EBOLA ! EBOLA ! Getting past the media hype and assessing Getting past the media hype and assessing

the real risksthe real risks

Nebraska Home Office Life Underwriters Nebraska Home Office Life Underwriters AssociationAssociation

November 18, 2014November 18, 2014

Jeffery Grubbe MD FACPJeffery Grubbe MD FACPChief Medical DirectorChief Medical Director

Allstate InsuranceAllstate Insurance

Presentation outline

1. Current & past Ebola outbreaks2. The virus & the infection3. Infectivity & fatality of Ebola4. Prevention & control5. Responses to the current Ebola outbreak6. The controversies around Ebola and the

responses to it7. The economic impact of Ebola8. Resources & additional reading

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Ebola Virus Disease (EVD)

• Previously known as Ebola Hemorrhagic Fever (EHF)

• Known to be a severe, often fatal illness in humans but can also infect non-human primates

• Initially detected in 1976 with two simultaneous outbreaks in remote villages of Sudan & the Democratic Republic of Congo (Zaire) in Central Africa• Since then 20+ separate outbreaks have been identified

• The current outbreak are occurring in countries of West Africa and have involved major urban areas as well as rural communities with cases reaching as far as Europe and the U.S.• The 2014 outbreak has by far been the largest and most deadly in history• A second, much smaller outbreak currently in DR Congo

• Outbreaks have been associated with Case Fatality Rates (CFR) from 25% up to 90% with an average CFR around 50%.

• The current outbreak has an estimated CFR of 70% overall

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The Current West African Outbreak

• The first infection, a six year old toddler, of the current outbreak was actually identified in Guinea in December of 2013 since then spreading across land borders to Sierra Leone and Liberia. Later spreading to Nigeria, Senegal and Mali. Nigeria & Senegal have since been declared free of Ebola. Mali had been declared free but several new cases have recently cropped up.

• The World Health Organization (WHO) was notified of the epidemic nature of the outbreak in March of 2014 and later declared it a “Public Health Emergency of International Concern” on August 8th.

• The second current outbreak in DR Congo is from the same species (Zaire) as West Africa but a different strain and therefore felt to be unrelated. The index case was a woman who had butchered a monkey (“bush meat”) given to her by her husband.

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Ebola outbreaks 1976-2014

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Country Town Cases Deaths Species Year

Dem. Rep. of Congo Yambuku 318 280 Zaire ebolavirus 1976

South Sudan Nzara 284 151 Sudan ebolavirus 1976

Dem. Rep. of Congo Tandala 1 1 Zaire ebolavirus 1977

South Sudan Nzara 34 22 Sudan ebolavirus 1979

Gabon Mekouka 52 31 Zaire ebolavirus 1994

Ivory Coast Tai Forest 1 0 Taï Forest ebolavirus 1994

Dem. Rep. of Congo Kikwit 315 250 Zaire ebolavirus 1995

Gabon Mayibout 37 21 Zaire ebolavirus 1996

Gabon Booue 60 45 Zaire ebolavirus 1996

South Africa Johannesburg 2 1 Zaire ebolavirus 1996

Uganda Gulu 425 224 Zaire ebolavirus 2000

Gabon Libreville 65 53 Zaire ebolavirus 2001

Republic of Congo Not specified 57 43 Zaire ebolavirus 2001

Republic of Congo Mbomo 143 128 Zaire ebolavirus 2002

Republic of Congo Mbomo 35 29 Zaire ebolavirus 2003

South Sudan Yambio 17 7 Zaire ebolavirus 2004

Dem. Rep. of Congo Luebo 264 187 Zaire ebolavirus 2007

Uganda Bundibugyo 149 37 Bundibugyo ebolavirus 2007

Dem. Rep. of Congo Luebo 32 15 Zaire ebolavirus 2008

Uganda Luwero District 1 1 Sudan ebolavirus 2011

Uganda Kibaale District 11* 4* Sudan ebolavirus 2012

Dem. Rep. of Congo Isiro Health Zone 36* 13* Bundibugyo ebolavirus 2012

Uganda Luwero District 6* 3* Sudan ebolavirus 2012

Guinea, Sierra Leone, Liberia

(Mali, Nigeria, Senegal, Spain, USA) (DR Congo)*

multiple14,413 (Includes 570 HCW)

(DR Congo 66 (8 HCW)*

5177 (324) health care workers)

(DR Congo 49 (8HCW)*Zaire ebolavirus 2014 (as of November 14, 2014)

West Africa & Dem. Rep. Congo

6 www.worldatlas.com/

The VirusGenus Ebolavirus is a member of the Filoviridae family

•Also includes the genera Marburgvirus & Cueavirus

5 distinct Ebolavirus species known:•Bundibugyo ebolavirus (BDBV)•Zaire ebolavirus (EBOV) (2014)•Sudan ebolavirus (SUDV)•Reston ebolavirus (RESTV)

