DrJLNarvaez Dec 14, 2014 Dear Gentlemen,

The latest issue of the New England Journal of Medicine contains a relevant article on the subject of 'the need for better management of fluid and electrolytes in Ebola patients'. That article is the third of a series dealing with electrolyte imbalance. Its title is "Disorders of Fluids and Electrolytes: Lactic Acidosis", the reference is N Engl J Med 371:2309-2319 | December 11, 2014.

Sincerely,

Dr. Jose Luis Narvaez Moreno

email address: [email protected]

thomasdk Dec 15, 2014 @DrJLNarvaez

The list of signs and symptoms of lactic acidosis includes the following

• Nausea • Vomiting • Hyperventilation • Abdominal pain • Lethargy • Anxiety • Severe anemia • Hypotension • Irregular heart rate • Tachycardia

Kabuonji Dec 8, 2014 Ebola is deadly, but could be minimised through surveillance and with rigorous hygiene and sanitation campaign at the village level. This will be a huge benefit for prevention thus minimising current rate of infection and deaths.

thomasdk Dec 8, 2014 @Kabuonji Which Ebola virus type affect people in the current outbreak? CDC has not yet revealed this. Having this knowledge would enable the ability to identify the reservoir and appropriate treatment. Fruit bats are obvious candidates. But so are African pygmy tenrecs.

R.I.P. Mr. Marcel Kanyankore Rudasingwa. http://www.newtimes.co.rw/section/article/2014-11-18/183175/

gwenn Dec 13, 2014 @thomasdk @Kabuonji

What I read is the Zaire type thomasdk Dec 3, 2014 Bradycardia is a unique symptom of severe infections.

Like Typoid Fever and Ebola like diseases.

J Infect.1996 Nov;33(3):185-91. thomasdk Dec 3, 2014 If typhoid fever is a serious complication to Ebola, the way tuberculosis is to AIDS, a simple way to identify victims is to check people for bradycardia

nstorm Dec 19, 2014 @thomasdk It was recently shown that most Ebola-infected patients in Guinea presented with tachycardia and not bradycardia (Bah et al 2014 - NEJM). I don't think this would be a reliable indicator of infection. Similarly, earlier studies have indicated that low blood pressure was common during filovirus infection, however, in the current outbreak, hypertension seems to be prevalent among infected patients. Also, bleeding is very uncommon in patients affected in the current outbreak. The virus seems to be doing a lot of things differently this time around.

thomasdk Dec 19, 2014 @nstorm

Yes I agree -totally- that the current virus infection is acting / affecting people differently than those we have previously experienced. I tried to bring this subject up to be discussed but my post was deleted immediately. Thank you so much for your feedback and making this point clear so that simple and straightforeward measures can be be used/ implemented to identify possible victims. Your point is VERY important since neither WHO nor CDC seems to be aware of your findings. engjb2010 Dec 1, 2014 I‘m a china students,and I'm curious the trouble of developping Ebola vaccine.Can someone share it with me ?

Cyclosilicate Dec 1, 2014

@fengjb2010 Mostly about money.

Rosa Manson Nov 29, 2014 Last Sunday, six doctors from Kenya were sent to Sierra Leone, but local people fear Non- Governmental Organisations (NGO's), the Government and the Health Care System, that is why they stay and die at home. It is a difficult situation due to the fact that there is lack of communication with local pastoral and local people communities on the ground. There are five specific viruses to do with the Ebola Virus and the Ebola Virus Disease (EVD), at the moment this one is the most virulent as it is the Zaire type of Ebola Virus. By communicating with local pastors and the locals on the ground, there would be less fear and more people would be able to be educated about the Ebola Virus, and this would reduce the spread of the Ebola Virus Disease, and would make people believe that they have a role to play in their own wellbeing. Food prices and Commodities have gone up by 75% and therefore there is a shortage of Vitamin A, although not a cure is a preventative measure is being denied to the people who need it the most. The Liberian Health Ministry and Social Welfare has said that there is a shortage of 1,000 beds not just in Liberia but Guinea and Sierra Leone, and this has hampered efforts to get people to the local clinics. This is also spread by diseased bush meat which is the local produce and by contact with diseased animals which are the staple diet of these countries. More equipment is needed to reduce the spread of the disease as well as the reduction of Food prices and Commodities for people to eat a nutritional balanced diet, especially where food is already scarce. More Education Awareness needs to be made available to the local pastoral and tribal communities in order for the spread of this disease to be reduced. urbanx_f Dec 1, 2014 @Rosa Manson Hi I am curious why this virus has not spread to local animals, including domestic. It has me wondering, due to the zoonotic nature of this disease.

thomasdk Dec 2, 2014 @urbanx_f @Rosa Manson African pygmy tenrecs have not been considered. Their use for food make them a possible source of the spreading of Ebola. Tenrecs are native to Mount Nimba, which rests along the border of Liberia, Guinea, and Ivory Coast in west Africa. Tenrecs exist from Kenya in East Africa to Guinea and Liberia, etc. http://commons.wikimedia.org/wiki/File:Atelerix_albiventris_range_map.png

Mark_Booth_Durham Nov 25, 2014 Home based triage for suspected Ebola patients

Could a diagnostic algorithm designed for domestic use slow down transmission within families?

Efforts to curb Ebola are now attempting to empower affected individuals to take appropriate action. UNICEF is distributing household protection kits for care outside of the formal health care setting (1), CDC-designed public health posters emphasise self-referral to health practitioners (2) and the BBC World Service offers podcasts and regular broadcasts to increase public awareness (3). W.H.O offers a verbal-autopsy tool for Ebola (4), but there is currently no algorithm available for diagnosis of Ebola amongst the living that can be used in the home by friends and family of someone who has fallen ill.

In the case of suspected Ebola, any delay in approaching health services is risky for both the affected person and caregiver. Delay may be caused by doubt that the underlying cause is potentially fatal, particularly if previous symptomatic episodes of a similar nature have resolved with basic care and/or treatment. Previous research on malaria illustrates that financial outlay is also common reason for not approaching health services during periods of sickness (5).

My suggestion is to develop an algorithm suitable for household use that combines epidemiological, symptomatic and behavioural indicators to help family members reach a decision on next actions. Although symptoms may overlap amongst potential causal infections, the epidemiology, ecology, socio-cultural aspects of disease may vary widely across the infection spectrum. Some infections may be seasonal, geographically restricted or related to specific behaviours. Eliminating competing infections on this basis may help family members come to a quick and potentially life-saving decision to act.

To ensure the algorithm contains generalisable and locally-sensitive components, that it can be used by family members and/or health practitioners with limited training, and that it addresses issues associated with false-positivity and false-negativity, I further suggest that it is developed by multi-disciplinary consortium of clinical, social, ecological and epidemiological experts prepared to pool their expertise. The algorithm could also contain recommendations for no-touch care in the event that Ebola is a likely cause of the symptoms. One important question will be, of course, what defines ‘likely cause’, hence the need for widespread consultation.

1. http://www.unicef.org/media/media_76030.html

2. http://www.cdc.gov/vhf/ebola/resources/posters.html

3.http://www.who.int/csr/resources/publications/ebola/Corrected%20CoverEboladoc1.p df?ua=1

4. http://www.bbc.co.uk/podcasts/series/ebola

5. Hill, Z., Kendall, C., Arthur, P., Kirkwood, B. and Adjei, E. (2003), Recognizing childhood illnesses and their traditional explanations: exploring options for care-seeking interventions in the context of the IMCI strategy in rural Ghana. Tropical Medicine & International Health, 8: 668?676. doi: 10.1046/j.1365-3156.2003.01058.x

morekersunil Nov 21, 2014 Natural Immunity against Ebola/Genetics and treatment trials/resource allocation and preparedness Certain studies by Centre International de Recherches Médicales de Franceville in Gabon were reported to have found that a high proportion of the Gabonese population is immunized against the disease with an estimated 15.3% possessing antibodies against Ebola, even in areas where no epidemic has ever been recorded (1)

There have been published reports where it has been postulated that there may be a genetic cause for immunity to Ebola which may be responsible for different responses in animal model (2)

Earlier reports have pointed out that by conducting sequence-based HLA-B typing using leukocytes isolated from human patients it is possible to hypothesize that Alleles B67 and B15 could be associated with fatal outcomes, whereas B07 and B14 could be associated with nonfatal outcomes and that HLA-B alleles associated with either fatal or nonfatal outcomes of Ebola Virus disease can be identified and can be used in a predictive model.(3)

This could only mean that genetic categorization of populations may be useful for preparedness for epidemics so that resource allocation may be logical and need based.

Besides that it may be useful to determine which patients need the vaccines whenever they are rolled out and which patients are naturally immune or may have non fatal outcomes.

