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Reality Check: How People Catch Ebola, And How They Don’t

Dr. Elke Muhlberger (Courtesy of Kalman Zabarsky for BU Photography)

Dr. Elke Muhlberger (Courtesy of Kalman Zabarsky for BU Photography)

It’s confusing. You hear that Ebola victim Thomas Eric Duncan was so contagious that two Dallas nurses in protective gear caught the virus. But then you hear, in more recent days, that apparently nobody else did, including the inner circle who lived with him and cared for him. The CDC announced today that all of Mr. Duncan’s “community contacts” have completed their 21-day monitoring period without developing Ebola.

How to understand that? And how to address alarmists’ claims that for the nurses and so many West Africans to have caught Ebola, it must have gone “airborne”?

I turned to Dr. Elke Muhlberger, an Ebola expert long intimate with the virus — through more than 20 years of Ebola research that included two pregnancies. (I must say I find this the ultimate antidote for the fear generated by the nurses’ infections: A researcher so confident in the power of taking the right precautions that she had no fear — and rightly so, it turned out — for her babies-to-be.)

Dr. Muhlberger is an associate professor of micriobiology at Boston University and director of the Biomolecule Production Core at the National Emerging Infectious Diseases Laboratories (widely referred to as the NEIDL, pronounced “needle”) at Boston University. Our conversation, lightly edited:

Is it really true you worked on Ebola through two pregnancies?

Yes, but in the proper protective gear. That makes a huge difference, if you’re protected, if you know how to protect yourself, and that is the case in a Biosafety Level 4 lab, of course. If you compare the protective gear we’re wearing in a Biosafety Level 4 lab and the gear they’re wearing in West Africa now treating patients, it’s like comparing a stainless steel vault to a cardboard box.

But on the other hand, if you look at the nurses in Dallas, you say, ‘How did they get infected?’ It makes you worry that maybe protective gear isn’t good enough — but you’re proof of the opposite.

A Biosafety Level 4 lab is such a high-end lab, it is not possible to use protective gear like that in every hospital in the U.S.

Could you please lay out a brief primer on the biology of how Ebola is transmitted?

We know from previous outbreaks, and also from the current outbreak, that Ebola is transmitted by having very close contact to infected patients. So we know that it is transmitted by bodily fluids, which include blood, first of all — because the amount of virus in the blood is very, very high, especially at late stages of infection — but it’s also spread by vomit, by sputum, by feces, by urine and by other bodily fluids.

The reason for that is that at late stages of infection, the Ebola virus affects almost all our organs — it causes a systemic infection. One main organ targeted by Ebola virus is the liver, and that could be one of the reasons that we see these very high concentrations of viral particles in the blood. But I would like to emphasize that that occurs late in infection.

Early infection is the other way around. The primary targets — the first cells that come in contact with Ebola virus and get infected — are cells that are part of our immune system. And these cells most likely spread the virus throughout our body. But there are not so many cells infected at the very beginning of the infection, which might be the reason why Ebola virus patients do not spread virus at the very beginning of infection. And that’s why it’s safe to have contact with these patients, because the viral titers in their blood are so low that we cannot even detect them with methods like PCR, which is one of the methods we use to diagnose Ebola virus.

Is a virus only contagious when it reaches a certain level of “titer” or load? Continue reading

Ebola: As Other Doctors Die, Heading Straight Into The Outbreak To Help

Dr. Nahid Bhadelia is in protective gear with Dr. Guillermo Madico at the National Emerging Infectious Diseases Laboratory in Boston, where she directs infection control. This gear is slated to be donated to the Ebola-fighting efforts in Sierra Leone when she goes there in mid-August. (Jackie Ricciardi/BU Photo Services)

Dr. Nahid Bhadelia is in protective gear with Dr. Guillermo Madico at the National Emerging Infectious Diseases Laboratory in Boston, where she directs infection control. This gear is slated to be donated to the Ebola-fighting efforts in Sierra Leone when she goes there in mid-August. (Jackie Ricciardi/BU Photo Services)

If all goes as planned, Dr. Nahid Bhadelia will soon head straight into the heart of the Ebola outbreak that has already killed more than 700 people in western Africa, including at least 50 health care workers. Global and U.S. health authorities announced Thursday that they would ramp up efforts to bring the epidemic under control, but that it would likely take at least three to six months.

Dr. Bhadelia is director of infection control at the National Emerging Infectious Diseases Laboratory in Boston and a hospital epidemiologist at Boston Medical Center. She’s slated to travel to Sierra Leone in mid-August, to share her expertise on infection control and also care directly for Ebola patients. Our conversation, edited:

This is the biggest Ebola outbreak ever, as far as we know. Is it notable in other ways?

This is the first time Ebola has been present in these three countries: Sierra Leone, Guinea and Liberia. Because these countries haven’t seen the infection before, that impacted their ability to recognize and manage the infection early on.

