H5N1

An Ebola patient treated in the U.S. chose to remain anonymous. Now he’s telling his story.

Via The Washington Post: An Ebola patient treated in the U.S. chose to remain anonymous. Now he’s telling his story. What happened to this American presumably happens also to African Ebola survivors, but their experience somehow doesn't deserve mention. Excerpt:

When they wheeled Preston Gorman into a light spring breeze outside the National Institutes of Health nearly five years ago, he was, medically speaking, among the most fortunate people on the planet.  

Gorman’s doctors had just defeated advanced Ebola virus disease, one of the most fearsome infections known to medicine. There were smiles and hugs and handshakes in the NIH Clinical Center in Bethesda, Md., where Gorman had spent the previous month in isolation, attended every moment by a medical SWAT team in moon suits.  

Doctors, nurses and other caregivers gathered for a short prayer with Gorman and his family before sending him home to Texas in the same private jet that had raced him to NIH from Sierra Leone. At his parents’ home outside Dallas, siblings, aunts and cousins turned out to celebrate the emaciated young man who had returned from the dead. 

 And then Gorman’s life fell apart.  

At a time when another Ebola outbreak is spreading, Gorman is a reminder of how easily trauma can be overlooked after severe illness. Gorman’s family and friends, and the medical system that so skillfully battled his disease, all missed the gravity of his condition. 

“No one said, ‘You’ve just been selected for a really hard journey, and by the way none of your family is gonna understand, none of your friends are going to understand and you’re not going to understand,’ ” Gorman recalled. “They’re thinking it’s all over, and I walk into this group of people, and I don’t even know what’s happening.” 

A prolonged battle with severe post-traumatic stress disorder cost Gorman his family, the woman he intended to marry, his friends and his job. One of the luckiest men alive, he considered suicide.  

Gorman, 38, who chose to remain anonymous until now, was one of 11 people treated for Ebola infections in the United States during the West Africa outbreak of 2014-2016. The others have been previously identified. 

Today Gorman is climbing back. He has a job, roommates and new friends in Austin. He maintains his faith, though his views on religion have changed. He still struggles at times, but he also feels joy again. And hope.  

“It forced me to dig deep, find out who I really was, and rely on God’s direction in the healing process that is still ongoing to this day,” Gorman said in one of many emails and conversations over the past few months. “There were many mistakes and dark moments. But a journey that, I hope, in the end will be worth it.” 

Research has revealed extensive post-traumatic stress disorder among Ebola survivors, their caregivers and witnesses to the widespread death in West Africa. During his brief stay in Sierra Leone, Gorman was all three.  

“He wasn’t just there to witness it, but rather became a victim himself,” said Lorenzo Paladino of SUNY Downstate Health Sciences University, who has studied post-traumatic stress. Fear, survivor’s guilt, deferred grieving and helplessness, as well as Gorman’s history of depression, all can play a role in post-traumatic stress.  

Medical experts are also learning that surviving a life-threatening illness that requires intensive care can leave cognitive and emotional scars, a condition called post-intensive care syndrome. 

“We’re not very good, even in this country, at figuring that all out and giving people that support,” said Natasha Tobias-White, an intensive care nurse who worked with Gorman in Sierra Leone.

Spike in Ebola cases alarms health officials in DRC

Via The Guardian: Spike in Ebola cases alarms health officials in DRC.

Health officials are investigating an alarming spike in Ebola cases in the Democratic Republic of the Congo, with many of the cases blamed on a single individual who appears to have contracted the disease for a second time this year. 

Amid the continuing struggle to bring the 16-month outbreak under control, the World Health Organization noted an almost 300% increase in cases in the last three weeks, with 17 out of 27 linked to a single chain of transmission from one individual.  

According to officials, it appears to be the second time the person has been documented as suffering from Ebola in six months. An investigation is being held to understand the circumstances around the case. 

Ten cases were notified on Wednesday alone in Mabalako, in North Kivu province, where the individual is believed to be from, after another six on Tuesday, according to officials who noted that three out of the six were practitioners of traditional medicine. 