One also needs to use these data in treatment trials where one arm may be already naturally immune or may be genetically better equipped to face the disease and this may cause bias in interpretation of results of treatment trials

One also needs to look at the possibility that antibodies from one genetic subgroup of people may work differently for another subgroup of genetically different people

1) http://en.ird.fr/the-media-centre/scientific-newssheets/337-possible-natural- immunity-to-ebola

2) Angela L. Rasmussen et al .Host genetic diversity enables Ebola hemorrhagic fever pathogenesis and resistance.Science 21 November 2014: 346 (6212), 987-991

3) Sanchez A(1), Wagoner KE, Rollin PE..Sequence-based human leukocyte antigen-B typing of patients infected with Ebola virus in Uganda in 2000: identification of alleles associated with fatal and nonfatal disease outcomes. J Infect Dis. 2007 Nov 15;196 Suppl 2:S329-36.

TomBoyles Nov 14, 2014 Research priorities-

It is good news that MSF have announced the initiation of 3 trials of treatments for Ebola. They include 2 anti-virals and convalescent blood products. The costs of these treatments, should they prove to be effective are not clear.

Working on the ground in west Africa I am struck by the lack of evidence for more simple measures and how each group has a slightly different approach. I believe that there are much simpler questions that should be answered before embarking trials of anti-virals.

Question 1 is the use of broad spectrum antibiotics. They have potential to cause great harm by disrupting gut flora but also great benefit if gut translocation occurs. This equipoise demands a placebo controlled trial of broad spectrum antibiotics with mortality as the primary outcome.

Question 2 is the use of loperamide or other antidiarrhoeals. Again opinion is divided on their use. The potential benefits in terms of preventing dehydration are clear but complications such as ileus may outweigh these.

Question 3 is the use of large amounts of oral potassium replacement in a setting where electrolyte monitoring is unavailable.

If regulators and ethics committee were energised it would be possible to answer these questions in a matter of weeks with relatively small trial.

It should be a priority to run these trials before those of novel therapies.

Hannah Faal Nov 14, 2014 The elephant in the room

The stark contrast between the Ebola masquerades and the utter poverty of its surrounds as the human conquered and claimed by the virus is carried out.

As the world hurries with the vaccines, the drugs,thermometers at entry and exit points, social media in hypermode, please can we not challenge the creation and preservation of slums? In today's world, and all that is available to it, can there not be a global determination to ban slums, degrade, rebuild do whatever it takes to give human beings a healthy surrounding?

Alongside the ebola response must be a slum Marshall plan especially in Liberia and Sierra Leone NOW! please let us not abdicate to politicians and local leaders, in those poor countries. The pictures of those slums is an indictment on today's world and its cream of the best in all fields of endeavour.

Community health strategies have focused on rural areas in LMIC, we must now focus on urban community health strategies starting with the urban slums. John_Gaudet Nov 21, 2014 @Hannah Faal I agree that the Ebola epidemic in Liberia demands an immediate emergency response, I also agree with Hannah Faal that unfortunately African countries are still faced with many other crises including civilian-targeted warfare, slum development and famine, which have catastrophic impacts on child survival. It will take a major effort to get the developed world to listen.

In arid countries the effects of epidemics, starvation and war are made even worse by drought. In Liberia the case is just the opposite, since in that country a great deal of water passes through the national watercourses.

Renewable surface water in Liberia is estimated at 200 km3/year, and internal groundwater is estimated to be 60 km3/year, which makes Liberia the African country with the highest amount of renewable water per inhabitant: more than 71,000 m3/year/person. Because of this, Liberia is in fact a rice growing country with many wetlands used for growing swamp rice.

The problem is that the water must be treated before drinking. It is tragic that they were doing so well in this direction in previous years. In 2006 for example, almost half the country's population had access to piped, clean water, and there were water treatment facilities in all 15 of Liberia’s counties. Now after the war their drinking water facilities are only pumping 30 percent of the pre-war level, and drinking water will get scarcer during the dry season now approaching (Oct-March). As a result of the Ebola crisis, they will have an immediate need for emergency water treatment, as well as water distribution supplies and equipment.

This humanitarian assistance is required on an immediate basis, but should be correlated with long-term development assistance in order to help in the reconstruction of the country’s infrastructure, institutions, and economy. For example, water purification in the long-term would greatly benefit from the use of filter swamps, a low maintenance, low-cost alternative to conventional treatment systems.

Filter swamps in Liberia could be constructed along the lines of those used elsewhere throughout the world. Even better would be filter swamps that follow models developed in rice-growing countries. Profitable and working examples are found in China where drainage from rice fields is directed through reed beds that are harvested and used for the production of paper pulp, insulation, fuel and construction material.

In looking for examples of efficient systems, attention should also be given to the use of papyrus, a plant native to Africa that is now being used in constructed filters in Thailand, Singapore and India as well as in many places in south, east and central Africa. This plant can help save the water resources of Africa, which are now more than ever in danger of being wiped out.

urbanx_f Nov 13, 2014 A bit of a change of subject from this thread.

I am wondering about why the "Super Powers", have not stepped up to the plate in response to this out of control Ebola outbreak.

Both the U.S. and Russia have stockpiles of this virus and others far worse, from intense efforts in bio-weapons engineering programs. Both "institutions" have explored offensive and defensive research and development in filoviruses, and have developed immunological protective measures (for potential accidents, and\or environmental contamination protocols) Surely the over-seeing authorities of these programs have vital information that could be shared immediately, in the face of this crises, even at the expense of revealing defensive counter measures to their respective opponents. It is absurd and counterproductive to conceal this information when the risk is this high. timdyck01 Nov 16, 2014 @urbanx_f I don't think the USA is sharing all the information they have on Ebola and other related viruses. But I do find it interesting that infected Americans that are brought home to the USA are recovering at a much higher percentage than in Africa. Perhaps whatever they are doing different needs to be done in Africa? But then who will pay for it? Sadly in our world the poor cannot afford to be cured and those with the money to cure them will not spend a nickel to help.

RainerWinkler Dec 4, 2014 @timdyck01 @urbanx_f The level of care is much better in USA and other rich countries. And care is important for Ebola patients. See for instance http://www.who.int/mediacentre/news/ebola/06-november-2014/en/ . The patients in rich countries receive an amount of care that cannot be delivered in West Africa. The same was for instance true for a patient in Germany, this patient developed many complications, see http://www.nejm.org/doi/full/10.1056/NEJMoa1411677 . From all I know of the african treatment centers, I would say, he would not have survived in West Africa. thomasdk Nov 3, 2014 We should analyze antibodies against ebola virus from people who have proved to have a natural resistance ASAP.Vaccine production is an excellent way to prepare for future epidemics. We therefore need develop an effective platform to develop prevention against microbial diseases such as Typhoid, Cholera, TB.We need more research in the many types of macrophages, and the cytokines & chemokines which control their activity. And find out how & why TB, HIV and Epstein barr virus survive inside these cells. Epstein Barr virus induce exposure of CD163 and CD 68 on macrophages in several cancer types. Does Ebola induce exposure of particular receptors on macrophages?

urbanx_f Nov 4, 2014 @thomasdk Excellent insight! Can the virus induce higher virulence in individuals with certain HLA types? Is individual macrophage differentiation a factor? Some phagocytes act much like a natural wild type amoeba, and others are smaller, more granular and dendretic.

thomasdk Nov 5, 2014 @urbanx_f @thomasdk Yes virus can induce particular surface recptors, which may change the behavior of immune cells like macrophages. And affect the behavior of lymphocytes.

Yes macrophages are able to induce trans- differention, of progenitor and stem cells. This is in particular of relevance in human cancer. Regards

@thomasdk DrEdo Nov 1, 2014 Craig----well said DrEdo Nov 1, 2014 From the article on wide spread Slums--The Elephant In The Room, one wonders how human waste is handled. In one of the Lancet papers, there was mention that the need for beds has exceeded 1700 ---"The number of beds at EVD treatment centres needed to effectively control EVD in Montserrado substantially exceeds the 1700 pledged by the USA to west Africa." The county, according to Wikipedia has eight hospitals, nine health centers, and approximately 93 medical clinics functioning as of 2008. Montserrado County has limited access to electricity. Electricity is needed to run sewer plants. The Liberia Water and Sewer Corporation (LWSC) was efficiently functioning within Montserrado County before the 1990s. Pipe-borne water from the Mount Coffee Hydro Electric dam ensured a constant supply of water to the County. With this supply there was a marginally efficient sewage management system in place. With the coming of the civil crisis, the dam was put of use and locals now have to rely on wells and hand pumps. The LWSC is working hard to restore water to some parts of the County, and has restored service in a few areas. Still, the majority of residents are without water or sanitary facilities, and this situation has often led to out-break of water borne diseases.

