From "concierge" services to iPads connecting new parents with their babies in the nursery, Kojo explores some of the patient-centered ideas coming from health care innovation labs at local hospitals.
The Ebola virus outbreak in West Africa has already claimed more than 700 lives in Guinea, Sierra Leone and Liberia. As medical workers on the front lines rush to isolate victims and stop the virus, scientists around the world are racing to identify future hot-spots and learn how human-animal relationships effect outbreaks. Kojo talks with global virus hunters about their work, the deadly Ebola outbreak and how “medical diplomacy” is impacting health from the most remote village to the largest metro area.
- Randal Schoepp Chief, Applied Diagnostics Branch, U.S. Army Medical Research Institute of Infectious Diseases
- Daniel Lucey Infectious Disease and Public Health Physician; Adjunct Professor of Microbiology and Immunology, Georgetown University Medical Center
- Jonna Mazet Professor of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis; Principal Investigator and Co-Director, PREDICT
Scenes from Liberia’s Ebola Testing Center
Randal Schoepp, chief of the Applied Diagnostics Branch of the U.S. Army Medical Research Institute of Infectious Diseases, has been studying and testing the Ebola virus that broke out in West Africa. He took these photos at the testing lab in Monrovia.
MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. Later in the broadcast, Femi Kuti, son of Fela, artist and activist in his own right -- he joins us to talk about agriculture in Africa, his life, his career and of course Fela. But first, today, as African leaders gather for a Washington summit, a health threat has cast a shadow over the event and Africa itself. An outbreak of the lethal Ebola virus in Liberia, Sierra Leone and Guinea has already claimed more than 800 lives and forced two leaders to cancel their Washington visit.
MR. KOJO NNAMDIBut even as health workers race to treat victims, global virus hunters are studying this disease and many other infectious agents to find out what makes them tick. Getting up close and personal with these diseases sounds like a scary job, but it's a vital task that goes on long before and well after hot-zones emerge. So how do these scientists act as both medical detectives and medical diplomats? What are they doing in the current crisis? And how are they tackling other emerging threats around the globe?
MR. KOJO NNAMDIJoining us to discuss this is Daniel Lucey. He's a professor of microbiology and immunology at Georgetown University Medical Center. Dan Lucey, thank you for joining us.
MR. DANIEL LUCEYThank you very much for having me, Kojo.
NNAMDIJoining us from studios of the -- at the University of California at Davis is Jonna Mazet, professor of medicine and epidemiology at the School of Veterinary Medicine at the University of California, Davis. She's also the principal investigator and co-director of PREDICT, a global early-warning system for infectious diseases. Jonna Mazet, thank you for joining us.
MS. JONNA MAZETThanks for having me, Kojo.
NNAMDIAnd joining us by phone from the U.S. Embassy in Monrovia, Liberia, is Randal Schoepp, chief of the Applied Diagnostics Branch of the U.S. Army Medical Research Institute of Infectious Diseases. Randy Schoepp, thank you for joining us. I'll start with you. Last week, the U.S. flew in an Ebola patient for treatment in Atlanta. And we're expecting another this week. While this is the first time this health crisis has touched the U.S., you have been working amidst the outbreak for months. Can you give us a sense of what it's been like to work in Liberia and Sierra Leone as this crisis has worsened since February?
MR. RANDAL SCHOEPPAbsolutely, Kojo. It is -- it's difficult. These areas in the world are ill-prepared for these very serious diseases. It's always a challenge working here. We have to bring most everything with us. When we arrive, it is -- at least in the case of Liberia, here -- we had to set up the entire laboratory, train the staff, and then supervise them as they help fight against this disease in their own country.
NNAMDIRandy, I would imagine that many of our listeners may not be familiar with USAMRIID and the work that it does. Can you tell us about your role there and around the globe?
SCHOEPPAbsolutely. USAMRIID is the Department of the Army's high-level biological containment laboratories where we do a great deal of research on medical countermeasures for some of the most serious diseases such as Ebola. We work on vaccines, therapeutics and, my area of expertise, diagnostics.