The spike – and the worrying circumstances behind it – appears to buck a trend towards a declining number of cases, although security issues in the key zones of Beni, Biakato and Mangina had recently paralysed the response after violent attacks on health workers. 

Among the possibilities being examined are reinfection with the disease – which would ring the most serious alarm bells as no case of reinfection has ever been recorded before – or a relapse. 

While rare cases of relapse have been documented, in which a person who has recovered from Ebola gets its symptoms again, reinfection would mean a person who has recovered has been infected anew with the virus by another person, a circumstance so far undocumented. 

Experts have long been anxious about the risk of recurrence because of the fact that the virus can persist for months in areas of the body that are immunologically protected, including semen, vaginal fluids, sweat, aqueous humour, urine, breast milk and even spinal fluid after initial onset and recovery.  

That has led researchers to speculate about the continued risk of transmission in individuals not showing any symptoms, including through sexual activity, leading to reactivation of the illness. 

Reinfection, relapse and recurrence are all sources of acute concern in controlling the outbreak, as Ebola survivors are employed widely in treatment centres in DRC on the assumption they cannot usually recontract or transmit the disease. 

In July another patient died from what was also presumed to be a relapse or reinfection, calling into question the assumption that Ebola survivors have lifelong immunity from the virus.

Ebola survivors battle grief and stigma in eastern Congo

Via Reuters: Ebola survivors battle grief and stigma in eastern Congo. Excerpt:

BUTEMBO, Democratic Republic of Congo (Reuters) - Arlette Kavugho was discharged from an Ebola ward in eastern Congo in March, but her troubles did not end there.

When the mother of six tried to return to work as a seamstress in her hometown of Butembo, her customers were too scared of catching the disease, despite doctors’ assurances that she was no longer contagious. 

Instead she found work as a caregiver to children suspected of having Ebola only to be accused by neighbors of faking her illness to get the job.  

To this day, Kavugho has not been able to find the graves of her 19-year-old daughter and two-month-old granddaughter, who died of Ebola while she was receiving treatment and were hastily buried to avoid any further contamination.  

“I try to find the dates on the crosses that may coincide with their deaths but I always come back empty-handed,” the 40-year old said softly as she clung to a picture of her daughter with the word “adieu” written alongside.  

As of this month, more than 1,000 people have survived the 14-month Ebola outbreak in Democratic Republic of Congo, the world’s second deadliest, helped by new medicines that have proven effective against the virus when administered early. 

More than 3,200 people are known to have been infected with the virus, of whom more than 2,100 have died since the outbreak was declared in the eastern region. 

The survivors, who call themselves “les vainqueurs” - French for “the victorious” - however struggle to return to their former lives as they deal with the fear of relapse, long-term health issues like blurry vision and headaches and stigmatization by their families and neighbors. 

Vianey Kombi, 31, was a maths teacher when he contracted Ebola last November. Like Kavugho, he found it impossible to return to his former job and now cares for Ebola patients.  

“It hurts when I walk past the school where I was teaching, and the children who recognize me start screaming in my direction: Ebola, Ebola,” Kombi said. 

“We have all been accused of receiving money to say that we had Ebola,” he said. “It hurts a lot when your community treats you as corrupt after you’ve been at your sickest.”     

GIVING BACK 

Accusations like this are common in eastern Congo, where many residents see the outbreak as a money-making scheme made up by the government and outside organizations. 

“I was even accused of having received money to bring people from my community to the treatment center, to kill them with the virus and then sell their organs abroad,” said Moise Vaghemi, 33, who survived Ebola in August.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published its weekly update: Ebola virus disease – Democratic Republic of the Congo. Excerpt:

The number of reported cases of Ebola virus disease (EVD) consistently declined in recent weeks, with 14 new confirmed cases reported in North Kivu and Ituri provinces during the epidemiological week of 30 September through 6 October (Figure 1). At peak transmission in April 2019, there were 126 cases in the week. 

Although the decline in case incidence is encouraging, it must be interpreted with caution as the situation remains highly contingent upon the level of access and security. 

