Things have devolved into a show where it’s a show about the destruction of global health capacity with two increasingly haggard subject matter experts who are into sobriety, despair, and…still dunking on our enemies. I have resolved to have a cocktail for our show on Friday. At least it will take the sting off the remaining despair.

Today, as ever, the topic is the extraordinarily bad situation in the Democratic Republic of Congo (DRC) and Uganda concerning the Bundibugyo ebolavirus outbreak. There are now more than 900 cases and 220 deaths, which is almost certainly an undercount. The outbreak is an epidemic now. It is on track to exceed the West African epidemic, which infected nearly 30,000 and took more than 11,000 lives.

This is, once again, entirely due to the American government cutting USAID foreign aid, withdrawing from WHO, and pursuing infectious disease policies like travel bans. Today we learned the US government plans to deploy the Public Health Service Commissioned Corps with the US military to Kenya, where they will screen Americans for Ebola before allowing them to return home.

Oh, you think the US will allow you to use the state-of-the-art biocontainment units for managing Ebola patients and saving their lives while protecting the community that your tax dollars paid for? NOPE! You thought your country would keep its promise to do everything in its power to bring you home if you are infected with a horrible lethal disease that we have specialized expertise and capacity to contain and treat? LOL this is Ebola we’re talking about here. You thought that it was your Constitutional right to return home as a US citizen? Not if acting CDC Director Lockdown Jay Bhattacharya and other Trump administration officials decide to apply the same unsupported policies for this Ebola outbreak that they applied to hantavirus: enforced quarantine because we don’t have emerging viruses here in MAHA-land. If we pretend they aren’t a danger, and we use our military to force our own citizens to suffer and die in another country, and we allow them to gaslight the world into thinking this is a meaningful outbreak response rather than a simulacrum meant to deflect accountability for the thousands of preventable deaths these policies will demonstrably cause.

To add insult to injury, there was so much serious talk about impending (and unfortunately supported by evidence) Ebola-related disaster, we didn’t even get to the more important and fun conversation: what the hell was US Health and Human Services Secretary Robert F. Kennedy, Jr. doing to these poor snakes??? We’ll try to rectify this with more commentary on the clownery.

To bring things back to the serious stuff, watch ’s excellent summary of this whole terrible situation on CNN last Friday.

Thank you , , , , , and many others for tuning in! Join us tomorrow morning for another update.

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Here’s what you need to know:

Lots more cases, but they need to be confirmed

There are now more than 900 cases and 220 deaths (suspected). Because of lagging molecular diagnostics, these numbers could change. There are a lot of diseases that share features with Ebola virus disease (EVD) in the region: malaria, gastroenteritis, sepsis, etc. Understanding the scale and scope of the outbreak requires confirmation using a molecular diagnostic (PCR) to distinguish EVD patients from those with malaria or something else. This is important for treating patients appropriately and it is critical to controlling the outbreak using the time-tested epidemiological methods that we know work. The problem is that there is violence and instability, challenges with mobility, and social and cultural barriers in place. Because this very large geographic area has been devastated by war and loss of foreign aid from the US, there is also a great deal of distrust of international health officials. And it’s not like the US has covered itself in glory with these dumbass travel bans.

Serious issues with outbreak control

was on CNN talking about how this terrible situation has been greatly exacerbated by the US government’s cuts to USAID and withdrawal from the WHO. I highly recommend watching the whole thing. The US abandonment of its obligations has deepened existing distrust and that couldn’t be worse for doing what is needed to control this outbreak: contact tracing, isolation, and quarantine. Because there is no vaccine or treatment for Bundibugyo virus and there won’t be one anytime soon, contact tracing and molecular tests are essential to outbreak containment. Response workers are so far behind, at this rate it will take months or years to contain.

