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Interview: Dr. Amesh Adalja on Ebola Virus

AAmeshAdaljamesh A. Adalja, MD, is a senior associate at the University of Pittsburgh Medical Center’s Center for Health Security, assistant clinical professor in the Department of Critical Care Medicine, assistant clinical professor in the Department of Emergency Medicine. He is board certified in internal medicine, emergency medicine, infectious diseases, and critical care medicine.

Dr. Adalja is a member of the Infectious Disease Society of America’s (IDSA) Public Health Committee, the American College of Emergency Physicians Pennsylvania Chapter’s EMS & Terrorism and Disaster Preparedness Committee, the Allegheny County Medical Reserve Corps, and the US Department of Health and Human Services’ National Disaster Medical System Disaster Medical Assistance Team (PA-1), with which he was deployed to Haiti after the earthquake in 2010. He has also served on U.S. government panels tasked with developing guidelines for treatment of botulism and anthrax in mass casualty settings as well as a FEMA working group on nuclear disaster recovery. He is associate editor of Biosecurity and Bioterrorism, contributing author for the Handbook of Bioterrorism and Disaster Medicine, and he has published in the Journal of Infectious DiseasesEmerging Infectious Diseases, and Annals of Emergency Medicine. He also writes a blog about his work.

Dr. Adalja is a member of various medical societies, including the American Medical Association, the Infectious Diseases Society of America and the HIV Medical Association. Prior to joining the Center, Dr. Adalja completed two fellowships at the University of Pittsburgh—one in infectious diseases, for which he served as Chief Fellow, and one in critical care medicine. He completed a combined residency in internal medicine and emergency medicine at Allegheny General Hospital in Pittsburgh, where he served as Chief Resident and as a member of the infection control committee.

I first became acquainted with Dr. Adalja over 20 years ago when he was a pre-med student and I was editor for a health policy and patient advocacy group in Orange County, California. This is an edited transcript of the interview.

Scott Holleran: Is there 100 percent certainty among scientists that the Ebola virus is not airborne?

Amesh Adalja: When you talk about Ebola there are different species. What the evidence has shown in multiple experiences and multiple outcomes is that the Ebola Zaire and Ebola Sudan strains cause infection in humans that lead to symptoms. The virus Zaire is most deadly. There are also the Sudan, Bundibugyo and Tai Forest strains—these four species of Ebola cause infections which lead to symptoms. There is a fifth strain, Ebola Reston, which is addressed in The Hot Zone, which is different and those infected [with it] didn’t have symptoms. There is some concern that that strain may have had the potential to spread airborne. With regard to this current outbreak, there is no evidence that the strain has natural airborne properties. You may read about airborne lab model infection and that is not the same thing as how people come into contact with Ebola in a natural setting. The primary means Ebola spreads between humans is through blood and body fluids—for example, through contact with vomit, blood or fecal matter.

Scott Holleran: What concerns if any do you have about the potential for an Ebola outbreak in the West?

Amesh Adalja: I have very little concern that Ebola will be able to spread in a modern, industrial country like the U.S. chiefly because of the way it spreads. You really have to work to become infected—it’s not like measles—and you have to be in very close contact while not wearing personal, protective equipment like gowns, gloves and masks. In a U.S. setting, a patient with Ebola would be placed under protection and we wouldn’t expect it to spread. We’ve had eight importations of lassa fever, another viral hemorraghic fever spread in the same manner as Ebola, and the Marburg [virus] is in the same family as Ebola—and we’ve had no secondary spread when it was imported.

Scott Holleran: You’ve said that a best case scenario is that an Ebola treatment may be available in one year. Do scientists know most of what they need to know in order to develop a vaccine or cure?