NNAMDIRandy, USAMRIID played a key role in the development of the serum that was given to the two U.S. medical workers now being treated for the virus. While I know that developing vaccines is not your department, I wonder if you could comment on this cocktail, what it showed in monkeys and if your diagnostics team had any role at all in its development?
SCHOEPPCertainly, Kojo. Again, my knowledge of this is through the colleagues from USAMRIID that worked on this particular therapeutic. I can tell you that it is basically a cocktail of three humanized monoclonal antibodies that were actually produced in tobacco plants. This cocktail came out of a cooperation or collaboration with researchers at USAMRIID, most notably, Mary Kay Hart, and researchers at Public Health Canada, Dr. Gary Kobinger. They looked at six antibodies, down-selected those six antibodies for the three that seemed to have the greatest effect on survival with Ebola infections.
SCHOEPPAnd then Dr. Kobinger at Public Health Canada tested these three monoclonal antibodies, this cocktail, in non-human primate models at various concentrations and at various time points within the infection. And I think the greatest thing that came of these studies was that this was effective in animals that were in the final, most advanced stages of Ebola, and brought them back. So that is huge in our field.
NNAMDI800-433-8850 is the number that you can call if you have questions or comments. If you have questions for our global virus hunters, 800-433-8850. You can send email to email@example.com or send us a tweet @kojoshow. Dan Lucey, if Kent Brantley and Nancy Writebol recover completely, what would be the next steps for the serum?
LUCEYWell, Kojo, this is a little bit beyond...
SCHOEPPKojo, again, this is not my area of expertise. But I believe that the next step would be for the developers to look into designing clinical trials.
NNAMDIThat's what you were going to say, Dan Lucey?
LUCEYYes, exactly. I think we can't make any definitive conclusions about whether the said monoclonal antibody cocktails were responsible directly for the clinical responses -- the improvement that the two patients apparently have shown, according to the media. So you need to do prospective clinical trials involving many more patients.
NNAMDIRandy, last month, you published a study that suggested Ebola may have been circulating in that part of Africa far longer than scientists previously thought. Tell us about your finding.
SCHOEPPCertainly. The paper that you speak of was work that I started in 2006 in Sierra Leone, looking at -- we originally got into Sierra Leone to help add capacity to the country for diagnostics for Lassa fever, which is another hemorrhagic fever. This is, unlike other hemorrhagic fevers, this is a virus that occurs at about the same time every year and we have a number of cases. So it's a good place to study. We found that we were getting 500 to 700 cases a year. And that when we looked at those, that only 30 to 40 percent of those cases were Lassa. So my interest was in the 60 to 70 percent that were not.
SCHOEPPSo I began to look at other diseases that could or possibly occur in that region of the world. One of the things I found was antibodies -- the earliest antibodies, IgM, to the Ebola infection. When we looked at this through other mechanisms of immunodiagnostics, we were able to see that this virus that was possibly infecting these individuals was closely related to the Zaire strain. About a week after the final review at emerging infectious diseases, the outbreak began. And it turned out to be a variant, a strain of the Zaire virus.
NNAMDIRandal Schoepp is chief of the Applied Diagnostics Branch of the U.S. Army Medical Research Institute of Infectious Diseases. He joins us by phone from Monrovia, Liberia. Jonna Mazet is a professor of medicine and epidemiology at the School of Veterinary Medicine at the University of California, Davis and the principal investigator and co-director of PREDICT, a global early-warning system for infectious diseases. And Daniel Lucey is a professor of microbiology and immunology at Georgetown University Medical Center.
NNAMDICan you explain how people can be exposed to awful viruses like Ebola, Lassa fever and Marburg and survive? What happens in their bodies, Daniel Lucey?
LUCEYWell, fortunately we have a very well developed over a long evolution immune system. And that's helped us over the many, many years that we've been on this planet to fight off common viruses and rare and brand-new viruses. So it's really our immune system up until recently, when we've been able to develop for some infectious diseases, specific antimicrobial treatments, and for some vaccines and now, for Ebola and some others, specific antibody treatments.
