease in.

00:07:23
Speaker 4: Your body exactly, So we're not one hundred percent clear on exactly what's happening inside your body. We know a few things. We know that it attacks your immune system a few different types of your immune cells, and then it causes spontaneous cell death in other cells in your immune system. So basically it's causing a lot of damage to your ability for your body to fight it off. Okay. We also know that it additionally infects your endothelial cells, which are the cells that line your blood vessels, which is why you can get hemorrhaging, which we'll talk more about later, because it basically makes your blood vessels leaky because it's damaging those cells. So then you have blood leaking out exactly caused by the virus. And one thing that is clear is that those people who survive in a bowla virus infection do so because they have a really good antibody response.

00:08:17
Speaker 5: Interesting, so somehow.

00:08:19
Speaker 4: Their bodies are making a lot of antibody and that's what makes a difference in the outcome of infection.

00:08:24
Speaker 6: That's really interesting that it has to do with an individual immune response, and I wonder what kind of whether that's entirely genetic, or whether that has anything to do with the number of.

00:08:34
Speaker 5: Diseases you've been exposed to in your lifetime.

00:08:37
Speaker 4: Or just the initial infection dose that you get infected with, like how many viruses you're infected with to begin with. And honestly, from my reading of it, and so someone can correct me if we actually know this, I don't think we really know. It's not really clear what the distinctions are between individuals that end up surviving and not surviving aside from this antibody response and what causes them to have that response is unclear.

00:09:00
Speaker 6: And also like high risk groups exactly right, Yeah, yeah.

00:09:04
Speaker 4: Ebolavirus has an incubation period, which we've talked about before, but I'll remind you is the period of time from when you get infected until when symptoms first appear. That's between two to twenty one days on average. I've seen about ten or eleven days, that's what it was. For example in the last outbreak in twenty fourteen, twenty fifteen, okay, was around eleven days on average.

00:09:26
Speaker 6: So you touch somebody or you get infected, get infected, and then.

00:09:30
Speaker 4: Eleven days later you start to show start to get the symptoms. And one thing that's important about ebolavirus is that you are not infectious until you start showing symptoms.

00:09:40
Speaker 5: That is very important, it's.

00:09:41
Speaker 4: Very important, and you are not very infectious for the first few days of your infection after you start showing symptoms. So what that means is that how infectious you are to other people, meaning how easily it is for you, as an infected individual to infect somebody else depends on how many viruses are in your life. And that number of viruses is going to increase over time. So at the beginning of your infection, you're not very infectious.

00:10:07
Speaker 6: And so this is different than some of the other diseases that we've covered exactly where you are highly infectious even before you show symptoms.

00:10:15
Speaker 4: Right, something like influenza, for example, you're infectious several days before symptoms start, and you tend to be most infectious at the beginning of the course of infection, whereas with this your most infectious at the end of the course of infection, which we'll talk about a lot later but is really important, was really important in this most recent outbreak, right, and is really.

00:10:36
Speaker 6: Important in general in terms of predicting what diseases might be related to outbreaks or epidemics and so on.

00:10:43
Speaker 5: Exactly interesting.

00:10:44
Speaker 4: Yeah, So the first symptoms of ebolavirus ebolavirus disease, so ebolavirus disease used to be called ebola hemorrhagic fever. It's no longer called that, but it The symptoms include a pretty sudden onset of fever and a relatively eye fever, fatigue, muscle pain, headache, and often a sore throat. Then this is pretty quickly followed by vomiting, diarrhea, rash, liver and kidney failure, and sometimes, although importantly not all the time, internal and external bleeding. So that's where it got its previous name hemorrhagic fever, right, because to hemorrhage is basically just to bleed uncontrollably, So internal bleeding, which is something that we talked about. I believe in yellow fever as well. That can result in things like black or bloody stool or vomit if you're bleeding into your GI tract and then external bleeding. It's not I think a lot of people have a misconception that ebola results in you like exploding blood out of your orifices. That doesn't happen in ebola. You can get oozing of blood from your gums or your nasal passages, maybe the corners of your eye and things like that because ebola can infect a huge variety of tissues. Ebola virus does exist in basically all of your mucous membranes and things, so anywhere that it exists, you can get bleeding. But you don't have like explosive bleeding.

00:12:12
Speaker 5: Right, there's no bleeding out.

00:12:14
Speaker 4: Right, So you tend to die from things like very similar to what you die from in septic shock, which is just your body being overloaded by both immune defenses and the virus itself and then just organ failure and that's what ends up actually causing death. The virus is transmitted via direct contact with certain bodily fluids. Actually most bodily fluids feces, saliva, blood, vomit, semen. No one said it, but I would assume vaginal fluids as well, And then the virus has to enter the next person that it's going to infect via contact with their mucous membrane so eyes, nose, mouth, or a break in the skin. So it's not like you can get ebola just from being in the same room as somebody with a bola. It tends not to be transmitted via respiratory droplets. But I'm hoping you're going to talk more about that just a little bit. Oh, it's really interesting, it's actually really terrifying. That's I think the thing that makes people the most scared about a bola is the potential for transmission via respiratory droplets, which we've talked about before, but again is coughing, sneezing, things like that h yeah, that's talkers, close talkers. So yeah, so that's how you get infected with.

00:13:30
Speaker 6: A Bola virus bodily fluids.

