The Flaw in “Where Did it Come From?!” Ebola Panic Narratives

I am an aficionado, if you will, of the mystery plague novel. I can probably place the blame for that somewhere between my father and the science fiction he raised me on, and Michael Crichton’s The Andromeda Strain.1 And of course, one of the key aspects of the mystery plague novel is the driving question of “where did it come from?” The thinking typically goes that if we know the plague origin, we can cure it, and a panicked rush to discover both origin and cure drives many (if not most) stories in the genre.

So it’s not too surprising to see the mystery plague origin pop up in the West Africa Ebola outbreak coverage. There seems to be a lot of concern about it’s unknown origins, how did the virus get from Central Africa to West Africa, and assertions that this must mean mutation of some sort.2

A quickly pulled together map showing the combined ranges of fruit bats mentioned in Hayman DTS, Yu M, et al., save straw-colored bats, along with the current Ebola outbreaks in West African countries.

A quickly pulled together map showing the combined ranges of fruit bats mentioned in Hayman DTS, Yu M, et al., save straw-colored bats, along with the current Ebola outbreaks in West African countries.

All of which, of course, is of limited accuracy to flat-out wrong. In fact, you don’t even need to know what you’re looking for to find this information; I was looking for an outbreak map when I came across this Emerging Infectious Diseases letter from 2012: Ebola Virus Antibodies in Fruit Bats, Ghana, West Africa. The authors of the letter found a relatively high proportion of EBOV-seropositive bats in a small sample size of mixed bat species across Africa.

Africa. Not Central Africa. Not West or South or Noth. Just Africa. Which is a big continent, but bats? They have wings. And while the EBOV-seropositive bats were largely not straw-colored fruit bats, which often migrate as far as 1550 miles/2500 kilometers, they did have a significant range.

It didn’t take terribly long for Ian Mackay3 to find a newer issue of EID reporting on testing Sierra Leone patient serum samples and finding a range of viral hemorrhagic diseases, including Ebola. Shortly after, he found a paper discussing EBOV antibodies in fruit bats in Bangladesh.

It isn’t a surprise that fruit bats are implicated in this current outbreak of Ebola, since they’ve long been considered a possible reservoir for the disease, and may also be the host. Nor is it terribly surprising that the bats have this large of a range, or even that as human settlement encroaches into the forest, there will be more spillover events. The bats, the humans moving into new habitat, the zoonotic virus spillovers; these are all part of the story of Ebola. It’s a story we’ve been piecing together for 38 years, because science is never so fast as it is in the books and movies, and it’s a story where the origin probably won’t inform the cure.

The mystery plague origin is one that appeals, and it’s easy to write. It plays into books and movies, people know the expected narration, and there’s a thrill to it; “is this the one?” as speculation for people who don’t really have to worry about if “this is the one.” It also ignores science and evidence, and turns real life tragedy into an adrenaline-based fictional story for reading before bed, erasing the victims, from that first family who died in December 2013, to those who died just a few minutes ago.

  1. I was always bitter about the differences between book and movie, moreso than just about any other adaptation. []
  2. I’m not linking because I refuse to drive traffic to bad science. It’s not hard to find the stories, if you know where to look. []
  3. He’s the real deal. If you really want to understand viruses, find a virologist to throw questions at. I recommend Dr. Mackay, but I’m biased–he answers my questions, after all. []

Ebola, Paternalism, and the Need for WHO’s Medical Ethics Review of Experimental Treatments

WHO_Logo_c300The World Health Organization has released a statement (in full, bottom of blog post) that they are going to convene, early next week, a panel of medical ethicists to “explore the use of experimental treatment in the ongoing Ebola outbreak in West Africa.” The statement goes on to say that

[t]he recent treatment of two health workers from Samaritan’s Purse with experimental medicine has raised questions about whether medicine that has never been tested and shown to be safe in people should be used in the outbreak.

It’s probably safe to assume that at least some of this statement was informed by the Wall Street Journal op-ed published by Jeremy Farrar, David Heymann, and Peter Piot.1 In particular, the authors note that it “is highly likely that if Ebola were now spreading in Western countries, public-health authorities would give at-risk patients access to experimental drugs or vaccines” and that the “African countries where the current outbreaks of Ebola are occurring should have the same opportunity.” Farrar, Heymann, and Piot also noted that ideally, the World Health Organization would assist the involved African countries with protocols for experimental treatment, research, and prevention, while simultaneously assisting with traditional treatment and containment measures.

