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Announcer:  Second Opinion is brought to you by Blue Cross Blue Shield.  Accepted in all 50 states.  Blue Cross Blue Shield, Live Fearless.


Announcer:  Second Opinion is produced in conjunction with UR Medicine, part of The University of Rochester Medical Center, Rochester, New York.


>> DR. PETER SALGO:  Welcome to this special edition of Second Opinion, Ebola, what we know now.  I'm your host, Dr. Peter Salgo.  Right now, in the second week of October, 2014, the epidemic is raging in Africa, cases are being treated in the United States. The story of Ebola in the United States has been unfolding since Dr. Kent Brantley was flown here after contracting Ebola in Africa. The person referred to as patient number 2 here in the United States contracted Ebola while assisting Dr. Brantley.  She is Nancy Writebol and she and her husband David join today from North Carolina via satellite.  Thank you both for being here.

>> NANCY WRITEBOL:  Thank you.

>> DAVID WRITEBOL:  It's good to be here.

>> DR. PETER SALGO:  We're delighted you could join us.

We have a terrific panel of experts joining us to hear your case, Nancy.  In studio, we have vaccine and travel medicine expert Dr. Mark Shelly from the University of Rochester Medical Center. Mark, Thank you.

>> DR. MARK SHELLY:  Thank you Peter.

>> DR. PETER SALGO:  Joining us by phone, Dr. Daniel Bausch, Ebola expert from Tulane University.

>> DR. DANIEL BAUSCH:  Thank you.

>> DR. PETER SALGO:  Also joining us by phone is tropical medicine expert Dr. Aileen Marty from Florida International University.  Thank you all for being here.  Nancy, David, you have done years of missionary work in the past and recently you were in Liberia in West Africa.  Tell us a little bit about that.

>> NANCY WRITEBOL:  We have spent the last year in Liberia.

We went to Liberia to not exactly be involved with Ebola, we didn't know the word Ebola when we first went, and it was not talked about at that point.  It had not started occurring when we went.  I was the personnel coordinator for SIM, and helping new missionary families that were coming into the country to get settled and to orientate them to Liberia.

>> DAVID WRITEBOL:  And I was taking care of the technical part of the campus there, running generators and water systems and building maintenance for 130, so it was a busy life.

>> DR. PETER SALGO:  Nancy, what were you doing as the epidemic hit?

>> NANCY WRITEBOL:  When the epidemic hit, I was asked by the doctors to come over and to be of assistance to them in order to help suit them up before they went into isolation unit, so I made sure that they had their PPE, which is the personal protective equipment, on, and that they had no skin that was showing.  And then when they came out of the isolation unit, I was the decontamination and was there to spray them down and to make sure they took their suits off properly.

>> DR. PETER SALGO:  Now both of you were on the ground and you saw people getting sick, you saw people dying, the devastation that this virus can cause.  What were your thoughts?  How did you feel?

>> NANCY WRITEBOL:  Well, I have to tell you it was really hard.  We had our first patient on June 11th, and from June 11th to July 22nd, I saw 40 people come into our isolation unit. We had one survivor of Ebola in those 40 patients. And to watch patients die of Ebola is very painful itself because patients lose their dignity, it's a very painful death, and it's a very lonely death.  Patients are in isolation.  So the only people they are seeing are doctors and nurses that are all dressed in PPE.  So it's very difficult, and especially when they don't really have a whole lot of communication with family.

>> DAVID WRITEBOL:  Families can't be together and can't touch each other and it's just very, very difficult to watch the emotional drain and the strain on not only family and patients, but also the community at large because there can be stigmatization and all sorts of different effects of that.

>> DR. PETER SALGO:  It sounds absolutely heartbreaking.

Then one day in July, you got news.  What happened?