00:13:32
Speaker 4: Bodily fluids, and direct contact. So healthcare workers are especially at risk of exposure because they're dealing with bodily fluids of people who are infected. Now, it's still not what I would call one thousand percent certain what the animal reservoir for a Bola is, but realistically it's bats. Yeah. Yeah, So more than a few studies have found a Bola virus at least RNA, naturally in bat populations and without any evidence of infection. So the thing is that we know that ebola viruses can infect other primates and other animals. They've been found in antelopes and things like that, but they tend to cause similar symptoms and massive mortality in a lot of those animals, whereas in bats we don't see that. So that is the evidence that the bats might be their quote unquote natural host, because if viruses circulate for a long time in a host, they tend to evolve to be less virulent in that host, whereas when they jump to new hosts, it's unpredictable what the virulence is going to be. But one thing that we do know for sure, and I think that this is going to be the transition to you talking about this, is that outbreaks tend to occur almost exclusively due to spill over events. So the question is how did we get here? What's up with a bola? And how did it start to be this virus that spills over and kills a bunch of people.

00:14:59
Speaker 6: That is question I am going to try to answer. Our story begins not in Africa, as you might expect, but rather in Germany. Oh okay, yeah, yeah, in a sleepy, picturesque little town in nineteen sixty seven, several people arrived at the hospital with symptoms of extreme headache, internal clotting, fevers, and most severely.

00:15:43
Speaker 5: Terminal shock.

00:15:44
Speaker 4: Oo.

00:15:45
Speaker 6: What did these people have in common? Well, they were all workers at a lab which produced polio vaccine from the kidney cells of African green monkeys. In total, thirty one people were infected with this infectious agent and seven of those died.

00:16:04
Speaker 4: Wow.

00:16:05
Speaker 6: During the outbreak, no one knew exactly what was causing the disease, but the appearance of similar symptoms and death rates in the green monkey populations at the lab pointed towards an infectious agent.

00:16:18
Speaker 2: Right.

00:16:19
Speaker 6: Eventually, researchers isolated the teeny tiny little nugget of RNA that was causing this terrifying disease and named it after the outbreak's location, Marburg.

00:16:30
Speaker 4: So now we don't have to do an episode on Marburg. How disappointing.

00:16:35
Speaker 6: I mean it could still be a future episode. Yeah, but this episode is not about Marburg.

00:16:40
Speaker 4: No, it's not.

00:16:41
Speaker 5: It's about Ebola. Yep. So why do I talk about Marburg?

00:16:44
Speaker 4: Great question?

00:16:46
Speaker 6: Well, to answer that, let's jump ahead to nineteen seventy six, nine years nine years after the Marburg outbreak in Germany. In mid September, a report came into Kinshasa, the capital of Zayer which is now known as the Democratic Republic of the Congo DRC, of a strange new illness causing bloody vomit, bloody diarrhea, bloodshot eyes, and ultimately death in dozens of people. The epicenter of this outbreak was a mission hospital in Yambuku. A few weeks before this report was issued, the first case appeared a local school headmaster named Mabolo Lokela. At first, the doctor's thought malaria and sent him home with some pills to deal with it. But he didn't get any better, not malaria. No, and saying he didn't get any better is.

00:17:39
Speaker 5: A bit of an understatement.

00:17:40
Speaker 6: He died, yeah, about a week after he left the hospital. He died in pain, confused, and bleeding from multiple orifices. His body was tended to and buried according to local customs, which include washing the body, clothing it, clipping fingernails, touch it, and kissing it during funeral proceedings.

00:18:02
Speaker 5: Yeah, yeah, yeah.

00:18:05
Speaker 6: And since as we know, ebola is spread through close personal contact, and it should come as no surprise to you that twenty one of his close friends and family members became infected during this funeral.

00:18:18
Speaker 4: And that's when your sort of most infectious is at the end of the course.

00:18:22
Speaker 6: But they had no idea, no idea, and so from there it erupted, prompting the panicked reports for help. International help did come in the form of epidemiologists, virologists, and physicians. They went to work mapping out victims and tracing contacts. One unusual pattern emerged first. The hardest hit group was women between the ages of twenty and thirty. Why do you think that these were the people most likely to suffer from ebola and have the highest death rates.

00:18:57
Speaker 4: Were they the healthcare workers? Were they nurses? No? Were they the ones preparing the bodies? Who were they?

00:19:05
Speaker 6: Females twenty to thirty tended to be the ones who were either pregnant or recently pregnant. Oh right. The one of the groups at highest risk or highest impact are those who are pregnant or recently given birth.

00:19:20
Speaker 4: Is that because their immune systems are depressed?

00:19:22
Speaker 5: I think that's one of the reasons.

00:19:24
Speaker 6: The other reason is that it turns out that this clinic, this hospital was used a lot for prenatal care. Oh no, And the nurses and nuns who were working at the hospital tended to reuse moodles contamination.

00:19:41
Speaker 4: That's so sad, right.

00:19:43
Speaker 6: So, yeah, the epidemiologists there were pretty confident that they were tracking an outbreak of an infectious disease, but many questions remained. First, what was the pathogen? Second, how is it being transmitted? And third where had it come from?

00:19:58
Speaker 4: Yeah? All good questions, right, essential in the answers.

00:20:05
Speaker 6: So to answer the first question, which is what was this, they sent blood samples from infected people to the CDC to try to isolate whatever pathogen might be in there. The earliest theory, which is that the cases were yellow fever, was quickly rejected because of the extremely high mortality rate and the different yet equally or even more terrifying symptoms of the illness next Marburg. Even though only a handful of people became sick during the Marbury outbreak, it made huge news and kind of woke up a generation of virologists, epidemiologists, physicians, and so on.

00:20:43
Speaker 5: So when these.

