Inside the Ebola Epidemic

Every second, the world gets zapped by about 100 lightning bolts - that's nearly 9 million strikes a day.  But we could see that number climbing dramatically, owing to climate change according to a new study by scientists at the University of California, Berkley.  This increase could harm people, it could start fires and it could even further intensify global warming itself by producing more greenhouse gases.  Victoria Gill told Chris Smith why we can expect more frequent bolts from the blue in future... 

Victoria -   Lightning, as well as being very dramatic, is really important because it causes chemical reactions to take place in the upper troposphere where our weather is.  And our atmosphere being mostly nitrogen and oxygen, that causes lots of chemical reactions between those two gases.  So, it produces lots of nitrogen oxide and also feeds chemical reactions for greenhouse gases.  So, it's not just this big dramatic display.  It's also doing stuff to the chemistry of our atmosphere. What these researchers were trying to find out was exactly how much more lightning we should expect as temperatures increase over the next century.

Chris -   And that would be relevant to global warming.

Victoria -   That would be relevant to global warming because we already have a temperature increase that's forecast up until 2100.  It's also because lightning does change this atmospheric chemistry.  It'll also feed it back into that global warming by actually directly and indirectly producing these puffs of greenhouse gases by feeding these chemical reactions.

Chris -   So, what did they do?

Victoria -   Well, they actually had access to quite an amazing data set.  In the US, there's a thing called the National Lightning Detection Network.  So, every time you get a lightning strike, you get this electromagnetic pulse and that's picked up by a radio receiver and they can detect that within a 1-km radius.  So, they've actually produced this animation of over the year 2011, how many lightning strikes were all over the US.  What they can do is then match that with the temperature changes and then they can project that forward and say how many more lightning strikes we'll expect over the next century.

Chris -   And how many more can we expect?

Victoria -   For every degree Celsius increase in temperature, we get a 12% increase in the frequency of lightning strikes. Now, to put this into real terms, what David Romps at the University of California Berkley says that means, is that for every 2 lightning strikes in the year 2000, there'll be 3 in 2100, so quite a noticeable difference.

Chris -   I did read somewhere that at any moment in time, there are 2000 thunderstorms crackling away all around the world.  Does it really matter though if we get more lightning strikes by 12% per degree in a hundred years time?

Victoria -   People do die from being struck by lightning, but that is very infrequent.  But you do see the huge frequency of these thunderstorms in this animated dataset.  Every single time one of those lightning strikes is happening, there's this little puff of nitrogen oxide and also, all of this extra energy that's feeding the chemistry in the atmosphere.  So, that is contributing to greenhouse gas formation in the atmosphere.  Also, lightning storms trigger half the wildfires in the US apparently.  So, what that means is that these very unpredictable patterns of lightning are going to increase in frequency and that's going to be triggering more wildfires which is obviously a real problem.

Chris -   So, we've got a situation where we could see an acceleration in the numbers of lightning strikes.  This could in turn affect the composition of the atmosphere, including producing more greenhouse gases which could in turn, increase the temperature and increase the frequency of lightning even more.  So, this is important to sort of model into climate change modelling and scenarios going forward I suppose.

Victoria -   Yeah, exactly because those little puffs of nitrogen oxide are very, very small and obviously, very quick. When you see a lightning strike, it's extremely fast.  If that's just growing exponentially in its frequency then that's going to build up and become something that is significantly contributing to the change in the chemistry of our atmosphere. This is a really interesting physical and what will be very visible change in our weather that's directly related to global warming.

Ebola has been dominating the headlines for many months with governments and healthcare providers worldwide caught off-guard by the outbreak that's happening in West Africa.  Recently, according to the WHO, the death toll passed 5,000 people and the number of infections is still rising. Suzie English, a virologist from Addenbrooke's Hospital in Cambridge, explained to Chris Smith what Ebola is and how it causes disease...

Suzie -   Ebola is a viral infection.   It was discovered in 1976 after two very large outbreaks in central Africa in Zaire, now the Democratic Republic of Congo and the Sudan.  In between human outbreaks, the virus is thought to hide out in fruit bats.  At the beginning of outbreaks, it's thought to be transferred to humans through the consumption of or contact with bush-meat which may be the bats themselves or other animals that have been infected by bats.

Chris -   What can you tell us about the present outbreak?  Where did it come from and why has it been so dramatic?