– found in the Philippines & China– *Reston Va. 1989, macaque monkeys

•Tai Forest ebolavirus (TAFV)

The natural reservoir suspected to be infected animals:

•Fruit bats felt to be a primary reservoir in Africa but the live virus has yet to be isolated. •Human transmission likely through close contact with monkeys, chimpanzees, gorillas, antelope & porcupines found ill or dead in the rainforest

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The Infection

• The incubation period is typically 2-21 days from infection to the onset of symptoms with an average of 6-8 days in the current outbreak

• Symptoms include:• The sudden onset of a high spiking fever, intense weakness, muscle

pain, headache and sore throat.• Followed by vomiting, diarrhea, rash, impaired kidney and liver

function.• Then, in some cases (~40%), the occurrence of internal and external

bleeding (e.g. oozing from the gums, bloody stools, hematemesis etc.) will occur

• Laboratory usually present include elevated liver function studies, low white blood cell and platelet counts

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The Infection

It is when symptoms occur that the virus is present within the blood and fluids of the infected individual making them highly contagious. •In those who survive, the virus may sometimes be detectable in semen and breast milk for up to 2 months after recovery

• In some situations, this has lead to isolation and banishment of survivors by their families and communities.

•At the peak of the illness, 10 billion viral particles may be found in just 1/5th teaspoon of blood (1ml)

• This compares to 50-100k for HIV and 5-10 million for hepatitis C

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Transmitting Ebola

• The infection is transmitted by direct contact with infected blood, secretions, tissues or organs of dead or living infected people or animals

• Contact with clothing, bedding and surfaces contaminated by direct contact with infected individuals is felt to be another potential means of transmission

• No airborne transmission of the infection has been reported and signs of viral mutation has not been identified as yet• One experimental lab study reported the possible occurrence of

oronasal transmission in animals (pigs to non-human primates)

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Diagnosing Ebola• The early symptoms of Ebola are quite similar to those caused by

other infectious diseases such as malaria, typhoid fever, yellow fever and meningitis, making Ebola difficult to distinguish from the others particularly in endemic areas like Africa. (Even “cause of death” may be difficult to establish at times)

• EVD is confirmed by testing for viral antigens and particles by using several different methods:• Antibody-capture enzyme-linked immunosorbent assay (ELISA) • Antigen-capture detection tests• Serum neutralization testing• Reverse transcriptase polymerase chain reaction (RT-PCR) assay• Direct visualization by electron microscopy• Viral isolation by cell culture

• The challenge is maintaining maximum biological containment conditions as these samples are extreme biohazard risks!

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Treatment of Ebola

• Individuals with Ebola are severely ill and require intense supportive care:• Rehydration using oral and intravenous fluids• Control of their symptoms of nausea, vomiting, fever, pain, seizures

and such• Treatment of any hemorrhagic complications when present is

needed using transfusions, clotting components etc.• Treatment and support of associated system and organ failure is

often required e.g. ventilation, dialysis etc.

• The earlier such care can be administered generally, the better the prognosis. Younger, healthier tend to respond better as well.

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Viral Directed Therapy of Ebola

No “approved” treatments available yet but numerous investigational modalities being tried including:

• Convalescent serum therapy- “passive immunization”

• Novel Immune therapies • ZMapp: a combination of three monoclonal antibodies against components of the

virus– Developed by Mapp Biopharmaceuticals (San Diego)– Manufactured in tobacco plants in a process called “pharming” by Kentucky

BioProcessing (a subsidiary of Reynolds)• Brincidofovir:

– Developed by Chimerix Inc. of North Carolina– Being studied as a treatment for infections in BMT

• Genetic therapy• TKM-Ebola:• Tekimira Pharmaceuticals of Canada

– Blocks genes essential in viral replication of Ebola13

Viral Directed Therapy of EbolaNo currently approved Ebola vaccines available but 3 potential vaccines

undergoing clinical studies and potentially available in early 2015

• GlaxoSmithKline (cAd3-ZEBOV)– In collaboration with the US National Institute of Allergy and Infectious

Diseases using a chimpanzee derived adenovirus• NewLink Genetics (rVSV-ZEBOV) (Ames IA)

– Developed by Public Health Agency of Canada & derived from livestock virus

• Crucell Biopharmaceuticals– Collaborating with the NIH and Thomas Jefferson University– Modification of a rabies vaccine

A lot of criticism leveraged at the pharmaceutical industry for not pursuing/completing Ebola vaccine development years ago• “Only affected poor African countries…” Dr. M. Chan, WHO Director-General

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How Deadly is Ebola?

15 www.aljazeera.com

* Current death toll estimated to be ~5100

How Deadly is Ebola?