00:20:43
Speaker 6: Healthcare professionals saw what was happening in Zayir mirrored what had happened in Marburg, they figured it could be a similar, if not the same, disease. But let's look past the conjecture to some cold hard facts. Yes I'm talking microscope. Oh yes, the scope. The virus in the sample received by the CDC looked very similar to Marburg. It was thin and filamentous. Yeah, so similar, So similar in fact, that later analysis would put them in the same family of viruses as we've heard, the philoviridae. But this new virus wasn't quite the same as Marburg. It needed its own name, and for this part, the healthcare workers in Sayir basically walked outside the clinic closed their eyes, twirled around a few times and pointed, and their fingers ended up pointing towards the Ebola River.

00:21:43
Speaker 4: Isn't it the case that they're not supposed to do that anymore? Name diseases after the place that they were discovered because it puts a lot of stigma on them.

00:21:51
Speaker 6: Very true.

00:21:52
Speaker 5: Yeah, it hasn't really stopped the trend in a.

00:21:54
Speaker 4: Bowler, No, not at all, Like every different species is named after where it was found. Come on, guys, get it together.

00:22:02
Speaker 6: Okay, So at this point the scientists can put a name to the face of this virus, but there are still unanswered questions. How was it being transmitted? Could it be vector borne? Researchers checked bedbugs, mosquitoes, biting flies, but found no trace of infection. The numbers have infected, though terrifying, seemed too low for it to be airborne. That left close physical contact and exposure through infected bodily fluids. Still, the last question remained, where did this disease come from? Seriously, and that is actually a question that researchers are still struggling to answer. It's probably bass, as we've heard, but to date, no live virus has been isolated from a bat.

00:22:50
Speaker 5: But why do we think bats?

00:22:52
Speaker 6: Why are bats the top contender? Well, first of all, bats are incredibly species diverse.

00:22:58
Speaker 4: Yeah they are.

00:23:00
Speaker 6: Did you know that one in every four mammalian species is a bat?

00:23:04
Speaker 4: No, one in every I knew there was a lot of them, but oh my god.

00:23:09
Speaker 6: Yeah, there are over eleven hundred species of bats.

00:23:13
Speaker 4: So you go, like cat, dog, monkey, bat, Yes, and then like armadillo, what are some other mammals? Dolphin, whale, bat, You do it.

00:23:26
Speaker 6: That's exactly how you do it.

00:23:28
Speaker 4: Wow, that was embarrassing for me.

00:23:31
Speaker 5: What are some other mammals besides.

00:23:33
Speaker 4: Oh, oh, here we go, Here we go, rat, shrew, vole, bat.

00:23:38
Speaker 5: There you go. Yeah.

00:23:43
Speaker 6: And so if each species of bat carries an equal viral diversity or viral load, that's a lot of bat viruses.

00:23:51
Speaker 4: Oh yeah.

00:23:52
Speaker 6: And to add to that is the fact that most bat species are highly social and live in large groups.

00:24:00
Speaker 5: Does that remind you of anything?

00:24:01
Speaker 6: Yep, Like what happened when humans start living in large groups.

00:24:06
Speaker 4: I was gonna say ants, but.

00:24:12
Speaker 6: Sorry on your disease ecolleges.

00:24:17
Speaker 4: Humans when they gathered in large groups, like during the agricultural revolution, that's when we saw a huge amount of infection, dilergence.

00:24:25
Speaker 5: Disease, tad, et cetera.

00:24:27
Speaker 6: Yeah. Also, many species of that tend to have lifestyles or natural histories sure that bring them into close contact with humans, like roosting in buildings or in fragmented forests.

00:24:39
Speaker 4: And that's because we tend to destroy their natural habitat.

00:24:43
Speaker 5: I'll get at that later.

00:24:44
Speaker 4: Okay, great.

00:24:46
Speaker 6: Finally, bats can fly, Yep. They can travel great distances, particularly during migrations, up to eight hundred miles, And so that allows for the exchange not only of pathogens within and among bat species, but also with humans and wildlife.

00:25:03
Speaker 4: Yeah, big time.

00:25:04
Speaker 6: Many Ebola outbreaks actually have been preceded by large scale die offs of primates such as chimpanzees and gorillas. In fact, one thing I read suggested that a third of the global gorilla population has been destroyed by Ebola outbreak Ebola specific one third.

00:25:23
Speaker 5: Oh my god, that's so sad, it's insane. Wow.

00:25:28
Speaker 6: Yeah, And so I mean, overall, the lack of information that we have about the natural history or the ecology of this virus is really pretty worrisome. Yeah, because it then becomes harder to predict or prevent outbreaks from happening, definitely, And it also means that we don't know how risk will change in the future as many countries in Africa continue to become more urbanized and the climate continues to change. So all of this, all of this this I thought about bats and the natural reservoir and primate and how they play a role. All that was in the background of these researchers' minds who were present at the Zaire outbreak in nineteen seventy six. Wow, what was actually occupying them was the extremely high death rate three hundred and eighteen cases with two hundred and eighty deaths. Oh my god, a mortality rate of almost ninety percent. That's it's really hard to imagine. All within the span of a couple of months, and eerily reports of another outbreak were coming in from southern Sudan around the same time. Oh no, Since there were already researchers on the Ganden Zayre, a few of them figured they'd head to Sudan to assess the situation, And once there they found a village already well within the throes of a similar outbreak.

00:26:47
Speaker 5: What were the chances, oh were they? I have no idea infinitesimal.

00:26:54
Speaker 6: Yeah, these outbreaks had to be related though, right right, I would assume so, But there was no way that an infected individual could travel with a long distance between the two impacted areas without a dying or b spreading infection to villages along the way in between.