Getting an idea of generated stool volume, one might venture to pull some numbers from another disease. Admittedly, stool volume during cholera is more than that of any other infectious diarrhea. But let's take a leap and assume this is the high side. Patients with severe cholera may have a stool volume of more than 250 mL/kg body weight in a 24-hour period. Because of the large volume of diarrhea, patients with cholera have frequent and often uncontrolled bowel movements.

Let us now move the 1700 down and assume an average patient weight of 130 pounds (59 Kg). That's about 3.9 gallons per day per patient. Assuming 1700 patients at 3.9 gallons yields 6625 gallons per day, and 46375 gallons per week. Is this an issue?

smipet Nov 2, 2014 @DrEdo I've never come across any reports of say norovirus being spread by sewage treatment works. It seems to me that the people at risk are those that are actually coming into physical contact with the diseased and dying, otherwise the numbers currently would be even greater

DrEdo Nov 10, 2014 @smipet @DrEdo In answer----As to the transit of Ebola through a sewer plant. There are little to no data, so the discussion is speculative but using the precautionary principle should suggest caution. Assume we get a blow out of the disease and numerous patients are housed in a hospital, dumping waste into the sewer. First, flushing toilets creates aerosols. Next the flushed waste enters the collection system of sewer mains and wastewater employees are constantly working on and in these systems. Rats frequent these systems as well as feral cats. Occasionally these systems clog and then the raw sewage backs up, opens a manhole cover and raw wastewater gushes down the street. Then we get to the raw waste which enters into the plant proper. It flows past, over and through various machines, belts and separators that require constant human attention, and many generate aerosols. The waste then enters systems for solids removal, usually with a flotation process where compressed air is driven up from the bottoms of large vats, the bubbles breaking at the surface as aerosols. Often, the effluent is used to irrigate community parks and school playing fields.

The wastewater industry just had a nation-wide webinar on this and there is much concern over the IT'S OK TO FLUSH attitude. This presumably was adopted by US CDC from WHO, and apparently with little thought or knowledge of just how sewer systems work. The other major flaw here is that the typical lab tests imposed on industry by US EPA, and thus the states and presumably WHO use the multi-Durham tube testing for coliform as an indicator,. These are Most Probable Number tests. The flaw here is: 1) the indicator is not a virus, 2) the test is highly susceptible to throwing false negatives because it can not see bacteria in the viable but non-culturable state, and can not see other pathogens that get get through (see:http://www.ncbi.nlm.nih.gov/pubmed/15933017).

There are so many holes in the system that the precautionary approach is warranted, anything else is being arrogant, demonstrating a cavalier attitude.

Dr Edo McGowan I—

lannycrist Nov 30, 2014 @DrEdo Only way to keep this out of the water and streams is to pre-treat by capturing in a container and treating it with concentrated chlorine. In vietnam it was put in a containment then added fuel oil and burned it. thomasdk Dec 3, 2014 @DrEdo Dear Dr. Edo. An efficient way to make sure the drinking water is clean is to set up reverse osmosis equipment, which is able to catch anything from virus to worms.Sea water can be de-salted and used for drinking water too, and be an efficient way to insure enough water if pipelines are built from the coast to mainland areas. This procedure has become standard in major countries like USA and India. Companies like H-O-H Water Technology have more than a decade´s experience in setting up large units all over the world, and proven its technology is safe, secure and efficient. http://www.hohwatertechnology.com/homepage-index.html Best regards

thomasdk Nov 1, 2014 The public need to be informed on simple guidelines. :

Body fluids, faeces, and bush meat, spread the infection.

The doctors we need to get involved, too, are the US Navy doctors at this point. These are some of the most competent in the world. ! And their access to, and ability to use, high tech technology are the best world wide. The disease has much in common with typhoid. Perhaps we should screen for typhoid. And treat affected patients with Cefuroxime as a first line antibiotic.

The increased bone resorption may implicate the increased formation of virus induced macrophage fusion. Indicating that Macrophages are infected. Just like in AIDS and TB.

Yours thomasdk Genetechnology and proteomics scientist. CraigLefebvre Oct 31, 2014 The Social Squalae of Ebola

Whether it is HIV being more prevalent among underserved and stigmatized population groups, or Ebola exposing the inability to manage emotional contagion (“Ebola hysteria”) and the assumptions of “prepared” health care and public health systems, there is as much to be learned about the social impacts of viruses as there is about their biology.

That there has historically been less foreign aid and development focus in Western African countries than in other parts of the continent has been exposed by the dismal quality of a public health infrastructure in Guinea, Liberia and Sierra Leone that is not prepared to contain the virus or treat the sick. This lack of concern and commitment to the region by developed countries may also explain the lack of any systematic response to the current Ebola crisis by most of them. That every US local and state health department is prepared and ready to respond to an infectious disease outbreak has been revealed as a convenient fiction, despite the billions of dollars in bioterrorism training and support they have received over the past decade. The presumption that hospital administrators and health care workers will respond appropriately to a potential public health crisis has been unmasked. These are just some of the frailties in our society that Ebola has been able to take advantage of – so far.

Yes, we are – as so many leaders are saying these days - learning as we go. But lessons learned from other public health crises including anthrax, avian flu, SARS and H1N1 seem to be forgotten. The most important discovery during those events was that communication becomes the most important weapon against the pernicious social effects of Ebola. If used well, communication can draw people together, acknowledge their fears, provide honesty and openness as to what health and elected leaders know and don’t know, demonstrate competence and expertise, and give people guidance on what to think about, how to think about it, and what to do to protect themselves and loved ones. When communication becomes a tool for hubris, fear-mongering and political one-upmanship, we should acknowledge the Ebola virus for demonstrating that we are more than our biology – we are a social collective, for better and worse. urbanx_f Oct 31, 2014 My impressions about the Ebola virulence you propose seems accurate, given past and present analysis of these epidemics.

I will add some caution to this assessment, because of the extent of the present population infected.

Just like HIV-2, there can come a point where the virus starts to branch off into different categories of virulence.

There are still some unknown factors to consider with this filovirus. A) Can the virus be carried through intermediary hosts like small mammals, or insects

B) Can the virus survive in a dormant encapsulated form in the environment

C) Are there inherent (environmental, timing) cycles which can collectively affect viral reproduction and virulence factors.

turyagaruka Oct 31, 2014 The most at risk are immediate family members involved in the care of the sick or who participate in burials and health care workers. Health facilities are potentially high risk areas as clinicians easily get infected and also easily pass on infection from patients to others.

Many Ebola patients are too weak to move.

urbanx_f Oct 27, 2014 I would like to provide some insight into this issue. Pathogens which are generally dangerous, usually have trigger points on surface receptors. These can degrade quickly under adverse environments. The viral RNA may remain intact, but it's ability to remain active enough to react with living cells will be limited.

The reason a virus like ebola is super active during the last stages before death, is designed so the next host (animal) consuming the body will provide opportunity to continue the cycle until a suitable host (usually the reservoir host) becomes available to complete the cycle. thomasdk Oct 27, 2014 Thank you so much editors of the #1 medical journal worldwide "The Lancet" for establishing this forum. So that we can restrict the spreading of the Liberian type of Ebola ASAP before it gets out of control in a few weeks.

In particular now that the US has NO General Surgeon. WHO leaders of the surveillance programs are obsolete .And American governors are free to do as they please.

DrEdo Oct 27, 2014 Dr Clement, do you have any feeling for how long the virus would remain viable and infective in feces from bats or other animals?

Dr Edo McGowan

camesekoOct 25, 2014 Ebola virus agro ecology and preventing zoonotic transmission: the way forward, Nigeria WHO has declared Nigeria Ebola virus free following effective management of the import by deceased Patrick Sawyer [1, 2]. What are the next steps toward preventing future outbreaks especially that the country is located within what may be described as Ebola region of West and Central Africa agro ecology [3]. In my opinion, attention should also be directed at the risks of transmission of zoonotic diseases like Ebola from wild animals in this region.

Though definitive reservoir host of Ebola Virus Disease (EVD) in the wild is yet not be established. Fruit bats of the genus rousettus have been described as possible reservoir in Africa; specifically the outbreaks in 2007 (Uganda) and 2014 (Guinea) were traced to fruit bats [4]. Non human primates (Monkeys, Chimpanzees etc) like humans are susceptible dead end hosts and would die when infected by Ebola virus [5]. Hence contact with sick or dead wild animals could transmit EVD to hunters or bush meat processors who in turn might transmit the virus to immediate family members and healthcare givers.

Factors that may favour emergence of Ebola virus from wild animals in Nigeria include: Location in the humid rain forest of West and Central Africa where EVD may emerge from yet to be fully understood reservoir hosts [5]; putative reservoir fruits and insectivorous bats colonies are abundant in the country [6], and these bats share fruits eating habit in the forest with humans. In addition, many Nigerian eat bush meat from wild animals that could also be infected by zoonotic pathogens. Therefore implementing policies and measures that would prevent zoonotic transmission of pathogens from reservoirs or infected animals in the forests cannot be over emphasised.

