Ebola Doctor: 'You Can't Put Out 99% of a Fire'

By Brenda Goodman, MA
WebMD Health News

Reviewed by Hansa D. Bhargava, MD

Oct. 16, 2015 -- Though the numbers show we've reached a turning point in the Ebola outbreak, the threat of the virus is far from gone.

A nurse from Scotland is fighting for her life a second time after her Ebola infection apparently relapsed. And two new studies published Monday in The New England Journal of Medicine highlight a rare but real risk of men who've recovered spreading the disease through sex months after a blood test doesn't turn up signs of the virus.

The first study looks at a man who survived the disease and apparently passed it to his female partner more than 6 months after he recovered. A second study found traces of the virus in the semen of about 25% of tested male survivors at least 9 months after the onset of symptoms.

The disheartening news comes amid brighter news regarding the Ebola outbreak. The WHO this month marked 2 weeks without new cases in the hardest-hit West African countries -- Guinea, Sierra Leone, and Liberia -- before two new cases were reported in Guinea on Friday. The week of Oct. 4 was the first with no new reported cases since the outbreak was declared in March 2014, the WHO says.

The persistence of the virus continues to surprise infectious disease doctors and Ebola survivors, many of whom are still struggling with lingering after-effects of the disease.

"It's not over even when it's over, and that's particularly going to be true for those who have survived the most severe disease," says Ian Crozier, MD, an infectious disease expert who won a long battle against the virus, only to have it come back 2 months later to nearly blind one of his eyes.

We asked Crozier and another infectious disease expert, Philip Smith, MD, director of the biocontainment unit at the University of Nebraska Medical Center, about what the persistence of the virus means for ending the outbreak and for those who have survived.

WebMD: Dr. Smith, you treated two Ebola survivors -- Dr. Rick Sacra, a medical volunteer in Liberia who worked for the Christian organization SIM, and Ashoka Mukpo, a freelance cameraman for NBC. Do you continue to follow them? Do they continue to have health problems?

Smith: We do continue to keep tabs on them, informally. They don't have anything close to what the survivor in London (Scottish nurse Pauline Cafferkey) has. One thing we've heard from them and other Ebola virus survivors, as well, is the slow recovery. I think that initially was a surprise to people. So even if you make it through the disease, which has a high mortality rate, many of these people who are young and vigorous and over in Africa working find, that for weeks and months, that they're just tired. It's a little bit like mononucleosis, but worse.

WebMD: The fact that this nurse could get so sick with Ebola for a second time has caught everybody off guard. I'm wondering if you, as an infectious disease specialist, continue to feel surprised by this virus. How steep does the learning curve continue to be?

Smith: I think it's a very steep learning curve. People have been caught off guard by this virus a number of times.

In the very beginning, I think the first thing that caught people by surprise was severe cholera-like diarrhea, vomiting, fluid-loss, which makes management very difficult and poses an infection risk.

The second thing that surprised everybody was the prolonged recovery -- arthritis, muscle aches, visual difficulties, muscle wasting, depression -- you might expect these things for a few days after a severe infection, but not for weeks and months.

Now we have evidence of recurrence, and the scientists who have taken care of Ebola patients have all been surprised by that, as I have. It appears to be a relatively rare phenomenon, but it's a serious concern.

WebMD: Dr. Crozier, what was your reaction to learning that Cafferkey relapsed 10 months after her initial recovery?

Crozier: I was personally very sad to hear she was struggling after going through such a difficult time the first time. And also, in some ways, I wasn't too surprised.

This, obviously, has been a common theme. In a sense, this virus is schooling us in many regards over the last 18 months.

WebMD: Dr. Crozier, you're in the club of survivors, and particularly well-known survivors. Do you stay in touch with each other?

Crozier: Some of the survivors know each other, and we keep in contact given our odd and sort of poignant connection. We're learning so much on the fly here. So I suppose in many regards, each person is thinking about their case in relation to the others.

WebMD: What do you take away from the new scientific reports about the persistence of the virus in semen? Are you able to read them coolly, with a doctor's eye, or do you find yourself taking a more personal interest?

Crozier: I'm terrifically interested in the findings, personally, as well as its implications for 16,000 to 17,000 West African survivors. I've been hoping to provoke discussion of these issues in many different arenas over the past months. I'm not surprised by these findings. They're very important.

Before this outbreak, we thought this affected a very few survivors. And we thought the window of time when this might be a problem was shorter -- maybe 3 months. No one was really sure what it meant for disease transmission.

So these studies that have just come out in The New England Journal are very, very important.

The virus is teaching us, in the last stretch, that you can't put out 99% of a fire.

But I will say that I think that if this is occurring, it is occurring rarely, but it's a very consequential rare event for sexual transmission to occur.

I do want to point out that this finding, as well as findings like finding the virus in my eye, cannot add to the stigma that many of the West African survivors are facing. Many have a great deal of physical problems they are still dealing with. Many of them have had unimaginable losses of family and friends and are facing a great deal of psychological and emotional trauma as they put their lives back together and reattach to life. These findings, though very important, shouldn't add to those hardships.

WebMD: Do you still have virus in your eye? Do you have other lingering problems?

Crozier: There's every indication that the virus has been cleared from my eye, though we haven't been able to repeat the definitive test for it, but there are no symptoms. I'm still dealing with other physical issues, as well.

I have persistent arthritis or joint pain. There are some residual thinking and memory effects. Doctors think my brain may be scarred from a brain infection and bleeding strokes during my first infection.

I have trouble with short-term memory. I had a recent seizure, maybe caused by the post-Ebola brain scarring. I'm now on an anti-seizure medicine. I have hearing loss and ringing in my ears, and trouble sleeping. It's a long list, like many survivors.

WebMD: Have you had to change how you work, or your schedule, or your workday to adjust to this new reality?

Crozier: I think each day is learning how to adjust to a new reality (laughs). In the big picture, I'm incredibly grateful to be alive and incredibly grateful to be seeing, for the most part, through both eyes.

Of course, it has required a reshuffle of the deck, in many, many ways that I'm still learning about.

I think we've always thought about this as a very acute illness that's over when it's over, meaning you either die, or if you live, it's finished.

In one sense, this is an old disease, but we're looking at it in a new light and with a state-of-the-art microscope that's teaching us it's not over even when it's over.

This is a very difficult space. I often talk about it as the survivor's predicament.

WebMD: Are you going back to Africa?

Crozier: I've been back. My plan is to be back. That's probably more home to me than anywhere else.

We went back to Liberia in April and more recently went back to Sierra Leone with Emory University's Quiet Eye project, to begin understanding an eye disease similar to what I have that's emerging in West Africa.

It's a difficult thing to go blind anywhere, but very difficult to go blind in West Africa. Some of the survivors are facing a second death of sorts. This is something that requires attention now.


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SOURCES: Ian Crozier, MD, infectious disease expert, Ebola survivor. Philip Smith, MD, director of the biocontainment unit at the University of Nebraska Medical Center. Oct. 15, 2015, New England Journal of Medicine. WHO Ebola Situation Report, Oct. 14.

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