>> NANCY WRITEBOL:  Well, I had been working at the isolation unit on July 22nd and not feeling great, but pushed my way through, and I had a colleague that was going to step in for me early that day, so I went home, and David and I were going to go out to dinner that night, and I just called our doctor because I felt like I had malaria.  Our doctor, Debbie Isenhut, said, well, come back out to the hospital, there's nobody in doctor's office, and I'll check you for malaria.  The malaria test was positive, and so I went home and started the medication for malaria.  And four days later, still not feeling good at all, I still was running a fever, and Dr. Debbie came and said Nancy, I think we should go ahead and run an Ebola test just to set everybody's mind at ease, because I was not showing any other symptoms but fever.  And I was really weak, I had not left our home, so they drew blood and later that evening David came back from a meeting with Dr. Debbie and shared with me that I did test positive, along with Dr. Brantley, for Ebola.

>> DR. PETER SALGO:  At that moment, when you both found out that, Nancy, that you had Ebola, what was that moment like?  What were your thoughts?  Both of you.

>> NANCY WRITEBOL:  First of all, David had told me that Kent, Dr. Brantley, had Ebola, and not only were Dr. Brantley and I colleagues, but our families are very good friends, and so my heart was broken just for Kent and his family. I don't know that I really stopped to think about, you know, what I was going to be dealing with with Ebola.  I remember saying to David, as he reached out to comfort me, I just said, just stop, Dave, don't, because I knew how dangerous it was and I did not want David to contact me and then get Ebola himself.

>> DAVID WRITEBOL:  It's not something that you contemplate or how do I tell someone that I love that they have a dread disease that will probably take their life and then how do we tell our family about all of that and what will happen in the days ahead?  You know, just kind of sends you reeling.

>> DR. PETER SALGO:  I want to stop your story just for a moment and talk to some of our doctors here. Dr. Bausch, Nancy told us she had fever, she wasn't feeling well, that's pretty generic.  Are her symptoms classic for Ebola?

>> DR. DANIEL BAUSCH:  They are, and that is exactly the difficulty with this disease is that people started with very generic non-specific symptoms, feeling tired, having fever, things that, especially in West Africa, that can often be confused with malaria and a lot of other things that, at least prior to this outbreak are much more common than Ebola.

>> DR. PETER SALGO:  Dr. Shelly, was Nancy contagious before her symptoms came up?

>> DR. MARK SHELLY:  In the outbreaks of Ebola, they've observed fairly clearly that the symptoms start at the point that contagiousness starts, that's when the virus is starting to come and be contagious, so she would not have been contagious until the symptoms started, perhaps that morning.

>> DR. PETER SALGO:  Dr. Bausch, how is Ebola transmitted, since we are talking about contagion here?

>> DR. DANIEL BAUSCH:  It's transmitted from blood and bodily fluids, so while I would agree that she was theoretically contagious as soon as her symptoms start, the data that we have is most people really pass on this virus to someone during the late stages of severe disease.  So really when they're very sick, have nausea, vomiting, diarrhea, potentially bleeding, shedding a lot of virus out into the environment, in the early stages even though the person is theoretically contagious, we probably don't have a lot of transmission at that point.

>> DR. PETER SALGO:  I know that people are concerned about this, I'll ask the question flat out, people are worried that if they're near someone with Ebola, it can be passed through the air, droplets or otherwise. Is this fear well founded?

>> DR. DANIEL BAUSCH:  I would say we have to distinguish a little bit droplets, that is someone that can cough and a small droplet could land on someone's lip or their eye or something like that, that could transmit the virus, but breathing the same air, being in the same room, walking down the hallway, that would not transmit the Ebola virus.

>> DR. PETER SALGO:  Now Dr. Marty, You just got back from Nigeria.  Perhaps you could give us a brief update about the situation there and what is going on.