I didn’t do slides but I did go off on pathogenesis

A word of caution about calculating case fatality rates with the current data: there are not enough confirmed cases and deaths to do this accurately. Yes, it is true that the two previous Bundibugyo virus outbreaks had lower mortality (30-50%) than good old original recipe Ebola virus (90%). However, these outbreaks were tiny in comparison to this one. Furthermore, now that there have been repeated Ebola outbreak, we know that it’s mortality rate isn’t really 90%. In most outbreaks, it’s closer to 50%. This is still unacceptably high, but my point is that this is hard to estimate and it’s more complex than this virus is totally mega pathogenic but this one is only a little bit extra pathogenic. Even if you did the crudest possible calculation (disclaimer that I am very obviously not an epidemiologist):

221 suspected deaths (220 in DRC, 1 in Uganda) / 913 suspected cases (906 in DRC, 7 in Uganda) = 24.2%. That’s one out of every four cases dying.

I covered this here. Different hosts develop different disease severity based on their response to the virus.

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We have assembled an expert group that will be putting out roundtable discussions about the outbreak every week, including:

• Kristian Andersen: Ebola evolution and genomic epi

• : treating Ebola patients, tracking outbreaks, biocontainment

• Megan Coffee: treating Ebola patients, tracking outbreak data

• : treating Ebola patients, policy and communication

• : treating Ebola patients, international policy

• : infection prevention epidemiology, global health security

• : Ebola pathogenesis, virology, vaccines

• : tracking Ebola outbreak data, epidemiology, infodemiology

• : treating Ebola patients, Ebola survivor, global health policy

I’ve also got a section at the end with all the great op/eds that have come out today. Both Craig and Krutika have written great pieces, as has our colleague, epidemiologist and vaccine champion Mike Osterholm at the University of Minnesota.

Here’s what you need to know today:

Current case numbers

World Health Organization (WHO) Director-General Tedros announced at the World Health Assembly today that there are nearly 750 suspected cases and more than 175 deaths. We are already approaching the upper limit of the projections made yesterday by the Imperial College modelers. This outbreak is continuing to look like it will prove all of our most grim predictions correct. I think none of us who have predicted this the past few days will take any satisfaction in knowing that we were right.

We need more molecular diagnostics

The US withdrawal from global health has created severe infrastructure deficiencies and that has hindered molecular diagnostics. That is critically important, given that Ebola virus disease can look a lot like other diseases endemic to the region, including malaria, various gastrointestinal pathogens, and sepsis. It is really important to identify who is an Ebola patient and who is not, both to prevent onward transmission by protecting healthcare workers and to ensure the patient is treated for the disease they have. Antimalarials can save a person’s life if they have malaria, but that won’t help someone with Ebola virus disease. Here is a clip from yesterday in which I addressed the issue of lagging molecular diagnostics.

We have a serious problem in that we are so far behind on molecular diagnostics. We have only identified 87 confirmed cases because of our lack of testing capacity.

Is it gonna be a pandemic?

Ebolaviruses are transmitted during outbreaks in two specific activities: caring for sick people and funerals and preparing bodies for burial. Although you can get infected by inhaling the virus, the specific details of how Ebola pathogenesis (the process by which the virus causes disease) works precludes it from being a pandemic virus. I have a more detailed piece coming out about why this is, but the bottom line is that ebolaviruses don’t shed into the airway. Although you can get infected from inhaling virus, you’re unlikely to pass the virus along by this route. It doesn’t transmit efficiently from person-to-person by the respiratory route, so it is not likely to cause a pandemic the way an influenza virus or a coronavirus might.

We know how ebolaviruses are transmitted in epidemics and we know how to stop them. But don’t tell our former Trump-appointed CDC Director, conspiracy nut and conversion therapy Robert Redfield!

Redfield is auditioning for a job in the Trump administration, so it’s unsurprising he’s blaming the virus for a disastrous outbreak that could be mitigated, rather than holding the regime accountable for what it is allowing to happen. The fact is there is no mystery about how to stop Ebola outbreaks or stop them from becoming Ebola pandemics. The US has chosen to no longer make this investment.

