Ebola Virus Disease New and Emerging Data

The WHO Ebola Clinical Team Rob Fowler, MDCM, MS(Epi), FRCP World Health Organization, Department of Pandemic and Epidemic Disease Associate Professor Department of Medicine & Critical Care Medicine University of Toronto fowlerr@who.int

Ebola Virus Disease New and Emerging Data

Ebola Virus Disease in West Africa

Ebola Virus Disease in West Africa

October 19 2014 (+ 24 cases in Nigeria, Senegal, Mali, USA, Spain)

Ebola Virus Disease: Current Case Count

This is the First

Ebola Virus Outbreak in West Africa.

The Worst

Ebola Outbreak in

History.

So far, by an Order of

Magnitude.

WHO acknowledges the tremendous efforts of all those involved in

the Ebola Response and in Patient care

DOI: 10.1056/NEJMoa1411100

Characteristics of Patients with Ebola Virus Disease

DOI: 10.1056/NEJMoa1411100

Characteristics of Patients with Ebola Virus Disease

DOI: 10.1056/NEJMoa1411100

Characteristics of Patients with Ebola Virus Disease

Ebola Virus Disease Signs and Symptoms

DOI: 10.1056/NEJMoa1411100

Ebola Virus Disease Signs and Symptoms

DOI: 10.1056/NEJMoa1411100

Ebola Virus Disease Signs and Symptoms

DOI: 10.1056/NEJMoa1411100

DOI: 10.1056/NEJMoa1411100

Ebola Virus Disease Signs and Symptoms

*

*

Ebola Virus Disease Signs and Symptoms

DOI: 10.1056/NEJMoa1411100

Ebola Virus Disease Signs and Symptoms

DOI: 10.1056/NEJMoa1411680

Vital Signs at Admission

DOI: 10.1056/NEJMoa1411680

Laboratory Values on Admission

DOI: 10.1056/NEJMoa1411680

Incubation Periods

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411100

Treatments Received

DOI: 10.1056/NEJMoa1411680

Time-to-Events

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411100

Case Fatality Ratios – West Africa

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411100

Case Fatality Rates - Sex

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411100

Case Fatality Rates – Healthcare Workers

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411100

Case Fatality Rates - Age

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411100

Case Fatality Rates - Age

DOI: 10.1056/NEJMoa1411680

Under 40 Years

> 40 Years

Case Fatality Rates – Admission Viral Load

DOI: 10.1056/NEJMoa1411680

Projections

• Capacity for clinical care is minimal and all on-the-ground are overwhelmed with need to perform immediate outbreak care*

• No pre-existing studies and trials truly “on-the-shelf”

• Virtually no existing research culture in healthcare system

• Substantial community and organizational resistance to ‘research’

• Limited capacity to provide a baseline standard of care to a ‘control’ group

• Challenging data collection when nothing can leave the facility

• Substantial regulatory approval delays at many levels

• Delay in truly getting funding to the most promising initiatives

• A disproportionate focus on magic bullets vs. improving the standard of care

Research Challenges

Potential Ways Forward

If we wait for an outbreak or epidemic to start planning, initiating research, we will almost always fail to improve care during the outbreak and for the future We must have somewhat generalizable, flexible observational studies, with paper and electronic case report forms, ready and ethics approved BEFORE These CRFs should be “tiered” and be the platform upon which biological sampling and interventions are tested

• Tier 0: 1-page minimal CRF with descriptors and outcomes • Tier 1: Traditional observational study with characteristics, severity of

illness, course of care, treatments, available labs, outcomes • Tier 2: Biological sampling studies • Tier 3: Intervention Evaluation, open or randomized

There must be funds / a virtual fund-in-waiting to get this work done

Potential Ways Forward

fowlerr@who.int rob.fowler@sunnybrook.ca