In mid-September, serious security incidents in Lwemba Health Area, Mandima Health Zone, stalled outbreak response activities for more than two weeks. To improve confidence and community engagement in response activities, an open forum for discussion and reconciliation was held in Lwemba with partners and civil society last week. Response activities have since resumed but remain limited. Improved access may result in enhanced case finding and contact tracing therefore could result in an increase in the number of reported cases and contacts in the area.  

There is a shift in hot spots from urban settings to more rural, hard-to-reach communities, across a more concentrated geographical area. During the past 21 days (from 18 September through 8 October), a total of 59 confirmed cases were reported from ten health zones (Table 1, Figure 2), with almost four out of five confirmed cases from four health zones: Mandima (31%, n=18), Mambasa (29%, n=17), Komanda (10%, n=6), Oicha (8%, n=5). 

This brings additional challenges to the response, including an extremely volatile security situation, difficulty accessing some remote areas, relatively poorer Ebola awareness and delays to engaging with the community leading to mistrust and misunderstandings, and potential under-reporting of cases, especial around some mining sites. 

The occurrence of transmission along a major road in from Komanda and Mambasa also poses greater risk of spread westward to other major cities in the country (such as to Kisangani).  

As of 8 October, a total of 3207 EVD cases were reported, including 3093 confirmed and 114 probable cases, of which 2144 cases died (overall case fatality ratio 67%). Of the total confirmed and probable cases, 59% (n=1797) were female, 31% (n=909) were children aged less than 18 years, and 5% (n=162) were health workers.  

As of 4 October, 1000 people have survived EVD in this outbreak. Since November 2018, the Ministry of Health and the Institute of Biomedical Research laboratory, with support from WHO, have undertaken a programme to aid in the reintegration of survivors into the community. The programme provides to EVD survivors monthly clinical, biological and psychological follow-up for a year after their discharge from the treatment center. Currently there are three operational clinics located in Beni, Butembo and Mangina.

Under Pillar 1 of the current Strategic Response Plan, the estimated funding requirement for all partners for the period July to December 2019 is US$ 287 million, including US$ 120-140 million for WHO. As of 10 October, US$ 60.4 million have been received by WHO, with additional funds committed or pledged. Further resources are needed to fund the response through to December 2019 and into the first quarter of 2020.

WHO AFRO: Ebola outbreak in DRC - Sitrep 62

WHO AFRO has published Ebola Virus Disease Outbreak in DRC - Sitrep 62: 08 October 2019. Excerpt:

In the past week, from 30 September to 6 October, 14 new confirmed Ebola virus disease (EVD) cases, with an additional nine deaths, have been reported from seven health zones in two affected provinces in the Democratic Republic of the Congo. Although the decline in the number of new cases is encouraging, the recent fluctuations in case numbers per week must be interpreted with caution, as case reporting is contingent upon the level of access and security. 

During mid-September, serious security incidents in Lwemba Health Area, Mandima Health Zone, stalled outbreak response activities for more than two weeks. Response activities have since resumed but remain limited. Last week, an open forum for discussion and reconciliation was held in Lwemba with partners and civil society to dispel mistrust and enhance engagement in future response activities. Improved access may result in enhanced case finding and an increase in the number of reported cases from the area. 

In the 21 days from 16 September to 6 October, 28 health areas in 11 health zones reported new cases. During this period, a total of 73 confirmed cases were reported, with the majority coming from the health zones of Mambasa (30%; n=22 cases), and Mandima (23%; n=17 cases). In the past 21 days, 10 cases were reported from Komanda and Oicha Health Zones with links to cases from Beni and Mambasa health zones. Issues with under reporting are possible in the Oicha Health Zone, as poor access and security constraints limit response activities. The occurrence of transmission along a major road in from Komanda and Mambasa also poses greater risk of spread westward to other major cities in the Democratic Republic of the Congo (e.g. Kisangani). 

As of 6 October 2019, a total of 3205 EVD cases were reported, including 3091 confirmed and 114 probable cases, of which 2142 cases died (overall case fatality ratio 67%). Of the total confirmed and probable cases, 59% (1796) were female, 30% (909) were children aged less than 18 years, and 5% (162) were healthcare workers. 