00:27:12
Speaker 4: Yeah.

00:27:12
Speaker 6: Samples were collected and shipped off to the CDC from the Sudan outbreak, who confirmed that, yes, this is ebolavirus, but a completely different strain. Wow, an apparently less lethal strain with only and only here is relative. Yeah, one hundred and fifty dying out of two hundred and eighty four cases, which is about fifty three percent.

00:27:34
Speaker 4: Yeah.

00:27:35
Speaker 6: So in nineteen seventy six, two outbreaks of abola occur almost simultaneously, crazy miles apart, alerting the world to this disease for the first time.

00:27:45
Speaker 4: And two completely different strains. Like, what are the chances that would happen at the same time?

00:27:51
Speaker 6: It's really wow.

00:27:53
Speaker 5: Yeah, it's very interesting.

00:27:55
Speaker 4: Yeah.

00:27:56
Speaker 6: After making its big debut in the seventies, Ebola goes underground for a while, with a few individual cases popping up here and there throughout the eighties and nineties, and one resurgence of the Sudan strain in the same location as the seventy six outbreak. It's not really until the mid nineties that we see outbreaks of similar size occurring, And I'll return to those later, but first I want to talk about one of the most infamousy Bola outbreaks, one with a human death toll of zero what. Oh yeah, Hazelton Laboratories, Reston, Virginia, Virginia, United States, by the.

00:28:37
Speaker 5: Way, nineteen eighty nine.

00:28:39
Speaker 6: Yeah. If you've read the hot Zone, as I suspect many of you, have to.

00:28:45
Speaker 4: Be honest, I haven't. But don't hate me for it.

00:28:48
Speaker 5: I don't hate you for it.

00:28:51
Speaker 6: This story may sound familiar, though, with a little less of the blood and gore that Richard Preston, let's face it, likes to overdo.

00:29:01
Speaker 5: In these labs.

00:29:02
Speaker 6: Crab eating macaques, a type of monkey imported for research purposes, started to show signs of extreme illness. Bloodshot eyes, bloody vomit, you know, the drill, and then they started to die.

00:29:16
Speaker 4: Oh red flags right, yeah, poor babies, Yeah for sure.

00:29:22
Speaker 6: Samples of tissue from infected monkeys are sent to the US Medical Research Institute of Infectious.

00:29:27
Speaker 5: Diseases you samrid heard of.

00:29:31
Speaker 6: Yeah, that's a long title where initial tests indicate the presence of ebolavirus zayre strain, but so far no human had gotten sick, very unlike Ebola zayere.

00:29:43
Speaker 5: Yeah.

00:29:44
Speaker 6: Nevertheless, blood samples were taken from a bunch of workers who handled the monkeys, and six of them actually ended up serial converting. Basically, antibodies free Bola were detectable in their blood.

00:29:56
Speaker 4: But they weren't sick at all.

00:29:57
Speaker 5: No one was ill. No one was sick, So I'm like Ebola and me so.

00:30:02
Speaker 6: Closer examination revealed that this virus, the very similar to Ebola zayere, was actually yet another strain of the Ebola virus, apparently not harmful to humans. Wow, and also transmitted by air.

00:30:20
Speaker 5: The scariest part.

00:30:21
Speaker 4: Of it this is the thing that when I read it, I was like, Oh, now I understand why they were like, oh, we need to do a crap ton of research on Ebola because there is a strain that is transmitted by respiratory droplets. Because these monkeys and cages that were separated from each other all got sick. It's very scary and what would happen if one of these very severe strains like zayeir. Because it's an RNA virus that mutates so rapidly, just happens to mutate something that makes it possible to be transmitted this way.

00:30:56
Speaker 6: I mean, that is all these hypotheticals I know are what you know drives our anxiety and fear.

00:31:03
Speaker 4: This is why I don't sleep. I need a night I bought two night guards today for my teeth grinding. It's too much personal information. I live with anxiety.

00:31:16
Speaker 5: Sorry, sorry for laughing.

00:31:18
Speaker 4: It's really pretty funny.

00:31:21
Speaker 5: This is how I measure my anxiety.

00:31:23
Speaker 4: Yeah, my dog ate the last one. I'm sorry, getting off topic here, Okay.

00:31:31
Speaker 6: So back on track. So, in keeping with the geographical tradition of strain naming, this virus is called ebol Arrestin over three months, about a third of the monkeys who were at the facility died, and at the peak of the outbreak, two or three were dying each day.

00:31:53
Speaker 5: If you really know your.

00:31:55
Speaker 6: Primate natural history, you know that crab eating macaques aren't from Africa, which is the continent we most associate with ebola, but rather Southeast Asia. Yeah, dude, these monkeys had been imported from the Philippines, while the rest and outbreak was happening in a contained facility in Virginia. More monkeys were dying by the dozens in the wild in the Philippines and also in China, along.

00:32:22
Speaker 5: With some pigs. Oh yeah, this.

00:32:26
Speaker 6: Outbreak revealed a few frightening things about ebola. One is that different strains of the Ebola virus might be a lot more widespread than we previously thought.

00:32:37
Speaker 5: Another is that.

00:32:37
Speaker 6: Outbreaks could easily occur in places where the ebolavirus reservoir doesn't exist. If the rest and strain of abola had been harmful and transmittable by humans, basically, if it had behaved the way we expected it too, it could have been an enormous epidemic, if not pandemic. And in the US, which obviously got a lot more people interested in it now that it wasn't just some quote over their disease, but one that could happen over here, you know, typical typical response.

