Archives for posts with tag: vaccine

Oh, just, subtle, and mighty opium! [T]hat to the hearts of poor and rich alike, for the wounds that will never heal, and for “the pangs that tempt the spirit to rebel,” bringest an assuaging balm; eloquent opium! that with thy potent rhetoric stealest away the purposes of wrath; and to the guilty man for one night givest back the hopes of his youth, and hands washed pure from blood; and to the proud man a brief oblivion for Wrongs [unaddressed] and insults unavenged ….. Thou only givest these gifts to man; and thou hast the keys of Paradise, oh, just, subtle, and mighty opium!

Thomas de Quincey[1]

 [This is Fred. Phil’s out with exhaustion, heat and otherwise, and asked me to take over today’s lesson. This isn’t an easy thing to do, because he has a list of heavy-duty subjects to cover some day, but most are not in my area of interest, and I don’t know enough to lecture about the rest. It would take too long to research “Philosophical Aspects of Modern Rap,” or “A Linguistic Analysis of Feminist Theory,” or “Will Ancient Spells Work on Mars?” [Although that last one really looks interesting.[2]]

But we’re not blazing new paths today; there’s a deadline; so let’s look for an old subject, one we know something about. How about opioids and our collective addiction to them? Heroin, an opioid, has been around and afflicting people in this country for some time.[3] Opium, the original opioid, has caused problems in the East for centuries and has addicted folks in the West for generations. Most of us kind of know about these things, but ignore them. The current furor about opioids only erupted because there are synthetics now loose in the drug economy. They’re very potent, and deadly, and their users die at a high rate.

So why not frame our current situation with some history? Did you know that opium was a big problem in England in the 18th and 19th Centuries? And what’s the evidence for that? Well, for one thing there’s a very famous book, first published in London Magazine in 1821, that chronicles the opium addiction of an upper class Englishman. My friends in sociology say it’s a classic. The book tells us quite a bit about how the author got addicted, who supplied the stuff, and how many users there were.

It says London had a well-established opium trade in the early 19th Century. The author reported: “Three respectable London druggists, in widely remote quarters of London … assured me that the number of amateur opium-eaters … was at [that] time immense; and that the difficulty of distinguishing those persons to whom habit had rendered opium necessary from such as were purchasing it with a view to suicide, occasioned them [the druggists] daily trouble and disputes.”[4] So why would druggists back then worry about would-be suicides? I don’t know. Perhaps it was a legal requirement. But apparently the prospect of suicide didn’t inhibit sales all that much. The population of users “was immense.”

Also, opium addiction was not just an upper class London phenomenon. Blue-collar types in other parts of England were getting into it, “so much so, that on a Saturday afternoon the counters of the druggists were strewed with pills of one, two, or three grains, in preparation for the known demand of the evening.”[5] The author said this happened because, for a time, opium was less expensive than alcohol, so the working class went with the new thing. But, he said, if the pricing reversed, the new addicts would not follow. “[T]hose eat now who never ate before; [a]nd those who always ate, now [will] eat the more.”[6] That is, opium addicts, once made, would not go back to the old vices simply because the market ordered it.]

The book is Confessions of An English Opium-Eater: Being an Extract from the Life of a Scholar, written by Thomas de Quincey.[7] He lived from 1785 to 1859, and was severely addicted from about 1813 until 1819. If you want to know more, there are some web-based biographies available[8]; but in my view they pretty much track the book; so that’s where we’ll concentrate. As to why De Quincey was a user, look at the quote that opens this piece. Opium held the keys to Paradise.[9]

De Quincey’s Life and Addiction

Or at least it did when he used opium sparingly, and at great intervals, for recreation. But I’m getting ahead of the story. Let’s look at the milestones on his road to and from addiction:

  1. Thomas de Quincey was born on August 5, 1785. His father was a merchant, just starting out, and had good prospects until he died, 7 years later. By my count, that would have been in 1792.
  2. Young Thomas had 4 guardians after that, and was shipped off to various schools for his education, apparently including Eton and an unnamed school at Oxford. “I was sent to various schools, great and small; and was very early distinguished for my classical attainments, especially for my knowledge of Greek. At thirteen I wrote Greek with ease; and at fifteen my command of that language was so great that I not only composed Greek verses in lyric metres [today, “meters”], but could converse in Greek fluently and without embarrassment …”[10]
  3. He tried opium for the first time at age 18, which would have been in 1803. He liked it, and over the next 10 years continued to use it “for the sake of the exquisite pleasure it gave me ….”[11]; but, he said, he spaced out the doses to preserve their effect, and that protected him “from all [the] material bad consequences”[12] of addiction. Or perhaps he just didn’t have the money to buy in quantity. Who knows?
  4. The situation changed in 1813, when he was 28. He had an eruption of a gastro-intestinal problem that first had hit him when he was a teenager. Apparently it was both painful and chronic; so much so that he began to treat himself with daily doses of his favorite drug. “It was not for the purpose of creating pleasure, but of mitigating pain in the severest degree, that I first began to use opium as an article of daily diet.”[13]
  5. He continued until he was thoroughly addicted, and didn’t kick the habit until 1819, six years later. How did he escape? By incrementally reducing his intake until he achieved a zero dose rate; and that wasn’t easy! He tried to do it in the early days, but failed. And he was a mess even after he succeeded. “Think of me as one, even when four months had passed, still agitated, writhing, throbbing, palpitating, shattered, and much perhaps in the situation of him who has been racked …. Meantime, I derived no benefit from any medicine, except one prescribed to me by an Edinburgh surgeon of great eminence, viz., ammoniated tincture of valerian.”[14]
  6. Valerian is an herb you can buy today at the vitamin store, but I’m not saying it will help you conquer opioids. So far as I can tell, there still aren’t any easy cures. Right now a cynic might say our technology isn’t much more effective than what was available to De Quincey 200 years ago. Reports are that there may be a vaccine in our future, but they’re speculative and a subject for a different blog.

Conclusion

His milestones sound pretty contemporary, don’t they? De Quincy, an occasional user of opium, the opioid of his day, liked it so long as he didn’t use a lot. Then one day he used it as a pain killer, began to take daily doses, and went straight down the toilet. And today what are our most popular pain medications? Opioids, for the most part. And where do we get them? Why, from druggists, doctors or street vendors, depending on our budgets. Oh brave new world, you look pretty old to me! I wonder, did 19th Century Londoners have street druggists like ours? If so, did they call them “pushers”? Or was everybody just a druggist?

I’m guessing it’s as hard to kick an opioid addiction today as it was for Thomas de Quincey. He said it was like being born:

[Some conjecture] that it may be as painful to be born as to die.  I think it probable; and during the whole period of diminishing the opium I had the torments of a man passing out of one mode of existence into another.  The issue was not death, but a sort of physical regeneration …. [15]

And once regenerated it was possible for him to be happy again. “[A]nd I may add that ever since, at intervals, I have had a restoration of more than youthful spirits, though under the pressure of difficulties which in a less happy state of mind I should have called misfortunes.”

Opium and its modern relatives can be very attractive until they take control of our lives. Thomas de Quincey discovered that, got out, and was better for it. Myself, I think it’s better not to get in.

See you next week!

 

[1] This quote is from Thomas de Quincey, Confessions of an English Opium Eater, Being an Extract from the Life of a Scholar. Believe it or not, this book is currently in print from the Oxford University Press.  It was first published in 1821 in London Magazine, then was picked up in 1886 by George Routledge and Son. You can find the hard copy on Amazon. However, in keeping with blog policy, we have found an alternate, free source for the text, this time in an eBook from Project Gutenberg.  Go to http://www.gutenberg.org/files/2040/2040-h/2040-h.htm “This eBook is for the use of anyone anywhere at no cost and with almost no restrictions whatsoever.  You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.net .” Henceforth the eBook will be cited as “Opium Eaters at __.” Page numbers, if given, will be approximations. The eBook version doesn’t appear to have such things. See Opium Eaters at Part II, The Pleasures of Opium, p. 28-29 for our quote. Even our quote is just a small part of what he actually wrote.

[2] I also like his partial draft of “Faces and Other Things on the Planets,” in which he argues that with modern digital technology any collection of pixels can be morphed into anything else, so why believe NASA’s pictures of celestial objects or any pictures at all?

[3] Check out the Wikipedia posting at https://en.wikipedia.org/wiki/Heroin for more information on this subject.

[4] See Opium Eaters at To the Reader, p. 3.

[5] Id.

[6] Id. “… I do not readily believe that any man having once tasted the divine luxuries of opium will afterwards descend to the gross and mortal enjoyments of alcohol ….”

[7]  See note 1.

[8] See, e.g., the home page for the most recent printed edition of De Quincey’s book, at http://robertjhmorrison.com/thomas-de-quincey/ ; and the Wikipedia entry for him at https://en.wikipedia.org/wiki/Thomas_De_Quincey .

