Saudi Arabia Is on the Cusp of Another MERS Outbreak

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In the last 24 hours, Saudi Arabia’s Ministry of Health has reported ten new cases of MERS in the capital city of Riyadh, and one death from the virus. Those numbers follow reports of nine new cases yesterday, along with two deaths. According to Helen Branswell, one of WIRED’s favorite infectious disease reporters, the state hasn’t seen that many new infections in a day since the height of the MERS outbreak last year.

 

This is especially concerning as travelers begin to arrive for the hajj, the annual pilgrimage to Islam’s holy sites that falls between September 20 and 25 this year. Over the course of the pilgrimage, Saudia Arabia hosts more than 2 million people, who sleep in hot shared tents and travel barefoot toward their destinations. Those conditions make it extraordinarily easy for a virus like MERS to spread—especially devastating because MERS kills about 50 percent of the people it infects. The country has not yet posted its health regulations for 2015 hajj travelers.

 

Grace Tung-Thompson

Somewhere on the North Carolina State campus, a machine has been puking vanilla pudding. Aerosolized vomit-pudding sprays out of its mouth, which stretches open in permanent retching position. Unpleasant? Not as unpleasant as the real-life scenario the vomiting machine is testing: whether norovirus spreads through aerosolized human puke.

Bad news, the answer is probably yes, according to the vomiting machine researchers who published their results in PLoS ONE today. Norovirus causes 20 million cases of food poisoning in the US every year—usually on cruises and other confined spaces with cafeterias. The virus is highly contagious. Epidemiologists have long suspected that barfing sends the virus airborne, allowing it to land on new surfaces or, for the especially unlucky bystander, right in his or her mouth. Gross, but very convenient for a virus that causes puking.

 

Side view of the vomiting machine. Grace Tung-Thompson

The NC State researchers spent two years building and then testing a miniature version of the upper digestive tract—essentially a tube (esophagus) connected to a pressurized chamber (stomach). Then they mixed together fake saliva, fake vomit aka vanilla pudding, and a real virus. Norovirus itself is too dangerous to work with, so they used a bacteriophage harmless to humans called MS2. The machine heaved this mixture into a chamber, and a device vacuumed out any aerosolized particles for analysis.

In a worst case scenario, a single puking episode aerosolized as many as 13,000 virus particles. And it only takes 20 to 1,300 virus particles to get someone sick. So be considerate when you puke, okay?

 

A man reacts to the camera as he works to dismantle shelters in an Ebola treatment center closed by Doctors Without Borders in the Paynes Ville neighborhood in Monrovia on March 25, 2015. ZOOM DOSSO/AFP/Getty Images

According to a study published today in the Lancet, an international coalition of researchers have suggested they may have an effective Ebola vaccine. The results are only preliminary—the study is about halfway done—but so far, none of the 2,014 people in Guinea who received it immediately after potential exposure to the virus got infected.1

Right now, Doctors Without Borders—one of a number of organizations involved in the research, including WHO and the Wellcome Trust—is recommending that health workers distribute the vaccine, called rVSV-EBOV, more widely in Guinea and Sierra Leone, where the Ebola outbreak is still active. (That stands for, take a breath: recombinant, replication-competent vesicular stomatitis virus-based candidate vaccine expressing the glycoprotein of a Zaire Ebolavirus.)

The results are so promising, in fact, that the research itself has changed. Instead of using two randomized groups of subjects—one that receives the vaccine immediately after potential exposure and one that receives the vaccine 21 days after—the researchers are now giving the vaccine to every subject immediately.

But…that doesn’t mean Ebola is solved. The research is still ongoing, and a story in the Wall Street Journal says that the US Food and Drug Administration has written a commentary critical of the study. As the Ebola outbreak has settled down in recent months, it has become more difficult to find groups of people exposed to the virus to test vaccines on. And the study’s design—a so-called ring vaccination trial, which doesn’t include a control group that got a placebo instead of the vaccine—makes it more difficult to draw out statistically significant results.

Still, though, “this is the only vaccine where we have efficacy data,” says Rebecca Grais, director of research at Epicentre, the research and epidemiology branch of Doctors Without Borders. If it’s possible for Merck, the manufacturer of the vaccine, to ramp up production and establish a cold chain to deliver the vaccine (it’s “live,” which means it’ll spoil without refrigeration) to the front lines, it may be possible to end the Ebola epidemic. “Even if the efficacy were significantly lower than 100 percent, it would still be worth using,” says Grais. “This is a disease that has an extremely high mortality rate.”

In the meantime, research and development into other vaccines and treatments will continue. But if evidence continues to support the efficacy of rVSV-EBOV—along with more analysis to learn how to scale it up—governments may soon face a difficult ethical decision: Choose to continue studies of other, potentially more effective drugs, or interrupt that research to give subjects a good-enough vaccine that could save their lives.

1UPDATE 6:10PM ET 7/31/15: This post has been updated to reflect the number of immediately-vaccinated individuals in the study. 4,123 subjects were assigned to immediate vaccination, but only 2,014 actually received the vaccine.

