‘This will happen again’: learning from the Ebola outbreak

Some scientists are cautiously predicting a turning point in the Ebola outbreak and attention is being focused on the lessons that can be learnt.

Health workers load the body of a dead woman suspected of dying from Ebola, onto the back of a truck in  Jene-Wonde, Liberia. A schoolteacher brought his sick daughter from Liberia’s capital to this small town of 300 people. Soon he was dead along with his entire family, all buried in the forest nearby.  Wade Williams / AP Photo
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Some scientists are cautiously predicting a turning point in the Ebola outbreak and attention is being focused on the lessons that can be learnt.

But while new knowledge about prevention and response is always valuable, nothing will actually prevent future outbreaks, argues infectious disease expert Dr Daniel Malamud.

“This will happen again, there is no question,” says Dr Malamud, a professor of medicine at the New York University School of Medicine.

“But if next year there was another epidemic, another place, another organism, another disease, I think we would respond faster.”

It is a theme Dr Malamud addressed this week in a talk at New York University Abu Dhabi.

Plagues: from Bubonic to Ebola was an examination of the lessons needed to help the world better prepare for what he says are inevitable future outbreaks.

“Ebola is not the last epidemic we are going to have,” he says. “There will be others, there have been others in the past.”

Even as the death toll nears 5,000 and new countries continue to report cases, some experts claim there is finally light at the end of the tunnel.

“We know now how bad it is and we know the risks, and the issues that we are having,” says Dr Malamud.

In his talk, he examined the similarities in human behaviour between this Ebola outbreak and previous disease epidemics.

“Early in the HIV epidemic, HIV was a death sentence and it also had stigma,” he says. “That’s exactly what is happening with Ebola now.

“The one nurse who had no contact with it in Maine, for example, she is getting death notices.

“People think that anybody who comes from one of the three countries should not be allowed in and everybody should be quarantined and as it’s pointed out, when this is over there’s going to be a lot more people this year that die from flu than die from Ebola in the US.

“Somewhere between 10 and 50,000 will die from flu this year. Yet people are very worried. It’s mass hysteria.”

Dr Malamud also draws on the writings of the 18th century English economist and demographer Thomas Robert Malthus, whose opinions on population growth and mass death, he says, are still relevant today.

In An Essay on the Principle of Population, Malthus examined imbalances between population growth and resource growth, and concluded that the world’s population would be kept in check by famine and plagues.

“He recognised that in order to control the planet there are going to be incidents of mass death, either by war or disease, because there is more people than the planet can support,” Dr Malamud says.

In Guinea, Liberia and Sierra Leone, the first countries to be hit by Ebola: “There’s data now to explain what happened in those three countries based on deforestation and very high population birth rate.

“Turns out that the primary culprit is a particular bat that used to live in trees. The trees were cut down and bats are very social creatures and there’s thousands of them in caves and in foraging they found thousands of people who they could bite and it was transferred form the saliva of the bat to a young woman in Guinea.

“A concentrated population of individuals and a high concentration of the species that is spreading the disease – this is exactly what Malthus predicted.”

Dr Malamud is one of a small number of scientists working to produce new technologies that should change the way with which Ebola is dealt in the future – a rapid testing kit.

His work is already being used to detect HIV and malaria, two of his main areas of interest, and he is now adapting it to detect Ebola in less than 20 minutes.

Tests can take hours or even days depending on the technology and expertise, with more delays caused by the fact that the only laboratories capable of doing them are often thousands of miles away.

Dr Malamud has already ordered samples of the relevant reagent – a substance added to something to produce a chemical reaction.

His reagents are being delivered by Biodefence and Emerging Infections Research Resources Repository and are already waiting in his New York laboratory.

“If everything goes well, which doesn’t always happen, we could have it as a laboratory test in six months.”

With the knowledge that outbreaks like this will happen again, Dr Malamud says it is important to use any technologies available to help minimise the destruction.

“The technology is such that it can be converted from one virus of bacteria to another fairly rapidly. The actual experiment, when we have all the reagents, it will only take two weeks.

“But you can’t do a test for just two weeks, do five of them and say you have finished. You have to do it in different places with different samples.”

Writing in The Guardian newspaper last month Dr Jeremy Farrar, director of the Wellcome Trust, said several recent developments with Ebola indicated that the world had reached “the end of the beginning”.

Attention from the “rich world”, progress in the search for treatments, and vaccine development changing up a gear were three signals that offered hope,” Dr Farrar wrote.

“Epidemics do tend to burn out,” says Dr Malamud. “The 1918 flu which killed 50 million people, killed off the susceptible people.

“There are people exposed to Ebola now that do not come down with it. And we are pretty sure once you have it you can’t get it again.

“It kills off the vulnerable first. In general, 50 per cent of people that were infected in previous Ebola outbreaks survived. There was something different about them.

“Maybe we wipe out a large percentage of the population but the ones that survive are immune either because of the behaviour, their physiology, their immunology. I think that’s when an epidemic dies out.”

But while the number of cases in some west African countries has declined, others, especially Sierra Leone, continue to have rising numbers.

International agencies such as the World Health Organisation came under some fire in the early months of the outbreak for not acting quickly enough, but opinions seem to be changing.

Work to produce new vaccines has more momentum than ever, with trials already under way and initial results expected to be released as early as next month.

Introducing new methods of testing and vaccine for something like Ebola is not as easy as it sounds. Between 1976 and 2012 there was an estimated 1,600 deaths linked to Ebola and it has not been a priority for scientists or international aid agencies.

The small company that ended up saving the lives of a handful of American missionaries who became infected with the virus only had a dozen doses of their experimental medicine and authorities could not obtain them quickly enough.

This week volunteers lined up at the University Hospital of Geneva to test one of two experimental vaccines on which all hopes are pinned.

Swiss regulators agreed to allow more than 110 people to take part, including some healthcare professionals who will go to West Africa. They will be fighting the epidemic, but also acting as human guineapigs.

VSV-ZEBOV, developed by the Public Health Agency of Canada, is one of two candidate vaccines that the WHO regards as promising enough to be “high priority”.

The second, AD3-ZEBOV is made by pharmaceutical company GlaxoSmithKline and uses a chimpanzee-derived virus into which an Ebola virus gene is inserted.

The Canadian government has already donated 800 vials of VSV-ZEBOV to WHO, which, once phase 1 trials are complete, should provide up to 2,000 vaccine doses.

Phase 2, to take place in affected countries, is expected to begin imminently, with large-scale vaccinations next year.

Donations have also poured in to help expedite the testing with the Wellcome Trust alone donating US$5 million (Dh18.3m).

Even if the virus is on its way out, Dr Malamud insists that anything learnt now will still be hugely beneficial.

“We will have at least two things that will benefit us in the future. If they find a vaccine or a good drug, even if this thing dies off, we know how to make that vaccine or drug.

“I think that the vaccine and drug development starting now will continue, which means there will be stockpile when the next Ebola outbreak comes.

“Secondly, we recognise they need to not ignore it early on. The WHO has all this data coming in and next time they see 10 or 20 cases, we will know.”