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The U of M’s Osterholm: What we should — and shouldn’t — be worried about regarding Ebola

A Q&A with Dr. Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy (CIDRAP)

It’s been three weeks since Thomas Eric Duncan became diagnosed at Texas Presbyterian Hospital in Dallas with Ebola, which he contracted while in his home country of Liberia. He died within days, and now two of the nurses who cared for him have also been diagnosed with the disease — the first people to become infected while on U.S. soil. One is being treated in a special unit at Emory University Hospital in Atlanta, while the other was transferred Thursday to the National Institutes of Health in Bethesda, Md.

In a Congressional hearing on Thursday, lawmakers on Capitol Hill pounded health officials from the Centers for Disease Control and Prevention (CDC) and elsewhere for their missteps in diagnosing Duncan and for their failure to prevent the two nurses from becoming infected. Some of the lawmakers called for the U.S. government to impose an air traffic ban on all flights from the west African nations hardest hit by Ebola: Liberia, Guinea and Sierra Leone.

Later on Thursday, President Obama said he would not impose a travel ban because health officials had told him it could lead to more Ebola cases in the U.S., not fewer. On Friday morning, the White House announced that the president was appointing Ron Klain, former chief of staff for Vice President Joe Biden, as “Ebola czar” to manage the government’s response to the disease.

Despite the fact that only three people have become infected with Ebola in the United States, anxiety about the disease among Americans is apparently strong. Earlier this week, a USA Today poll found that almost half of Americans are very or somewhat concerned about personally catching the disease, even though the chances of doing so are extremely unlikely. On Thursday, three schools in Texas and Ohio closed because staff members said they might have been exposed to one of the nurses being treated for Ebola.

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How concerned should we be about the spread of Ebola here in the U.S.? Will the virus, as some people fear, mutate into a form that will “become airborne” and thus much more transmissible? And what exactly should our public health officials be doing to contain not only the disease, but also our fears about it? For answers to those and other questions , MinnPost spoke Thursday with Dr. Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy (CIDRAP). An edited version of that interview follows.

MinnPost: How worried should we be about Ebola here in the United States?

Michael Osterholm: We should be very worried in the United States, but not about the United States. What I mean by that is we’re not going to have community outbreaks of Ebola in the United States. We just are not. … The bottom line is healthcare workers will continue to be the frontline challenge in the United States, not the community.

MP: You’re confident then that we can handle it here.

MO: I am. What absolutely horrifies me is what is going to continue to happen in Africa. That situation is the most dire of all that I’ve seen in my 40-year career. We have no Plan A, and we still don’t. I mean, the United States has still not made one hospital bed available to a patient in those three countries [Liberia, Guinea and Sierra Leone] despite the fact that six weeks ago the president made it a top priority. The only country in the world that is currently staffing hospital beds in West Africa is Cuba, and they are doing a great job. We are moving in program and bureaucracy time, and the virus is moving in virus time. The [World Health Organization’s] estimate earlier this week of 10,000 new cases next month is, I think, conservative.

Dr. Michael Osterholm
Dr. Michael Osterholm

My real concern is not just the situation in the three countries and the very real humanitarian crisis there, but the fact that there are very well recognized migration patterns of workers in Africa. In the months of July, August, September, and into October, young men and boys come home to those three countries to help with the harvest. And then in October, they take off and head east and north. They go back to the gold mines. They go to the cocoa plantations. They work in the illegal charcoal operations. They even do fishing. This migration is happening right now, and I don’t know how [Ebola] will not spread to the rest of central Africa. Think about that potential. Think of the slums of Lagos [in Nigeria] or Kinshasa [in the Democratic Republic of the Congo]. The slums of either of those cities have more people in them than in the three countries combined that are currently impacted by the epidemic.

Basically, we’ve had a match thrown into a can of gas in West Africa. If this spreads to the rest of equatorial Africa, it will be like throwing a match into an open tanker truck of gas.

MP: But Americans seem so much more fearful about what’s going on here.

MO:  That’s exactly why I’ve said it’s a “tale of two cities.” We are misplacing our anxiety. I understand completely why people are concerned about what’s going on in Dallas, because it’s the unknown to them. And I understand that they are concerned about credibility in terms of what we’ve been telling them. We’ve told them with a certainty that we never should have used. Of course, we are very certain about some things. I am absolutely convinced, for example, that we will not have a community-wide outbreak here in the United States. We may have isolated cases, and we still have the potential for more cases in Dallas among the people who came into contact with Mr. Duncan. But this is not going to spread like we’ve seen in West Africa.

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MP: Is there anything you’d like to see the CDC and other public health officials do that they haven’t done so far here in the United States?

MO:  First of all, we have to acknowledge where our shortcomings are. The idea that all 5,000 hospitals in the United States will be able to take care of an Ebola patient — that’s simply not true. And we don’t want to do that. We want to have regional centers throughout the United States where both patient care and worker safety can be addressed. We also need to have every hospital, every doctor’s office, every private minute-clinic type environment be able to recognize potential cases of Ebola. If you have a travel history in the last 21 days of having been to West Africa, no matter what illness you’re being seen for, [the medical staff] has to consider Ebola.

