Course correction

The following editorial appears in the November issue of Nature Medicine.

The international response to the ongoing Ebola epidemic has in many respects been more reactive than proactive. But there are changes that, if made, may shift the balance toward future readiness. 

The projections are appalling. At the time of this writing, the World Health Organization (WHO) stated that the number of new Ebola virus disease cases could reach 10,000 per week before the end of the year. The three most heavily afflicted nations—Guinea, Liberia and Sierra Leone—remain woefully underequipped to stem the tide of infection. Severe shortages in medical personnel, protective gear, treatment beds and burial teams hinder almost every aspect of the effort. Cases of transmission were also reported in the US and Spain.

One thing is clear: the international community was not prepared to respond to this outbreak. Less clear is how, with limited resources, to stop the current epidemic. But several broad areas stand out as particularly important for efforts to stem Ebola’s spread and improve preparedness for future outbreaks. Continue reading

White House suspends enhanced pathogen research

Past research made the H5N1 virus transmissible in ferrets.

Past research has made the H5N1 virus transmissible in ferrets.{credit}Sara Reardon{/credit}

As the US public frets about the recent transmission of Ebola to two Texas health-care workers, the US government has turned an eye on dangerous viruses that could become much more widespread if they were to escape from the lab. On 17 October, the White House Office of Science and Technology Policy (OSTP) announced a mandatory moratorium on research aimed at making pathogens more deadly, known as gain-of-function research.

Under the moratorium, government agencies will not fund research that attempts to make natural pathogens more transmissible through the air or more deadly in the body. Researchers who have already been funded to do such projects are asked to voluntarily pause work while two non-regulatory bodies, the National Science Advisory Board for Biosecurity (NSABB) and the National Research Council, assess its risks. The ban specifically mentions research that would enhance influenza, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). Other types of research on naturally occurring strains of these viruses would still be funded.

This is the second time that gain-of-function research has been suspended. In 2012, 39 scientists working on influenza agreed to a voluntary moratorium after the publication of two papers demonstrating that an enhanced H5N1 influenza virus could be transmitted between mammals through respiratory droplets. The publications drew a storm of controversy centred around the danger that they might give terrorists the ability to create highly effective bioweapons, or that the viruses might accidentally escape the lab. Research resumed after regulatory agencies and entities such as the World Health Organization laid out guidelines for ensuring the safety and security of flu research.

The OSTP’s moratorium, by contrast, is mandatory and affects a much broader array of viruses. “I think it’s really excellent news,” says Marc Lipsitch of Harvard University in Cambridge, Massachusetts, who has long called for more oversight of risky research. “I think it’s common sense to deliberate before you act.”

Virologist Yoshihiro Kawaoka of the University of Wisconsin–Madison, who conducted one of the controversial H5N1 gain-of-function studies in an effort to determine how the flu virus could evolve to become more transmissible in mammals, says that he plans to “comply with the government’s directives” on those experiments that are considered to be gain-of-function under OSTP’s order. “I hope that the issues can be discussed openly and constructively so that important research will not be delayed indefinitely,” he says.

The NSABB, which has not met since 2012, was called back into action in July, apparently in response to a set of lab accidents at the US Centers for Disease Control and Prevention in which lab workers were exposed to anthrax and inadvertently shipped H5N1 virus without proper safety precautions. The NSABB will spend most of its next meeting on 22 October discussing gain-of-function research, and the National Research Council plans to hold a workshop on a date that has not yet been set. Lipsitch, who will speak at the NSABB meeting, says that he plans to advocate for the use of an objective risk-assessment tool to weigh the potential benefits of each research project against the probability of a lab accident and the pathogen’s contagiousness, and to consider whether the knowledge gained by studying a risky pathogen could be gained in a safer way.

Correction: This post has been changed to specify that Yoshihiro Kawaoka’s 2012 gain-of-function research increased the transmissibility of H5N1.

First US Ebola case diagnosed

A man has been diagnosed with Ebola virus disease in Dallas, Texas.

The man diagnosed with the illness on 30 September is the first in the United States, and the first person ever diagnosed outside Africa with the Zaire species of Ebola virus, which has killed more than 3,000 people in Africa in the current outbreak. A handful of Ebola patients have been treated in the United States during the current outbreak after being diagnosed with the disease in Africa.