Suzie -   Well, the origins of the present very large outbreak in west Africa are not precisely known, but it is thought that there is an animal origin and that it has been transferred into humans through the consumption of bush-meat.  The present outbreak began in a very rural area of Guinea, near the Liberia and Sierra Leone borders where there is a lot of cross border travel.  And the viruses rapidly spread through those countries.

Chris -   Do we know anything about how it got started in the first place?

Suzie -   The index case has been traced back to a small child in December of 2013 in Guinea.  Early work has looked at how the virus was transmitted firstly to people who cared for this child and then for people who cared for those people, and looked at in particular, the amplifying effects of hospitals and funerals in propagating the infection.

Chris -   And talking of propagating the infection between individuals, how does it spread because there's been enormous controversy in the media about whether or not there's airborne spread or other mechanisms?  How does it get about?

Suzie -   So, Ebola is spread from person to person through direct contact with infected bodily fluids.  A person who's infected with Ebola is particularly infectious during the later stages of their disease when they produce vast amounts of viruses in many bodily fluids.  And also, people who have recently died from Ebola are also very infectious. Their bodies are very infectious.  Funeral practices can propagate the infection when a large number of people come into contact with the recently deceased person's body.

Chris -   Once a person has got it, a, how do we diagnose it?  And, b, what can we do about the infection?

Suzie -   So, when a person first becomes infected with Ebola, there's a period of silent multiplication of the virus within the body.  This is called the incubation period.  During the incubation period, the person is asymptomatic which means they don't have any symptoms, they don't have a fever, and they're not infectious.  The first detectable manifestation of the infection is a fever which the person may or may not be aware of.  And this is why people who've been exposed to Ebola have their temperature monitored.  After the onset of the fever, the patient may develop flu-like symptoms - sore muscles, sore joints, headache, severe fatigue, and then after a few days may develop tummy pains, lack of appetite, nausea, vomiting and diarrhoea.  Towards the end of the first week of their disease, the patient will develop dysfunction of many organs.  So, they may develop kidney damage, liver damage, an inability to clot their blood and a severe immune response throughout their body which can damage their body further.  For those who do not survive Ebola, this is the time when they develop multiple organ failure and shock.  For those who survive Ebola, the disease typically lasts for approximately 2 weeks.  But even after they recover from the virus, they can still be shedding the virus in their bodily fluids for some time and need to be retested to see if they have cleared the virus.  In terms of treatments, the treatments fall into roughly three categories and all of them are under study.  So, there's no definitive treatment for Ebola at present.  The first category of treatment is supportive care.  So, this is designed to support the body through the period of the disease until their body can fight off the infection.  The second broad category of treatment are immunological therapies.  These treatments involve giving antibodies from people who survived Ebola or synthetic antibodies to try and neutralise the virus and prevent it from infecting more cells in the body.  The last category is anti-viral drugs which aim to prevent the virus from replicating in cells after they've infected the cells.

The Ebola outbreak doesn't mean that all of the other major health problems, like malaria, that were previously in affected countries like Sierra Leone, have disappeared.  In fact, the strain of coping with Ebola is having some serous knock-on effects and it's robbing people of routine care for many other diseases and even child birth.  Dr. Yaron Wolman is the head of the child survival section at Unicef.  He's currently in Free Town, the capital of Sierra Leone, where he's leading the charity's efforts to stop the outbreak becoming a full blown humanitarian crisis.  He explained to Chris Smith what factors turned Sierra Leone into a ticking time bomb for Ebola...

Yaron -  One of the reasons that the Ebola outbreak has expanded so quickly in this country is that the health system was very fragile even before the Ebola outbreak from very long civil war in these countries.  The impact of the Ebola outbreak on this very fragile health system is that less women and children are visiting the health facilities.  Many of them have less access to all the essential primary healthcare services like vaccinations, treatment for malaria, treatment for pneumonia, treatment for diarrhoea, skilled birth attendants.  Things that were there before the Ebola outbreak are not there anymore.  People are scared to go to the health facilities because they're afraid of being infected there.  And also, in some of the health facilities, some of the health workers unfortunately got infected and some of them have died.  So, there are also some health facilities that for some period of times do not have the health workers to provide the healthcare services there.

Chris -  In theory, the impact of the other problems could be far and away much larger than the impact that Ebola has had.