New sequences can help us understand more about the outbreak

It’s really too bad that so much funding has been cut for infectious disease research in other countries, because we’ve made big investments in sequencing technology that can help us use genomic data to look back in time to when an outbreak began. RNA viruses like ebolaviruses constantly evolve at a set rate. If you have enough viral sequences collected over time to analyze, you can establish a molecular clock, or a way to trace viral evolution over time. My colleague and friend Kristian Andersen was on a US NIH-funded team that pioneered this technique, called genomic epidemiology, during the West African outbreak. It is now an increasingly critical tool for use in outbreaks—when there are sequencers and reagents and trained personnel and reliable electricity and an internet connection and there aren’t .

There isn’t very much sequence data available yet because there are so many issues with testing and sample collection. There were only four sequences available, yet there were already people saying things along the lines of “this is a new variant” (we’re not). However, we are getting some more. New sequences were posted today on Pathoplexus (viral genomic sequence database), including one from the American patient taken to Charité Hospital in Berlin.

Andrew Rambaut at the University of Edinburgh posted a phylogenetic tree of all the sequences so far on Virological. Guess what, it’s not a variant! They are all regular degular Bundibugyo virus evolving during a single outbreak.

We don’t have enough sequence data (yet) to say for sure how long the outbreak has been going on and I’ll leave it to my colleagues who are experts in viral evolution and molecular clock analysis to estimate timing.

There are a lot of reasons Americans should care about this

My colleague and friend was infected with the Makona (West African) strain of Ebola virus while treating patients in an Ebola treatment unit (ETU) in Guinea in 2014. He was one of several American health care workers who was evacuated to one of America’s world class biocontainment units (BCUs). The US spent hundreds of millions of dollars to build the best facilities staffed by extensively trained specialists. This saved Craig’s life, as well as the lives of every other American with Ebola who received this treatment.

There has been extensive criticism, including from Craig and some of his fellow Ebola survivors, about the disparities of the treatment he received with those of the patients he treated in Africa. Yesterday Craig published this incredible essay in the New York Times describing in excruciating detail the response capacity that we have lost due to the annihilation of USAID.

Our government has now abdicated its responsibility even to its own citizens. The White House has sent the American doctor infected with Ebola to Germany rather than bring a citizen in need back home.

I am glad Craig survived Ebola, because not only do I enjoy our very good-natured it’s-not-really-even-a-real-NFC-rivalry Seahawks vs Lions shit-talking, but he can explain better than anyone I know why we should care about this. Ebola is a horrible disease. I am an expert in Ebola pathogenesis and can tell you in gory molecular detail about how horribly ebolaviruses kill you. But Craig has seen it. He has seen how it spreads through caring for sick loved ones as well as funerals and burying the dead. He has seen entire families suffer and die together from this terrible disease. He has experienced Ebola virus disease himself.

I know this may not move the needle for everybody, but for me this is why we should care about a virus we are unlikely to get: why would you sit by idly and just allow people to die of a disease like this? What kind of a human being would?

Additional reading:

Our Ebola expert group’s op/ed in USA Today on how outbreak response is demonstrably harmed by the US’ withdrawal from our commitments to global health

’s deeply moving perspective in the New York Times

Gavin Yamey’s dissection in the BMJ of how the entire US approach to global health is an extortion racket weaponized against the world’s most vulnerable people

’s view in STAT on the suffering and stigmatization caused by US policy as a physician returning from treating patients in West Africa

Mike Osterholm’s warning in the Washington Post about the massive gaps in preparedness that this outbreak exposes

’s reflections here on Substack on all these op/eds

Me and ’s updates:
May 21st:

May 20th:

May 19th, with :

Here is the first expert roundtable. Next episode out today (I think)!

Thank you , , , , , and many others for joining! Join me tomorrow when I’ll be joining and to talk about this on Dead Air for !

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Anyway, here is what you need to know about the Ebola outbreak today:

New model says the outbreak is big

The team at Imperial College in the UK has projected outbreak size using two different models. They estimate that there are 400-900 cases, but don’t exclude the possibility that this could be in the thousands. Because of ongoing conflict, population mobility, and movement restrictions, doing contact tracing is very difficult. Yet we urgently need to do it, because to improve survival, we desperately need to identify cases and provide them with supportive care.