The patient travelled from Liberia to the United States on a flight that landed on 20 September, began experiencing symptoms on 24 September, sought care on 26 September and was admitted to an isolation ward at Texas Health Presbyterian Hospital Dallas on 28 September. The US Centers for Disease Control and Prevention (CDC) in Atlanta and a state health department lab in Austin, Texas, both diagnosed Ebola in samples from the patient.

CDC director Thomas Frieden said that the patient was in the United States visiting family and did not appear to be involved in the Ebola outbreak response in Africa.

Frieden said that public-health officials began tracing the contacts of the individual today, and do not think that passengers who were on his flight are at risk of infection with Ebola. Frieden said that officials have identified “several family members and one or two community members” who had contact with the patient after he became sick and so therefore may have been exposed to the virus. Officials will monitor them for 21 days, the period of time in which they will show symptoms if they have been infected with Ebola.

“Ebola doesn’t spread until someone gets sick, and he didn’t get sick until four days after he got off the airplane, so we do not believe there was any risk to anyone who was on the flight,” Frieden said.

“I have no doubt that we will control this importation, or case of Ebola, so that it does not spread widely in this country,” Frieden said. “It does reflect the ongoing spread of Ebola in Liberia and West Africa where there are a large number of cases.”

Frieden said further that doctors were considering providing experimental treatments to the patient such as injections of blood or serum from other Ebola survivors.

“That’s being discussed with the hospital and family now and if appropriate, they would be provided to the extent available,” Frieden said.

Few other details about the patient were provided, though officials did say that he is “ill and in intensive care”.

 

Ebola: a call to action

The following editorial appears in the September issue of Nature Medicine.

The size, speed and potential reach of the 2014 Ebola virus outbreak in West Africa presents a wake-up call to the research and pharmaceutical communities—and to federal governments—of the continuing need to invest resources in the study and cure of emerging infectious diseases.

At the time of this writing, more than 2,200 people are estimated to have been infected by a new strain of Zaire ebolavirus in four West African nations, and more than 1,200 have died. Infection can cause fever, vomiting, diarrhea and internal and external hemorrhaging that can lead to death. Neighboring as well as non-neighboring countries are at risk because of porous borders and air travel of presymptomatic infected individuals, the latter having resulted in the spread of infection to Nigeria. And while the death rate—estimated at 55%—is lower than that of many previous Ebola outbreaks, the total number of cases exceeds all ebolavirus infections since 1976. We don’t know when the outbreak will end, or how far it will spread, but its control is expected to take months and may involve extraordinary measures.

Ebola virus first emerged in the Democratic Republic of the Congo (DRC) and in South Sudan in 1976 and reappeared in South Sudan in 1979, but it caused no further outbreaks until 1994. Since then, there have been several outbreaks in Africa, but none approached the magnitude of the current outbreak. The natural reservoir of the virus remains unclear, but it is suspected to be the fruit bat. However, Ebola virus also infects nonhuman primates, a species of antelope and porcupines, all of which could be sources of human transmission.

The unusually rapid and far-reaching spread of the virus during the current outbreak has been facilitated by insufficient treatment and containment facilities in West African nations that had no prior experience with Ebola; a distrust of Western medical practices; the stigma associated with infection, causing failure to seek early treatment; as well as the long asymptomatic incubation period of the virus (up to 21 days), which enables dissemination through travel.

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Ebola outbreak in West Africa lends urgency to recently-funded research

Electron micrograph of Ebola virus

Electron micrograph of Ebola virus{credit}CDC/ Frederick Murphy{/credit}

Earlier this year, the Ebola virus popped up for the first time ever in West Africa. How it got there, some 2,000 miles from previous Ebola hotspots in remote parts of Central Africa, remains a mystery. Experts are particularly concerned about the current outbreak, which has sickened more than 250 and killed at least 140, because the pathogen has made its way into Conakry, the densely populated capital city of Guinea.

Unfortunately, there are no vaccines or treatments approved to work specifically against the virus, which first emerged in the forests of Zaire (now the Democratic Republic of Congo) in 1976. The virus’s high virulence and lethality make it challenging to study, and its rarity means that any effective therapeutics that are developed will likely have limited commercial potential, leaving pharmaceutical companies little financial incentive to develop treatments against the pathogen.

Very few candidate therapeutics against Ebola have proven effective in non-human primates, the gold-standard animal model for research against such viruses. But there is, amidst the ongoing outbreak, mobilization of funding toward anti-Ebola agents that have proven their mettle in such models: last month the US National Institutes of Health announced that it was putting a combined total of more than $50 million towards a handful of the most promising approaches.

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