Amesh Adalja: Yes, I do think we have the answers for how to control Ebola. Right now, in terms of vaccines, we have a product that was used in a lab in Germany which is being developed by the Canadian government, which, when tried in monkeys, was 100 percent effective. In fact, it works so well in non-human primates, which is the closest you can come to humans, that it leads me to believe that this will be the vaccine that will hopefully lead to the means to control future Ebola outbreaks. Vaccines don’t cure disease. However, it’s very early. It really has to be tested. With regard to cures, I would think about ZMapp, which was administered to [recently infected and admitted U.S. Christian missionaries] Dr. Brantly and Nancy Writebol. I wouldn’t call it miraculous, though, because, for instance, Dr. Brantly also received a blood transfusion and there were other factors, such as the best medical treatment by doctors. There is a third product made by a Canadian company—a drug which shows strong results against [the] Marburg [virus].

Scott Holleran: Recently, an Ebola outbreak has been reported in the Congo. Briefly explain who is being infected with the Ebola virus.

Amesh Adalja: What usually happens with Ebola outbreak in remote regions of Africa—in countries like the Congo, Sudan and Uganda—is that you have an individual who may have been in the forest hunting animals, such as antelopes, gorillas or chimps or bats, and that person gets sick and goes to the local health care facility in their village and the symptoms may mimic other conditions such as malaria or typhoid and may be misdiagnosed. Then, there’s an outbreak because people [caring for the infected patient] don’t realize that the person is infected with Ebola and [they treat the patient in a way that actually accelerates the spread of the virus]. For example, we’re hearing that people are using the same thermometers for patients in Liberia [where Ebola is spreading]. When that person dies, the outbreak is magnified.

Scott Holleran: Do experts know how the two infected Americans, who were working as Christian missionaries in Africa, were contaminated and, if so, how do experts know what they know?

Amesh Adalja: I haven’t seen any definitive answer to how they were contaminated. We do know that they were working there with personal protective equipment, which is very difficult to wear in those settings. Due to heat and humidity, some people may not be fully compliant [with necessary guidelines and use of equipment]. It’s always important to wash hands, especially for missionaries, who aren’t there to respond to [an] Ebola [outbreak] and they may have been there for treating some other condition. My understanding is that they were there [for some other purpose] and Dr. Brantly is not an infectious disease specialist. He’s a family medicine doctor. Doctors who work with Doctors Without Borders are very meticulous and compliant. Not everyone else is.

Scott Holleran: What criteria does the government hold if any for admitting or re-admitting those infected with a communicable disease?

Amesh Adalja: It’s largely going to depend [upon the context] and be handled on a case by case basis. For example, there are diseases that are quarantinable. Recently, there was an arrest warrant for someone with tuberculosis. The number one priority for the government, in this context, is to protect people from contracting a contagious infectious disease. Really, the criterion is to avoid putting someone at undue risk at becoming infected with a contagious pathogen. Typhoid Mary and individuals with tuberculosis are much more contagious than those with Ebola virus.

Scott Holleran: When the infected Americans were re-admitted into the United States, what medical treatment was administered at Emory University?

Amesh Adalja: When these two patients came to Emory [University in Atlanta] they would have received standard supportive care and treatment, such as supplemental oxygen, intravenous fluids, medicine to control fever and medicine to control nausea and vomiting, electrolyte repletion, and possibly blood products were administered they also received doses of ZMapp. The special blood transfusion was administrated in Africa.

Scott Holleran: Do infected individuals pose a risk to society?

Amesh Adalja: I do not believe the infected individuals pose a risk because of the nature of how Ebola is transmitted.

Scott Holleran: As a doctor who writes about ethics in health care, does the U.S. have a moral obligation to re-admit any infected individual American—or groups of infected Americans—under any circumstances?

Amesh Adalja: I believe that in the case of these Ebola patients—because they pose no risk of infection or contagion to Americans—this isn’t an issue, so there would have been no justification to prohibit their re-entry into the United States. However, I don’t believe that this fact is self-evident. Ebola has captured the minds of writers and the ordinary person is very fearful against Ebola. But it’s not like the virus has never been in the U.S.-it’s been in U.S. labs since the 1970s.

