Infectious Diseases and the News Cycle: Why Ebola is Different Jeffrey R. Boscamp, MD Vice President & Chief Academic Officer Hackensack University Medical Center Marvin I. Gottlieb, MD Chair in Pediatrics Joseph M. Sanzari Children’s Hospital Associate Professor of Pediatrics Rutgers-New Jersey Medical School

ID and the News Cycle: Definition The 24-hour news cycle (or 24/7 news cycle) refers to 24-hour investigation and reporting of news, concomitant with fast-paced lifestyles. The vast news resources available in recent decades have increased competition for audience and advertiser attention, prompting media providers to deliver the latest news in the most compelling manner in order to remain ahead of competitors. -Wikipedia

ID and the News Cycle: Perspective “In this 24 hour news cycle, overblown stories reign supreme. The world of overblown news is a scary one, indeed. Every day the sky is falling, and then, miraculously, we wake up to find that it has not yet fallen – but that today will surely be the day!” -Garth Sundem

ID and the News Cycle: Perspective • Federal debt vs. mortgage fraud • Ebola vs. not expanding Medicaid • Missing airliners vs. climate change “Within too much of modern journalism, a perverse news calculus is at work. That which has little likelihood of ever harming or impacting us enjoys a steady stream of intense, breathless coverage, creating a constant background buzz of dread. By contrast, the banality of actual, everyday crisis gets routinely ignored, subsumed under a media tide of sensationalist speculation. As a result, we’re trained to be most scared of what should scare us least.” - Reed Richardson, The Nation, October 2014

ID and the News Cycle: Perspective • “Breaking” and “Developing” news events • “The Inflection Point”: ISIS moves to Ebola • CNN chyron: “Ebola : The ISIS of biologic agents?”

ID and the News Cycle: Perspective “While the number of people likely to get or die from Ebola in the United States will almost certainly be tiny, tens of millions of Americans are already victims in an epidemic of fear that is sure to contribute to sickness and death among many…the vast majority of those who will be harmed in this epidemic will suffer directly from the serious health impacts of fear itself.” -Reed Richardson, The Nation, October 2014

ID and the News Cycle: Perspective • Young ME, Norman GR, Humphreys KR. Medicine in the popular press: the influence of media on perceptions of disease. Plos one 2008 Oct 29; 3 (10). • Reader impressions of 10 infectious diseases • Media common: anthrax, SARS, West Nile virus, Lyme disease, avian influenza • Media rare: tularemia, babesiosis, yellow fever, lassa fever, hantavirus • Undergraduate psychology students and medical students • Asked to rate seriousness of the diseases • Both groups rated “high media frequency” diseases more serious than “low media frequency diseases” • Repetitive media coverage can bias the public’s perception of disease

ID and the News Cycle: Plague • • • •

1st Pandemic: Early middle ages, AD 541-542, 588 Constantinople, Mediterranean May have killed 100 million people Europe’s population dropped by 50% between 541-700

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2nd Pandemic (black death): 14th century to 19th century 1347-1351, started in China, Silk Road to Asia, Europe, Africa China lost 50% of population; 123 million to 65 million Europe lost 33% of population; 75 million to 50 million Africa lost 13% of population; 80 million to 70 million Largest death toll from any known non-viral epidemic

ID and the News Cycle: 1918 Influenza Epidemic • AKA: “Spanish flu” • WWI – the Great War. Censorship in Germany, Britain, France and U.S. • Spain neutral • Infected 500 million; killed 50-100 million (3-8% of world population) • Case fatality rate: 10-20% • Secondary bacterial pneumonia

ID and the News Cycle: The Forgotten Spanish Flu Pandemic • Familiarity of pandemic disease in the 19th-20th century: typhoid fever, yellow fever, diphtheria, cholera • Killed most of its U.S. victims in 9 months: limited media coverage • Not reported on: only mention in newspapers were advertisements for “drugs” that purported to cure it • Overwhelmed by the reporting of WWI – foretold the news cycle

ID and the News Cycle: Legionnaire’s Disease • July 21, 1976 – American Legion opened a 3 day convention, Philadelphia • Bellevue – Stratford Hotel • United States bicentennial • July 27, 1976 – Ray Brennan, 61 year old AF Captain, became ill and died • Within 1 week: 130 hospitalized, 25 died • Eventually: 221 cases, 34 deaths • High fever, pneumonia • Previous winter, H1N1 swine flu similar to 1918 strain • Swine flu? Nickel toxicity? • Michael Crichton’s Andromeda Strain