These measures can be inter-disciplinary and include surveillance to detect EVD and other zoonotic pathogens at the wildlife-human interface. Hunters and bush meat processor/traders need to be engaged on preventive measures that would reduce occupational exposures while safeguarding their livelihood [7]. Hunters can also be educated on animal conservation and behavioural changes [8]. Behavioural changes such as not touching sick or already dead animals and provide information on early warning of die offs in the wild [9]. The African proverbs (paraphrased) below are examples of instructive ethnic risk communication messages for avoiding transmission of infectious diseases from wild animals.

“You don’t butcher a dead buffalo that was found by the river bank, it couldn’t have died from drinking excessive water” and “He who carries a dead partridge of unknown cause may attract pestilence to himself”

In summary, Nigeria’s agro ecological zone is a hotspot for emergence of Ebola and other infectious pathogens in nature. However, proactive disease surveillance and monitoring with community engagement could help detect and manage infections before it gets out of hand. References

1. Shuaib F, Gunnala R, Musa EO et al, (2014). Ebola Virus Disease outbreak- Nigeria. MMWR, 63 (39); 867-872.

2. WHO (2014). WHO declares end of Ebola outbreak in Nigeria. www.who.int.crs/disease/ebola/ent (accessed 25th October 2014)

3. Peterson AT, Bauer JT, Mills JN et al., (2004). Ecologic and Geographic distribution of filovirus Disease. Emerging Infectious Disease, 10: 40-47.

4. Olival KJ, Islam A, Yu M, et al., (2013). Ebola Virus Antibodies in Fruit Bats, Bangladesh. Emerging Infectious Diseases, 19(2): 270-273.

5.Leroy EM, Kumulungui B, Pourrut X, Rouquet P, Hassani A, Yaba P. et al. (2005). Fruit bats as reservoirs of Ebola virus. Nature. 438:575– 576.

6. Angelici FM, Wariboko SM, Luiselli L, Politano E. (2000). ‘A long-term ecological survey of bats (mammalian, Chiroptera) in the Eastern Niger Delta (Nigeria)’ Italian Journal of Zoology, 67: 2, 169-174

7. Kanu A. and Olubade A. (2014). Bush meat sellers cry out: Ebola is killing our business. New Telegraph.www.newtelegraphonline.com (accessed 18th October, 2014)

8. Can M. (2014). Ebola Virus Disease in West Africa- No Early End to the outbreak. N. Engl J Med, 371: 1183-1185.

9. Rouquet P, Froment JM, Bermejo M et al., (2005). Wild animal mortality monitoring and human Ebola outbreaks, Gabon and Republic of Congo, 2001-2003. Emerging Infectious Diseases: 11(2):283-290.

I declare no competing interest

Meseko Adebajo Clement, DVM, PhD. Virology Dept. National Veterinary Research Institute, Vom Nigeria.

thomasdk Oct 27, 2014 @cameseko I totally agree with you Dr. Meseko Adebajo Clement, DVM, PhD. You are absolutely correct in everything you point out, as issues. Yours Sincerely Bo Soegaard, MD, et D.D.S

thomasdk Oct 25, 2014 Use soft nitril gloves when you handle a patient. Otherwise you may also put the ebola patient at unnessary risk of containing other diseases.

thomasdk Oct 25, 2014 Please do NOT touch an Ebola victim. SajithKumar Oct 25, 2014 Thanks ,

Lancet for the very useful opening for us.

We need more information......

R. Sajith Kumar, MD, PhD Prof. of Infectious Diseases Govt Medical College, Kottayam, Kerala, India

RodrickWallace Oct 24, 2014 Fastracked commentary on the agroecology of Ebola in West Africa:

http://www.envplan.com/epa/fulltext/aforth/a4712com.pdf

Rodrick Wallace, Division of Epidemiology, NYSPI at Columbia University, [email protected]

DrEdo Oct 23, 2014 As to preparedness. I traced through the ability and willingness of my city and county to mount a response with emphasis on contingency planning related to sewers. When it came to a contingency plan to deal with sewer plant generated aerosols, there were no plans and oddly enough, there was no interest in developing such a plan. In the event of a large outbreak with an aerosol potential, the local sewer plant needs to develop a contingency plan to stop the release of aerosolized pathogens. Ebola under these conditions has a high potential for aerosol formation. The settling and separation vats or tanks in many sewer plants use air injected at the bottom of the liquid and use the rising bubbles to carry up the solids which are then skimmed away. When these bubbles break the surface they explode and shatter water droplets and small bits of the bubble fly off creating an aerosol. This aerosol generation by sewer plants is well documented in the literature, see below.

In these cases large sheets of plastic, such as that used in construction can be spread over the tanks/vats to retard aerosol loss.

In many areas, sewer plants also produce reclaimed or recycled water which is used via sprinkler irrigation to irrigate municipal green spaces as well as school playing fields. As a source of aerosol generation, sprinkler systems are well discussed in the literature. Many of the sewer plants carry treatment through the tertiary level. This does not stop an array of pathogens including viruses, as noted by the study by Harwood cited below:

Dr Edo McGowan, Santa Barbara http://www.ncbi.nlm.nih.gov/pubmed/15933017 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1435663/

urbanx_f Oct 23, 2014 @DrEdo I'm sure your suggestion will be taken into consideration when the time has past for prudent action on this issue.

Your report on this subject has not fallen on deaf ears in some quarters.

DrEdo Oct 25, 2014 @urbanx_f @DrEdo

I'd like to communicate with these people, but how thelancet moderator Oct 27, 2014 @DrEdo @urbanx_f We don't have access to email addresses of people leaving comments on this site.

DrEdo Oct 22, 2014 Ebola can be aerosolized. One way to do so is to run it down a sewer and into a sewer plant. Most sewer plants use some form of flotation to separate the solids from the liquids and often this is driven by up-rising air charged into the fluids. As the charged air breaks the surface of the fluid, it creates small droplets that continue to rise as an aerosol. Being an aerosol then sees the entrained material drift down wind. This is well documented.

There is a push to use reclaimed sewage water for irrigation and the standards under which this water is produced fail to account for pathogen carriage. The antiquated coliform test completely misses numerous pathogens which may exist even-though the coliform count is well within standards. The papers noted at the end of this comment spell this failure out quite clearly. Additionally, some sewer plants are prone to fail absent replacement parts, many of which place difficult foreign exchange demands on developing nations. As an example, the electric panel blew out at the sewer plant in Kampala a few years back. Because of a lack of parts to fix the system, the whole plant was shut down and raw sewage soon over-topped the plant and started running across the surface. The cessation of the plant's operation lasted a very long time and the raw sewage finally reached the edge of Lake Victoria, entering the lake about 0.25 mile away from the city's fresh water intake system. In Botswana where I worked on the 5-year plan for water, there was serious discussion of inter urban agriculture operating on reclaimed sewage effluent. But, as can be seen from the cited papers, the treatment available today does not remove pathogens, even with tertiary treated water.

Thus, flushing Ebola waste into sewers is not a good idea. The US CDC suggesting such seems to be an ill-informed suggestion.

Dr Edo McGowan http://www.ncbi.nlm.nih.gov/pubmed/23755046 http://www.ncbi.nlm.nih.gov/pubmed/15933017 http://aem.asm.org/content/43/2/371.full.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1435663/

urbanx_f Oct 21, 2014 It is a known fact that viral RNA polymerase and replicase enzymes can jump around and scavenge genetic material. If the viral activity in a host population is large and active enough, there is a good chance that viral exchanges with other microbes can take place. If for example, the Ebola filovirus donates genetic material to a normally benign virus in a human or animal, (or the reverse) there could develop a new strain of virus never seen by nature.

This could result in nothing more than a harmless species or could cause catastrophic etiology.

If the health scientific community thinks the Ebola crisis can be contained and eliminated until better protocols are in place, they are thinking in fiction.

Viruses and other pathogens are integrated into the evolutionary patterns of life. Humans have tinkered in this process for sometime, and now there is a turning point in the biologic ecology.

The best way to "weather the storm" is to create a global plan for pandemic readiness.

HenryLahore Oct 21, 2014 The Modeling study is ABSOLUTE TRASH Ignored other than non-stop – even for refuelling Ignored infected but did not yet show symptoms Ignored 13% who do never run a fever Ignore the taking of pills to reduce the fever Ignored the 2X increase in Ebola every 3 weeks – study assumes a constant StephenFagbemi Oct 20, 2014 The Ebola epidemic had forced the entire world to see the fragility of the overall global health system. It also brings home the truth that when danger lurks somewhere then there is danger everywhere. While it is important for nations to defend there sovereignity and teritorial integrity, we are sadly reminded that Viruses do not respect this norms. It is now imperative that in dealing with issues like this, prompt and proactive measures that circumvent the bureacracies of international reltions must be deveoped and rapidly deployed. sadly this outbreak had reinforced the old saying that indeed a stitch in time saves nine.