00:33:13
Speaker 4: That's still true today.

00:33:14
Speaker 6: I mean, it's basically the only time that any westernized country cares about any of these diseases.

00:33:21
Speaker 5: Is if it could actually happen to mostly wealthy white people.

00:33:25
Speaker 6: Right anyway, anyway, After the rest and outbreak in nineteen eighty nine, Ebola went relatively quiet for another couple of years until nineteen ninety four through nineteen ninety six, when Ebola Zayer caused outbreaks in Gabon and the DRC, with mortality rates ranging from sixty.

00:33:45
Speaker 5: To eighty one percent.

00:33:47
Speaker 6: God Again, scientists deployed to the impacted areas attempted to trace the outbreak to its natural origin, but were unable to. In one outbreak, several of the index cases were workers and minds inhabit it, also by bats. In another, it was traced to the consumption of a chimpanzee that had been found dead in the forest.

00:34:07
Speaker 4: It's not a good idea.

00:34:09
Speaker 6: Nop samples were taken from many species of animals, but still active infection was not found. Two thousand through twenty thirteen saw outbreaks in Uganda, Gabon, Republic of the Congo Sudan DRC, with the number of cases ranging from a few dozen to over four hundred, finally reaching nineteen seventy six numbers and mortality rates around fifty to sixty percent.

00:34:36
Speaker 4: Wow.

00:34:36
Speaker 6: These numbers, of course, would pale in comparison to what the world saw in twenty fourteen, but we'll get to that.

00:34:42
Speaker 4: In a bit. Yeah.

00:34:43
Speaker 6: First, though, let's chat about the evolutionary history of ebola. Okay, why has it taken so long to show itself?

00:34:52
Speaker 5: Or has it popped up.

00:34:54
Speaker 6: Many more times but we failed to recognize it.

00:34:57
Speaker 4: It's a really good question. Do you know the answer?

00:35:02
Speaker 5: No one does.

00:35:04
Speaker 4: If only we could answer these unanswerable questions on this podcast, we'd make millions, just kidding, we'd solve world problems. It's more important.

00:35:12
Speaker 6: I know where your mind first went, though, and I'm judging you. Okay, So anyway to try to answer this question though, viral palaeontologists, which how cool would it be to have that on your business card?

00:35:27
Speaker 4: Oh?

00:35:27
Speaker 6: My God traced the origin of the family of viruses that he both belongs to, the vy La vida.

00:35:35
Speaker 4: I want to I don't know which one it is.

00:35:37
Speaker 5: Whatever, they traced it back millions of years.

00:35:41
Speaker 6: Really, Apparently this family may have emerged as far back as fifteen to twenty three million years ago. What and then they continue.

00:35:51
Speaker 5: To evolve and diverge.

00:35:52
Speaker 6: Interesting, So these viruses aren't brand new, but maybe some of the strains are brand to humans. Anecdotal reports suggest that at least one of the doctors who tended to people with abola in the nineteen seventy six outbreak was immune to the disease, having recovered from a very similar severe illness six years prior. Interesting, but still reports of earlier ebola outbreaks are pretty sparse. Yeah, so why nineteen seventy six. In a word, urbanization. Urbanization means increased contact between humans and wildlife and a subsequent exchange of pathogens between the two. But before you break out your pitchforks and kill all the bats, seriously, don't do that. Bats are incredible and they also perform a.

00:36:45
Speaker 5: Lot of ecosystem functions.

00:36:47
Speaker 6: Know that humans really only have ourselves to blame.

00:36:51
Speaker 5: Yeah, as usual, urbanization.

00:36:54
Speaker 6: Is responsible for, I think it's safe to say, really the majority, if not all, of the zoonotic spillover events in the past one hundred years.

00:37:04
Speaker 4: Yeah. Well, plus on top of that, just on top of the fact that you're going to have more spillovers the more that you're encroaching on forest systems, you also then have humans, like we've talked about, in close contact, which allows for human to human transmission.

00:37:17
Speaker 6: I mean, it has to do with the difference between an outbreak and an epidemic, or an outbreak in a pandemic, or.

00:37:23
Speaker 4: A single case sure that you might never hear about so exactly.

00:37:28
Speaker 6: Yeah, Yeah, And urbanization plays a huge role in the twenty fourteen epidemic that left over twenty eight thousand people infected.

00:37:39
Speaker 4: Yeah.

00:37:40
Speaker 6: Until twenty fourteen, all of the Ebola outbreaks tended to be limited to Central Africa in rural villages close to forested areas, and the twenty fourteen epidemics started off that same way, with one important difference. It began in the West African country of Guinea, something that would delay its recognition as an outbreak of a bowld. The first person infected with ebola during this epidemic was a two year old named Emil, who lived in a rural Guineaan village. He picked up the virus in December twenty thirteen, probably when he and a group of children were playing near a hollow tree occupied by a colony of bats. Sadly, Emil died of his infection, and during the burial ceremony, several other family members and village members became infected. From there, the disease spread, eventually jumping beyond this index village, crossing borders and invading large urban areas where it spread like wildfire, infecting and killing thousands. But that is a story that I want you to tell, so please erin. Tell me about the biggest epidemic of ebola so far.

00:39:06
Speaker 4: I'll try so. Like you said in the we call it the twenty fourteen outbreak, But it started in twenty thirteen and it continued until well into twenty fifteen. Yes, in total, there were twenty eight thousand, six hundred and sixteen cases according to WHO, and eleven thousand, three hundred and ten deaths. Wow.