New cases

Yesterday there was a report of a preliminary positive in a part of South Sudan with large refugee camps. Today there was a report that a patient is suspected in South Kivu province in DRC, in an area held by the Alliance Fleuve Congo, a rebel group that controls the area in what is basically an ongoing civil war. According to the AFC, the patient traveled from Kisangani and died. There is another suspected case being isolated. It’s unclear what this means for contact tracing, since I don’t know whether groups like the Rwanda-backed AFC would work with the DRC’s Ministry of Health to address this. I’m guessing probably not, though I defer to people with expertise in this area (which, to be clear, I DO NOT have). This is another example of how the complex security situation creates many challenges to actually doing contact tracing and determining the extent of the outbreak. Here’s another example:

Uganda US response

US Secretary of State Marco Rubio has been bragging about the response, supposedly giving $13 $23 million to relief efforts. This is nothing. The US is bragging that they are already hard at work building 50 Ebola clinics in the area. But oops! That’s news to the Ugandan Ministry of Health!

Travel bans don’t work: Wednesday edition

In today’s example of how travel bans are dumb and don’t work, a Congolese national with no known exposure risk was removed from a flight to Detroit in Montréal because the US has imposed a travel ban on all citizens of the DRC and Uganda. They really don’t want any stray Ebola getting in!

Except this protocol wouldn’t work for that, since the flight went on to Detroit without screening any of the passengers who flew from Europe with the guy from DRC. If he had Ebola, everyone on that plane would need to be quarantined. But according to MAHA infectious disease doctrine, all you have to do is get rid of the African guy to minimize risk. Not only is this appallingly racist, it’s completely stupid and actually exposes Americans to greater risk. Viruses don’t selectively infect people based on nationality.

America won’t help Americans

The Washington Post reported that the White House not wanting Ebola patients in the US was the reason that the infected American doctor, his family, and another doctor who was exposed were sent to Germany and Czechia instead of the US for treatment.

We’ve invested heavily in biocontainment capabilities in the US for this exact reason. We treated doctors evacuated from West Africa in 2014 at Emory, NIH, and Bellevue Hospital with no onward infections, and all the patients’ lives were saved with world-class supportive care.

Americans should see this for what it is: the US government will abandon us when we most need help abroad, and will deny us access to lifesaving medical care that our tax dollars paid for. Americans cannot count on the American government to look out for them if they get in trouble abroad.

Grifters: You’re on Notice

A lot of people say I’m a bitch when I call them out for lying, so I’d hate to disappoint. I am, after all, a genuine Ebola expert. Now that all the armchair hantavirologists are becoming armchair ebolavirologists, I need to make sure my reputation for calling bullshit remains intact.

Spreading bullshit about variants is actively harmful. This situation is bad enough. So brace yourselves: I’m entering my ebolavirus rap beef era.

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Here’s what you need to know about today:

The situation is not good

The World Health Organization (WHO) has issued the first Situation Report on the Bundibugyo ebolavirus outbreak in the Democratic Republic of Congo (DRC) and Uganda. These were the numbers we heard last night:

• More than 500 cases (confirmed and suspected)

• More than 130 people dead

• New cases in Uganda up to 12. It’s unclear if these are all imported or are locally acquired, probably because contact tracing and epidemiological investigations are ongoing

• Cases have occurred in multiple cities: Kampala in Uganda and Goma, Butembe, and Bunia in DRC

• Conflict, lack of resources, and movement restrictions are severely hindering contact tracing in some parts of DRC

• Only a fraction of cases have been confirmed by testing, due to insecurity and access issues

• DRC and Uganda have trained response teams and WHO is sending support

• The WHO has deployed medical and testing supplies, PPE, and additional personnel and mobile labs are being set up, although they are not operational across the boards

• Some places don’t have access to adequate clinical facilities, PPE, or medical supplies

• Safe burial practices are not being consistently applied

Wk Ext Sitrep 0118052026

741KB ∙ PDF file

Download

Download

It is very clear from reading this situation report that we have no idea about the scope and scale of this outbreak. What goes unmentioned throughout the grim situation report is why there has been so little testing, and why all the relief is coming from WHO and partners not named the United States of America. The US has bowed out. They aren’t part of the WHO and they aren’t going to do anything more than they have to.