As an african, it is commendable to note that more than 80% of the human and financial resources being deployed across the epicentre of this outbreak is by foreigners. Many times in the past African leaders are quick to heap blames on the Western nations, however in this outbreak there had been very little resources deployed from sister African countries, which is very worrisome. Self proclaimed African regional giants like Nigeria and South Africa should have taken the lead in this regard by sending both human and material resources, by so doing they will probably be developing the much needed expertise in this field Finally, from the Public Health perspective, it had been noted that most countries had struggled with managing their index cases and contacts. The idea of placing primary contact under a relaxed medical surveillance that depends on their self reporting and individual cooperation may be suitable in compliance with respect for individual rights but it appear to be difficult to manage. Perhaps it may be necessary to adhere strictly to full quarantine in instances where the primary contacts of index cases are minimal and manageable. Individual countries may now consider different forms of incentives and remuneration for them for the period of their confinement. in the long run this may turn out to be far cheaper and easier than scampering everywhrere searching for passengers on flight and other possible contacts when a primary contact breaks self surveillance.

Princess Obienu Oct 17, 2014 Ebola Outbreak

To contain this recent pandemic deadly disease, Ebola, it must be carefully tracked down from the original source, Liberia (from case to case), and this requires the global effort (WHO). Without the tracking, this debilitating disease will continue to spread and may consume or wipe out many lives. It's so unfortunate that we sing "Emergency preparedness" as a song, yet; have failed to prepare for such sporadic event as in the case of Ebola in the C21th. “The CDC is also in the process of being prepared” according to one of the articles posted on their website on this subject.

kbsunkutu Oct 15, 2014 My concern with this is the fact that we have a problem in Africa, but we are looking for solutions elsewhere. Africa has to start a stepping up to the plate and resolving our own problems. If I am a leader in a western country, I would be more interested in preventing the Ebola from getting into my country and going through the motions to be seen to be concerned about the problem in Africa.

I do not believe that all the diamonds in Sierra Leone and the wealth of Africa cannot be mobilised to resolve our problems.

joseleon Oct 15, 2014 @kbsunkutu Likely that the depth and pervasiveness of diversion of "public funds" is essentially incomprehensible. nicolay Oct 15, 2014 Picking up on discussions about international policy responses to Ebola, see this: "Ebola regional fund shows growing solidarity in West Africa" has been published on The Conversation.

Here's the link: http://theconversation.com/ebola-regional-fund-shows-growing-solidarity-in-west-africa- 32715

Karki Oct 15, 2014 The R0 for Ebola is estimated around 1-2. In Texas case, which has been reported of infection control breach, we already have 2 cases from the index case, that makes a R0=2. Here we are talking about a health setting in US, and at any level better than the one in those in outbreak regions of West Africa. I wonder if we are underestimating the R0 in African setting? or Asymptomatic infection and naturally acquired immunity is playing a role in African setting, thus keeping the R0 lower? I think Bellan et al. are very correct that we should be seriously thinking about investigating on Asymptomatic infections. thomasdk Oct 15, 2014 The Ebola virus is most likely accumulated in macrophages. And use these cells as a reservoir. Just like HIV and TB. Having been on the team which diagnosed, and treated, the first victims of HIV in Europe. It is disturbing that nobody seems to inspect the Ebola patients thoroughly. So that a fast, noninvasive, and efficient approach can be applied, to identify victims. In order to prevent implementation of obsolete procedures. And panic.

kbsunkutu Oct 15, 2014 I would like to find out what the current ethical thinking in balancing the need to restrict movements of people from areas of extreme Ebola risk, until they are cleared to be free of the disease and their human right to freedom of movement and association.

Is it ethical to restrict such movement? Is it prudent to have free movement?

What are the ethical landmines in even consideration such options?

When does public good outweigh individual rights? Who makes such decisions and when do you know that the time is right? urbanx_f Oct 13, 2014 I run across this all the time. For example, I know an expert in parasitology who has discovered certain anti psychotic meds can "re-set" chemical imbalances which occur post- infection. Many people who have been treated for parasites or infections, continue to suffer from chronic symptoms. This expert has used antipsychotic drugs to cure patients of chronic symptoms with a very high average of success.

I have not seen any published work on this, or any real attention turned toward this discovery.

The fact is, many health professionals feel the governing health organizations do not take advantage of the average clinical expert.

In the US, the "Four Corners" epidemic is a good example of how the CDC dithered on the problem before finally consulting with local doctors and native medicine men to gather important information. Eventually this did happen, and the leading cause was elucidated.

It should have been obvious from the start in my opinion.

BLAIRMCB Oct 14, 2014 @urbanx_f This is very true. Too many small men with wisdom are being shut out, because of those that think they are of wisdom, but are fools to wisdom and knoweth not of knowledge. I Shall ask; to show me the mill stone that grindeth their corn, or wheat, to feedeth their knowledge to cometh wisdom.

urbanx_f Oct 13, 2014 Could this be a case of education and\or culture? Many burial rights in these parts of the continent involve washing the body, and other rituals which cause direct contact with the deceased, and bodily fluids. It has always been a problem in past cases of Ebola outbreaks according to health workers in the field.

Walt FOct 13, 2014 I would guess that it's the density and social connectedness in the locale where infection is going on, rather than how many people are outside that area. joseleon Oct 13, 2014 The impact on individuals of the tragedy West Africa has nothing to do with numbers used to track the Ebola virus epidemic.

That said, one aspect of what is happening in West Africa that is not being discussed or analyzed widely is the differences in the number of cases and deaths per capita in Liberia versus Guinea versus Sierra Leone.

Liberia has about eight times the number of Ebola virus disease deaths per million people (566)as Guinea (68) and more than three times the death rate as Sierra Leone (162 per million).

The number of cases per million persons in Liberia (996) is more than eight times the rate per million in Guinea (118). Per capita, Liberia has about twice as many cases as in Sierra Leone (514/million).

Perhaps understanding the causes of these differences from the perspectives of transmission and treatment will, at some point, be instructive.

In making this calculation, the WHO report of October 10 was used along with generally accepted population numbers, in millions: Guinea, 11.5; Sierra Leone, 5.7; Liberia, 4.1

magoonl Oct 14, 2014 @joseleon Some, perhaps much, of the difference in death rates is a function of record keeping. This has been discussed by virologists on twitter, and one country official posted an explanation on a facebook indicating the country's policy had been to only report Ebola deaths that occurred in an Ebola Treatment Unit or hospital setting. (That policy had been changed). Keep in mind these are reported numbers. (Can't find a source right now, sorry). joseleon Oct 14, 2014 @magoonl @joseleon Most helpful. Keep me posted on any details you find. Thank you.

urbanx_f Oct 12, 2014 This is a refreshingly intelligent suggestion. It could also extend to other epidemiological records which include veterinary treatments which are found to be especially effective, or produce unexpected results.

dfedson1 Oct 13, 2014 @urbanx_f If it is an intelligent suggestion (that could make a difference), why aren't Ebola scientists, MSF, CDC, NIAID, the Gates Foundation, the Wellcome Trust, WHO, the World Bank and the UN paying attention to it? urbanx_f Oct 12, 2014 I for one have taken serious note of this. I also would consider the serendipitous use of other common pharmaceutical treatments which have shown, or could potentially show effectiveness in controlling Filovirus and\or other dangerous infections.

kevin2kane Oct 11, 2014 Given that there is an ethical debate about the use of randomized clinical trials, and also some anecdotal reports of some success with some treatments, is it not obvious that we need a global registry of the treatment of patients and their survival outcome? This would enable some basic evidence to accumulate on relative effectiveness of potential treatments. With a registry of this sort, every patient infected with ebola would contribute useful information to inform the treatment of subsequent infected patients. Without a registry, thousands of people are dying in vain. Medical history and demographic data would add further insights and potential for analysis.

dfedson1 Oct 11, 2014 The Ebola outbreak in West Africa may affect more than 1 million people by the beginning of next year [1], and this means more than 500,000 people could die. Ebola scientists who focus on developing new vaccines or agents that target emerging viruses [2] ignore existing drugs that don't prevent infection, but instead shore up host defenses and improve chances of survival. For more than a decade, these scientists have known that the endothelial cell dysregulation and coagulation abnormalities seen in patients with Ebola virus disease are also seen in severe sepsis [3]. More recently, investigators have shown that prompt treatment of sepsis patients with atorvastatin reduces the development multi-organ failure by 83% [4], and multi-organ failure is what kills Ebola patients. Statins and other immunomodulatory drugs (e.g., ACE inhibitors and angiotensin receptor blockers) have been shown to significantly reduce 30-day mortality in patients hospitalized with pneumonia and influenza [5]. These drugs are produced as inexpensive generics and are available to doctors in West Africa today. Because they are known to be safe when given to patients with acute critical illness, they could be tested as treatment for Ebola patients and used to prevent complications in healthcare workers and other caregivers who might become infected. Ebola scientists and staff at CDC, NIH, WHO and the UN all know about these drugs, yet they continue to ignore them. If this continues, increasing numbers of Ebola patients will be denied the hope that simple oral administration of one or more of these drugs could save many lives.