NNAMDIYou have spent years following the SARS virus as well as the newly-emerged Middle East respiratory virus called MERS. In all of these viruses, it's human interaction with or consumption of animals that precipitates the spread. Have we been able to pinpoint definitively which animals are carriers of these nasty viruses?
LUCEYFor some of them, yes, Kojo. But for others the work is still going on. For example, Ebola, it's still going on. For the Middle East Respiratory Syndrome, or MERS, camels are highly suspected as being a sources, but perhaps bats also, as is suspected for Ebola and for quite a few other diseases. SARS and Marburg virus, the Rabies virus, bats are often thought to be infected, even if they don't become ill themselves. With SARS, in 2003, it was an animal called the civet cat, but also again bats were implicated. And again this is work that Dr. Jonna Mazet also does around the world.
NNAMDIJonna Mazet at U.C. Davis, you and your team work in areas around the world to identify and even to predict viruses and viral outbreaks before they happen. First, I have to get the obvious question out of the way. Was an Ebola outbreak in West Africa on your radar screen, Jonna?
MAZETYes, it certainly was. And I think what we need to do now is sort of move away from predicting the next Ebola and instead predict where the areas are ripe for emergence of an infectious disease like this horrible Ebola outbreak. Working together with the U.S. Agency for International Development, another U.S. agency that's helping like USAMRIID, we really are trying, around the world, to get to a place where the communities have the local capacity to do diagnostics, not just for Ebola or whatever is happening in the neighboring country right now or whatever happened last year.
MAZETBut instead get to a place where they can diagnose what might be coming and know just what you said, Kojo, in what host these pathogens might be, so that we can help them and they can pass on to their children the best practices to prevent these kinds of outbreaks from happening.
NNAMDIWe've been talking about how our interaction with animals -- you mentioned hosts -- has contributed to sickening people around the globe. But, Jonna, how does our manipulation of the environment contribute to it?
MAZETYeah, exactly. So we often see these kinds of outbreaks happening right where we have disruption of the environment -- people moving into areas where they weren't necessarily populated before and interacting with animals both in a different way than they had before, like eating species they might not have eaten before that might have a virus like Ebola, that those people in that community hadn't seen. But also, just disrupting the area so much that the animals are starting to behave differently. Maybe their immune systems are shocked by suddenly having the forest cut down.
MAZETAnd so they start to shed these viruses or pathogens and make them available to people in ways that haven't happened. So Ebola, for example, seems to be one of those diseases that happens exactly when the health infrastructure is poor, education is poor, there is sort of environmental disruption. And then we have maybe a change in environmental influences like temperature. And the animals start to get debilitated as well.
NNAMDIIs that the kind of environment in West Africa that makes, if you will, a perfect storm for an Ebola outbreak?
MAZETYeah, I think the perfect storm is that environmental situation along with the social and behavioral situation that we're seeing in this outbreak. So it also has to do about education. And I think even the way we're reacting here in the U.S. to this Ebola outbreak is really a lot about the fear because it's a scary horribly devastating disease. But it has nowhere near taken the death toll that we've seen in recent years with flu, for example, or ongoing outbreaks of malaria and cholera around the globe that are claiming thousands to hundreds of thousands of lives.
MAZETBut we accept those, like we accept the risk of driving in our car. So what we'd really like to see is get to the place where we know what's out there, we know how it might be transmitted and reduce that fear.
NNAMDIGot to take a short break. If you have called, stay on the line. We'll try to get to your calls as soon as possible. If you'd like to call, the number's 800-433-8850. Do you think the Ebola outbreak in Africa will bolster more attention, more funds for fighting infectious diseases internationally? 800-433-8850 or you can send email to firstname.lastname@example.org or shoot us a tweet @kojoshow. I'm Kojo Nnamdi.