Yaron -  Well, it's very difficult also to differentiate between the two because they're very strongly interlinked.  Currently still, probably more people are affected by malaria than they are affected by the Ebola number-wise.  But the nature of the expansion of the Ebola outbreak means if we do not contain it in the coming weeks, we might face a very severe catastrophe like previous large scale global outbreaks from the early 20th century like the Spanish flu for example.  So, unless currently we do manage to concentrate all our efforts and to contain the outbreak in the coming weeks, the scope of the outbreak will deteriorate very quickly and we might encounter massive numbers of patients because of the very high mortality rate, massive numbers of casualties.

Chris -  Can you paint a picture for us of what the situation is like at the moment on the ground?

Yaron -  Well, I'm based in the capital which is called Freetown.  Freetown is one of the epicentres of the outbreak currently.  We do see even here that it's very difficult to provide proper treatment services to the Ebola patients.  However, because of the efforts of the different development parties with the government, gradually, things are improving in terms of the number of beds that are being available for treatment and the laboratory facilities.  But still, the number of cases are on the increase.  We do need to ensure that in such a setting who have crowded urban settings with slums, we do manage to invest enough, both in the prevention of Ebola.  So, very strong social mobilisation and communication campaigns and at the same time also in the Ebola treatment part, which is to ensure that there are enough treatment beds for patients, enough laboratory capacity in order to provide rapid and accurate diagnosis of the cases.  And at the same time also, cater to the special vulnerable groups like children and women because women and children are disproportionately affected by the outbreak and we have multiple cases of children who are either they're mothers or both their parents have been affected by the outbreak.  They have suspected contacts, but they haven't yet develop the symptoms.  These are the kinds of challenges that all of the partners, the development partners are encountering in our efforts to work together with the government to contain the outbreak.

Unicef is one of many national and international charities helping to fight the Ebola outbreak, to find out how you can help click 
here.

Why has the Ebola outbreak been so hard to control, and why has it hit the world now? Colin Russell, a disease modeller from Cambridge University, explained to Chris Smith how many epidemics begin with an animals reservoir of the disease...

Colin -  The majority of pathogens that are perceived to pose a pandemic risk originate in animals.  These are things like influenza viruses that come from pigs or from birds, Ebola viruses, which we typically get from bushmeat but have their original home in bats, and a plethora of other pathogens which cause a tremendously severe disease when they get into humans.  The difficulty is that there's a tremendous number of pathogens that exist in animals all over the world.  One of the main challenges that we face as scientists and public health officials is, picking which one of those is most likely to cause the next pandemic and developing measures to be able to mitigate the spread of that virus, should it become transmissible from human to human.

Chris -  So, in other words, we know the risk is there, we just have to be alert to the fact that it can happen and pick it up quickly.

Colin -  Indeed.  I mean, response is really the critical element here.  So, there have been a number of Ebola outbreaks over the last 40 years.  They've been contained long before they ever reached the stage, just because in general, when response is swift and effective, it's easy to contain an Ebola outbreak.  But it's when response is slower than one would like, things can turn into the situation that we have right now.

Chris -  But arguably, Suzie English [in an earlier interview] was saying, Ebola was first described in 1976.  The world was a much more primitive place in terms of medicine, communications, population was lower then than we have today and it's today that it's escaped and caused a big problem.  Why is that?

Colin -  It's a complex situation where there was not a sufficiently rapid response to bring the situation under control to limit the early stages of the spread of the disease.  Once the disease gets into its exponential growth phase whereby, two cases create four cases, create 16 cases, etc. then it becomes exponentially more difficult to contain as well.  Because when the number of individuals who are infected is doubling, the number of resources that it takes to control that sort of outbreak is more like quadrupling or worse.

Chris -  So, in terms of actually doing surveillance, you would argue then that what we need to do is be aware of the fact we've got this risk, be aware of the fact that, as populations grow and people have more likelihood of coming into contact with wild animals- do we need some kind of network around the world then where scientists like you are watching for warning signs that something might be about to happen so you can deploy the sort of rapid response you're saying we need?