This, surprisingly, turned out to be a somewhat controversial view, at least on Twitter. But the West is pretty enamored with the Western Cowboy Doctor who swoops in and saves the day, and there is an enmeshed culture of paternalism and rescue when it comes to how America views, or even talks about, the countries of Africa. It’s one of the reasons any effort to combat pandemics needs to be interdisciplinary; the heroic myths of one field can easily end up being the illustrative horror stories in another. In particular, the West has not been kind to African countries during outbreaks, previous Ebola outbreaks included.2 As anthropologists Barry S. Hewlett and Bonnie L. Hewlett note in their book on Ebola, culture, and politics, there is a tendency for outbreaks to only be contextualized through Western biomedical knowledge and technology. While that might have worked when outbreaks were merely local, as everyone and their grandfather has taken to pointing out, we live in a global environment, with global travel. As such, our approach to outbreaks needs to be global, not local.

There is a long and exploitive history of white intrusion into African countries, and that said history has created a culture of mistrust shouldn’t be surprising. And I’m not just talking about colonialism; pharmaceutical companies have used African countries as testing grounds for “clinical trials” that would never get off the ground in America or other developed world countries. (This was helped by the 2008 decision by the FDA to drop the requirement3 that international clinical trials follow the requirements of the Declaration of Helsinki.4) Meningitis cure testing in Nigeria, AZT trials and contraception testing in Zimbabwe;5 we’re not talking the distant past, but the past 35 years.

This is why I’m glad to see that WHO has taken Farrar, Heymann and Piot seriously, and, in a step further, that they’re going consult actual ethicists on the ethics of providing experimental, untested treatment to a vulnerable population in need, rather than just allow the status quo to continue. There’s no news yet on just who will be participating in this convention of ethical experts, but here’s hoping WHO has learned from their past mistakes and will be including a diverse range of voices with experience in the research mentioned above, the history of mistrust, culture, and of course ethics. While I’d hope it goes without saying that medical ethical representatives from the affected African countries should be present, past experience has taught me it’s best not to assume people will automatically reach for diversity over expertise. Again, here’s hoping; after all, I’d really hate to have to reach for awful WHO’s on first style jokes next week to highlight poor panel selections.

 


WHO to convene ethical review of experimental treatment for Ebola

WHO statement
6 August 2014

Early next week, the World Health Organization (WHO) will convene a panel of medical ethicists to explore the use of experimental treatment in the ongoing Ebola outbreak in West Africa. Currently there is no registered medicine or vaccine against the virus, but there are several experimental options under development.

The recent treatment of two health workers from Samaritan’s Purse with experimental medicine has raised questions about whether medicine that has never been tested and shown to be safe in people should be used in the outbreak and, given the extremely limited amount of medicine available, if it is used, who should receive it.

“We are in an unusual situation in this outbreak. We have a disease with a high fatality rate without any proven treatment or vaccine,” says Dr Marie-Paule Kieny, Assistant Director-General at the World Health Organization. “We need to ask the medical ethicists to give us guidance on what the responsible thing to do is.”

The gold standard for assessing new medicine involves a series of trials in humans, starting small to make sure the medicine is safe to use. Then, the studies are expanded to more people to see how effective it is, and how best to use it.

The guiding principal with use of any new medicine is ‘do no harm’. Safety is always the main concern.

Media contact:
Tarik Jasarevic
WHO Department of Communications
Telephone: +41 22 791 50 99
Mobile: +41 79 367 62 14
E-mail: jasarevict@who.int

  1. As I said on Twitter last night, when Peter Piot talks about Ebola, I stop and listen. []
  2. “First the French and then the Americans came up the river. Each time they took four tubes of blood, even from sick children. They never returned, and we never received the results of the tests.” Local people of Mékouka and Makokou, Gabon, discussing the rivalries between American and French researchers during the 1996 Gabon outbreak of Ebola. Taken from the Hewlett’s book Ebola, Culture, and Politics: The Anthropology of an Emerging Disease. []
  3. The Food and Drug Administration should rethink its rejection of the Declaration of Helsinki. Nature 453, 427-428 (22 May 2008) | doi:10.1038/453427b; Published online 21 May 2008. []
  4. Instead of providing the best standard medical care to control groups, placebos can be utilized. Smashing. []
  5. Read Harriet A. Washington’s book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present for more. []

Ziploc: There’s No Better Way to Protect Your Select Agent Investment

A lot of interesting testimony came out of yesterday’s House Energy and Commerce Oversight and Investigations Subcommittee hearing, which was titled “Review of CDC Anthrax Lab Incident,” but broadly covered the numerous slapstick-’cept-it-ain’t-funny errors around dangerous pathogens research at the Centers for Disease Control and Prevention.