00:39:30
Speaker 5: Yeah, that's so crazy.

00:39:31
Speaker 4: Yeah. So one thing that was really important in this outbreak was being able to diagnose cases rapidly on the ground and trace those cases based on their contacts. So to tell you more about that, let's go back to Lauren Crowley, who was there helping to do exactly that.

00:39:52
Speaker 1: It was. Back in November twenty fourteen, Public Health England, which was where I worked at the time, decided they were going to set up three diagnostic labs in Sierra Leone and I volunteered to be a member of Team one. So we set up and ran the Abola Diagnostic Labs in Port Loco in Sierra Leone and we provided a bola and malaria diagnostics for the area. So we served at a bola treatment center and the surrounding towns and villages. And so I was there for five weeks and we ran the diagnostics lab there and I came home on Christmas Day and then I actually went out again. I was deployed six months later in June twenty fifteen to Guinea to provide reveal time and sequencing of newerbola cases using nano four sequencing technology. And this was in collaboration with the European Mobile Lab, and the frequencing lab was set up adjacent to an abola treatment center in like the outskirts of a town called Koir in Guinea, and there we were using RNA extractions from new cases of a bola that were sent from all over Guinea to be sequenced, and then we used these sequences to look at transmission tracing in epdeineological investigations. Yeah, so we were trying to look at genetic similarity to try and classifications that might be part of the same transmission chain based on their genome sequences for a disease like a Bola. In order to effectively tackle an OUTRK, you quickly need to be able to establish very fast diagnostics and transmission tracing and then hopefully chain interception by the epteologists. And this, as we've looked at with the Bola, you were actually able maybe to be able to use genetic information to help with this.

00:41:36
Speaker 4: So that's pretty incredible that they were able to do this rapid diagnostic testing both in PCR but also with sequencing. So one thing that's important is that this left over ten thousand survivors of the disease, and we've never seen numbers of survivors of Ebola that are that high, So that's something that countries and the world are sort of grappling with at this point, is how to best serve these survivors of the disease.

00:42:08
Speaker 6: And here to tell us about that are a couple of experts, Sarah and Nell, whom you've heard from earlier, and they're going to talk about their awesome project, Ebola Survivor COREP. This project was originally submitted as part of a Gates Grand Challenge. It wasn't funded, but it did receive a lot of encouragement, so they took it upon themselves to raise funding for this organization. Let's let them share their experience.

00:42:36
Speaker 3: And there was an opportunity to volunteer with Partners in Health or Medicine san Frontier. But once you started going to the volunteer application, first they would say, yeah, how we want anthropologists, but then there's no place to actually check off the box. I was like, this is what I've been waiting for, this is what my training is about. But there wasn't a chance to get involved. So instead sort of convene the helped convene on the lab the University of Wisconsin in this disease ecology group, the lab together to come up with a proposal to respond to a USA Gates Grand Challenge to sort of encourage treatment seeking, and thought it would be really useful and empowering and obvious to support a bull at survivors sort of re entry into society and into communities and take advantage of this existing immunity from renewed infection and put them to work as first responders and sort of train them up to do infection prevention control and to sort of look them into the surveillance teams. It became really consuming, but also.

00:43:44
Speaker 7: Really really rewarding because we were able to do something to respond within our skill sets, our and what space there was for us.

00:43:54
Speaker 3: So we raised fifteen thousand dollars and during that campaign we found that well and now was able to transform the Eboler Survivor Core concept into a project on the ground and we'll let Nell take over from there.

00:44:12
Speaker 2: So I went in twenty fifteen inside of the project. So the evil outbreak at that time was sort of winding down. It was still happening, but it was winding down. And when I got there, our first goal was to identify, i mean like talk with all the stakeholders and identify people of survivors to work with. And so we went onto the field and we're working in this really remote area of northern Syrira Leone in Quinnadugu District, and it had sort of like got the outbreak later and didn't have quite as intense of an outbreak, but that actually worked well for us due to the scale of our project, so we could actually like manage the relatively smaller number of survivors. So I went there and met with the survivors and with the chief and everything, and started doing infection prevention control training with them and like a social mobilization training and got them basically set up to work as initially as sharing the infection prevention control information, but also as sort of like a resource, like a health educational resource for the community. So they're going out and they're talking to different people in their community in the local language and like explaining different health issues, mostly infectious disease stuff on a level that people can really understand, and like trying to make that information more accessible.

00:45:35
Speaker 4: Yeah, there has been a lot of critique of the response to this outbreak. There's actually a really great article that I'm not going to wait to cite because I know a lot of people don't listen to our citations. That's okay, Yeah, it's a fine, But I want to tell you about this article because it's great. It was called Critiquing the Response to the Abolat Outbreak, and you can find it. It was by Vera Scott at all in twenty sixteen Google. So the World Health Organization response to this outbreak was very similar to the response that they've had to all of the other outbreaks. It's what we would probably call a classic outbreak control response, which basically means a whole bunch of technical and medical professionals swoop in and they isolate people and they try to break the chain of infection. And the thing is, in past outbreaks this has been fairly effective in blocking further transmission. We never saw outbreaks that reached even the thousands before this. What was the biggest one in two thousand and one or two thousand and two, fifty four hundred and fifty not that that's not a ton of people, and that really sucks, but it's nothing like what we saw in twenty fourteen. So this outbreak clearly spiraled out of control. There are a lot of reasons for this. It's not like there's one single answer as sure why this happened. For one thing, when people swoop in and start telling everyone on the ground what to do, there's often resistance and in many cases in these areas. So the three countries that were most affected by this outbreak were Guinea, which is where it started, Sierra Leone, which is where it spread next, and Liberia right which is where it went after that. So in many cases in these countries, there's not a lot of trust of the government or authorities, and especially not foreign authorities that are just coming in and telling people what to do, which is exactly.