NNAMDIWelcome back. We're talking about tracking, treating and preventing viral outbreaks with Daniel Lucey, a professor of microbiology and immunology at Georgetown University Medical Center. Jonna Mazet is a professor of medicine and epidemiology at the School of Veterinarian Medicine at the University of California Davis, and the principal investigator and co-director of PREDICT which is a global early-warning system for infectious diseases.
NNAMDIAnd Randall Schoepp. He is chief of the Applied Diagnostics Branch of the U.S. Army Medical Research Institute of Infectious Diseases. You can go to our website kojoshow.org and you can see a slideshow of pictures that Randy has taken in and around the testing lab for Ebola in Monrovia, Liberia. That's at our website kojosho.org. If you'd like to join the conversation, give us a call at 800-433-8850. Here is Ken in Gaithersburg, Md. Ken, you're on the air. Go ahead, please.
KENHi. Thank you for taking my call. As a physician, I'm fairly unconcerned about the possibility of Ebola spreading into various world societies because it's not a terribly infectious disease in the kind of environment that we have. What I am concerned about, and I was wondering if any of the panelists heard about, is outbreaks of pneumonic plague in China.
LUCEYYeah, so periodically there are small numbers of persons who develop plague. It's due to a bacteria called Yersinia pestis. When this bacteria involves the lungs it's called pneumonic plague and it causes pneumonia. Usually if it doesn't involve the lungs it's called bubonic plague, meaning involving the lymph nodes. So just recently, sir, I think -- I was actually in Hong Kong in Beijing at the end of July and there was a report at that time of one patient with pneumonic plague in a specific province in a specific city in China.
LUCEYAnd there were reports in the media in the South China Morning Post, for example, in Hong Kong that China had taken various strong countermeasures, if you will, in terms of closing off the city until they were sure that there were not additional cases. Because the form of plague called pneumonic plague is transmissible through the air, is contagious through the air, unlike bubonic plague.
NNAMDIThank you very much for your call. Jonna Mazet, you've spent a lot of time looking at the Nipah virus that's been particularly deadly in Bangladesh. What have scientists discovered about why that virus is spreading?
MAZETSo that's a great example of these behavioral practices that can be changed. It's hard to change people's practices but that one was really being spread primarily by people drinking date palm sap. And bat's like to drink it too. So when people put out the pots to collect the sap, the bats tend to drink from those pots and also maybe urinate and defecate in those pots.
MAZETAnd it's actually a wonderful story of success of how you can sort of get people to change their behaviors because some of the folks that harvest that sap would put exclusionary bamboo kind of devices around to keep the bats out basically because they didn't like the idea, the disgust really of the poop and urine being in their sap that they were going to drink raw. And so when folks found out that you could easily, without a lot of extra cost, make the sap better, cleaner and also prevent this disease, the practice -- the behavioral practice changed really quickly. So we hope to find more ways that we can change people's behaviors quickly and easily through knowledge and trust.
NNAMDIRandall Schoepp, we got an email from Loraine who says, "According to health experts, Ebola keeps unpredictably popping up in random places, and they don't even have a cure for it. So how is it that they are so sure that the only time one is contagious is when one has the symptoms?
SCHOEPPKojo, this virus has been studied for a long time in nonhuman primate models. Obviously it's difficult to study in a sporadic virus like this the disease in humans. But in a situation where you have a controlled study with a nonhuman primate model, you can infer a lot of -- you can set the studies up to infer a lot of information. And that's where a lot of this information about the disease course and how long it takes before you see symptoms and when those symptoms appear, when you actually spread the virus or excrete the virus. So most of it has come from animal studies.
NNAMDIDan Lucey, before Ebola grabbed international headlines, the MERS virus in the Middle East was spurring warnings from the WHO. What do we know about the origin of that novel virus? Is it now under control?
LUCEYSo the origin is still being studied but it seems, in my opinion, to be clear that camels are one source of the virus that people can be infected from from camels. But there might be other animal sources. And certain species of bats may actually be the original reservoir source of this Middle East Respiratory Syndrome virus. After a large increase in the number of cases in both Saudi Arabia and in the United Emirates part of the Abu Dhabi Emirate back in March, April and May, fortunately now throughout the month of Ramadan with a large number of pilgrims performing Umrah and Makkah Madina the number of cases has gone down dramatically in Saudi Arabia over the past three weeks.