I don't know about you, but I feel safer already.

I don’t know about you, but I feel safer already.

For those just joining the conversation, these hilarious mishaps have included leaving activated anthrax in unlocked, unsecured refrigerators; mixing high pathogenicity avian influenza with low pathogenicity avian influenza and then shipping it over to the US Department of Agriculture in the worst version of novelty surprise in a can ever; and using ziploc bags to transport petri dishes between labs. And as an added bonus, there was some discussion about the broader issues of the proliferation of biosafety laboratories working on select agents.

In particular, the statement of Nancy Kingsbury, PhD, the Managing Director, Applied Research and Methods, at the Government Accountability office, is worth a read. The statement pulls no punches, saying:

No federal entity is responsible for strategic planning and oversight of high-containment laboratories. … No one agency is responsible for determining the aggregate or cumulative risks associated with the continued expansion of high-containment laboratories; according to experts and federal officials GAO interviewed for prior work, the oversight of these laboratories is fragmented and largely self-policing.

In fact, since 2001, the proliferation of biosafety laboratories has resulted in nearly 1500 laboratories in the United States alone that handle and do research on dangerous pathogens.

If only there were some sort of national advisory board for biosecuri-oh wait!

Except, as has already been noted, the NSABB hasn’t met in nearly two years. But that’s okay, you see; the current chair of the NSABB1 wants you to know that this is intentional! Samuel L. Stanley Jr., MD, says that the NSABB has “been waiting essentially for the new federal guidelines to come out on institutional implementation of DURC policy. We wanted to have a look at what the federal agencies would come up with.”2

PicardOneJob-200One job.

You guys had one job.

Well, wait. Okay. This can easily be clarified by looking at the NSABB charter, which was recently revised, so clearly it is timely and up-to-date and will clarif-

The NSABB will provide advice on and recommend specific strategies for the efficient and effective oversight of federally conducted or supported dual use biological research, taking into consideration both national security concerns and the needs of the research community to foster continued rapid progress in public health and agricultural research.3

Damnit.4

In Stanley’s defense, he argues that these recent “issues” at the CDC are surely concerning as a scientist, but they’re really not about dual-use or gain of function research, so they don’t involve the NSABB. It wasn’t, you see, created to be about biosafety.

It’s really such a bitch when the first bulleted item on the list of “description of duties” on your charter contradicts the interviews you give: Recommend strategies and guidance for enhancing personnel reliability among individuals with access to biological select agents and toxins.5

Funny thing. The last time I looked, anthrax sure as hell was a select agent. Oh look! So is H5N1.

Your move, Stanley. I suggest it involve picking up a phone and dialing 11 different numbers.

  1. Someone who has been the chair since 2012, so you do the math on how much practice he actually has being the chair of an organization that hasn’t met since… yup, 2012. []
  2. All of Stanley’s comments in this blog post are taken from CIDRAP‘s interview with him. Hi! Love you guys! []
  3. “Objectives and Scope of Activities,” NSABB Charter 2014. []
  4. Fun bonus note: the NSABB is, per their very own charter, supposed to be meeting twice every fiscal year. Should I give Stanley the benefit of the doubt to assume this is new with the 2014 charter, and that everyone would have loved to have met in the previous two years, but there just wasn’t anything going on in dual-use or gain of function rese…nevermind. []
  5. “Description of Duties,” NSABB 2014 Charter. []

Becky Bird Flu and HPANTHRAPOX (Biosecurity Satire)

As any fan of The Daily Show knows, satire is often the only defense.1 2

Adventures-Biosafety

HPANTHRAPOX-Cycle

  1. Becky Bird Flu coined by Nick Evans. …I can’t pin HPANTHRAPOX on anyone, though. That one is all mine. []
  2. If you’re wondering what this is a defense against, there’s an overview here. []

Remaining Inaugural Members of NSABB Dismissed Last Night

NSABBHowardFineIt’s not exactly been what one would call a banner month for the National Institutes of Health or the Centers for Disease Control and Prevention. In the last week and change, it’s been revealed that oops, the CDC completely screwed up how it handles anthrax and possibly exposed 86-odd people to anthrax and they accidentally shipped out H9N2 that had been contaminated with H5N1. Then, this morning, a study from the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service–a study that the CDC has known about since July 10–revealed such charming details as anthrax being stored in refrigerators in an unrestricted hallway with the key to one sitting in its lock.1 (I hope you weren’t planning on sleeping ever again.) And of course, in case any of that isn’t close enough to a Richard Preston novel, there was the whole “forgetting those vials of smallpox in cold storage” thing with NIH and the Food and Drug Administration.