ID and the News Cycle: Legionnaire’s Disease • Illness responded to macrolides • Cooling tower water • Bellevue – Stratford closed in November 1976 due to media publicity of the outbreak • Joseph McDade discovered the bacteria 1 year later

ID and the News Cycle: Streptococcus Pyogenes “Killer flesh eating bacteria” Pharyngitis vs. impetigo Necrotizing fasciitis or toxic shock syndrome Jim Henson: May 4, 1990 – sore throat; May 13 – fatigue, malaise: May 15 – SOB, hemoptysis. Died NY Hospital, May 16. Age 53. • Highly pathogenic strains. M protein prevents opsonization; also can produce toxin • • • •

ID and the News Cycle: Severe Acute Respiratory Syndrome (SARS) • November 2002 – July 2003: Outbreak, Southern China • 8096 cases, 774 deaths • Hong Kong, then 37 other countries by early 2003 • Coronavirus • Eradicated by January 2004; no cases since

ID and the News Cycle: SARS - CoV • Public spotlight in February 2003 – American businessman (James Earl Salisbury) traveling from China developed pneumonia on flight to Singapore; died in Hanoi • Medical staff treating him developed SARS • Fever, pneumonia, lethargy • Masked palm civets, raccoon dogs, ferret badgers, Chinese bats

ID and the News Cycle: 2001 Anthrax Attacks • Tuesday, September 18, 2001: 1 week after September 11 terrorist attacks • News media offices and 2 Democratic U.S. Senators • 5 died, 17 others infected • Fear of weaponized anthrax • Bruce Edwards Ivins declared a suspect on April 4, 2005 • Died of acetaminophen overdose on July 29, 2008 • FBI closed case: 2010 • Total damage (FBI): $1 billion

ID and the News Cycle: 2001 Anthrax Attacks 1 YEAR LATER On April 22, 2009, Lyn Finelli, Chief of flu surveillance at the Centers for Disease Control and Prevention, gathered her team and advised them to prepare for the worst. A flu epidemic was brewing caused by a virus never seen before in humans. In Mexico, hospital workers were sick and dying. “That scared all of us”, Finelli said, because “we all know from SARS and Ebola what a red flag it is” when health workers who guard themselves against infection fall ill themselves. “It means the virus is very contagious and very virulent”. -USA Today, April 22, 2010

ID and the News Cycle: Influenza A, Subtype H1N1 • Novel H1N1 Virus (CDC) • Pandemic H1N1/09 Virus (WHO) • Swine Flu • Reassortment of genes from different influenza viruses • Swine (American, Europe/Asia), Avian, Human • Mexico, April 2009 • Pandemic, WHO, June 11, 2009

ID and the News Cycle: Novel H1N1: Statistics (Fall 2009) • Who knows? • Testing issues • Age 25 and under; few cases over age 64 (8.5-13% of hospitalizations since 9/1/09, ? x-reactivity with prior flu) • • • • • •

Projections (Fall 2009): 2 billion cases next 2 years (WHO) U.S.: 1.8 million hospitalizations Up to 90,000 deaths (young people!) Up to 50% of U.S. population infected: 150 million ICU utilization

ID and the News Cycle: NOVEL H1N1: WHAT DID WE LEARN?

By Mid-March, 2010: • 60 million infected in US • 270,000 hospitalized • 12,270 deaths • Age 17 and younger: 19 million infected (25% of population) 86,000 hospitalized, 1270 deaths

ID and the News Cycle: Ebola Virus Disease (EVD) • Amongst the most virulent pathogens in humans • Case fatality rate prior to 2014-2015 West Africa outbreak: 80-90% • 2014-2015 West Africa outbreak: case fatality rate 70%

ID and the News Cycle: Ebola Virus Disease Filoviridae: Ebola, Marburg Non segmented, single stranded RNA virus EVD vs. hemorrhagic viruses 5 species: 4 cause human disease Zaire – 1st recognized in 1976 – multiple Central Africa outbreaks; causative agent of 2014-2015 outbreak • Sudan – 50% mortality in 4 epidemics • Ivory Coast – cause of illness in 1 person • Bundibugyo – Uganda 2007. Lower case fatality (30%) • • • • •