1. Meltzer MI, Atkins CY, Santibanez S, Knust B, Petersen BW, Ervin ED, et al. Estimating the future number of cases in the Ebola epidemic – Liberia and Sierra Leone, 2014-15. Morbid Mortal Wkly Rep MMWR 2014; 63 Suppl 3: 1-14.

2. Marston HD, Folkers GK, Morens DM, Fauci AS. Emerging viral diseases: confronting threats with new technologies. Sci Transl Med 2014; 6: 253ps10. 3. Fedson DS. A practical treatment for patients with Ebola virus disease. J Infect Dis 2014. Epub August 25th.

4. Patel JM, Snaith C, Thickett DR, Linhartova L, Melody T, Hawley P, et al. Randomized double-blind placebo-controlled trial of 40 mg/day of atorvastatin in reducing the severity of sepsis in ward patients (ASEPSIS Trial). Crit Care 2012; 16R231. 5. Fedson DS. How will physicians respond to the next influenza pandemic? Clin Infect Dis 2014; 58:233-7.

BLAIRMCB Oct 12, 2014 @dfedson1 the only thing that will wake up many people ideas, is to have them before the court of law.

dfedson1 Oct 13, 2014 @BLAIRMCB @dfedson1 Thoughts on the Ebola crisis in West Africa

“It is not enough to say, 'We are doing our best.' You have got to succeed in doing what is necessary.”

Winston Churchill

(We are not doing all that is necessary.)

“The ‘sound’ banker ... is not one who sees danger and avoids it, but one who, when he is ruined, is ruined in a conventional and orthodox way along with his fellows so that no one can really blame him.”

John Maynard Keynes (Only the extraordinary containment efforts underway in West Africa hold promise for success. Thus far, conventional and orthodox clinical treatments are not succeeding.)

“Try again, fail again, fail better.”

Samuel Beckett

Worstward Ho1983

(Is this the best that clinical treatment has to offer?)

“A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.”

Max Planck (In other words, scientific progress is made through a series of funerals. As long as the funerals are those of scientists, that’s okay. If the funerals are those of thousands of patients, that’s an entirely different matter.)

“The most difficult subjects can be explained to the most slow-witted man if he has not formed any idea of them already; but the simplest thing cannot be made clear to the most intelligent man if he is firmly persuaded that he knows already, without a shadow of doubt, what is laid before him.”

Leo Tolstoy, 1897

(Recognize anyone here?)

“The failure to prepare was a mistake embedded in the banality of organizational life and facilitated by an environment of scarcity and competition, elite bargaining, uncertain technology, incrementalism, patterns of information … (and) organizational structures … that normalized signals of potential danger and re-aligned action with organizational goals.”

Quoted in K Cerulo. Never saw it coming. Cultural challenges to envisioning the worst. Chicago: University of Chicago Press, 2006.

(Does this describe some of our institutions?)

“To see what is in front of one’s nose needs a constant struggle.”

George Orwell

Tribune, March 22, 1946

(Or, to paraphrase Yogi Berra, “If you pay attention, you can learn a lot.)

Incestuous amplification “… happens when a closed group of people repeat the same things to each other - and when accepting the group’s preconceptions itself becomes a necessary ticket to being in the in-group. A fundamentally flawed notion … becomes part of what everyone knows, the “everyone” means by definition only people who accept the flawed notion.”

Paul Krugman

The New York Times

29 January 2013 (Does this help us understand why most Ebola scientists believe the only way to confront Ebola virus disease is to beat up on the virus?)

" The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty, and we must rise -- with the occasion. As our case is new, so we must think anew, and act anew. We must disenthrall ourselves, and then we shall save our country.” Abraham Lincoln

Annual Message to Congress, 1862 (This statement says it best. We must disenthrall ourselves.)

Walt F Oct 10, 2014 thanks. I think it is ironic that the correspondence that we are commenting on says "call for the urgent use of experimental and innovative treatments to address the current Ebola outbreak". I was trying to suggest such.

The first part is speculative, without claim, safe and cheap. The second part has various PubMed papers, albeit about a different malady, such as 23947403. I consider this experimental and innovative, and will continue to urge its trial,

urbanx_f Oct 10, 2014 Moderator: Whatever happened to creative and collective brainstorming? This is how some of the worlds most innovative ideas develop. It may not be sound science, or even relevant, but could inspire those who are so close to the problem to see things from a different view.

thelancet moderator Oct 10, 2014 Sorry, we not allowing speculative claims of treatment efficacy without peer reviewed evidence.

urbanx_f Oct 10, 2014 I think they want you to take this because it is a fever reducer. If you are being scanned at the airport, and you have an unrelated elevation of body temp., then there may be unnecessary delays in your departure.

On the other hand it could be something that can work against you, and the rest of society.

Bintu Oct 10, 2014 As a medical doctor currently working in Sierra Leone I just shake my head at the outrageous comments people make. We're fighting a disease we new nothing about. I had a one page note on ebola whilst in medical school in Sierra Leone bcos it wasn't endemic to my region instead we extensively studied Lassa Fever, Yellow Fever, Rabies etc under haemorrhagic fevers. Nurses never even heard the word ebola so for some people to be blaming health personnel who are dying that we're being careless is heartrending. Av lost colleagues and friends to this fight that has no end in sight. We work in hospitals with no running water. We tell people about handwashing when they get their water from streams. We have patients coming into the hospitals lying about their symptoms. Everyone now knows the symptoms of ebola and they carefully deny each one.Only God knows the quality of these PPE'S being donated. But in Sierra Leone we're still working. The things we've seen and are still seeing just breaks my heart. You wear a PPE and in an hour ure sweating like ure in hell. Uve got 50-80 patients to check on and by the time ure on patient 20 you can no longer breath in that PPE. Ebola is a scourge that should soon be eradicated. My prayer is on the vaccine. In Sierra Leone we have 136 doctors for about 6 million people. 5 are dead. All we depend on now is on international help.

Dr Bintu Mansaray

Ministry of Health Amd Sanitation, Sierra Leone [email protected]

BLAIRMCB Oct 11, 2014 @Bintu Hi Dr. Bintu, you are right and I am fully in agreement with you. I am also a Medical Doctor. I am going to send you via your e mail, the treatment for the Ebola Virus that I have sent to WHO, CDC and NIH over two months ago of which I am 99% certain of. I have been trying to contact someone in your Ministry of Health for the past two months. Please help your people.

joseleon Oct 10, 2014 Please note: I am going to say something a bit outrageous. But first: Let us note that all the cases in Nigeria and the one case in the U.S. [Texas] occurred because persons did not tell the truth on their health questionnaires. The Liberia to Lagos case is notorious. The derivative case in Port Harcourt, equally so. It also appears that the Texas case involved a traveler who did not reveal Ebola contacts prior to flying.

That said, what would you do when exiting West Africa? Risk that on a particular day you might have a fever from any number of sources, including Ebola virus? Or get on the plane which likely involved complex ticketing. Even if you thought you were dying from Ebola, would you want to stay and face near-certain death? Or go get state-of-the-art back home?

Surely these renegade health workers know the drill. And surely if they thought they had Ebola they will not be coughing in people's faces. And surely upon arrival in home country will go straight to the ER and hopefully meet a better fate than with an ER in Texas.

So, let us not be excessively sanctimonious.

If a health care worker really thought they had Ebola and were smuggling themselves home, they likely would be extremely careful not to transmit the virus.

And having said that: Yes, it is true: one way Ebola will spread will be from people concealing their conditions, unless they are taking extreme precautions, as a health care worker might. If someone had true symptoms, such as vomiting and diarrhea then it is another matter. But to avoid the chance high temp and miss your flight home? Let's be realistic : Most people are not eager to commit suicide. Hope I have not disgraced myself permanently in the eyes of the science and health community.

ververs Oct 10, 2014 Health personnel have advised to people having worked in West Africa on EVD to take paracetamol in order to lower potential fever, i.e. to cover the symptom used for screening on entry/departure of a country. (Because everbody, if infected, prefers to be in Europe or USA for treatment....). That procedure will mask potential fever.

If authorities keep on screening on fever, I assume this advice will be a public health threat for all of us. Am I wrong?