>> DR. AILEEN MARTY:  When we originally got there in early August, the outbreak had just started.  There was a tremendous amount of fear and confusion and lack of resources and tremendous worry that it would spread into the very very populous very impoverished parts of Nigeria and very very quickly the Nigeria government once they knew that Ebola had entered their country called for international assistance and the World Health Organization, the US CDC, the UNICEF, Medicine Sans Frontieres (Doctors without Borders), responded and their minister of health, a very brilliant professor of medicine, and he made sure that the Lago state , ministry of health, the specific ministries of health, every particular region that was involved, got involved, and with all those individuals coming in together we were able to create an isolation ward with three levels contact for suspect cases and for confirmed Ebola cases, and we did have one serious glitch in one contact who, the minute he became symptomatic, turned off his cell phone and decided to take an airplane trip four-hundred and twenty miles away and started a new outbreak in another state but we quickly mobilized a second emergency operation center in, at River State and did all the appropriate contact tracing, and we were able to extinguish the outbreak and the fear by doing a very appropriate management of messaging to the population in every way we could think of and most importantly we established very good point of entry screenings for both entrances and exits we didn’t want a second importation (Salgo Talks over)

>> DR. PETER SALGO:  Is it safe to say (Talks over Dr. Marty)

>> DR. AILEEN MARTY:  And we certainly weren’t going to allow any exportation from Nigeria.

>> DR. PETER SALGO:  Nancy, tell us what happened to you, right after you were diagnosed. 

>> NANCY WRITEBOL:  Ok.  Well, the … they isolated me right away in our home, and that became the isolation unit, and David was not permitted to come back into our home at that point. IV was started just pretty immediately so that they could get fluids into me, antibiotics were given to me, I had already taken the malaria medications and so they were just pushing fluids and vitamins and your body just grows weaker and weaker many people experienced severe diarrhea with vomiting and just a growing weakness.


 >> DR. PETER SALGO: I know that you got an experimental drug, ZMapp, did that happen in Africa or the United States?

>> NANCY WRITEBOL:  It happened in Africa, when I got sick and also when Dr. Brantley got sick, we didn't even know that that experimental drug was available. Dr. Kent and I both received it.  I know for me, the experimental drug seemed to just stabilize the progression of how fast the disease seemed to be moving.

>> DR. PETER SALGO:  I know that you were then air‑evacuated to the United States.  But we've had a description now of your symptoms or symptoms, of course, of advanced Ebola.  Dr. Bausch, could you bring us up to speed with these symptoms?  What's actually going on inside the body of somebody that's been infected with the Ebola virus?

>> DR. DANIEL BAUSCH:  They're starting now of course with usually a very small amount of virus, and that virus is entering numerous different types of cells and replicating, and it's very clear in this disease that the sicker that a person is, the higher their level of virus is and vice versa, more virus makes you sicker and sicker.  So as you start out with very few viruses, you have just the fever and weakness and then as you get a lot of viruses, you go on with those symptoms that Nancy just described in the nausea and vomiting and diarrhea, and some patients, progress to very severe shock and bleeding and of course often fatality.

>> DR. PETER SALGO:  Yeah, in the ICU we would describe this as sepsis or inflammatory response with multi-organ system failure.  Dr. Shelly, you are the son of medical missionaries, you spent ten years in what is now the Democratic Republic of the Congo, you were there at the first epidemic in 1976.


>> DR. PETER SALGO:  That was 30 years ago, people knew about Ebola back then, and Nancy was given this new drug, ZMapp which by the way was never tested on human beings with Ebola prior to this moment. 30 years, it is still not approved for use in humans, why in this 30 year gap, in your view, don’t we have something better?

>> DR. MARK SHELLY:  It's hard to get a lot of excitement treating for something that happens in these little bursts, and so somebody might keep a little serum in the back, but feel they don't need to work on it very much.  Now I think there's obviously a lot of scrambling to say wow, I wish we had made a lot more.

>> DR. AILEEN MARTY:  Can I interject? First of all a whole lot of different kinds of experimental drugs have been developed for the use in Ebola, and a lot of them are experimental.  The use of ZMapp, that particular, if you will, drug for me, it's just antibodies, that were devised for the use of Ebola, is a brilliant invention, but it's much more recent than the others.  Although I do agree that of course the fact that it was limited in its geographic zone and the number of people affected is one of the reasons none of those went to massive clinical trials because of the cost of clinical trials.