16 www.aljazeera.com

* CFR for the current West Africa outbreak is now reported to be ~50-70%

How Infectious is Ebola…the R naught factor

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http://www.npr.org/blogs/health/2014/10/02/352983774/no-seriously-how-contagious-is-ebola

What is the risk of contracting Ebola?

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http://www.npr.org/blogs/goatsandsoda/2014/10/23/358349882/an-answer-for-americans-who-ask-whats-my-risk-of-catching-ebola

What else is going around…other infectious disease outbreaks in 2013-14

• Middle East Respiratory Syndrome-coronavirus (MERS-CoV)– Qatar, Turkey, Saudi Arabia, Austria, UAE

• Avian Influenza H7N9– China

• Chikungunya– France, St. Martin, Anguilla, BVI, Dominica, French Guiana, Martinique, St. Bart– Imported cases reported in the U.S., Mexico & Aruba

• Marburg virus– Uganda

• Poliovirus– Cameron, Brazil, Guinea, Syria, Somalia, Egypt, Gaza

• Enterovirus D68– USA

• Cholera– South Sudan, Mexico, Cameroon

• Yellow Fever • DR Congo, Ethiopia

• Legionnaires’ Disease• Portugal 19 www.who.int/csr/outbreaknetwork/en/

Prevention & Control Measures

• Reducing the risk of wildlife-to-human transmission:• Limiting contact with infected fruit bats or monkeys/apes and the consumption of

their raw meat

• Reducing the risk of human-to-human transmission:• Reducing direct or close contact of with Ebola symptoms or acute infection, their

bodily fluids and contaminated clothing

• Prompt and safe burial of the dead:• Estimated that 50-70% of disease transmission occurs due to contact with the

dead

• Identifying those people who may have been in contact with someone infected with Ebola• Monitoring the health of contacts for 21 days • Separating the healthy from the sick to prevent further spread

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Local contributing factors in West Africa• Civil unrest & weak governments

• Decades of coups, juntas and civil wars

• Inadequate health-care infrastructure and services• Lack of money, supplies, treatment centers and trained care givers

• Local cultures• Burial preparations and traditional kissing/hugging of corpses of family members may be responsible for 50-70% of new infections

– Forced compliance to safer practices by the U.S. and British military has lowered the infection rates• Consumption of “bush meat”

• Deforestation rampant in West Africa• 96% Sierra Leone’s forests has been wiped out• Agriculture has replaced 20% of forests in Guinea & Liberia• Increases concentrations of wild animal and drives people closer to reservoirs

• Increased mobility and access to remote areas • Increase in roads and travel• Increases potential human-animal contacts

• Climate change causing intense periods of rain following extreme droughts• Increased fruit during rainy brings increased bats and apes to feed• Humans seek more disease ridden sources of food

• Many of the prior outbreaks can be connected to some sort of human behavior• 1994 gold miners in Gabon ate an infected ape• 2014 in DR Gongo a woman butchered an infected dead animal given to her by her husband• Hypothesized that forestry in Guinea cut far enough into the forest to find a reservoir in current outbreak

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“This little virus went to the market…”

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TravelCDC recommendations for foreign travel:

• “Avoid non-essential travel to high risk countries (Guinea, Sierra Leon, Liberia)”• “Practice enhanced precautions” (Democratic Republic of the Congo)

Enhanced Ebola screening and tracking at five U.S airports • JFK (NYC); Dulles (Washington, DC); Newark, NJ; O’Hare (Chicago); Atlanta

– These airports receive over 94% of travelers from these countries– Prior to outbreak the estimated number of travelers was ~130/day. Since it has

dropped to roughly 1/3 of this• Tracking is done by Homeland Security’s Customs & Border Protection (CBP) unit• Exit screening performed prior to leaving an outbreak area• Entrance screening done on arrival to destination country

Travel bans introduced in Australia and Canada

Rwanda’s response…

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World ResponseWorld Bank taking a major financial role with $400M committed

Bill & Linda Gates have pledge $50M & Paul Allen $100M (Microsoft)

Cuba has sent or committed to send 600+ nurses and doctors to West Africa, about the same as the U.S.• Currently has 46,000 medical workers worldwide

U.S. has committed $350M to West African countries and ~3000 troops to help build hospitals and treatment centers

UK committed to $120M and additional funding & medical support of 1000 treatment beds

Medecins Sans Frontieres / Doctors without Borders is the major non-government aid organization providing care & supplies at six care centers with ~ 300 international & 3,000 local staff

Criticism has been aimed at China and Asia not doing it fair share financially and otherwise despite Africa being their largest trade partner

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Public Health Response

• Raise awareness of travelers• Raise awareness & preventative skills of healthcare workers • Prepared health system response

• Points of Entry: ports, airports, ground crossings• Health care setting and first responders: ERs, ambulance services,

fire departments etc.• Notification protocols• Training on basic infection control and prevention, waste

management, use of PPE, isolation of suspected & confirmed cases• Contact tracing• Specimen and waste handling

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Ebola in the U.S… Who all is weighing in on the Ebola threat?