[9] The Oxford Dictionary of Quotations has a ridiculously shortened version of the original. See Knowles [editor], Oxford  Dictionary of Quotations (6th Edition, 2004) [hereafter, ODQ at __]  at Thomas de Quincy, p. 264, n. 20. “Thou hast the keys of Paradise oh just, subtle and mighty opium.” That reads like someone’s note on a page, next to the real thing, rather than a genuine effort to reflect the original.

[10] See Opium Eaters at Preliminary Confessions, p. 5.

[11] See Opium Eaters at Preliminary Confessions, p. 4.

[12] Id.

[13] See Opium Eater at Preliminary Confessions, p. 4-5

[14] See Opium Eaters at Part II, June 1819, p. 46

[15] See Opium Eaters at Part II, June 1819, p. 46

 

In the final analysis, however, the implication that there is a decision to be made (seek medical care or not) or a ‘spreader’ to be found is merely a cognitive convention that has been imposed on the PPE-bereft care nexus by western philosophy.

Eugene T. Richardson and many others, in The Ebola suspect’s dilemma[1] 

[Hi everybody, this is Fred. You might be wondering what epidemic I’m talking about, and what that quote means. Frankly, I don’t have a crystal ball; I don’t know what the next epidemic will be. We’ll discuss the quote later.

Of course the last really scary epidemic was Ebola; there are multiple varieties of that, and one or another of them could break out at any time. But there are other possibilities as well: hemorrhagic fevers that have yet to imitate Ebola’s success; Zika, a virus spread through common varieties of the mosquito, that horribly damages the unborn; or things we don’t know about, hiding in the nooks and crannies of the planet. Nature is tenacious, and evolution is one of her weapons. When silly humans poke into areas they don’t normally invade, the local flora and fauna adapt, and their parasites do as well. Then, perhaps a new epidemic!

I don’t know what the next epidemic will be, but definitely there will be one. There always is.

So if there’s another plague coming, how do we prepare for it without a crystal ball? Well, the other option, I guess, is to look to the past to see what it tells us about the future. Learn from experience?

So let’s talk about how and why Ebola spread so rapidly the last time it broke out. It just so happens that the Washington Post recently put out an article on that very subject.[2] It seems that, according to the Post report, Ebola was spread mostly by a few people who just wouldn’t go to the hospital. “If super spreading had been completely controlled, almost two-thirds of the infections might have been prevented, scientists said.”[3] So problem solved! Just confine the people who have Ebola and you confine the disease!]

Ebola

Let’s back up for a minute. If you followed the outbreak of two years ago – I did – you were told at the time that there was no known cure for Ebola; only “palliative” care, if any, could be provided at local hospitals; the disease was spread by personal contact with Ebola victims; and that fatality rates were ranging from 53 to 64%[4]. So let’s say that you lived in one of the infected areas, and you developed symptoms. You had fever, vomiting, muscle pain and headache. Those are signs of Ebola for sure; but they’re also symptoms of malaria, and that also was prevalent in your area.[5] So which did you have?

Governments and doctors knew that the best way to contain Ebola was to isolate the people who had it. The problem was there was no easy way to tell Ebola from malaria, until Ebola more fully presented itself. So why not err on the side of caution? Gather together everybody who might have Ebola and treat them as a group?  

The problem was that Ebola was very contagious; it spread mostly by personal contact with people who are infected; and it was difficult even for health care workers to avoid getting it in a hospital setting.  So if you took someone who had malaria and put him [or her] in with Ebola patients, the malaria sufferer could get Ebola as well. Also, two years ago there was no known cure for Ebola. The best the so-called treatment centers could do was offer “palliative” care, i.e., infusions of fluids, etc., to help sustain the patient until his or her immune system deployed against the disease. I don’t have any statistics, but my impression is that palliative treatment was more effective than expected, but wasn’t available everywhere.

This is not to criticize the brave people who fought Ebola in West Africa. They did the best they could with what they had, and the epidemic was contained. But even so why didn’t everybody cooperate with authorities in the crisis? Well, because there were major incentives to do the opposite.