As of 4 October 2019, 1000 people have survived EVD in this outbreak. Of the approximately 1555 confirmed cases admitted to Ebola treatment centers, 1000 of them, or nearly two thirds, have survived. The reintegration of survivors into community can create opportunities to discuss their experiences and strengthen the participation of local communities in the response. Many survivors are working within the response, and are an important part of caring for the sick and reaching out to communities. A programme is in place to monitor survivor health and support them in the year after they leave care. 

Under Pillar 1 of the Strategic Response Plan, the estimated funding requirement for all partners for the period July to December 2019 is US$287 million, including US$120-140 million for WHO. As of 8 October 2019, US$60.4 million has been received by WHO, with additional funds committed or pledged. Further resources are needed to fund the response through to December 2019 and into Q1 2020. 

Under Pillar 5 Regional Preparedness, the funding requirement for all partners is US$66 milllion, of which WHO requires US$ 21 million. As of 8 October 2019, WHO has received US$ 1.6 million. While some additional pledges are in the pipeline, increased funding for preparedness in neighbouring countries is urgently needed. WHO is appealing to donors to provide generous support. A summary of funding received by WHO since the start of this outbreak can be found here.

Ebola in Butembo: 'The Church will not give up until the disease is declared over'

Credit: Radio Moto

Radio Moto Butembo-Beni pays a lot of attention to local religious news, and Catholic officials have been energetic in mobilizing the faithful against Ebola. But sometimes doctrine can conflict with infection prevention: Ebola in Butembo: "The Church will not give up until the disease is declared over" (Mgr Sikuli PALUKU). The Google translation and then a comment:

The Church continues to preach faith to Christians even in the context of the epidemic. This is what the Bishop of Butembo-Beni said during an interview with the RFI, the RMBB and the Voice of the UCG on Saturday October 5th at the bishop's palace. 

Addressing people who, after more than a year, continue to doubt the existence of the disease, Monsignor SIKULI PALUKU Melchizedek advises to believe in the number of people who lost the life of this disease. The prelate of the Butembo-Beni Church used the example of the disease that once attacked the bananerais.  

Using his own experience, SIKULI PALUKU Melchizedek explains that the banana field in which he was born no longer exists as a result of an illness that has been named EBOLA. The bishop complains of people who, after seeing many people lose their lives, continue to doubt.  

"We are cultivating corn, we plant the bean where we had the banana plantations. At the time it came, curiously, the word Ebola was already known. It was said that no, banana has caught a disease called Ebola. Now that it happens in men, I do not understand why you do not understand that it can kill. As much as you have seen a banana plantation disappear completely, why do you doubt it?" asked the Bishop.  

The Nande culture does not advocate proximity to the bodies of the dead  

It is in these words that the bishop of Butembo-Beni responds to those who brandish the culture to refuse the dignified and safe burials. Monseigneur the bishop says that in time, parents took care to keep their children away from the dead. And, the funeral rites were reserved for a fringe of people.  

Monseigneur the bishop deduces that this practice of wanting to touch the corpses arrived with the mixing of the customs of peoples from elsewhere. From where SIKULI PALUKU Melchizedek calls to return on the old customary practices which, today allow to limit the dangerous contacts.  

"Here at home, I think those who are older can remember that here at home, growing up, since even until the age of 20, parents did not even allow children to see a dead person. I who speak to you, I was, I believe 19 years old before I saw a corpse. And even the funeral toilet was made, not by everyone, but it was by a group. I myself was surprised that everyone is trying to touch the body. In principle in our Nande customs, I do not believe that it was something that existed," said Bishop Sikuli PALUKU. 

Abstinence to limit Ebola  

Monseigneur the Bishop of the diocese of Butembo-Beni reminds the winners of EBOLA abstinence. Monsignor SIKULI PALUKU Melchizedek thus addresses Catholic healers who can never use the condom. 

While expressing their sincere congratulations on their healing, Monsignor SIKULI PALUKU Melchizedek reminds them that the gospel remains constant. 

"When one becomes a Christian, it means that one changes the behavior".  

What the Church advises is abstinence. What Jesus tells us, the Gospel, we must stick to. This is not the message that can change overnight; because men change, the gospel remains the same," he said. 