As a result of all this Three Stooges-esque mishandling of select agents and scary things, the House Energy and Commerce Oversight and Investigations Subcommittee is convening Wednesday to ask Dr. Thomas Friedan, director of the CDC, and friends (like Joseph Henderson, deputy director of the CDC’s Office of Security and Emergency Preparedness; Jere Dick, associate deputy administrator of APHIS; and Nancy Kingsbury, a managing director of the Government Accountability Office) to come explain exactly how Larry, Moe, and Curly ended up wreaking havoc at the Center.

So naturally, Sunday night was the perfect time to dismiss the remaining inaugural members of the National Science Advisory Board for Biosecurity.
WTELF
Now, apparently the NSABB hadn’t met in two years, and according to Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, Twin Cities, his last contact with the NIH regarding the NSABB was in the Spring of 2013.2 Which, if you’ve been following dual-use research of concern or gain of function research news, is concerning, to say the least.

But possibly even worse is how utterly tone deaf and cheerful this “your services are no longer required, you’re dismissed” email is. Apparently Mary Groesch is, in addition to being the Executive Director of the NSABB, the Queen of Perky. Don’t believe me? Lucky for you, I just so happen to have acquired a copy of the dismissal letter.

Dear Members of the NSABB,

Greetings! I hope that all is well with each of you. My purpose in writing to you—the last of the original NSABB members—is several fold. First, I wanted to tell you that a new slate of NSABB members has been approved as your replacements, and thus your service on the board is ending. Since you have all been so gracious as to extend your service for several years beyond your initial term, this may come as welcome news!

Yes, I’m sure it’s welcome news that, after a week of Really Bad Revelations from the CDC, NIH, and FDA, their expertise will no longer be needed. The expertise they bring as inaugural members of the NSABB. SiskoIsNotAmusedThe expertise they bring being the people who had to figure out how to deal with the Fouchier and Kawaoka H5N1 publishing crisis. I can’t imagine how any of that might be necessary or needed now.

But hey, don’t worry. The inaugural members of the NSABB that were dismissed have been invited to join the next NSABB meeting in the fall, where they can watch, as ad hoc members, as the new committee largely goes “nyah nyah” and ignores their recommendations. Of course, that’s just my interpretation of the email, but “I welcome you to attend in an ad hoc capacity the next meeting of the NSABB, where we will recognize your service on the Board,” “We will also recognize your service and introduce the new members to the Board,” and “We also would welcome your attendance at this meeting in a non-voting, ad hoc capacity both to contribute to our discussions and to say farewell” doesn’t exactly inspire confidence, faith, or trust in the now-gutted NSABB. In fact, I’m really only surprised that “YOU CANNOT VOTE AND YOU HAVE NO SAY” wasn’t included in bolded, underlined text.

What in the bloody hell is the NIH thinking? I’d ask if they have no policy or communications advisers on staff, except that I see at least one science policy analyst on the email CC list, so clearly this was signed off by at least one person who should know better.

When the theoretically premier laboratory in the world is as badly compromised by ineptitude as the CDC has stunningly demonstrated that they are, you don’t turn around and dismiss your experts. You hang on to those experts, grateful that they’re still around, and you say help. You say help really loudly. And then you sit down, shut up, and listen.

You don’t fire the people who’ve been around so long that they can say “I told you so.”

Unless, of course, that’s the point.
LowerYourExpectations
And frankly, at the moment, given who was released and their expertise, it’s hard to see how this is anything other than an effort to stack the deck towards people who will be sympathetic to the NIH and CDC, rather than be the critical, independent review board with teeth, a la the National Transportation Safety Board, that biosecurity research needs.

Which is not to say that all is lost, or that there are not people much more impressive and with much bigger sticks who are not willing to sit down and shut up and let the NIH run amok without oversight. While I wish the House committee all the best this Wednesday, my faith more strongly lies with the Cambridge Working Group,3 who ever-so-coincidentally met today in Cambridge,4 and their Consensus Statement on the Creation of Potential Pandemic Pathogens (see below for full text).