NNAMDIA recent study suggests that MERS was now airborne. What do we know about that?
LUCEYSo that's based primarily, but not exclusively, on a study -- a very recent study in the past month from Saudi Arabia where there was some evidence that in a camel barn, a barn with camels in it the virus could be detected in the air. And these are camels that were themselves infected with the MERS coronavirus. So I think it's suggested but not definitive at this point.
NNAMDIRandy Schoepp, the programs that both you and Jonna Mazet are participating in practice a kind of medical diplomacy by developing and sharing diagnostic tools to fight these emerging diseases. What kinds of tools are you developing at USAMRIID to help, Randy?
SCHOEPPWell, Kojo, we rely heavily on kind of a two-prong approach. We use molecular assays, such as PTR that look for particular genomic signatures in the genome of the virus. And we also use immunodiagnostics, that is antibodies to detect either the virus or detect the antibodies in an infected individual. Some of the earliest antibodies IGM or the later antibodies IGG. All of those are developed and studied at USAMRIID. And we continue to try to improve on those particular assays to make them easier, more specific and more sensitive.
NNAMDII mentioned earlier, I'll mention it again, that you can see photo slide shows at our website kojoshow.org of pictures that Randy Schoepp has taken in and around the testing lab for Ebola in Monrovia, Liberia. Jonna Mazet, it's my understanding that creating a diagnostic lab can be, well, as easy as stacking two shipping containers on top of each other. Tell us about your tools.
MAZETYeah, I've learned so much in working with the universities and governments and communities in the developing world. And, you know, I have a nice big lab here at the University of California that cost a lot of money, let's just say. And my colleagues in Tanzania showed me how we could stack a couple of shipping containers and make it beautiful with granite counter tops and marble tile on the floor. For $40,000 we could have a complete molecular virology laboratory.
MAZETSo when you're in the situation of really strictly limited funds, you can find ways to do amazing things. And that's I think collaboratively with these 59 ministries in these 20 countries we've really found some amazing ways to do that medical diplomacy that you mentioned with the diagnostics. So we've developed a diagnostic platform that's very low cost, learning from our colleagues again that we had to do with what we had and the equipment that we could get.
MAZETAnd with that in the 20 countries where we're working, we have identified 700 viruses. More than 550 of those are brand new viruses or they're in an area just like we're finding this Ebola in an area where we didn't think it should be. So that's what we're trying to do is identify what's out there and in which potential animal and human hosts that these things are circulating so that people know what's out there, can be ready and can put in the right prevention measures.
NNAMDIDan Lucey, two years ago there was an outbreak of Ebola in Uganda but it was brought under control. What makes the difference between a virus that's controlled quickly versus a virus that crosses borders? Is it diagnostic capability?
LUCEYThat's one component, Kojo, diagnostic capability. But it's really a much more holistic or integrative approach that's necessary. The original outbreak -- well, the outbreak you mentioned two years ago in Uganda, I was actually in Cairo at the time and I flew to Entebbe and went to Kampala and went out to the outbreak site. And fortunately there was a very fast response. It was in a rural area and the Doctors Without Borders, World Health Organization, USCDC, the Administrative Health of Uganda were all there working with the health care providers.
LUCEYAnd they were able to isolate people who were sick and quarantine those who were exposed, to provide support of care for those who were infected. And the outbreak was stopped. In this outbreak I think it's been much bigger crossing borders. And it's been much more difficult, as I think Randy eluded to, in getting it under control early on. And now it's really spread quite extensively.
NNAMDIEducating medical workers and the general public about how to protect themselves against infection is such a critical component of keeping viruses in check. What have we learned about safety in the medical setting from fighting viruses like SARS and MERS over the years?
