A week after sharp criticism met the U.S. military’s announcement that it planned to help Liberia combat its Ebola epidemic with a “deployable hospital” that has a mere 25 beds, U.S. President Barack Obama tomorrow plans to unveil dramatic new efforts to assist the West African countries besieged by the disease.
(Update: The White House on Tuesday morning released a fact sheet outlining its planned response. It will be coordinated by a U.S. Army general stationed at a new command center in Monrovia with an estimated 3000 troops. The Department of Defense has asked to "reprogram" $500 million toward the effort.)
Obama will be visiting the U.S. Centers for Disease Control and Prevention in Atlanta to discuss the U.S. response, At about the same time, a U.S. Senate hearing on Ebola will also take place with testimony from key public officials and Ebola survivor Ken Brantly.
Nicole Lurie, assistant secretary for preparedness and response at the U.S. Department of Health and Human Services (HHS), spoke with ScienceInsider on Friday and said she expected there would be “a substantial surge” in the U.S. government’s assistance. She particularly wants to see more attention paid to providing infected people with good care. “There’s a very, very wide variability in what’s being delivered as clinical care,” says Lurie, noting that case fatality rates differ dramatically in different locations. “We know that simple interventions are likely to save the most lives.”
Lurie stresses that in the absence of proper, basic care it becomes exceedingly difficult to determine whether any biomedical interventions actually work. ZMapp, an experimental cocktail of Ebola antibodies, has been given to seven people (two of whom died) and received enormous attention despite a complete absence of clinical data that suggests the treatment helped. A researcher familiar with blood tests from two of the five surviving ZMapp recipients who spoke with ScienceInsider, but asked not to be identified, said the drops in their levels of Ebola virus mirrored what was seen in monkey experiments with the antibody cocktail. But without being able to compare the clinical care they received—leaving aside the fact that there was no untreated control group—the data have little meaning.
Michael Callahan, a clinician at Massachusetts General Hospital in in Boston who consults with HHS about Ebola and has responded to past outbreaks, said that “many” people die from Ebola even though their natural immune responses are driving down levels of the virus. Callahan notes that they do not die from Ebolavirus itself, but succumb to what he refers to as “secondary events,” such as low levels of potassium, wasting from vomiting and diarrhea, and bacterial infections. And many clinics in West Africa do not have the simple devices that exist and can safely monitor blood electrolytes, organ dysfunction, and acid-base balances. “The point is critically important for the current outbreak,” says Callahan, who believes proper care will drive reported case fatality rates of as high as 75% “down into the low 40% range.”
What Lurie says will be a “substantial surge” in the U.S. government’s response likely will also include sending staff to train more people how to safely care for Ebola patients. One idea being considered is to teach people who survived an Ebola infection to help with caregiving as they presumably will be immune to a second infection. “It’s a very important question and something we’ve had lots of discussion about,” says Lurie, who said she spoke with a Liberian public health worker who is putting together a registry of survivors. “It’s very challenging for them to go back to their communities,” Lurie says. “I’m very intrigued by the idea of putting together a training program with people who are otherwise having a hard time.” She notes that jobs are also difficult to find in Liberia, and this could give otherwise underemployed people additional skills.
In a widely discussed op-ed The New York Times ran on 11 September, epidemiologist Michael Osterholm of the University of Minnesota, Twin Cities, argued that on top of more support, the global response to the Ebola epidemic required far better coordination. “Many countries are pledging medical resources, but donations will not result in an effective treatment system if no single group is responsible for coordinating them,” wrote Osterholm, who formerly was a bioterrorism adviser to HHS.
Osterholm suggested in the op-ed that the United Nations coordinate the response, but he told ScienceInsider he was just floating one idea and hoped the global community would find a leader who understood not just the medical issues, but supply chain, and tactical and logistical movement. “I don’t want the world’s best treatment doctor for Ebola,” Osterholm says. “You need to have someone in charge who can make command decisions and be the spokesperson to really say what’s needed and not needed.”
Osterholm says that at the moment, the U.S. government and every other well-meaning country or nongovernmental organization trying to help operates without a master battle plan. “We don’t need 50 sergeants in the room trying to run D-Day,” Osterholm says. “Right now, everything moves with the speed of water in a Minnesota winter. That’s exactly what we can’t do. We need to be able to move quickly and at the same time pace ourselves. This is a fast marathon. That’s been missing completely.”
*The Ebola Files: Given the current Ebola outbreak, unprecedented in terms of number of people killed and rapid geographic spread, Science and Science Translational Medicine have made a collection of research and news articles on the viral disease freely available to researchers and the general public.
*Update, 16 September, 11:45 a.m.: This item was updated to provide a link to the White House fact sheet.