Colin -  There's a variety of types of response networks that are administered by WHO, by various national governments, that are meant to detect abnormal activity.  But the difficulty that we face in a variety of low income countries is there's a real difficulty in differentiating normal from abnormal.  And so, in a lot of place in west Africa, people go in to see a doctor because they feel sick and without even doing any kind of diagnostic test, they're told that they have malaria and that they should go back home.  And yet, there's a number of different diseases that have malaria-like symptoms in their early days.  So, in malaria endemic portions of Africa, this is not an unreasonable thing to assume.  But it means that you're going to miss those extraordinary cases that have the potential to set off situations like the one that we have right now. 

One of the things that we need on a really fundamental level is we need the development of basic public health infrastructure worldwide.  And something that I find shocking is that every year, approximately 1.8 million people die of diarrhoea.  Now, those people aren't by and large in the UK.  They're typically in low income countries where the public health infrastructure is generally very weak.  But if we were to develop - we, as high income nations - were to develop the basic public health infrastructure in low income countries so they could deal with diseases like diarrhoea, we'd stand a much better chance of being able to discriminate ordinary diseases from extraordinary diseases and being able to catch cases like the current Ebola outbreak while it's still early enough, well, we could really do something about it.

Chris -  In other words, it's all about prediction.

Colin -  It's all about our ability to respond swiftly when something happens...

Every day there are new headlines about Ebola as the death toll rises. But do we in the West have a reason to fear Ebola? Are we doing enough to stop disease outbreaks in the developing world?

Suzie English, Colin Russell and Peter Walsh, all from Cambridge University, discuss the likelihood of Ebola spreading, how health organisations work against disease outbreaks and the media's fascination with the virus.

Chris -  Now, let's take a sort of broad view and ask everyone's opinion on this.  Suzie, let's begin with you. What do you think actually the threat is in terms of a British or an Australian, a sort of western healthcare system?  Do you think we're well-prepared?

Suzie -  Well, we've had warning.  We've been able to observe the outbreak occurring in west Africa.  And I think that early warning is very important for us to be able to mobilise people in our own health system, both in public health, in hospitals, in GP practices to be aware of Ebola, to know what to look for, to know who's at risk of catching Ebola.  These are really important for preventing an outbreak in Britain or Australia.

Chris -  Peter, do you think that we are at risk of this thing spreading much more if it were to go in a toehold in a country like Britain?  Would it spread or would it just fizzle out?

Peter -  It's not going to spread in Britain or in Australia.  As Suzie said, we have very good public health systems.  It's not really that's transmissible.  The flu which Colin studies is much, much more transmissible.  It's relatively easy to contain if you know what to do and you have a public health service.

Chris -  Colin, Peter is saying that many of these international organisations don't play well together.  You're saying that in order for them to interact, if we're going to succeed and stop this and other kinds of outbreak like this in the future, they need to be playing well together.  That doesn't sound like good news then.

Colin -  For influenza for example, WHO and Centres for Disease Control (CDC) work very well together.  But it's the lack of international coordination on a variety of different levels that ultimately creates problems.  Coming up with this sort of ability to respond locally to outbreaks which is what we really need because international response is great.  But if you're really going to catch on the first day or the second day, you really need people on the ground in each country who are ready to respond at a moment's notice.  That's something that is not going to be necessarily developed by a big international organisation.  But it's something we have to develop within these countries themselves.

Chris -  Peter, what about other sorts of disorders which might be lurking out there because Ebola is just one of the many?  What should we be doing to be more on our guard against those?

Peter -  It's a resource allocation problem.  Until they've killed a bunch of people, nobody is wanting to spend any money.  What we really need to be doing is we need to do the research and surveillance but before the fact, nobody is willing to spend the money to do it.  And so, it's a huge problem.

Chris -  Colin, you're nodding.

Colin -  I think the current situation really highlights a broader international problem that we have which is, until there's a lot of people dying in some other place and then there's a threat to us here in the UK or the United States or Australia, it's their problem.  But we don't invest enough to develop that sort of very basic public health infrastructure to actually help them stop the problem before it becomes a potential problem for us.

Chris -  So, why has there been such a media storm?

Colin -  Always, as humans, we're attracted to things that are spectacular and extreme.  In terms of horrific disease, Ebola is one of the worst that there is.  We're not concerned that much about the things that actually kill us, like influenza for example.  Approximately 500,000 people die of influenza every year, but we're so comfortable with what flu is and the fact that we've had it and didn't die from it, that we don't worry about it that much.

Chris -  Peter...