BLAIRMCB Oct 10, 2014 I wouldn't be surprised, because if some that are in authority speaks outrageous things, or things that are false and has no bearings whatsoever on the issue, how wrong can a lay man be, in venting his folly. Anyway Paracetamol will have no effect on a person who has been infected with the Ebola Virus. The only way it help an infected person is if the person is febrile. I hope this also is not coming from a health personnel. chublin Oct 10, 2014 As an aside, I understand that for some time nowchikungunya is also widespread in the West Indies and America. Can be fatal for people with medical problems. ververs Oct 10, 2014 PARACETAMOL - BEFORE ONE ENTERS A PLANE OF AIRPORT? I am working on Ebola and have come across various field workers that were told to take paracetamol before they board the plane going back home. Though perhaps understandable this may be, this is an outrageous advice and undermines the public health efforts to control EVD on global level. This should be looked at as soon as possible in my opinion.

Mija Ververs

Arno Rosemarin Oct 10, 2014 Sanitation?

Inadequate health care facilities is one central aspect and obviously the top priority. But what about the inadequate sanitation systems, including transport and treatment of faecal material? The % population using improved sanitation facilities in Guinea is 19% (11% rural), Liberia 17% (6% rural), and Sierra Leone 13% (7% rural) (WHO-UNICEF JMP, 2014). All three countries are off track from the MDG target for sanitation. The bigger battle is thus to safeguard the 25 million people in Sierra Leone, Liberia and Guinea plus the neighboring countries.

There are little data on resilience in sewage and low temperatures but the virus can remain virulent outside the body in bodily fluids for 6 days (CDC) and for 5 weeks at 4 degrees C according to www.ebola.org.za . Because sanitation coverage and functionality is so poor, most of the necessary protection will need to come from hand washing, treatment of drinking water, proper cooking of food and similar measures. Sanitation (containment and treatment) in the health care units where infected persons are being taken require secure toilet systems like dry (lime-treated) or incineration. Exactly how excreta and vomitus is being dealt with in the health care centres is a question.

Arno Rosemarin PhD Stockholm Environment Institute Sustainable Sanitation Alliance www.forum.susana.org

JimBynum Oct 10, 2014

@Arno Rosemarin

According to EPA and USDA viruses may survive in soil for 6 months and on plants for 2 months. http://thewatchers.us/pathogen-survival.html

urbanx_f Oct 10, 2014 @Arno Rosemarin This is a very good question to ponder. To add to this mess, what about rodents and other animals who may feast upon this and become infected, essentially becoming intermediary hosts of this zoonotiic disease?? urbanx_f Oct 7, 2014 Well, a good thing about Ebola, is that it does not belong to the family of Retroviridae, which essentially have "jumping genes", and can integrate into a host cellular genetic material. In the case of these particular viruses, it is accomplished through an enzyme called "reverse transcriptase." Targeting the viral genetic sequences for this enzyme, could disable the reproductive power and adaptability of the virus--a feat not so easily accomplished.

I cannot answer your question specifically, because I have yet to study the molecular biology of Filoviridae , which is what I assume you are referring to.

This virus may have many adaption capabilities, and in a population supporting trillions of single point mutations in a constant battle with human (and other) immune systems, there will inevitably be the development of new clades. The virus will have a goal of finding equilibrium with the host, and may tone down it's destructiveness, and try and reduce it's recognition by host immune cells. It may attempt to hide in macrophages and stay inactive for longer periods. It could also hide in specific organ cells.

One way to isolate the perfect target genes would be to infect amoebae (if you can find and grow a species willing to ingest the virus), and see if digestion of virus completes. Next, use sonification and separation gels to isolate amino chains.

Step 2, do comparative analysis of the particles by using human serum. Clusters will form; analyze what segments the serum proteins are so interested in.

The virus will have something in their genome that primates have seen before, and this may be a good way to narrow down the important ones. Plus, the virus may use quorum-sensing and start to assemble parts of itself--good to analyze those genes.

Yes there will be some confusion with amoeba genes, but I will bet the clusters will have something important to show. P.S. I'm just brainstorming here.

Jan Borg Oct 6, 2014 Any ideas or literature on the evolutionary pressures on a fast mutating virus, i.e. higher transmit ability (e.g. aerosol) and lower virulence (e.g. higher and longer survival)? Where and how are these two 'variables' coded? urbanx_f Oct 4, 2014 Just wondering if the virus being a zoonotic microbe, could possibly start infecting livestock leaving another challenge for containment strategies in an already overburdened response initiative. Could the virus alter it's genetic status through numerous immunological exchanges with multiple host populations? Would this expose this rare virus to new transposons and plasmids from other viral sources--being an RNA virus and all?

Could the virus wipe out host ability to produce interferon?

Do we know for sure this virus cannot be sustained in fluid minuscules from infected host expulsions? Can a vaccine be mass produced by using mixed serum antibodies from multiple survivors, exposing them to wild-type virus and isolate target zones as high potential antigens to be artificially reproduced using SPPS technology, and booster reagents?

TamaraLucas Oct 3, 2014 Comment received today via WhatsApp:

"What is the origin of this virus.What r the signs n symptoms of ebola. Is there any lab inv to diagnosis it. Is it present in india. What is the treatment."

thelancet moderator Oct 3, 2014 Answers to most of these questions are in this reviewhttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960667- 8/fulltext, which is available on the Ebola Resource Centre.

Natural host for the virus is probably bats in Africa. There is no specific treatment, although supportive care (eg, provision of fluids and electrolytes) seems to reduce mortality. The virus is not present in India. However, while the outbreak continues in west Africa there is always a risk that cases will be exported.

Petra Boynton Oct 2, 2014 Hello, I'm Petra from the UK. I wanted to share details of Hesperian who create numerous guides on public health and health care - particularly the famous 'Where there is no doctor'. These are printed in numerous languages and delivered in a variety of formats. Most importantly they are free to those of you living/working in resource poor communities.

Although not specifically dealing with Ebola the guides to address concurrent issues many people will be dealing with (sanitation, child health, maternal health etc) http://hesperian.org/books-and-resources

Lucy Hillier Sep 22, 2014 The Psychological First Aid Guide during Ebola Virus Disease Outbreaks is now available online. You can find more information, updates and resources related to the Ebola crisis on the Ebola, West Africa 2014 group on mhpss.net neilpw Sep 21, 2014 Thank you to The Lancet for making content on Ebola freely available to all. It is vitally important that policy makers, health professionals, researchers and the general public have access to reliable information about Ebola. People are dying (and, tragically, killing others as in Guinea) because of lack of understanding of Ebola. We invite all to join HIFA (Healthcare Information For All), a network of more than 13,000 health professionals, one-third of whom are based in Africa. We interact on 5 discussion forums in 3 languages in collaboration with WHO. www.hifa2015.org

The Lancet is a lead sponsor of HIFA Voices, a database that brings together the collective experience and expertise of HIFA members. This includes a growing collection of HIFA Quotations on Ebola: here is a selection of 16 HIFA Quotations, taken from HIFA discussions on Ebola over recent weeks (scroll down to see 16 items): http://tinyurl.com/o338rst Let’s build a future where people are no longer dying for lack of healthcare knowledge: Join HIFA www.hifa2015.org

Dr Neil Pakenham-Walsh, HIFA Coordinator [email protected] mimulus Sep 13, 2014 Searching Pubmed , it seems cytokine storm is responsible for the devastating symptoms of ebola. Nutritional factors have been shown to be important in the development of cytokine storms in past H1N1 flu epidemics. Could we think outside of the box of anti-virals and vaccines and begin using oral and IV therapies of Vit D, Vit C, N-acetyl cysteine to help prevent the immune system from going down the path of cytokine storm? Also, certain botanical medicines have shown to be helpful once the storm develops: Curcumin, Silybum, certain mushrooms.

Chigbo Sep 10, 2014 The action of our government in Nigeria, leaves one wondering whether our leaders are in any way concerned about the welfare of the people or whether they think that living in exulted mansions is a fortification against ebola. They have to appreciate that they have servants who are not as privileged as they are and as health conscious as they are. Again, did the federal government consult the association of resident doctors before taking the decision on re-opening of schools? Do our Nigerian politicians/leaders think that ebola could be handled in the Nigerian political way(doing the workables)? All others leaders in Nigerian should emulate the efforts of R. Fashola in containing this virus. I must warn that any form of laxity must not be condoned and that any external suggestion (s) must be subjected to Nkrumah's consciensism. We must be skeptical about any type of help so that we will be able to protect our own. If ebola wipes all the followers, who will be led by the leaders. Do not join others to reduce the population of your people. If you do, you must feel the pain in one way or another.

NyawiraNjoroge Aug 29, 2014 Sadly waking to the news of Senegal's first Ebola case. Then yesterday there were the biographies of the 5 West African co-authors who died before the publication of their Ebola genome Science paper. Then this report: "W.Africa,near complete collapse of all non- Ebola care; unassisted deliveries, unattended auto accident injuries," deaths are not just stemming from the virus." I feel crushed and heart broken. If the estimates given by the WHO of nearly a half billion dollars are needed to contain the crisis then I think we might see more spread to even more countries because resources have not been forthcoming. I'm sorry to be the bearer of all sad news.