As for the idea about fever, we have a real concern about that because it’s potentially a very spotty standard. I personally have received information from clinicians in West Africa where potentially 20 percent or more of the patients have no fever and they die of Ebola. Fever is present most of the time, but I don’t want to see a case fall through the cracks because they didn’t present with fever. A constellation of other symptoms combined with the fact that they were in West Africa within the past few weeks should absolutely raise suspicion — even if you find another illness. We’re now finding patients who present with both malaria and Ebola, or cholera and Ebola. So we have to rule out Ebola, and that needs to be done safely. If they come into a community hospital, we have to have the expertise to handle them safely there. But they shouldn’t receive clinical care as such. At that point they need to be moved on to a regional treatment facility where they get the kind of care they deserve and where the workers are protected.

MP: What do you think about blocking flights into the U.S. from western Africa?

MO: I understand the concern about the virus coming out of there. I think we need to do everything we can to screen that from happening. It’s a fluid situation. But we need to have people get in and out. And if planes don’t come out, planes don’t go in. Anybody who’s ever dealt with a blizzard in the Upper Midwest knows that. Right now I’m very concerned about that issue. How do we get planes in with resources that are desperately needed?

MP: Some people have also criticized government officials for permitting U.S. healthcare workers who become infected with Ebola back into the States for treatment.

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MO: I had a number of people who were very upset when the first physician was brought to the United States for treatment. They said that all we’re doing is potentially spreading this in the United States. They had some far-fetched ideas, like the plane might blow up while landing at the Atlanta airport, but they were concerned. My response was, “I understand why you might feel that way, but we know how to do this safely.” Remember, [Médecins Sans Frontières, or Doctors Without Borders] has cared for over 4,000 patients in West Africa under the most dire of conditions, and only two international workers have become infected. We know we can do this safely.

The single biggest critical shortage we have right now is trained workers who are willing to put their lives potentially on the line to go to Africa and treat patients. And we find the biggest deterrent to getting people to go is the worry that if they get infected, they won’t be brought home for treatment. It should be no different than in the military. We don’t leave people on the battlefield. We bring them home. I want to do everything I can to encourage health care workers to go over there. But I want to promise them that we will do everything to protect them while they’re there and that we’ll do everything to bring them home if they get infected.

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MP: What effect have funding cuts had on our ability to deal with this epidemic?

MO: We have more than enough donations committed to begin to respond to West Africa. But just because the donation has been committed doesn’t at all translate to outcome. We have a boatload of money promised that hasn’t materialized in any way, shape or form in West Africa. That’s [an example of] “virus time” versus “bureaucracy/program time.” It’s one of the things we have to work on, breaking the bureaucracy log jam over there.

I’m also not sure that the cuts to CDC have made any changes in how we might respond. We have seen infection control in hospitals and healthcare facilities around the country continually axed over recent years, but that’s not really public health per se. It’s private plus some public health. But we really need to maintain that [funding], and not just for this [Ebola outbreak]. We need it for all aspects of getting an infection when you go into the hospital. We clearly need more funding support in that area, both public and private.

MP: How concerned are you about the Ebola virus mutating and “becoming airborne”?

MO:  We don’t know. But in the patient setting, when you do pulmonary procedures, when you have projectile vomiting, when you have incubation issues, clearly the virus [could be transmitted through the air]. This virus can infect the lungs. This virus is in very high levels in many of these patients, which could enhance [that airborne transmission]. From a precautionary principle, therefore, we should protect the workers. If you’re treating an Ebola patient, you should be using a [powered air respirator]. It’s just that straightforward.

That’s in the patient setting. As far as respiratory transmission — like, say, the measles — [in the general population], there are several lines of evidence that we at least have to be thinking about. I’m not saying it’s happened yet, and I don’t know if it ever will happen. But I don’t want any more “Black Swan” events where we don’t know something that we should have known.

First of all, this virus clearly can infect the epithelium of the lungs. It’s not true that a lot of things have to mutate [for the virus] to infect the lungs. Just like the influenza virus, this virus will cross into the lung across the barrier of the epithelium. Second, we have had outbreaks where we have had monkeys transmit to other monkeys unintentionally in laboratories. We’ve also had pigs transmit to monkeys. So we do have a biological model that says that this can happen, at least in some non-human primates. And Gary Kobinger [of the Public Health Agency of Canada] has put the Ebola Guinea strain into macaques. They saw an illness in those macaques unlike any they’d seen with Ebola before. Higher virus [concentrations] and much more damage in the lungs, right up into the bronchi. In the words of Gary, who I regard as one of the leading virologists in this world, “This is very worrisome to me regarding the potential for respiratory transmission.”

I don’t know if it’s going to happen, but the way we can guarantee it won’t happen is if we put out that forest fire of infection in West Africa. But who’s planning right now so that this doesn’t get into Central Africa? We can’t fight this on one front. How the hell are we going to fight it on two fronts or three fronts?

I’m not saying that respiratory transmission is currently in the community. We have no evidence of that today. But I don’t want another “Black Swan” event where we’re not prepared.

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Some people have said to me, “Don’t say that because it’s too scary.” Risk communication research has shown over and over again that people don’t get concerned when you tell them scary things that might possibly happen. They get concerned when you keep telling them things that aren’t true. The same people who are saying this can’t happen with respiratory transmission are the same people who said 12 weeks ago that an outbreak like this couldn’t happen because it never had. We have to have creative scientific imagination right now to anticipate the future.

MP: How much worse is this going to get before it gets better?

MO: A lot worse. We’re in the long haul here. This is not a sprint. It’s a marathon. We’re not even at mile one yet.

Osterholm was the featured speaker last week at a symposium at Johns Hopkins University on the Ebola epidemic. He spoke about the challenges the epidemic is presenting to national and global health systems. You can watch that presentation below.

Dean’s Symposium on Ebola: Crisis, Context and Response