The following NSABB members were informed they were no longer needed Sunday evening:
Arturo Casadevall, MD, PhD – Chair, Department of Microbiology & Immunology, Albert Einstein College of Medicine
David R. Franz, DVM, PhD, Colonel, USA (Retired) – Former Commander, United States Army Medical Research Institute for Infectious Diseases
John A. Gordon, General, USAF (Retired) – Former Deputy Director, CIA
Michael J. Imperiale, PhD – Professor and Associate Chair, Department of Microbiology and Immunology, University of Michigan School of Medicine
Paul Keim, PhD – Regents’ Professor and Cowden Chair in Microbiology, Department of Biological Sciences, Northern Arizona University
Stanley M. Lemon, MD – Professor of Medicine, Division of Infectious Diseases, University of North Carolina School of Medicine
John R. Lumpkin, MD, MPH – Senior Vice President and Director, Targeted Teams, Robert Wood Johnson Foundation
Stuart B. Levy, MD – Director, Center for Adaptation Genetics and Drug Resistance, Tufts University
Michael Osterholm, MD, PhD – Director of CIDRAP, University of Minnesota
David Relman, MD – Department of Medicine, Division of Infectious Diseases,
and Department of Microbiology & Immunology, Stanford University
James A. Roth, DVM, PhD – Director, Center for Food Security and Public Health, Iowa State University

Maybe it’s just me, but that’s a list of guys5 and expertise I’d feel better having on the NSABB than off.

Especially right now.

Definitely right now.


The below text has been reprinted with permission. Please share. Please do not credit Kelly Hills for this work. She just happened to get a copy and the permission to post it.6

July 14, 2014

Cambridge Working Group Consensus Statement on the Creation of Potential Pandemic Pathogens (PPPs)

Recent incidents involving smallpox, anthrax and bird flu in some of the top US laboratories remind us of the fallibility of even the most secure laboratories, reinforcing the urgent need for a thorough reassessment of biosafety. Such incidents have been accelerating and have been occurring on average over twice a week with regulated pathogens in academic and government labs across the country. An accidental infection with any pathogen is concerning. But accident risks with newly created “potential pandemic pathogens” raises grave new concerns. Laboratory creation of highly transmissible, novel strains of dangerous viruses, especially but not limited to influenza, poses substantially increased risks. An accidental infection in such a setting could trigger outbreaks that would be difficult or impossible to control. Historically, new strains of influenza, once they establish transmission in the human population, have infected a quarter or more of the world’s population within two years.

For any experiment, the expected net benefits should outweigh the risks. Experiments involving the creation of potential pandemic pathogens should be curtailed until there has been a quantitative, objective and credible assessment of the risks, potential benefits, and opportunities for risk mitigation, as well as comparison against safer experimental approaches. A modern version of the Asilomar process, which engaged scientists in proposing rules to manage research on recombinant DNA, could be a starting point to identify the best approaches to achieve the global public health goals of defeating pandemic disease and assuring the highest level of safety. Whenever possible, safer approaches should be pursued in preference to any approach that risks an accidental pandemic.

Amir Attaran, University of Ottawa
Barry Bloom, Harvard School of Public Health
Arturo Casadevall, Albert Einstein College of Medicine
Richard Ebright, Rutgers University
Nicholas G. Evans, University of Pennsylvania
David Fisman, University of Toronto Dalla Lana School of Public Health
Alison Galvani, Yale School of Public Health
Peter Hale, Foundation for Vaccine Research
Edward Hammond, Third World Network
Michael Imperiale, University of Michigan
Thomas Inglesby, UPMC Center for Health Security
Marc Lipsitch, Harvard School of Public Health
Michael Osterholm, University of Minnesota/CIDRAP
David Relman, Stanford University
Richard Roberts, New England Biolabs
Marcel Salathé, Pennsylvania State University
Silja Vöneky, University of Freiburg Institute of Public Law, Deutscher Ethikrat
Affiliations are for purposes of identification only and do not imply any institutional endorsement

  1. U.S. inspectors find further anthrax violations, mishandling []
  2. Quote taken from Jon Cohen’s rapid coverage of the dismissals. []
  3. This link may not have propagated yet, but the domain was registered and should be going live any minute now. Aaany minute now,… []
  4. No, really. It’s been in the works for week. It was one of those TIMING OF THE CENTURY sort of things. []
  5. Yep, all guys. I know. Different topic for a different night. []
  6. Can’t imagine how that happened. []