Rose

joseleon Aug 27, 2014 Treatment with a group of 8 Ebola patients occurred in 1995 in the Democratic Republic of the Congo. Seven patients survived.

This article about the treatment appeared in the Journal of Infectious Diseases: "Treatment of Ebola Hemorrhagic Fever with Blood Transfusions from Convalescent Patients" A related article appeared in the Journal of Virology: Ebola Virus Can Be Effectively Neutralized by Antibody Produced in Natural Human Infection, appearing to support the initial work.

Newsweek reported on August 1, 2014, that the treatment was used on healthcare worker Kent Brantly.

The protocol does not appear to be highly technical nor complex.

If you wish to publish the journal links, they are here:

http://m.jid.oxfordjournals.org/content/179/Supplement_1/S18.full and http://jvi.asm.o rg/content/73/7/6024.full Lucy Hillier Aug 26, 2014 MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT RESPONSE TO EBOLA

Hi All,Thanks for this resource centre, I have shared it with the mhpss.net network in the Ebola Group. MHPSS.net is a leading global mental health and psychosocial support network. Please do join if you are interested in participating in and supporting mhpss information sharing and mhpss responses to the Ebola outbreak. The Ebola group is open to all http://mhpss.net/groups/regions-and-countries/africa/ebola-west-africa-2014/

but you must join mhpss.net first to upload and post comments. IFRC have already developed and are sharing Ebola modified mhpss resources, which you will find in this group site.

All the best, Lucy, Africa Host of mhpss.net

BLAIRMCB Aug 25, 2014 Hi Rose I am happy to say that what you have written here is closer to the truth than what many with in authority would like to hear. Africa needs to stand up and unite for the benefit of its people and give priority to what will remain priority. I did not go the site mentioned as yet but I sure will. Thanks NyawiraNjoroge Aug 25, 2014 @BLAIRMCB Thanks a lot for supportive and kind remarks. I am African. So obviously I want to see our continent progress. But this will need real transformation and honest good will from all stake holders. I wish we had selfless statesmen/women for leaders to steer such efforts. At the moment, in most African countries, self interest at the public's expense hinders any such efforts where they even exist. It is sad that we might continue to shed helpless tears as we navigate almost blindly from tragedy to tragedy for a long time but I hope and pray that this changes. Rose

NyawiraNjoroge Aug 24, 2014 What is the true situation in the DRC though. Most reports indicate there are two confirmed cases but an earlier report by Reuters (Aug 21st) indicates there may be as many as 70 which the WHO subsequently denied. Now I worry if we even know the real stats. Please see this Reuters report: http://reut.rs/1AL1OhI Samuel Dilito Aug 25, 2014 @NyawiraNjoroge The Ebola disease comes with denial even among the educated population. The population that is expected to play a leading role in the fight against the disease. Why?

NyawiraNjoroge Aug 25, 2014 @Samuel Dilito I have no idea why there's so much stigma around Ebola disease. I mean, with HIV it was easier to understand due to mode of transmission - not that that justifies it of course. But denial stems from stigma which in this case might be fueled by ignorance if we were to call a spade a spade. Just my two cents though. I'm not a social scientist so just guessing. Rose

Emmanuel Ben Aug 23, 2014 I am an epidemiologist in training (Msc in public health epidemiology option) at the college of medicine, university of Lagos, Nigeria.

Mass information on hand washing seems to be making the rounds. I've noticed an increase in demand and use of hand sanitizers more than hand washing.

Amidst the poor functioning of the health system in west Africa where the Ebola outbreak is, the cultural practices with regards communal living (a community functions as a family also religious institutions "being a brothers keeper") in my view is key. As such life style behaviour modifications that predispose to Ebola outbreak ought to be inculcated in the management of this health crisis.

At Prof. Gbakim we are all in this together, we would come out stronger.

NyawiraNjoroge Aug 24, 2014

@Emmanuel Ben Hi Ben, of all the views about the current outbreak I found Dr. Paul Farmer's the most useful (at least of the ones I have managed to read/listen to). You can listen to him here: http://www.democracynow.org/2014/8/22/dr_paul_farmer_on_african_ebola

NyawiraNjoroge Aug 23, 2014 I have worked in disease surveillance in East Africa and the current outbreak is really heartbreaking. I have been puzzling over what the role of surveillance organizations like the Global Viral Forecasting Initiative (GVFI) - they might have changed their name- who have a substantial presence in West Africa had been prior to the outbreak and has been since. Beyond that, I think Africa needs to reexamine the stand on some key NTDs (Neglected Tropical Diseases) and may be prioritize a few for research and drug development within the continent. Further ruminations on this can be found here: http://bit.ly/1raAxV3 on my blog although the article has been dubbed as being too harsh on Africa but really we must not be afraid to ask the tough question on where we will go from here. Thanks.

Rose N. Njoroge

PhD Student Northwestern, Chicago.

Debashis Bhattacharya Aug 23, 2014 As the battle against Ebola rages on, there is an urgent need to devote ourselves to organise at multiple levels. There needs to be a concentrated effort in education, awareness, change in attitudes, cultural practices and an augmented social and political response at a micro level along with a global level. Alongwith an international response there is a need for grassroots organisation

In this regard we are producing a series of audio movies to educate the general population at a grassroots level to empower people and aid various agencies in tackling a more mature population.

funsho_65 Aug 23, 2014 Will UV light sterilization suffice for treating the ambulance cabbing used for evacuation of patient with EVD BLAIRMCB Aug 24, 2014 @funsho_65 This I am not certain to give a definite answer or comment, more info is needed, but if such is true then such cases should not be that complicated to brake the transmission Dr Blair

HollyGardner Oct 14, 2014 @funsho_65

"Only one laboratory study, which was done under environmental conditions that favor virus persistence, has been reported. This study found that under these ideal conditions Ebola virus could remain active for up to six days.1 In a follow up study, Ebolavirus was found, relative to other enveloped viruses, to be quite sensitive to inactivation by ultraviolet light and drying; yet sub-populations did persist in organic debris." http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html ahmedi_hassi Aug 22, 2014 I am consultant ID from the middle east and I am the responsible person in my city to follow Ebola outbreak. KizitoLubano Aug 22, 2014 The threat of ebola is a wake-up call for the African leadership to invest in health systems including research to tackle conditions unique to their region. This further calls on international community to offer support, but guard against dependency by African Governments on anything health gbakimaaa2009 Aug 21, 2014 Subject: Greetings and overwhelmed by the Ebola Outbreak in Sierra Leone

Dear Colleagues,

Greetings from Freetown, Sierra Leone, where by now and under normality, we would have had a training with participation by both of you. But, it is not to happen with this kind of health issues at stake in my country at the present time. Every activity in our lives here are almost quarantined and public gatherings have been banned, schools closed etc. Despite all this, we are panning on a meeting this coming Saturday and with permission from the security forces, we will have our in house meeting with reviewers and interns. I hope we will be able to contain this virus in the next few months so life could return to normal. pray for our country.

God Bless.

Best regards,

Aiah A. Gbakima

Editor-in-Chief, Sierra Leone Journal of Biomedical Research (SLJBR).

AbenaPhD Aug 22, 2014 @gbakimaaa2009 Dear Prof Gbakima, good to read from you. I met you about decade ago at the Noguchi Memorial Institute for Medical Research in Accra, Ghana. Hoping for a quick resolution to the situation and that mechanisms are put in place for the future.

Best wishes,

Abena FlagShare

WAHRNET ROARES ROAPES Aug 22, 2014

@gbakimaaa2009 Dear Prof Gbakima, very happy to hear from you now. We are very sad of what we heard and have seen on the medias because of Ebola. However, we are sure that you be able to contain the virus. So stay strong and be courageous.

We think about you and also our colleagues of WAHRNET members from Guinea and Liberia.

We love all of you.

God Bless

BALIMA Thomas

Administrator WAHRNET, ROARES, ROAPES aidam Aug 23, 2014 @gbakimaaa2009

Hello Prof.,

We stand in solidarity with you and all our colleague researchers and Healthcare providers in Sierra Leone, Guinea, Liberia and Nigeria as we struggle arm-in-arm to overcome this EVD in our region.

We give thanks also to all our colleagues and partners from the West African region and from around the world. Please let us not be paralyzed by fear but address it with caution, respect, science and a willingness to change our cultural practices.

The "re-newed" ECOWAS regional strategy is being fashioned with the Ministers, and all the major partners in Accra from 26-28 July 2014 so let look out.

Regards,

Jude...

West African Health Organisation www.wahooas.org