00:47:33
Speaker 6: What happened historical, right, But that's like that's because of historical reasons, exact colonization.

00:47:38
Speaker 4: Right, yeah. Yeah. On top of that, there's not any good treatment options.

00:47:45
Speaker 6: For a bola, right, it's just maintained.

00:47:48
Speaker 5: Yeah.

00:47:48
Speaker 4: So if you bring your family member to the hospital and they end up dying, and then you bring your next family member to the hospital and they end up dying, why would you want to keep bringing your family members to the hospital. They're just going to die. So during this outbreak, and especially towards the beginning, hospitals honestly weren't even trying to treat, and there's not any evidence that hospitalization made a difference in terms of mortality rates. So they set up a bunch of these ebolavirus disease treatment centers, but they were basically holding cells like quarantine. Yes, they were isolate isolation facilities that were just trying to break the cycle of transmission, which from a public health perspective, I understand you have to try and break the cycle of transmission, But imagine that you're a mother or a father or a child of a person who's infected, why would you bring your family member to a place where they're not going to be able to touch anyone or see anyone, just to die. Like, there's not a lot of incentive to cooperate with these people who are just taking your family members away, not doing anything to help them, and just letting them die. Plus, healthcare systems in these three countries were woefully understaffed and underfunded and just overwhelmed by the sheer numbers that were coming in in these healthcare facilities. They also didn't always have protocols in place, or they didn't have enough equipment to even follow protocols, So you had a lot of what we call nosocomial infection, which just means hospital acquired infection. So both healthcare workers and maybe people who were in the hospital for other illnesses ended up getting infected with ebola because of practices that were happening in these hospitals. So there were a lot of sort of issues that led to this epidemic being as big as it was. Distrust in the authorities people swooping in and just sort of not being cognizant of local customs in the areas that they were dealing with. One of the biggest things that directly led to a large number of cases were local burial practices. So you mentioned this before, but local burial practices in these areas, because of religious reasons, involved directly touching or washing the body. And it's estimated that at least twenty percent of new abola infections occurred during the burials of people who died from a Bola virus. Yeah, because, like we mentioned before, at the time of death from a Bola, your viremia, the number of viruses in your body is really really high, so you're really infectious. And at first I didn't see this explicitly written anywhere, but from what I gathered reading various sources, the who was requiring that all bodies of people who died from a Bola be cremated, which is very much against the normal practices in these areas.

00:50:56
Speaker 6: Right, So you imagine all of these people coming in and being like, uh huh, don't do it the way that you've been doing it for generations, right, don't do it according to your religion, right to your traditions.

00:51:08
Speaker 5: Do it my way.

00:51:09
Speaker 6: Yeah, how is that gonna be about well received?

00:51:11
Speaker 4: Like we're going to take your family member away from you, not let you give them a burial that is important for their like after life the rest. You know. It's it's extremely problematic, and so it took them a long time. They eventually got together a safe burial protocol and they sort of got their ish together in figuring out a way to sort of work within what is normal for that region and still prevent further infection. But yeah, I mean it's just another example of sort of Western countries coming in or people from Western countries coming in and not.

00:51:52
Speaker 6: Being sensitive to cultural practices.

00:51:55
Speaker 4: And because of that making things a lot worse.

00:51:58
Speaker 6: Right and being like, how don't you know that this is not what you're supposed to do.

00:52:01
Speaker 4: Right, So a lot of people were not bringing their family members into the hospitals or once they died, not bringing them in to because they didn't want them to be cremated.

00:52:13
Speaker 8: Yeah.

00:52:13
Speaker 4: On top of that, the infrastructure there, like we said, wasn't very good, So a lot of people couldn't survive the trip from maybe their village to the hospitals because rote infrastructure, roads, vehicles weren't available to them to even transport their family member to begin with. Right, So there was a lot of things working against the who before they even got there, but they didn't do a great job. I think the problem was that they sort of expected this to be like every other outbreak they had dealt with before, and it wasn't. The outbreak definitely started in December of twenty thirteen. Who was notified about outbreak status I believe in March of twenty fourteen, And it wasn't until August of that year that they said, Hey, this is a really huge public health problem.

00:53:04
Speaker 5: Are you freaking kidding me?

00:53:06
Speaker 4: August? I think it was August eighth of twenty fourteen that they were like, this is a problem.

00:53:10
Speaker 6: How many thousands of people had died?

00:53:12
Speaker 5: Are you kidding?

00:53:13
Speaker 4: Yeah? I mean it definitely got worse from there, is the thing. So yeah.

00:53:20
Speaker 5: Yeah.

00:53:21
Speaker 4: So one thing that I'll say that's important to keep in mind is that there's a lot of reasons that these countries weren't able to deal with this these epidemics on their own that have to do with former colonization and with the World Health Organization and other international organizations sort of constantly being in these countries taking over, if that makes sense, So.

00:53:51
Speaker 6: Like not actually building up infrastructure the public health, but just coming in when needed exactly.

00:53:58
Speaker 4: So the international public health community has a focus on like disease preparedness, like we have to prepare for the next outbreak, which a lot of people have implicated this in weakening the health systems for day to day life in these areas where if you're only focused on you know what's coming next, then you're not necessarily building general health systems. You're siphoning off these resources that could be used. So then when an outbreak actually does happen, you don't have the resources in place to be able to deal with it.

