Transcript Ebola - Nebraska Home Office Life Underwriters Association

EBOLA !
Getting past the media hype and assessing the real risks
Nebraska Home Office Life Underwriters Association
November 18, 2014
Jeffery Grubbe MD FACP
Chief Medical Director
Allstate Insurance
Presentation outline
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Current & past Ebola outbreaks
The virus & the infection
Infectivity & fatality of Ebola
Prevention & control
Responses to the current Ebola outbreak
The controversies around Ebola and the responses to it
The economic impact of Ebola
Resources & additional reading
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Ebola Virus Disease (EVD)
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Previously known as Ebola Hemorrhagic Fever (EHF)
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Known to be a severe, often fatal illness in humans but can also infect non-human
primates
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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
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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
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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
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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.
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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.
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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
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
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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
Zaire ebolavirus
2014 (as of November 14, 2014)
Guinea, Sierra Leone, Liberia
(Mali, Nigeria, Senegal, Spain,
USA) (DR Congo)*
multiple
14,413 (Includes 570 HCW)
(DR Congo 66 (8 HCW)*
55177 (324) health care workers)
(DR Congo 49 (8HCW)*
West Africa & Dem. Rep. Congo
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www.worldatlas.com/
The Virus
Genus Ebolavirus is a member of the Filoviridae
family
•Also includes the genera Marburgvirus & Cueavirus
5 distinct Ebolavirus species known:
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Bundibugyo ebolavirus (BDBV)
Zaire ebolavirus (EBOV) (2014)
Sudan ebolavirus (SUDV)
Reston ebolavirus (RESTV)
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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
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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
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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
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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)
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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
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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:
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Convalescent serum therapy- “passive immunization”
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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
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Genetic therapy
• TKM-Ebola:
• Tekimira Pharmaceuticals of Canada
– Blocks genes essential in viral replication of Ebola
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Viral Directed Therapy of Ebola
No 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?
* Current death toll
estimated to be ~5100
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www.aljazeera.com
How Deadly is Ebola?
* CFR for the current West Africa
outbreak is now reported to be ~50-70%
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www.aljazeera.com
How Infectious is Ebola…
the R naught factor
http://www.npr.org/blogs/health/2014/10/02/352983774/no-seriously-how-contagious-is-ebola
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What is the risk of contracting Ebola?
http://www.npr.org/blogs/goatsandsoda/2014/10/23/358349882/an-answer-for-americans-who-ask-whats-my-risk-of-catching-ebola
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What else is going around…
other infectious disease outbreaks in 2013-14
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Middle East Respiratory Syndrome-coronavirus (MERS-CoV)
– Qatar, Turkey, Saudi Arabia, Austria, UAE
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Avian Influenza H7N9
– China
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Chikungunya
– France, St. Martin, Anguilla, BVI, Dominica, French Guiana, Martinique, St. Bart
– Imported cases reported in the U.S., Mexico & Aruba
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Marburg virus
– Uganda
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Poliovirus
– Cameron, Brazil, Guinea, Syria, Somalia, Egypt, Gaza
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Enterovirus D68
– USA
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Cholera
– South Sudan, Mexico, Cameroon
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Yellow Fever
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DR Congo, Ethiopia
Legionnaires’ Disease
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Portugal
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www.who.int/csr/outbreaknetwork/en/
Prevention & Control Measures
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Reducing the risk of wildlife-to-human transmission:
• Limiting contact with infected fruit bats or monkeys/apes and the consumption of
their raw meat
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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
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Prompt and safe burial of the dead:
• Estimated that 50-70% of disease transmission occurs due to contact with the
dead
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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
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Civil unrest & weak governments
• Decades of coups, juntas and civil wars
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Inadequate health-care infrastructure and services
• Lack of money, supplies, treatment centers and trained care givers
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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”
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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
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Increased mobility and access to remote areas
• Increase in roads and travel
• Increases potential human-animal contacts
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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
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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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Travel
CDC 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 Response
World 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?
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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…
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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
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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
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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
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Reinsurers response…
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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
“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…
PropertyCasualty360: Oct.28, 2014
“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
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The many controversies of Ebola…
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CDC’s response and support: Delays, inadequacies and back stepping
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Where is the Surgeon General?
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Travel Prohibition to/from “Ebola Zone” countries
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Evacuating foreign aid/medical workers:
• Who is left behind?
• What message does this send?
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Public safety vs. individual’s rights
• Returning health care workers & missionaries …
• Self monitoring vs. active monitoring
• Individual’s liability for infecting others
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State/local quarantine guidelines vs. CDC/Medical guidelines: who SHOULD make the call?
• NY, NJ, Illinois and Georgia: mandatory quarantines
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Euthanizing pets and destroying personal property: necessity or reaction?
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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
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Added cost of care and preventative measures
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Estimated costs to bring first two American missionaries back…$2 million
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Liabilities
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Loss of business
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Dallas Presbyterian Hospital: 50% decrease in ER visits and > $8M loss in revenue within the first
month
•Public Health Authorities
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Added staffing & policy demands and controversies
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Legal costs
•West Africa & Ivory Coast
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Loss of tourism and business investments: Cocoa industry in Ivory Coast
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Lack of workers
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Lack of inspectors
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Decreased exports
•NYC & Dallas
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Loss of tourism & decreased consumerism due to fear
•Health & Life Insurers & industry at large
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Pandemic planning
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Underwriting and legal reviews
•Airports, military & humanitarian commitments etc. etc.
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Ebola 2014… it’s not a movie!
Contagion
Panic in the Street
West Africa 2014
Outbreak
Andromeda Strain
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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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