Today, an international coalition of researchers published a study in the medical journal the Lancet that suggests a vaccine called rVSV-EBOV protects against Ebola. It’s been a long, hard road to develop and test that vaccine, which may or may not prove to be the perfect protector that initial results indicate. But there’s another side to the fight against Ebola: the work being done by some of the same organizations to develop not a preventive vaccine, but a treatment for people who have already been infected by the deadly virus.

In December, reporter Erika Check Hayden traveled to Sierra Leone to report on the front lines of the medical and research response to Ebola. In the early days of the outbreak, medical care was painfully simplistic: Volunteers and doctors treated patients with antibiotics, pain medications, and vitamins, and rehydrated them orally or—if they couldn’t drink—with IV fluids. Containment within these sometimes-gruesome facilities was key: Volunteers and doctors wore Tyvek waterproof suits for protection, and obsessively washed themselves and surfaces with buckets of chlorine.

Sometimes, full protection wasn’t possible—and it was in the unfortunate exposure of some health care workers to Ebola that a hint at an answer appeared. Some outreach workers, like Mohammed Sankoh Yillah, tested positive for Ebola but then recovered. (Some of those survivors, seemingly immune to re-infection thanks to their antibodies against the virus, returned to help and treat others.) Doctors thought that they could find a solution in those people’s antibodies: What was it about them that helped them survive where others did not?

In her feature for WIRED in July, Hayden documents the efforts of one research group to unravel the mystery of those survivor’s antibodies.
Read the full story here: Ebola Survivors May Be the Key to Treatment—For Almost Any Disease

 

This map, dated July 15, shows the number of days since active cases were discovered in the three countries where ebola is still a threat.This map, dated July 15, shows the number of days since active cases were discovered in the three countries where ebola is still a threat. CDC

Officially, it’s called the Ebola Outbreak of 2014. But it’s 2015 now, and the disease is still infecting people. For the past two months, that rate was about 15 people a week. But in the past two weeks, the rate has doubled.

This is bad. Not last summer-bad—when weekly infection rates were in the hundreds—but bad enough that relief agencies have begun to worry about a resurgence. And even a trickle of infections is a wear on the aid workers, government authorities, and most of all, communities living in months of fear. “I was here in 2014. If you would have told me in 2014 I would see 30 cases of Ebola every week I would not have believed it,” says Marc Forget, Doctors Without Borders’ relief coordinator for Guinea.

What’s behind the continued spread? Depends on where you go. In Guinea and Sierra Leone, Ebola never died, and the new cases are a continuation of the same strain that first emerged in December of 2013. In Liberia—which declared itself ebola-free on May 12—experts believe the new outbreak was transmitted through sexual intercourse, from latent viral bodies that were alive in a man’s sperm.

In some ways, it’s tougher to stamp out a flicker of disease than it was to handle an apocalypse-sized outbreak. “If you have a big disease center, you have the ability to isolate as many patients as you can,” says Forget. It might not be apparent who is giving the disease to whom, but you can be pretty sure that everyone is in the same place.

On the final sprint, aid workers have to track down every single case, and make sure every person that the infected case came into contact with have been identified. “We track each case and try to get ahold of all the people they contacted while sick, and then follow each of them for 21 days,” says Forget. Despite all the resources in place, about a third of all new cases are coming from people without known prior contacts. “So these are contacts that we either weren’t able to identify, or who ran away and were hiding,” he says.

As an example, Forget brings up a case that came in just a few days ago. “A young medical student was working in a private clinic on the side,” he says. While there, the student encountered a few infected kids and caught Ebola. Then he went home to his big room inside a big communal cluster of homes. “There you have 33 people who were in contact.” The man, who was diabetic, started to feel sick, and thinking he was experiencing symptoms of his prior condition went to a clinic. The workers there gave him diabetes-specific tests.

Still feeling sick the next day, he went to a much larger university hospital—through triage, examination, and the endocrinology ward. Eventually his symptoms were identified as Ebola, but not before he came in close-enough-to-transmit contact with 65 people. And counting. “Even if he was in contact with 80 people, and we got 75, there are still five people we didn’t identify,” says Forget.

Even though the disease was so prevalent, people are still hesitant to out themselves as having been potentially exposed. “If they have symptoms and people know they will be restricted,” says Forget. Not just for the 21 days, but socially the stigmatization can last for much longer.

More than that, people in the affected region are tired of the disease—much more tired than you are of seeing it reappear in the headlines. Not just because of the uncertainty and fear, but also for the way it has affected the economy, education, and other basic structures of society. “I would just like people not to forget about Ebola because it’s not done,” says Forget. “If you are here you can’t stop paying attention.”

So, by the numbers: 19 months, 27,741 infections, 11,284 dead. And counting.

 

This map, dated July 15, shows total ebola infections since the current outbreak began.This map, dated July 15, shows total ebola infections since the current outbreak began. CDC