ID and the News Cycle: Ebola 2014-2015

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1st West African outbreak: all previous outbreaks in Central Africa Far larger than all previous outbreaks combined Non-human primates: contact with unidentified reservoir (bats?) Human epidemics due to handling or consumption of sick or dead animals for food Began in Guinea in late 2013; confirmed by WHO in March 2014 Spread to Liberia, Sierra Leone, Nigeria, Senegal, Mali April 26, 2015: 26,277 cases; 10,884 deaths Magnitude and deaths underestimated: many outside of hospital 850 healthcare workers infected: 60% died

ID and the News Cycle: Ebola in the U.S. • September 30, 2014: 1st travel associated case of Ebola in U.S. • Liberia to Dallas, Texas • Patient developed symptoms 5 days after U.S. arrival; died • 2 nurses caring for patient developed Ebola; both survived • Dr. Craig Spencer; quarantine

ID and the News Cycle: Ebola Transmission • Contact with meat or body fluid of infected animal • Person to person: blood, skin, body fluids of dead or infected person • Blood, feces, vomit, urine, semen, saliva, breast milk • Likely: tears, sweat

ID and the News Cycle: Ebola – Lessons from West Africa 2014-2015 • Ebola Virus Disease, not Ebola Hemorrhagic Fever • Volume losses (vomiting/diarrhea) is the major contributor to severe disease • Incubation: 6-12 days after exposure (range 2-21 days) • Not infectious before symptoms • Abrupt onset of fever, chills, malaise, fatigue, HA, vomit, diarrhea, anorexia • Fever with relative bradycardia (like typhoid fever) • Rash: erythematous, nonpruritic, day 5-7 • GI: early in illness • Hemorrhage: only 20%. Usually in terminal phase • Neurologic: meningoencephalitis after day 10

ID and the News Cycle: Ebola Diagnostics • • • • • • •

Leukopenia Thrombocytopenia Increased AST/ALT DIC Proteinuria Increased BUN/creatinine Electrolyte abnormalities

ID and the News Cycle: Ebola Risk Stratification High: • Mucous membrane or percutaneous exposure to body fluids (or blood) of person with symptomatic EVD • Exposure to body fluids/blood of person with symptomatic EVD: no PPE • Processing body fluids/blood of person with symptomatic EVD: no PPE or biosafety • Direct contact with dead body without PPE in country with widespread EVD • Lived in household and provided care to person with symptomatic EVD Some Risk: In countries with widespread EVD: • Direct contact with appropriate PPE • Any direct patient care in other healthcare settings • Close contact in households, healthcare or community setting (close contact: within 3 feet without PPE)

ID and the News Cycle: Ebola Risk Stratification Low: • In country with widespread EBV in past 21 days: no known exposure • Brief contact (e.g. shaking hands) without PPE of person with early EVD • Brief proximity – same room as EVD patient with symptoms • Direct contact (with PPE) with patient with symptomatic EVD, non-endemic country • Travel on airplane with person with symptomatic EVD

ID and the News Cycle: Ebola Virus Treatment • Supportive care: maintain cardiovascular function while immune system mobilizes support • Prevent volume depletion, correct electrolytes, ameliorate shock complications • Symptom management: fever, pain, nausea, vomiting, diarrhea • Anti-emetics, anti-diarrheal, blood products, dialysis (?)

ID and the News Cycle: Ebola Virus Treatment

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Antiviral therapy: anti-Ebola activity in cell cultures or lab animals Favipiravir: inhibits wide range of RNA viruses Brincidovir: inhibits DNA viruses, but has had vitro activity against Ebola ZMAPP: combination of humanized monoclonal antibodies targets Ebola virus surface glycoprotein given to U.S. MD/RN who survived; 2 other severely ill healthcare workers died TKM-Ebola: short interfering RNA (siRNA) binds to specific sequences in viral mRNA – blocks replication targets 3 different EV genes non-human primates: given 1 hour after EV challenge: 80% survival; all controls died Antisense oligonucleotides (PMOs) BCX 4430 – inhibits viral RNA polymerase function

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Convalescent and whole blood

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ID and the News Cycle: EVD Prognosis • Poor prognosis: signs of severe intravascular volume depletion, metabolic abnormalities, impaired oxygen delivery • Manifests as: tachypnea, anuria, delirium, shock, coma • Older age poor prognosis: 94% case fatality >45 years old; 57% case fatality