• Center for disease Control- CDC• World Health Organization- WHO• Occupational Safety and Health Administration- OSHA• National Security Agency- NSA• Department of Homeland Security- DHS• Transportation Security Administration- TSA• Customs and Border Protection- CBP• Health Insurance Portability and Accountability Act- HIPPA (HSS)• American Disability Act- ADA• Labor relations groups- healthcare and service unions• White House, Governors & Congress…• And a sundry of medical and legal groups…

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Who potentially could be affected?

• Medical missionaries and foreign aid workers and…

• Health care workers• Airline and travel industry• Laboratory workers• Emergency responders• Mass transit and other public service personnel• Pharmacy, public health, mortuary and death care workers • Border, customs and quarantine workers• Custodial personnel (hospitals and other care facilities)

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Employer Concerns

• Workplace safety• Travel policies• Employee relations• Leave of absences• Refusal to work requests• Emergency preparedness and response plans

• Whose assigns responsibility for assessing the risk, effective communications and implementing the action plans?

• Who actually makes the decision to pull the levers?

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Potential life insurance responses

• Underwriting travel to “Ebola Zone” or areas of regional outbreaks• Potential underwriting actions:

– Decline/postpone recent travelers– Adverse ratings– Face-to-face applications– Suspension on temporary insurance agreements– Good health statements or medical clearances– “Nuclear option”… stop writing new business– Others..

• Restrictions on underwriting travel in several states• Public image issues…especially with returning healthcare workers

• Reinsurers response…

• Updating Pandemic and Business Recovery Plans• Putting a risk on “ELFS”: Extremely Low Frequency Scenarios

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Related Headlines from the Insurance Industry

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PropertyCasualty360: Oct.28, 2014

“Aon launches Ebola liability product for health care industry…” current liability products may only cover “facility-borne” infections or may not cover costs of disinfection and decontamination…

“Healthcare workers who contract Ebola while caring for patients will be covered under most state’s worker’s compensation… however, non-healthcare employees who are infected by a co-worker may have difficulties establishing eligibility for benefits…”“To the extent that an employee contracts Ebola because he or she violated the employer's protocols, an employer may have grounds to defend…”

PropertyCasualty360: Nov 3, 2014

The many controversies of Ebola…• CDC’s response and support: Delays, inadequacies and back stepping

• Where is the Surgeon General?

• Travel Prohibition to/from “Ebola Zone” countries

• Evacuating foreign aid/medical workers: • Who is left behind?• What message does this send?

• Public safety vs. individual’s rights• Returning health care workers & missionaries …• Self monitoring vs. active monitoring• Individual’s liability for infecting others

• State/local quarantine guidelines vs. CDC/Medical guidelines: who SHOULD make the call?• NY, NJ, Illinois and Georgia: mandatory quarantines

• Euthanizing pets and destroying personal property: necessity or reaction?

• Fast tracking vaccines and medications through the approval process: Assessing effectiveness and safety?

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Economic impacts abound…World Bank: Estimated cost of $359 million if contained at current levels & more than $32 billion by 2015 if

continues to spread– 20,000 cases vs. 200,000 cases

Beyond the cost of care in West Africa...•Health Care Systems

– Added cost of care and preventative measures• Estimated costs to bring first two American missionaries back…$2 million

– Liabilities– Loss of business

• Dallas Presbyterian Hospital: 50% decrease in ER visits and > $8M loss in revenue within the first month

•Public Health Authorities– Added staffing & policy demands and controversies– Legal costs

•West Africa & Ivory Coast– Loss of tourism and business investments: Cocoa industry in Ivory Coast

• Lack of workers• Lack of inspectors• Decreased exports

•NYC & Dallas– Loss of tourism & decreased consumerism due to fear

•Health & Life Insurers & industry at large– Pandemic planning– Underwriting and legal reviews

•Airports, military & humanitarian commitments etc. etc.32

Contagion

Andromeda Strain Outbreak

Panic in the Street

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Ebola 2014… it’s not a movie!Ebola 2014… it’s not a movie!

West Africa 2014

Resources on Ebola

• Centers for Disease Control and Prevention (CDC): www.cdc.gov/vhf/ebola/index.html

• World Health Organization: www.who.int/csr/disease/ebola/en/

• The New England Journal of Medicine- Ebola Outbreak site: www.nejm.org/page/ebola-outbreak

• Aon Hewitt- Ebola Response site: www.aon.com/ebola-response/

• David Quammen: “Ebola- The Natural and Human History of a Deadly Virus” , Norton Publishing

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