Ebola has proven itself time and again to be a menacing killer. The virus behind the world’s deadliest outbreak also is a stubborn survivor.
Health care workers have saved some of its victims and scientists have found ways to eradicate the presence of the disease in specific settings. But even when subdued, Ebola has endured, always threatening another highly contagious outbreak.
For Ebola fighters, such as UNC-Chapel Hill doctors Billy Fischer and David Wohl, November has been a month with good and bad news.
On Nov. 17, an infant girl in Guinea born to an infected mother had received two negative tests for the virus and was believed to be the last known Ebola patient in the West African country.
That cause for celebration was quickly muted two days later, when Liberia, twice declared Ebola-free, announced three new cases in its capital city.
Nathan Groote, a 15-year-old boy who died on Nov. 24, was the first Ebola death in Liberia since July. His father and brother also were infected, prompting the monitoring of at least 150 people.
“The reality is, we’re not done with this outbreak,” said Fischer, a critical care physician and pulmonary disease researcher who is preparing to return to Liberia on Dec. 5.
The recent Ebola outbreak, which claimed the lives of 11,314 people, according to the World Health Organization, also left behind some 17,000 survivors. Both Fischer and Wohl, an infectious disease specialist who has researched and treated HIV, said they believe that many of those survivors hold meaningful clues to a greater understanding of the mysterious virus.
“This story doesn’t end with the declaration of no more transmission,” Fischer said in his Chapel Hill office last week. “The reality is the virus is still present in survivors. We have to establish care for survivors. We have to protect them and their loved ones.”
Many survivors, according to Fischer and Wohl, suffer from eye problems, lingering joint pain, headaches and other chronic health issues after fever and other symptoms of the virus subside. Doctors know the virus can stay in the semen, ocular fluid, breast milk and spinal fluid of survivors for months, but Fischer and Wohl both think there is much to learn about the potential for transmission and about long-term psychological effects.
Ebola survivors not only have lost many members of their families and communities to the disease, they often are isolated afterward in a manner similar to the way people with AIDs and HIV were in the early days of the epidemic.
“The parallels are uncanny – the stigmatization, the fear,” Wohl said.
Many outbreaks in four decades
Ebola, often described as the global health disaster of 2015, was first identified in 1976.
Though the virus was named after a river, it is thought to live in Central Africa’s equatorial forests and infects people who live, hunt or work in those regions and on their fringes.
Since workers at a cotton factory in Nzara, Sudan, were infected from an unknown source almost four decades ago, there have been two dozen recorded outbreaks.
Health care workers do not know exactly how the virus emerges after dormant periods. But there has been much speculation among researchers that initially it is transmitted from animals to humans – quite possibly by bats that can fly over rivers and vastly different geographic regions separated by great distances.
“This outbreak occurred well over a thousand miles from the previous outbreak,” Wohl explained this week. “I think it is probably something that flies that is the match that starts it.”
But it is people, traveling along roads and waterways through impoverished areas, who spread the virus quickly.
The onset of the recent outbreak, which thrived at the intersection of Sierra Leone, Liberia and Guinea through 2014 and into 2015, has been traced back to a 1-year-old boy named Emile, whose family was flummoxed by the high fever, bloody stool and vomiting that ravaged his body after he played near a hollow tree where bats roosted.
A recent panel of experts has criticized the World Health Organization for a slow and ineffective response to that outbreak.
Learning from survivors
The criticism and calls for reform are important as the health care community takes a breath and tries to move forward, the UNC doctors said.
But Fischer and Wohl hope to persuade others about the need for stepped up care of survivors and for the continued clinical research of those patients so the global health care community can be on a more informed perch when the virus returns.
Eye drops have helped with ocular issues. Steroids can be prescribed to ease muscle pain.
Wohl, an infectious disease doctor who treats HIV and AIDS patients, is fascinated – and troubled – by what physicians call “viral shedding.” Viral shedding happens when a virus is present in bodily fluids or open wounds and can thereby be transmitted to an uninfected person.
There has been at least one confirmed case of sexual transmission of Ebola – a fatal case in a 40-year-old woman whose boyfriend was a survivor with the same genetic makeup of the virus as hers.
“Ebola as a sexually transmitted disease is something Billy and I have been very concerned about for a while,” Wohl said.
Through a collaboration with ELWA (or Eternal Love Winning Africa) Hospital, Clinical RM, a research organization, UNC and Duke physicians, Wohl and Fischer hope to find out more about when survivors are no longer at risk of transmitting the virus to others.
Though there is much to learn, both doctors recalled what it was like a year ago for health care workers in this country going back and forth to the outbreak regions, as politicians called for travel restrictions and quarantines. It was shortly after a Texas health care worker who provided care for an Ebola patient tested positive for the disease.
Wohl recalled returning from the outbreak region on a military plane and seeing soldiers being applauded as they boarded and exited. There were no such greetings for him. Instead he was isolated for 21 days, monitoring himself for any symptoms of the virus.
“When I come back from the airport after being in Liberia, I felt like a criminal,” Wohl said.
That won’t stop Wohl or Fischer from doing work that, though dangerous, they cannot refuse.
Even before the new cases emerged last week in Liberia, Fischer and Wohl were planning a return to the West African country the first week of December. They hope to build an infrastructure in the region that adds clinics, providers, needed resources and education for health care workers that could have a lasting impact.
“I think we’re at a critical juncture where it could be easy to forget about Ebola,” Fischer said. “Or we can step up the effort and really put out the last lines of transmission.”