This is the point of The Ebola suspect’s dilemma, the article we quote at the beginning of this piece. The argument is simple. Two years ago in West Africa:

  • If you had malaria, you had a 0.2% chance of dying from it at home, and no chance of dying from Ebola Virus Disease;
  • If you had undiagnosed malaria and you went to an Ebola Treatment Unit, you had a 16.1 % chance of catching Ebola and dying from it.[6]
  • If you had undiagnosed Ebola and stayed home you had a 70.8% chance of dying from it.
  • If you had Ebola and were treated at an Ebola Treatment Unit, you had a 64.3% chance of dying from Ebola.[7]

So think about it. What’s the rational thing to do? If a patient knows he [or she] has malaria, and not Ebola, he/she would be stupid to go to an Ebola Treatment Unit, even if the Government wanted that. There’s too high a risk that the patient will get and perish from Ebola, and malaria is not that hard to treat at home and survive.

In our example the patient doesn’t know his illness. Nobody, with or without Ebola has very good luck at the ETUs. If they don’t have Ebola they may catch it; and if they do have it, the ETUs aren’t very good at curing people. Why don’t they just rationalize; tell themselves they have malaria and stay away from the ETU?

There is a reason to do the other thing, but it’s altruistic, not practical. If Ebola is everywhere, and spreading rapidly, perhaps citizens with undiagnosed illness ought to isolate themselves from the community. Perhaps it’s better to check into an ETU, even a dangerous one, rather than risk spreading a virulent disease. I’m not sure how many folks accepted this notion in West Africa, but altruism was on display during the Ebola crisis. Think of the health care workers, for example, who worked the front lines of the epidemic and died on the job. No doubt there were lots of other people like that who we didn’t hear about.

Nevertheless, getting back to our authors and their quote, it’s not clear they accept altruism as socially useful. Is it simply a concept left over from “western philosophy,” and therefore to be discarded? Or are they saying we should avoid the need for self-sacrifice by doing more advanced planning? Or are they saying both things?

I would agree with the second point, but not the first. Health crises tend to expand from one place to others. It’s better to prepare now rather than wait for the crisis to come to us. And what about altruism? Well, sometimes we just have to do things for the greater good. Self-sacrifice is not immoral.

Vaccines

Since we’re talking about planning and looking to past experience to guide the future, let’s consider Ebola vaccines. There the news is pretty good. Currently there are at least 8 of them in clinical trials[8], with one granted Breakthrough Therapy Status by the FDA and PRIME status by the European Medicines Agency. Research is continuing to extend the immune response generated by all research approaches. The most recent information suggests that all of them should continue for now. “[I]t would be unwise to rely on a single vaccine candidate, and it is reassuring that the assessment of other potential vaccine strategies is ongoing.”[9]

So perhaps competent research, world-wide, really is a way to tackle potential epidemics. Did you expect me to say something else?

[1] See The Lancet, Comment, Richardson, et al., The Ebola Suspect’s Dilemma (March, 2017), available at http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30041-4/fulltext?elsca1=etoc (Cited hereafter as Dilemma at __).

[2] See The Washington Post, Sun, ‘Super spreaders’ were driving cause of 2014 Ebola epidemic, study finds (February 14, 2017) at p. A2.

[3] See Dilemma at e254.

[4] See, e.g., CDC, Morbidity and Mortality Weekly Report,  Ebola Viral Disease Outbreak — West Africa, 2014 (June 27, 2014), available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6325a4.htm “On March 21, 2014, the Guinea Ministry of Health reported the outbreak of an illness characterized by fever, severe diarrhea, vomiting, and a high case-fatality rate (59%) among 49 persons (1). Specimens from 15 of 20 persons tested at Institute Pasteur in Lyon, France, were positive for an Ebola virus by polymerase chain reaction (2). Viral sequencing identified Ebola virus (species Zaïre ebolavirus), one of five viruses in the genus Ebolavirus, as the cause (2). Cases of Ebola viral disease (EVD) were initially reported in three southeastern districts (Gueckedou, Macenta, and Kissidougou) of Guinea and in the capital city of Conakry. By March 30, cases had been reported in Foya district in neighboring Liberia (1), and in May, the first cases identified in Sierra Leone were reported. As of June 18, the outbreak was the largest EVD outbreak ever documented, with a combined total of 528 cases (including laboratory-confirmed, probable, and suspected cases) and 337 deaths (case-fatality rate = 64%) reported in the three countries. The largest previous outbreak occurred in Uganda during 2000–2001, when 425 cases were reported with 224 deaths (case-fatality rate = 53%) (3). The current outbreak also represents the first outbreak of EVD in West Africa (a single case caused by Taï Forest virus was reported in Côte d’Ivoire in 1994 [3]) and marks the first time that Ebola virus transmission has been reported in a capital city.”