LUCEYI think we've learned a lot in part because of the strong motivation to protect oneself and your colleagues. And for communicable diseases to protect your family and your loved ones and people that you share breathing space with if the viruses spread through the air, which Ebola fortunately is not. And it's required education but also I think it's very important to emphasize the need to train, to train repeatedly on the proper step-by-step procedures needed to use the personal protective equipment.
NNAMDIJonna Mazet, it's my understanding that your role in educating people about infectious diseases brings you to what may be the heart of where these diseases emerge, the Bushmeat trade. How do you work with these traders?
MAZETWell, again I think it's very difficult and I think part of this Ebola outbreak we're seeing, it's very difficult to tell people that what they're eating or what they're doing or their families have potentially done for centuries is dangerous when they haven't experienced that danger first hand. Or they may not trust the medical infrastructure or the educational infrastructure. So it is very difficult, I think. Behavior change is something that has to be done collaboratively with the communities. Just like I mentioned for Nipah virus, when there is a motivating factor like disgust actually tends to be a really useful motivating factor, people will change their behaviors.
MAZETThings like Ebola, we think about nobody wants to let their loved ones die alone and are willing to take those risks. But the loved ones themselves don't want to put their families at risk. So working with the families so that the loved ones don't put their family members at risk is really critical. So it's finding that motivator. And I think really knowledge is the powerful motivator in this one.
NNAMDIRandy Schoepp, how important is it to incorporate cultural beliefs into educating people about preventing viral outbreaks? Can you give us maybe a couple of examples from your work?
SCHOEPPYes, Kojo. That actually is huge. Many of the things that we're dealing with today, especially with Ebola, come from the cultural preparation of the dead. In Africa, in other countries it's traditional to wash the body, to caress the body, to kiss the body. Even in some of the societies that are more isolated, there's even talk of if it's a particular noted individual to drink the blood.
SCHOEPPAnd so all of these things are leading to an increase in the number of infections we're seeing. Those cultural practices that are very delicate to deal with in a society like we have here in West Africa that you have to be very careful and tread very lightly. But bring it to them in a way such that they will understand and begin to consider changing those. We haven't made it to that point yet and I think that's why we're still seeing this outbreak continuing.
NNAMDIFinally Dan Lucey, do we know why diseases like Ebola burn themselves out? And what's the follow-up role for epidemiologists once they do burn out?
LUCEYSo again I think it's multifactorial in terms of why do they burn out. In a sense I don't really think of them as burning out. It's the effort of the response. Like some of the people that are on the call today, both John and Randy and their colleagues, it requires a very strong public health and epidemiological and clinical, and really a political will is very important also, to stop the outbreaks.
LUCEYBut then the virus persists in animal reservoirs. And it's very important after the outbreak is over, controlled to find out where the viruses persist. And as Jonna said, to be able to predict where the next outbreaks may occur. In the meantime, to develop safe and effective vaccines and antiviral drugs and antibodies and other ways to treat and prevent these outbreaks.
LUCEYAnd in general I'd say this Ebola, this outbreak emphasizes the importance of what's called the global health security agenda, which is a 30-nation initiative that began this February coming out of the White House, the Department of State, Department of Defense, the Department of Agriculture along with World Health Organization and the world animal organization OIE, food and animal organization FAL in 30 countries to emphasize the importance of infectious disease as a threat to all of society.
NNAMDIDaniel Lucey is a professor of microbiology and immunology at Georgetown University Medical Center. Jonna Mazet is a professor of medicine and epidemiology at the School of Veterinarian Medicine at the University of California Davis. She's also the principal investigator and co-director of PREDICT, a global early-warning system for infectious diseases. And Randall Schoepp is chief of the Applied Diagnostics Branch at the U.S. Army Medical Research Institute of Infectious Diseases. Thank you all for joining us.
NNAMDIWe're going to be taking a short break. When we come back, Femi Kuti, son of Fela, artist and activist in his own right. He joins us to talk about agriculture in Africa, his life, his career and of course Fela. I'm Kojo Nnamdi.
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