>> DR. PETER SALGO:  We also don't have an Ebola vaccine.

Right now that's been proven.  Where are we in the development of this, Dr. Shelly?

>> DR. MARK SHELLY:  The development with a vaccine is you have to find out what antibodies are the important antibodies and how to get them produced by the person after given injection. There are two vaccines that are currently tested in animals and seem to be effective, and those are now moving into safety trials to find out are they safe in humans and how much do you need to give in order to get a response that would expect to have some effect on Ebola.

>> DR. PETER SALGO:  Nancy, what was it like having Ebola, what did it feel like to be an Ebola victim?  David, what was it like watching her suffer with Ebola?

>> NANCY WRITEBOL:  Well, I think, you know, after a while, you're just so sick, and with the fever, there were many days when I just didn't even remember anything.  And as it has been pointed out, it gets pretty painful, and so you just don't want to move very much even because of the sensitivity even in your skin.

 >> DAVID WRITEBOL:  Yeah, you want to try to do something to relieve the pain or the suffering, and you are helpless, you don't know what to do, and you can only watch from a distance and hope that the body will respond to fight the virus, and it's a frightful thing to watch.

>> DR. PETER SALGO:  Nancy, you were airlifted out of Africa, brought to Emory University Hospital and treated there. And we've heard that the treatment for Ebola is symptomatic, basically it's supportive care.  Dr. Shelly, what does that mean?

>> DR. MARK SHELLY:  Well, what we know that works when people are losing a lot of fluid is to replace the fluid and also the salts the body has, you may have to also support other organ systems that fail, help somebody breathe or replace kidney function, those sorts of things.  Those are the things that we do in intensive care to support somebody with sepsis of any kind and it would be very difficult to do without all the blood tests that we can run so easily here.

>> DR. PETER SALGO:  I understand also that some of the blood from Kent Brantley who also recovered presumably has antibodies against Ebola has been given to other Ebola victims in an attempt perhaps to modulate the course of the disease.  Do we know how that's working?

>> DR. MARK SHELLY:  I don't think we know for sure how it's working, but it's a way to short‑circuit the vaccine side.  Somebody who has been through the disease has antibodies, they've made them, having seen the disease, and hopefully those are the same antibodies which will help someone else to survive.

>> DR. PETER SALGO:  Dr. Marty, you got a handle on Ebola in Nigeria and controlled it, you contained it.  Why is Ebola then spreading so quickly elsewhere in West Africa?

>> DR. AILEEN MARTY:  The answer to that question is basic epidemiologic understanding of how diseases spread.  Ebola, when it is in a rural area has a reproductive rate of one because the average person with Ebola is only exposed in close contact with ten other people.  In the urban setting where the Ebola is now, the average infected person has up to 60% of close contact, so we're seeing a 2 to 6% reproductive rate.  In order to extinguish an outbreak, you've got to bring the reproductive rate below 1 and we have the measures and the means to do that, and it was much easier to do it when we were working in rural areas.  I would like to mention something about the vaccines that you asked earlier.  There are also quite a number of different vaccines that have been produced experimentally and tried over the years and a tremendous amount of money has been poured into this, and there are actually three different vaccines that are currently undergoing clinical trial.

>> DR. PETER SALGO:  Dr. Bausch, what are we going to do to stop Ebola right now?  If you had all the money you needed, all the resources you needed, how are you going to stop it right now, Dr. Bausch?

>> DR. DANIEL BAUSCH:  There's no easy answer to that.