Note that the sequelae of the virus can remain long in the sperms of the survivors of EBOLA, according to the body of each cured. For this reason, the cured are subjected to frequent health checks to approve their total recovery. 

In his words, Monsignor Sikuli Paluku encouraged the faithful to adhere to good practices advocated by the Ebola response in order to eradicate this disease. 

In the end, the Bishop welcomed the advances made in epidemiological statistics today. He declared that the Church will not give up until the illness is declared over. In this interview, the Bishop reminded every Christian family and all people of good will to continue the fight against EBOLA.

Expecting abstinence of all male Ebola survivors, rather than using a condom, is criminally naive.

Surely the bishop doesn't suppose that a survivor with live Ebola virus in his sperm could successfully inseminate his partner, who could then give birth to a healthy baby. Instead he would simply add a female casualty to the list of Ebola cases and deaths. Good doctrine that isn't good public health is very bad doctrine.

Mothers survive Ebola while pregnant against the odds in the DR Congo

An encouraging report from WHO AFRO: Mothers survive Ebola while pregnant against the odds in the Democratic Republic of the Congo. Excerpt:

“I put my feet on the ground and wiggled my toes. It felt strange to touch the ground for the first time in weeks. Slowly, I stood up, holding the hand of the nurse. I held my swollen belly and smiled.” That was the moment Rachel Kahuko Kavugho began to let herself believe that she might survive Ebola “and that the baby in my belly might get to live”.  

She is one of five women in Beni, in northern Democratic Republic of the Congo who have not only survived Ebola while pregnant but given birth to wriggling, screeching babies – welcome signs of survival. 

Women are especially vulnerable to Ebola. According to data from the World Health Organization (WHO), women and girls aged 11 and older have been infected by Ebola at a higher rate than men and boys in the same age range.  

The main reason for this, according to Dr Maurice Kakule Mutsunga, focal point for the WHO Ebola Survivors Programme in Beni, is that women are “primary caregivers within their families – especially for children and older persons – and often within the wider community”. 

This extends to bringing children or sick relatives to hospital and staying with them there while they receive treatment. In many areas, women also continue providing care to sick relatives. It is, again, women who are usually in charge of funeral arrangements, including preparing the body for burial. These activities leave women at greater risk of exposure to Ebola. 

For pregnant women, the risks are greater still. Once infected with the virus, they face higher mortality rates from Ebola than the general population. During the West Africa Ebola outbreak, the largest to date, few pregnant women or their unborn foetuses survived. Now, because of access to an Ebola vaccine, new therapeutic treatments and improved detection systems, more and more pregnant women are recovering from Ebola and delivering their babies. 

“When my results came back positive, I thought I would die,” says Uleda Kisenye Kahambu, another of the five mothers who survived Ebola. “Even after I was cured, I worried every day for the rest of my pregnancy that my baby would die.”  

Today, three months after giving birth, both Kahambu and her baby, Merdi, are doing well. Pregnant Ebola survivors in Beni are invited to come and stay in a special facility built for new mothers and babies next to the Ebola treatment centre a month before their due date, a practice borrowed from a public health strategy to limit maternal mortality generally. This helps doctors monitor them closely. When they go into labour, they are brought to the treatment centre, which means babies can be tested for Ebola straight after delivery. 

Kavugho’s baby, Kakule, tested positive for Ebola soon after he was born. “I was scared,” she says, “but, having survived myself this time, I had more confidence. The doctors and the nurses treated him, and he got better very quickly.” 

As well as testing the babies, health care workers, who have been trained by WHO, also test the mother’s breastmilk. While Kavugho’s breastmilk was found to contain traces of the Ebola virus, this is not always the case.  Kahambu and her friend Aimer Bikengya Kavira, another survivor and new mother, were both given the all clear to breastfeed.  

“I miss breastfeeding,” says Kavugho. “I breastfed both my other children, so it feels strange to use a bottle.”

Long-lasting severe immune dysfunction in Ebola virus disease survivors

Thanks to Greg Folkers for tweeting this link to this preprint in Research Square: Long-lasting severe immune dysfunction in Ebola virus disease survivors. The abstract:

Clinical follow-up of Ebola virus disease (EVD) survivors revealed a persistence of clinical symptoms and higher risk of mortality. Long-term analyses of the immune and inflammatory profiles of EVD survivors are currently lacking. 