Also, because of the recent travel of the American Patrick Sawyer to Lagos [where he died of Ebola], I think it has raised a lot more concern about transfer of Ebola abroad, which has not been much of an issue in the past.

A lot of the U.S. media coverage has focused on, ‘Could it come here?’ Part of that fear seems to stem from the sense that Ebola, with its hemorrhages and high death rate, is particularly horrible. Is it?

In some ways yes and in others no. Ebola Zaire, the strain we’re seeing right now, is one of the most deadly strains; it’s been shown in the past to have 90 percent mortality when no treatment is given. But in some ways, it’s much harder to transmit at a population level compared to respiratory viruses we’ve been hearing about such as SARS or MERS. It requires close contact with bodily fluids. So, for example, there’s been a lot of concern about travel of folks from the areas impacted to the developed world, and I think the reason it’s less likely to spread is because it’s limited to people who come into contact very closely with the person who’s impacted.

So many health care workers have been getting infected. Do you have a sense of why? Are there practices that might be easily correctable that you could have an impact on?

There are a lot of talented people there in the field already, not just from international organizations but people who’ve been working there a very long time. In Sierra Leone, for example, though they haven’t had Ebola before, they’ve dealt with Lassa fever, another viral disease that causes hemorrhagic fever, at Kenema — one of the places where Dr. Khan, the leading physician who just died of Ebola, worked. That center has dealt with Lassa fever for over 25 years, and there are nurses there who have long experience. The issue is the amount of patients. You have nurses there who were taking care of maybe a dozen Lassa patients and now they have to see 70 Ebola patients. I think the major issue is the fact that the health care system is so overwhelmed.

One of the major ways to alleviate that would be the presence of more personal protective equipment and more sterile medical equipment in general. I know that the PPE — the personal protective equipment — is a major concern because there’s a dearth of it right now in the field.

Also, we understand that the virus can be transmitted from surfaces — so if someone comes into contact with bodily fluids with the virus in them on a surface, that’s another way to get it. The virus can live outside the host for a couple of days. So this contamination of the environment is another important component — and that’s very difficult if you can imagine 70 patients in a small space. Ebola is not hard to kill, so it’s easy to avoid contamination in general. It’s only because of the number of people and poor health infrastructure that it becomes difficult.

Still, it’s so baffling that these leading, incredibly knowledgable doctors are getting infected. How can that happen? Continue reading

Boston Biolab Clears State Hurdle For Max-Security Work

The National Emerging Infectious Diseases Laboratories, on the BU Medical Campus. Photo by Kalman Zabarsky, courtesy of BU)

The National Emerging Infectious Diseases Laboratories, on the BU Medical Campus. Photo by Kalman Zabarsky, courtesy of BU)

It’s widely referred to as the “needle” — as in NEIDL, the acronym for the National Emerging Infectious Disease Laboratory. It’s a futuristic, seven-story tower near Boston Medical Center in the South End, built to house high-level infectious-disease labs. And its fate has been mired in controversy for years, the kind of struggle you’d expect around a plan to research some of the world’s deadliest pathogens right near a densely populated neighborhood.

BU Today explains: “Construction on the $200 million facility was completed in September 2008, but controversy and litigation have kept much of the building’s 192,000 square feet of laboratory space closed.”

Now, BU Today reports that the NEIDL has just gained a key approval:

The Massachusetts Secretary of Energy and Environmental Affairs has given approval for the lab to conduct research at Biosafety Level 3 (BSL-3) and Biosafety Level 4 (BSL-4). The state agency issued a Massachusetts Environmental Policy Act (MEPA) certificate on Friday, clearing the way for the issuance of final state permits for the project.”

Some background:

As the Globe’s Stepehen Smith wrote in 2010: “South End and Roxbury residents have taken to the streets and the courts to protest the project. While state and federal judges allowed construction on the $200 million project to continue to completion — it includes both a high-security Biosafety Level-4 lab, as well as other research facilities — they mandated further safety reviews before it could open for research.”

WBUR’s Delores Handy took a press tour of the building last year, and officials told her that the NEIDL was probably the safest building in the city, and that the fence around it could stop truck bombs.

NECN’s Peter Howe described “foot-thick reinforced concrete walls, triple microscopic air filtration systems, intensely guarded entrances and exits, doors controlled by iris scanners to allow only authorized scientists and security personnel in to specific floors, and hundreds of surveillance cameras to prevent anyone from trying to sneak deadly biological samples out of the building to create terrorist weapons.”

Critics point out that the building is just off the Southeast Expressway in the densely populated South End. This, they say, is an issue of environmental justice.

But Boston Mayor Thomas Menino told reporters on the tour: “This is about the future. It’s about making sure that we have the tools in our city to do the research and the findings that we need to cure some of these diseases out there.” Continue reading