00:54:33
Speaker 3: Right.

00:54:34
Speaker 4: So yeah, it's it's a pretty depressing thing. And I don't know, I hope that that there's a lot that will be done now that we've sort of recognized this to be able to make it better in the future, just not only for a Bola but.

00:54:52
Speaker 6: Overall, yeah, for overall health.

00:54:54
Speaker 4: But jumping back to a Bola, one thing that I think is really interesting is that initially both after this the nineteen seventy six outbreak that was the first outbreak, but especially after the was it eighty nine outbreak in Virginia in monkeys, Yes, So because of that outbreak specifically, there was a lot of interest in ebola, because of its potential as a bioterrorism agent.

00:55:17
Speaker 5: Uh huh. Yeah.

00:55:18
Speaker 4: So for a while there was a ton of research that was being done about ebola, not because it was actually causing small outbreaks every year and killing people, but because Western countries were afraid of bioterrorism. Course, because they knew that they and other countries were working on ebola, like engineering it to be an agent of bioterror mm hm. So there was a ton of research being done into vaccine development well before this twenty fourteen outbreak, and at some point, I don't know exactly when, but it seems like the money kind of dried up for vaccine development. So at the point of this most recent outbreak, there were a lot of vaccines that had been tested and been shown to be effective in monkeys and non human primates. That's why in twenty fifteen there was actually a vaccine tested and deployed for the first time in humans. And the good news is it was shown to be extremely effective. One hundred percent of people that were given this vaccine did not develop a bola So it's awesome. Yeah, it's really exciting. There's definitely still a lot of work to be done. There's a lot of questions as to how long lasting this immunity is. So there's a question as to whether this vaccine could be effective in preventing illness overall, Like whether this should be a vaccine that sort of like the chicken pox vaccine now where everybody gets it so that we just sort of try and not have chicken pox be a thing, or if this is just a vaccine that could be used in the case of future outbreaks where you do something like they did in twenty fifteen called ring vaccination, where you vaccinate all the contacts of cases and all the contacts of those contacts. But in that case, this has shown to be very effective, which is cool and exciting.

00:57:03
Speaker 5: It's very cool.

00:57:04
Speaker 6: So instead of asking how scared we should be about ebola, what have we learned from the twenty fourteen epidemic.

00:57:13
Speaker 4: Well, let's actually let Sarah answer that, because I think she had some really nice things to say.

00:57:19
Speaker 3: I think we've learned a lot, but I think it's the same lesson we've always been learning when there's an infectious disease outbreak of any kind of scale, and that's whenever there's an event or an outbreak. One of the first things that a country will do is set up their national task force and then deploy people to do active surveillance and risk communication. And there's this assumption that risk communication is obvious, that messages are already developed, and all you do is bless them, level the radio or drive around in the white pickup with a speaker on the back and blast them through the local language and people will just automatically accept the information and change behavior. It's becoming clearer and clearer that that approach, the very top down vertical approach, isn't effective. And what ended up being the most effective for stopping the outbreak was communities actually taking it upon themselves to change their behavior in the midst of not necessarily going with the flow of what the outside people who were coming in and telling people what to do and wanted them to do. So it took a long time for people to for sort of the messaging and the behavior change to harmonize, and it required a lot more than just blasting messages. Acquired a lot of community meetings and one on one personal stuff and getting the you know, the survivor stories out and the affected family stories out and people realizing the bull was real and even if it was a Christian of the neighbor. It's still could kill regardless of where it's coming from. And there's a huge among us focus back on Africa now and sort of reinforcing some of the negative stereotypes about the Dark continent as being like the heart of disease emergence. So we're neglecting Asia, I think in this process. So I think we need to not lose sight of the fact that emerging disease can come from any part of the world, and infections like antimocrobo resistance can be found in rich countries too, So I think that it's I think we need to figure out how to be laser focused and broad at the same time. And then we also need to figure out how to do better engagement with communities and people on the ground and sort of take advantage of all the local experts that exist in all these countries at their universities or maybe even in the diaspora who can be tapped to join that rapid response team. So there's lessons learned, and I think we are seeing some changes actually.

00:59:52
Speaker 6: So while the twenty fourteen epidemic was very scary, it seems like we learned a lot of lessons from it.

01:00:00
Speaker 4: Yeah, and hopefully things are going to change for the better moving forward.

01:00:06
Speaker 5: Sources time.

01:00:08
Speaker 8: Yeah, So, because we had such an action packed episode this week, we are going to instead of going into detail on our sources, just direct.

01:00:21
Speaker 6: You toward our Facebook and podbeam website where we will list our sources for this episode.

01:00:27
Speaker 4: You can find them all there. Check check check it out. Thank you again to Nel and Sarah and Lauren for sharing your stories with us.

01:00:45
Speaker 5: Oh my gosh, they're amazing.

01:00:47
Speaker 4: Yeah, and thank you for what you do like you guys are incredible.

01:00:50
Speaker 5: Yeah.

01:00:51
Speaker 6: And thanks to Bloodmobile for providing the music as always.

01:00:55
Speaker 4: And get real pumped because next week is gonna be it really is. Get your crying hat on. Is there a hat you wear when you cry? No?

01:01:07
Speaker 6: I just wear my crying blanket and sweatpants.

01:01:10
Speaker 4: Okay, So get your crying sweatpants on. You're gonna need it for next week.

01:01:14
Speaker 6: It's true, It's very true.

01:01:16
Speaker 5: And you know what, wash your hands

01:01:19
Speaker 4: You filthy animals, just in case