[5] See Dilemma at e254. “West Africa is the region with the world’s highest incidence of malaria.”

[6] Id. As the authors explain, that’s about a 25% chance of catching Ebola, adjusted by a 64.3% mortality rate. A disease caught at a hospital is called “nosocomial.” Write that down for future reference. No doubt you and I will need to know the word at some point.

[7] Id.

[8] See The Lancet, Comment, Snape, Persistence of immune responses induced by Ebola virus vaccines (March 2017)

http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30039-6/fulltext?elsca1=etoc  (Cited hereafter as Immune Response at __).

[9] See Immune Response at p. e239.

 

 

 

 

 

 

The vaccine, called rVSV-ZEBOV, was studied in a trial involving 11 841 people in Guinea during 2015. Among the 5837 people who received the vaccine, no Ebola cases were recorded 10 days or more after vaccination. In comparison, there were 23 cases 10 days or more after vaccination among those who did not receive the vaccine.

WHO[1]

[As the man says, recently there’s been good news and bad news about Ebola. You remember Ebola, don’t you? That’s the version of hemorrhagic fever that exploded in West Africa two years ago, and for a time pretty much terrorized the continent and, ultimately, much of the world. Ebola breaks out periodically, and we don’t seem to know where it hides between rampages. The most recent outbreak also was by far the largest; and survival rates vary widely, ranging from a low of just 10%, to a high – in the most recent outbreak – in the neighborhood of 50%. The “advantage” of a high death rate, if you want to call it an advantage, is that there are fewer survivors to care for, and less people who might carry residual amounts of the virus. More survivors may equal more potential medical problems down the road.

Sorry to be so callous, but there’s something about Ebola that makes me cold. It’s a truly a horrific disease, and two years ago we didn’t have much available in the way of medical care, other than to relieve symptoms and hope for the best. Nevertheless, last time the overall survival rate was close to 50 percent. “Sierra Leone’s survival rate is currently about 65 percent. Guinea’s hovers around 50 percent, and Liberia’s is around 40 percent[,]”according to one contemporary source.[2] Why the improvement over, say, 10 percent? Well, the thought is that the palliative care doctors could provide allowed many patients to survive long enough for their own immune systems to take over and repel the disease. Anyway, that’s what people today think might be the case.

With these survivors, of course, came a sheaf of new questions, the big one being: “Is he [or she] infectious, after recovery, and if so for how long? We didn’t really focus on this when we last discussed Ebola, mostly because we didn’t know much about survivors. Of course even then doctors thought survivors might be a problem; it was estimated, for example, that the virus could hide in a man’s seminal fluid for weeks after he recovered from Ebola.[3] Now the list of areas where the virus can hide is expanding. These include the eye, cerebrospinal fluid, the female breast, the urinary tract[4] and, most recently, the lower respiratory system.[5] That is, Ebola can hide in areas of the human lung.

That’s interesting because, as far as I know, the official US government position is that Ebola can’t be transmitted through the air.[6] However, once Ebola strikes, it can take up long-term residence in the human lungs? Without being detected, until now? So my question is, what happens if a person infected in the lungs coughs, spits, kisses another, or even breathes in a closed space? Are others in danger? Is it time to go back to the laboratory, perhaps, to look again at transmission?

OK, let’s move on to the better good news. Of course, it was good news that more people survived the last Ebola outbreak than is customary, but that good news also had negative consequences. The survivors need to be continuously monitored – in some cases, for an unknown period – to determine if they become infectious again. That’s bad news.

The better good news is that we – i.e., the world – seem to be making progress in developing an Ebola vaccine. That’s the point of the quote that introduces this piece. I first saw this good news in an article from the Ghana News Agency.[7] It said the vaccine, rVSV-ZEBOV, was studied by WHO [and others] in Ghana during 2015. A total of 11, 841 people were involved; of these, 5837 were vaccinated; and of that group, none of them were recorded as having Ebola “10 days or more” after vaccination. Of the group not vaccinated, “there were 23 cases [recorded] 10 days or more after [the] vaccination [date].”

The research team also found that, when people in a group were vaccinated, those around them tended to benefit also from so-called “herd immunity.” As people in a group are immunized to a disease, the remaining individuals also are less likely to catch it because, guess why? The potential sources of infection have been reduced.

