Ebola ça Suffit-Let us Hope

Scanning Electron Micrograph of Ebola Virus (NIAID, NIH)

It was less than a year ago that the world seemed to be on the brink of catastrophe. There were predictions that hundreds of thousands around the globe would die from Ebola which, at the time, was raging in West Africa. Ebola, named after the river in the former Zaire near which the first recognized outbreak occurred in the 1970’s had, and still has no known cure. In an outbreak of the magnitude that was developing in West Africa, experts from all around the world were floundering as to how to stem its menace: Anyone that came into contact with body fluids of an infected individual was at considerable risk of becoming a patient too and became primed, thereby, themselves, to spread the disease in ever expanding ripples of contagion. That kind of infectivity, coupled with the ways in which the disease manifests itself - the fever, the diarrhoea, the vomiting, bleeding and bloodshot eyes, collapse in the streets- induced a state of terror that was almost medieval in scale. 

Things were not helped by how some sectors of the press stoked up fear by publishing irresponsible statements and wild speculation. As the epidemic progressed, it appeared once in America, that sanctum of wellness and purity: If the walls of citadel America had been breached, where else was safe? Civilization was at the brink. It seemed that the world would regress back to the Dark Ages in the short space of a few months. 

          But nothing like that happened, we are relieved to say. Instead, cool scientific heads systematically considered options. The real challenge was in the outbreak’s epicentre, West Africa, where serious obstacles stood in the way of coping with an epidemic of the scope that was this outbreak. Nevertheless, with public health and acute medicine specialists hanging heads, and with generous support from world governments and medical charities, it was hoped that the disease would remain largely confined to the three countries where it raged, even in the absence of specific treatment or preventive measures.

          Options for managing the epidemic that were considered include administering combinations of so-called monoclonal antibodies engineered in plants (ZMAPP), serum from patients convalescing from the infection, or direct anti-viral agents such as Avigan, an experimental anti-influenza virus agent.  These treatments, although conceptually sound, had the handicap of not having been widely tested in humans before, even though studies had shown that they were effective in animals. Another confounding factor was that none of these treatments was available in any quantity at all. Only a few patients, lucky enough to be carrying the right passport had the opportunity to get access. 

It would be idle to consider the ethical issues involved in deciding who got the treatment, where, how and when. The more important consideration was how to make the treatments available for all in need by scaling up production to hundreds of thousands and perhaps even millions of doses. No one wanted to put up the money for such massive emergency production without reasonable expectation that the products would be effective and safe when used on a community scale. But first, it was how to get round an even greater problem namely, the idea of treating sick patients with medicines that have not gone through the usually mandatory phases of pre-clinical efficacy and safety trials. It was argued back and forth about where the ethical balance laid between trialing treatments that had not gone through the preliminary stages of evaluating safety in sick patients and thereby putting them to unknown hazards on the one hand, while on the other, worrying about the ethical soundness of not treating people who were dying just because we were too timid to try 'newly-hatched and un-fledged remedies'.

However, in the confusion, the well-founded principle that viral diseases are better prevented than treated was not forgotten. But here again, it was not such an open and shut case either because, although candidate vaccines were available, they too, had not undergone the rigorous pre-clinical trials to confirm their safety. So, you’re damned if you do and damned if you don’t. 

          As it has turned out, we escaped damnation alright: the ordinary barrier procedures surrounding nursing, and burial of the dead, gradually ensured that disease transmission was interrupted among those caring for the sick and the dead whilst quarantine, an always inconvenient imposition, ensured that community transmission was curbed. Thus, by time of this writing, the incidence of new cases in West Africa has sunk to zero. And at this time too, the CDC reports a total of 27,988 cases worldwide, with11, 299 dead (CDC Ebola Update 3rdWeek August 2015). The figures are horrible enough, but considerably less dire than the holocaust predicted a few short months ago.

          The rapid fall in the numbers of affected individuals and people at risk had meant that testing other therapeutic measures would prove difficult, not to mention the ethical difficulties that I referred to earlier. But researchers from the WHO, United States, South Africa, Switzerland and Mali, crafted a field trial in Guinea of such elegance (dubbed with the slogan Ebola ça Suffit by the investigators) that issues of ethics and falling numbers could not stand in the way of demonstrating a 100% effectiveness of the trial vaccine, rVSV-ZEBOV (Ebola ça suffit).

          There has been much jubilation, rightly, at this breakthrough, achieved so quickly and against such odds. But perhaps there should be a note of caution. This is because there have been reports of a “post-Ebola” syndrome, consisting of arthritis, hearing loss and visual problems. And we should note that preliminary studies to determine the rVSV-ZEBOV best dose for the Ebola ça Suffit trial showed that at a certain level, some recipients developed arthritis, requiring scaling down of the dose.

The question that arises then is, if rVSV-ZEBOV is approved for general use, could there be a risk, in the long term, of similar complications developing in those receiving the vaccine? 

   

Tell Fren Tru