This is definitely unchartered territory for us.  We know how to stop Ebola but we know how to stop it on a much smaller level, for example, you know, the largest outbreak we've ever had before was 425 cases for the entire outbreak.  That's a number that we accumulate now in a matter of days in West Africa.  What we definitely need to scale up our response by quite a few orders of magnitude from what we have now.  I think the funds are coming in, there is activity in this regard, but how I often explain it to people is sort of like if we say, okay, we want to put a man on the moon tomorrow and it costs whatever, $7 billion, you can say, okay, here is the $7 billion, but it's still unlikely that man will be on the moon tomorrow, there's logistical impediments, it takes time to get things together.  So we need to move beyond in many areas an idea where we're dealing with kind of an individual case in terms of contact tracing.  We just don't have the capacity.  Usually we would trace each individual; we can't do that when there's thousands and thousands of contacts.  We need to take a broader public health approach.

>> DR. PETER SALGO:  What are the chances of a major Ebola outbreak in the United States? 

>> DR. DANIEL BAUSCH:  I think the chances are very slim.

I think we know how to control this, we know how to control it especially when we have a limited number of cases.  I think that we may have more imported cases, a small number of imported cases, and that may on occasion unfortunately lead to what we call secondary transmission to healthcare workers or other people who had contact with them, but we know how to control this, we know how to do the contact tracing, we have the technology in the United States, we have good medical care, we're not going to have a large outbreak of Ebola in the United States.

>> DR. AILEEN MARTY:  This is something that we have the knowledge and technology to handle, as a nation.  However, it is absolutely imperative that all our healthcare workers be attune to the fact that while this outbreak is out of control, there is a slim but real possibility that someone with the symptoms may show up on their door.

>> DR. PETER SALGO:  Nancy, David, is there a final message from each of you that you would like to give to our viewers?

>> NANCY WRITEBOL:  Well, I think one of the greatest needs, and we've been hearing it today, is that our response in West Africa just needs to be quicker, we need to be really advancing in there and getting medical people on the ground to be able to help, so I think our attention needs to be turned just to West Africa with development of the serums and with the vaccines, all of that needs to just continue in as rapid a pace as possible.

>> DAVID WRITEBOL:  Yeah, our hearts are with the Liberians, Sierra Leonians and Ghanaians and their struggle against this and anything that can be done to send resources to help contain this and relieve their suffering is much need and we appeal for that, but also we see a good thing that good information is being disseminated and the right messages are being communicated so that everybody will be able to understand how the disease is spread and what the effects of it are so that they can be protected but yet not be overly anxious and overly paralyzed because of fear.  Fear, we saw that in Africa, that fear was the thing that was stopping people from doing what needed to be done and getting in front of it early on.

>> NANCY WRITEBOL:  I just wanted to say that, one of the things that we are often asked is what do we think really saved my life, whether it was the ZMapp, whether it was supportive care, early identification of what was happening, and I just want to say that, you know, we really believe that God saved my life, that he uses all those means, whether it's ZMapp or whether it's doctors and nurses and supportive care, I just really want our west African friends to know that we are just really praying for them and trust that God is working in this way to be able to help in their suffering.

>> DR. PETER SALGO:  Well, thank you both so much for joining us.

I know everybody has been wanting to talk with you, and it was lovely of you to spend some time with us today. 

>> NANCY WRITEBOL:  Thank you.

>> DR. PETER SALGO:  I want to thank our panel for sharing their experience with us today.  Dr. Shelly from the University of Rochester Medical Center.  Dr. Dan Bausch from Tulane University. Dr. Aileen Marty from Florida International University and I would like to thank you our audience for watching too.  You can find more about Ebola on our website at SecondOpinion‑, there you will find videos about Ebola as well as many resources so you can continue to learn about this important topic.  I'm Dr. Peter Salgo, and I'll see you next time for another "Second Opinion."




Announcer:  Second Opinion is brought to you by Blue Cross Blue Shield.  Accepted in all 50 states.  Blue Cross Blue Shield, Live Fearless.


Announcer:  Second Opinion is produced in conjunction with UR Medicine, part of The University of Rochester Medical Center, Rochester, New York.