Here, we evaluate immune profile status and gene expression profiles in 35 Guinean EVD survivors (EBOV_S) from the last West African outbreak, a median of 23 months (IQR [18-25]) after discharge from the Ebola treatment center. We show a persistent increase of several biomarkers of inflammation, immune activation and gut tissue damage in EBOV_S compared to healthy donors living in the same area. 

These results are confirmed by phenotypic characterization of immune cell subsets revealing increases in activation marker expression and the frequencies of CD8+ T cells, exhausted B cells, non-classical NK cells and circulating dendritic cells. 

All survivors have EBOV-specific IgG antibodies and robust and polyfunctional EBOV-specific memory T-cell responses. Deep sequencing studies of the genes expressed in blood revealed a significant enrichment in genes associated with antiviral responses in EBOV_S.

Ebola survivors can pass on the virus: We're trying to understand what role sex plays

Via The Conversation Africa, an important article by Jason Kindrachuk and colleagues: Ebola survivors can pass on the virus: we're trying to understand what role sex plays. Excerpt:

The current Ebola disease outbreak in the Democratic Republic of the Congo (DRC) is the second largest in history. It has been raging for over a year with no indication that it is nearing an end. Many of the issues that prevent effective containment of Ebola disease outbreaks have been discussed. These include porous borders, community mistrust of health workers, and the spread of misinformation.

But one area that requires further study is Ebola virus’ persistence in the reproductive systems of otherwise healthy survivors. Understanding how Ebola disease outbreaks are exacerbated by sexual transmission is important to stop new chains of transmission and to prevent the disease from spreading to new geographic regions.  

Multiple reports strongly suggest that re-emergence of Ebola disease is linked to persistent infections and sexual transmission from survivors. What this means is that people who have survived infection by Ebola virus – and who no longer show any symptoms of the disease – can continue to carry the virus and pass on the infection months after they have recovered.  

Our research group recently reviewed the current understanding of rates and mechanisms of Ebola virus persistence in male disease survivors. We are using this information to fill in gaps about how persistence relates to sexual transmission of the virus.  

In addition, we are combining molecular investigations with insights from survivors to better equip future outbreak response efforts. We also hope the work will help address long-term health issues faced by Ebola disease survivors.

DRC Ebola: France funds a project called "Ebola Winners," dedicated to the care of survivors

Via 7sur7.cd: DRC  Ebola: France funds a project called "Ebola Winners", dedicated to the care of survivors of this virus. Excerpt from the Google translation: 

France is financing a project called "Winners of Ebola" which aims to take care of the survivors of this deadly epidemic that scours the eastern regions of the DRC, particularly North Kivu, epicenter of the disease and the province of Ituri.  

According to a statement from the French Embassy reached 7SUR7.CD Wednesday, this program was launched Monday, September 23 at the Hotel du Fleuve Kinshasa, under the chairmanship of the technical secretariat of the Multisectoral Committee of the response to the Ebola virus disease, delegates from the Ministry of Health, the National Institute for Biomedical Research (INRB) and the Ebola Special Envoy for France, Professor Yves Lévy.  

Its establishment was made possible thanks to "the fruitful collaboration of Professor Lévy with Professor Muyembe, Director General of INRB and national coordinator of the Ebola response". Its fundamental ideal is to completely stem the virus from the body after healing. 

"This management program is therefore fundamental to treat survivors, to understand and define strategies for treating these sequelae and to propose solutions to eradicate the virus from the body after healing, in order to avoid cases of contamination. secondary ", reads in this release.   

France justifies the quintessence of this project by the fact that among the approximately 3000 confirmed cases of cured Ebola, nearly 950 must be supported. The vast majority of them present sequelae that are both psychological (anxiety, depression) and medical (musculoskeletal pain, loss of hearing, decreased vision or blindness, etc.).  

In addition to these sequelae, says the same source, it was found that the virus can persist in the body once cured as in sperm, breast milk and this up to 500 days after healing.