Peter -  I agree completely.  Another contributing factor is zombie movies.  People have gotten so used to these movies where like, you get one little splatter and then 30 seconds later it's a zombie.  Everybody is a zombie and everybody is going to die, that they have come to think that's actual science rather than science fiction.

Chris -  Don't come to the cinema with me.  Not if you're going to wave your hands around like that. I mean people will give us funny looks. But no, it's true though.  People do like a good story and they do like being professionally scared really.  But it is important though.  Someone was also highlighting to us,  isn't it interesting that lots and lots of people have died in Africa of this for 40 years like Suzie is saying and it's when finally, someone dies in America that people go, "Oh, maybe we should take some notice of this"?  Suzie...

Suzie -  Absolutely.  I agree with everything that my fellow speakers have said about the need for infrastructure in countries that are least able to cope.

Chris -  So, following on from that then.  We've got this question that's just popped up on social media.  Does the media reaction actually affect how we respond?  Colin, what do you think?

Colin -  Well, indeed it does.  There's a couple of different components to it.  So, the short term is that a really strong media reaction can help facilitate the funding of a long term international response which is incredibly positive.  However, one of the things that happens over time is that Ebola ceases to become news.  So, if we look at the number of headlines that reported the word 'Ebola' over the past 3 months, they actually peaked in October and they've been declining ever since then.  Because at this point, everyone knows there's a big outbreak going on in west Africa.  So, it's not so much news anymore.  We get fatigued from it.  It's not that similar to the situation with influenza.  H5N1 bird flu back in 2006, it was the big scary thing that was going to kill us all and there was a big threat.  But it's not in the news anymore, but the threat itself hasn't changed.  And so unfortunately, we, as humans, we get tired of hearing the same thing day after day and so, we have to hear new stories.  One of the things that really needs to be balanced in terms of what the media does and how it covers the Ebola outbreak is to stimulate long term public interest.  

Chris - Today, the Wellcome Trust have announced they're putting in one and a half million Pounds to fund a number of little start-up projects to try to come up with new sort of Ebola initiatives.  You're nodding at that, Peter...

Peter -  The director of the Wellcome Trust, Jeremy Farrar, was - if you can pick one person who was instrumental in actually creating reaction to this outbreak was he.  He really shamed the international community into acting on this when everybody else was not doing anything.  He's a hero for that.

Chris -  Suzie, are you getting lots and lots of phone calls to the hospital from worried well?  That's another way that people are reacting.

Suzie -  We're getting so many calls from the worried well though I'm sure that GPs and hospital emergency departments undoubtedly will be seeing people who are very concerned about Ebola.  The fear is real whether or not there is a true threat.  That is something that health professionals have to deal with.  Certainly, people who've been coming back from west Africa from treating people have encountered an awful lot of fear and that fear is real.  So, we do have to be sensitive to what people think and the reaction that the media attention has generated.  I'm hoping that this media attention will bring about changes including vaccines and treatments which will be a legacy that can be used to treat Ebola going into the future.

Chris -  So, what do you think should be done right now?

Suzie -  So, I'm very happy that the treatments and the vaccine trials are progressing more quickly.  I think this is long overdue.  Furthermore, a concern from the current outbreak is that Ebola virus will become endemic in west Africa when it hadn't previously been there before.  And so, there may be more outbreaks going into the future and we desperately vaccines and treatments to combat these outbreaks.

Chris -  Colin, I guess on your wish list would be better international surveillance and cooperation, wouldn't it?

Colin -  Indeed and it's something we're going forwards from here.  Hopefully, we'll be in a situation where we can end the current epidemic with no subsequent endemic circulation.  But once this outbreak is over, that doesn't mean that the threat from Ebola is gone.  It came from an environmental reservoir somewhere and that threat will persist over time.  We have to find good ways to monitor it and we have to find better ways to respond next time.

Chris -  Peter...

Peter -  First of all, as Colin knows, I think we should be modelling bat populations.  I think this is much more predictable than people will admit.  I think that if - in 2005, colleagues and I published a paper saying that it was predictable and if you did X, monitor bat populations, you could predict it and had they done that, this might not have happened.  And so, I think that there has to be some money invested.  What I was going to say is that the media has to be much more intelligent about advocating things that are actually solutions rather than just crying about how dangerous things are.  And they must be much more sophisticated, but understanding what's actually a good response and a constructive response and what's just inciting fear.  That's what has not happened enough to date.