Actually, the US is totally helping

Yesterday the US State Department proudly announced that the pathetic $13 million they’ve pledged to outbreak containment and relief efforts will go toward building 50 “Ebola Response Clinics.” We have no idea what sort of shitty tents they will be, but this isn’t enough money to build 50 functional Ebola treatment units (ETUs), and considering health care workers treating patients are at extremely high risk of infection, this could actually lead to a much bigger problem.

Americans Against Americans

But no worries, the American doctor won’t be coming back in our borders anytime soon, because the White House doesn’t want gross Ebola polluting our shores. Lest you think we’re exaggerating, the Washington Post reported today that President Trump’s attitude toward keeping Americans safe and bringing them home no matter what hasn’t changed much since he expelled this tweet in 2014:

So that explains why the American doctor was sent to Germany. His own country wouldn’t take him. Or his American wife, who is also a doctor and who also suffered an extremely high-risk exposure performing an ultrasound on a pregnant patient that later died. Pregnancy and ebolaviruses are extremely bad combinations, both for the patient and any health care workers taking care of her. She and her four young children can’t return to America either, because their President abandoned them, just like he abandoned all of America’s commitments and leadership in keeping people healthy. He is choosing to let people die, including Americans.

Sitrep is outdated on arrival

Well, the Situation Report was out of date as soon as we saw it, because we already had a report of a preliminary positive in South Sudan. In Western Equatoria province where there are large refugee camps that have been ravaged by conflict. This is a developing situation but an outbreak in a refugee camp like this one would be very, very bad.

We will keep you updated, as this situation is changing very rapidly and it’s not getting better. The risk to people outside the outbreak zone is low for getting Bundibugyo virus but high for lasting, destructive impacts to global health, the economy, national security, and America’s standing on the world stage.

You do need to know about this, even if you’re not going to get Ebola yourself. It will still get us all, if the catastrophe that’s about to happen isn’t stopped.

Thank you , , , , , and many others for tuning into our first episode of Primary Series with ! Join us tomorrow at 12 pm ET/9 am PT!

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Briefly, the third outbreak ever of Bundibugyo virus (BDBV) is in progress in the Democratic Republic of Congo (DRC) . There are multiple species of ebolaviruses, just like there are multiple species of mice or monkeys or foxes or birds. They all cause Ebola virus disease. BDBV has only emerged twice before, in Uganda in 2007 and the DRC in 2012. Because it’s so rare, we don’t have vaccines or monoclonal antibodies in clinical development. Vaccines for OG Ebola won’t work for BDBV. And the US withdrawal from WHO and any kind of public health effort, actually, has created a crisis in terms of response.

How’s that outbreak response going, btw? NOT GREAT AT ALL.

There are now more than 500 suspected cases and more than 130 deaths. This is 10X more than prior outbreaks. This has likely been going on for at least two months. Maybe longer. Ebola virus disease can be confused with other common infectious diseases, like malaria or other hemorrhagic fevers. If it has gone on for months that means cases are severely underreported. We don’t know about them and they may not realize they have a type of ebola.

Cases are confirmed in multiple major cities in both DRC and Uganda. Given the length of time this has gone on, the conflict in the area, and the mobility of the population, this can spread to other countries in the region too. Cities suffered massive mortality due to inadequate protection in health care settings and funeral and burial practices.

One American has tested positive and his family has been evacuated to Germany. According to a decidedly uninformative CDC press conference yesterday, this is supposedly because it’s logistically shorter and easier, but actually because Trump’s Ebola outbreak policy hasn’t changed in more than a decade:

Test positivity is high, although there are still issues with testing reliability and access. In any case, there is likely serious underreporting. Depending on how much, this outbreak could be larger than the West African epidemic of 2014-2016 that killed more than 11,000 people.