According to WHO’s Assistant Director for Health Systems and Innovation, the study’s lead author, “[w]hile these compelling results come too late for those who lost their lives during West Africa’s Ebola epidemic, they show that when the next Ebola outbreak hits, we will not be defenceless.”[8]

This news definitely is good, but there’s still plenty of work to be done. For example, WHO is not really sure how the vaccine works. “It was not possible,” WHO says, “to collect biological samples from people who received the vaccine in order to analyse[9] their immune response. Other studies are looking at the immune response to the vaccine including one conducted in parallel to the ring trial among frontline Ebola workers in Guinea.”[10]

Fine, you might say, but answer one final question. What in the world is a “ring trial?” Well, that’s relatively simple. When an Ebola case presented itself, the researchers immediately tried to identify all people who had contact with the victim in the previous three weeks. These were a part of the victim’s “ring,” or cluster and were included in the study. WHO says that, all in all, “a total of 117 clusters … were identified, each made up of an average of 80 people.”[11]

Anyway, there’s a long road to follow before this vaccine, apparently the most promising of the current lot, is fully approved for use. Technically it’s not licensed, and normally this can take a long time. However the U.S. FDA and the European Medicines Agency have agreed to follow expedited procedures in this case.[12] Also the developer of the vaccine, Merck, has agreed to manufacture some 300,000 doses for emergency use, and to submit it for “licensure” by the end of 2017.[13] We’ll see how that works out.

All in all, we are much better off than we were back in 2015. Of course, there’s more than one type of Ebola, and a vaccine that works on one may not work as well on the others. Nevertheless, call me an optimist. The next time there’s an Ebola outbreak, most likely we won’t be defenseless. If that’s not good enough for you, support more research!

 


 

[1] See World Health Organization,  News Release (December 26, 2016), available at http://www.who.int/mediacentre/factsheets/fs103/en/

[2] See International Business Times, Ross, Ebola Survival Rates: Why Patients’ Outcomes Vary (10/21/14 ), available at http://www.ibtimes.com/ebola-survival-rates-why-patients-outcomes-vary-1708555

[3] See CDC, MMWR, Possible Sexual Transmission of Ebola Virus — Liberia, 2015 (May 08, 2015), available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6417a6.htm?s_cid=mm6417a6_w  “If male survivors have sex (oral, vaginal, or anal), a condom should be used correctly and consistently every time until further information is known. Used condoms should be handled and disposed of safely to avoid contact with semen. After handling of condoms, or following any physical contact with semen, skin should be washed thoroughly with soap and water.” See also New England Journal of Medicine, Mate et al., Molecular Evidence of Sexual Transmission of Ebola Virus (December 17, 2015 ), available at http://www.nejm.org/doi/full/10.1056/NEJMoa1509773?query=featured_ebola&#t=articleTop

[4] See CDC, Interim Guidance for Management of Survivors of Ebola Virus Disease in U.S. Healthcare Settings, available at https://www.cdc.gov/vhf/ebola/healthcare-us/evaluating-patients/guidance-for-management-of-survivors-ebola.html

[5] See FoxNews.com, Ebola can hide out and multiply in the lungs (January 6, 2017), available at http://www.foxnews.com/health/2017/01/06/ebola-can-hide-out-and-multiply-in-lungs.html “Ebola has been found lingering in patients’ semen and breast milk several days after conventional tests can detect it in blood. But now, scientists have confirmed another likely haven for the virus, which ravaged West Africa and killed more than 10,000 people during the 2013-2016 outbreaks: the lungs.” See also WebMD, Dotinga, Ebola Can Linger in Lungs, Study Finds (Jan. 5, 2017), available at http://www.webmd.com/news/20170105/ebola-can-linger-in-lungs-study-finds

[6] See CDC, Ebola, Transmission, available at https://www.cdc.gov/vhf/ebola/transmission/

[7] See Ghana News Agency, Awumah, Experimental Ebola vaccine trial shows positive prospects (Jan. 6, 2017)     available at http://www.ghananewsagency.org/print/112001

[8] A note to Microsoft: “defenceless” is not a misprint; it’s the British spelling. Over here we would say, “defenseless.”

[9] Another British spelling.

[10] See World Health Organization,  News Release (December 26, 2016), available at http://www.who.int/mediacentre/factsheets/fs103/en/

[11] Id.

[12] Id. “The vaccine’s manufacturer, Merck, Sharpe & Dohme, this year received Breakthrough Therapy Designation from the United States Food and Drug Administration and PRIME status from the European Medicines Agency, enabling faster regulatory review of the vaccine once it is submitted.”

[13] Id.