Scott Holleran: Government corruption has recently been discovered in nearly every branch including government-controlled science and medicine and military and national security intelligence. Is any degree of skepticism toward government on the Ebola virus or infectious disease in general warranted in your judgment?

Amesh Adalja: Just prior to the Ebola outbreak, there had been reports of laboratory mishaps where certain pathogens were handled in a manner which wasn’t what biosafety guidelines would recommend. There were incidents and mishaps at the CDC, though no one had been infected. I think it’s important that Americans question what safeguards are in place and what protections and protocols are being taken. I do think they will be reassured that there are a lot of safeguards in place.

Scott Holleran: You’re an expert in bioterrorism and you work within government agencies to protect against an attack. Is a terrorist attack using biological or nuclear weapons likely to be detected by the U.S. government in advance?

Amesh Adalja: There’s been a lot of preparation after 2001, when five individuals were killed by an attack using anthrax. Biological weapons leave no signature—they’re natural pathogens. The fact that the former Soviet Union had a biological weapons program in violation of a treaty [banning such weapons] is a reminder of the danger. In Japan, they tried to weaponize botulism and Ebola. We know that Al Qaeda tried to do the same thing. So, these are real threats. This is a core function of government to protect against these threats. The Soviet Union proved how extensive a program can be created. Since the George W. Bush administration funded these programs and created these agencies, we’ve come a long way. But there are still a lot of gaps. [Anthrax infected newspaper editor] Robert Stephens initially thought he contracted anthrax from going into the wilderness and [it became apparent that] he got it from a letter in Florida. In 1984, in the state of Washington, a religious cult that wanted to influence a local election through voter turnout ordered salmonella and went to a salad bar and poured salmonella on the salad bar and the [Centers for Disease Control and Prevention (CDC)] came in and investigated, thought it was poor food preparation and fined the business—but the salad bar had been poisoned by religious terrorists.

Scott Holleran: What is the single worst bioterrorist threat to the United States?

Amesh Adalja: Anthrax—because it’s been proven to be effective.

Scott Holleran: Is there a single source, such as a book or movie, that contains reliable information for a general audience on infectious disease—its facts, history and the risks and dangers—such as The Hot Zone or the movie Outbreak?

Amesh Adalja: I read The Hot Zone and I think it’s a fascinating book and it does get people to think about Ebola. It does provide very good information on the Reston, Virginia [strain of] Ebola out in an animal facility. In terms of movies, the movie Contagion is probably the best, though it dramatically accelerates how quickly a real-life vaccine can be developed.

Scott Holleran: What is the most encouraging news on the topic of infectious disease?

Amesh Adalja: I think the infectious disease in the future is going to harness the ability to use genome sequencing to create targeted therapies at just the pathogen to avoid collateral damage to other microbes or bacteria that may live in your body.

Jonas-SalkJonas-SalkStarzlScott Holleran: Dr. Jonas Salk created the polio vaccine in Pittsburgh, where you work with Pitt to study, treat, cure and prevent infectious disease. Is Pittsburgh still a center for innovation in science and medicine?

Amesh Adalja: Absolutely. Not only do we have Pitt, CMU [Carnegie Mellon University] is here as well. People think of Pittsburgh’s past with the Industrial Revolution and great industrialists like Andrew Carnegie and they’re really idolized—and they’re idolized by me, too—but there are heroes such as [Thomas] Starzl [pictured], a pioneering transplant surgeon, and Dr. Salk, who have also been true to the [enterprising] spirit that built this city with steel and heavy industrial technology and transportation. Pittsburgh is still part of the Industrial Revolution. But now it’s a biotechnological revolution. ZMapp and all the anti-viral medicines were created as a result of the aftermath of 9/11. The threat of Ebola being used as a potential biological weapon has created an incentive [to counter with protective medicine] – so it’s important to remember that, as scary as Ebola can be, it’s been a market incentive, too.