US is totally helping, though! We are going to build 50 Ebola clinics with some spare change they found in the ballroom couch. Just kidding, the US isn’t really doing shit. This is going to increase the body count and it may take years to contain this because there just isn’t funding.

WHO also sucks, according to MAGA! Not really, but Marco Rubio said that WHO was late to the game because he’s a gaslighting prick who needs to spend the entire rest of his life being accountable for the deaths he has demonstrably caused by destroying USAID, of which this is just going to be one grim example.

Actually, Trump is skipping out on his debts, as usual. The US is $250 million in arrears for old WHO dues and those funds don’t seem to be forthcoming anytime soon! It’s not like WHO might be able to use that to…respond to an already catastrophic GODDAMN RARE KIND OF EBOLA OUTBREAK.

This is both a humanitarian disaster in the making and a major national and global security issue. Just because you aren’t at high risk of getting Bundibugyo ebolavirus doesn’t mean you won’t be affected by thousands of people dying from it.

We covered all of that and will be covering it more in the days to come. A lot more, unfortunately.

Thank you , , , , , and many others for tuning into today’s episode of TAKING SHOTS with ! We’ll see you back here next time.

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Even worse, the Ugandan Ministry of Health is reporting a case of a Congolese man who traveled to Kampala from DRC, became ill, died, and tested positive for Ebola. Kampala is a huge city and there’s no indication of where this man may have gone or everyone who he interacted with, although the Ugandan MOH is quarantining one high-risk contact (a close relative) and actively investigating other contacts.

Uganda has experience with outbreaks of all three species of ebolaviruses: Ebola virus (EBOV; old name Zaire ebolavirus, what we all think of as “Ebola”), Sudan virus (SUDV; a different species of ebolavirus, with similar mortality to EBOV), and Bundibugyo virus (BDBV; yet another species of ebolavirus, which has caused 3 outbreaks that have slightly lower mortality than EBOV and SUDV, with it around 30-50%). It is good that Uganda has this experience, because an outbreak in Kampala—a densely crowded city of millions with a major international airport—would be completely disastrous. When the West African EBOV epidemic moved into the cities of Conakry, Guinea, Freetown, Sierra Leone, and Monrovia, Liberia, the scale of sickness and death increased dramatically. That was also when the US was very actively involved in the response and provided significant support, both through federal employees, the US military, and external partners that responded in various ways (NIH- and CDC-funded researchers, American foundations, and American experts working for organizations like Médecins Sans Frontières (Doctors Without Borders). American expertise and US-developed medical countermeasures like monoclonal antibodies and vaccines (both the Merck recombinant VSV-vectored EBOV GP vaccine and the GSK chimpanzee adenovirus-vectored vaccine).

This is a much bigger crisis than hantavirus, not because BDBV is likely to cause a pandemic, but because it is putting a fragile, resource-limited, war-torn region at high risk. Health emergencies often lead to other crises, so this will have a potentially continent-wide and even global destabilizing effect. The US will not be sending experts, because most of them have been defunded, fired, or otherwise removed from their positions. The US has withdrawn from the World Health Organization and will no longer coordinate with the global community to respond. Cuts to USAID, NIH, CDC, and other foreign aid that set up critical infrastructure in past outbreaks have severely hampered response capacity compared to prior large EBOV outbreaks in West Africa in 2014-2016 and in DRC in 2018.

On the other hand, in hantavirus news, there’s not much going on besides all the evidence pointing out that the AIRBORNE crowd’s speculative concerns continue to be unsupported by any evidence from this particular outbreak. Well, that, and the fact that Admiral Brian Christine, the urologist charged with leading the hantavirus response, is an expert in penile implants who has spread far-right conspiracy theories on his podcast, Erection Connection (yes, really). Let’s finish off with a fun video I made with about the completely unqualified dick doc.

On that uplifting note, we will be back Tuesday with another update! Sooner if something comes up first. Let’s hope not…

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Thank you , , , , , and many others for joining me and . See you next Friday at 5 pm ET! We are going to try to bring more of our friends to the party from now on.

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