Micrograph of Marburgvirus (credit: The University of Texas Medical Branch at Galveston)
Last month, the Ugandan Ministry of Health (MOH) declared an outbreak of Marburg Virus Disease (MVD) in Eastern Uganda. To date, three cases have been reported (two confirmed, one probable), and all have died, resulting in a case-fatality rate of 100% for the outbreak. News of the outbreak led many to wonder: what is Marburg?
In a sense, Marburg is Ebola’s sister. More accurately, Marburgvirus is member of Filoviridae, a family of viruses that includes Ebolavirus, meaning they are similar in their structural and genetic makeup. They both cause severe hemorrhagic fever in humans and other non-human primates, and both have very high case-fatality rates. The endemic zones for the two viruses overlap a great deal, as they are both found in Central Africa. Scientists have long suspected that bats are somehow connected with the transmission of Ebolavirus to humans, while with Marburg, the association is known.
Marburgvirus was discovered in 1967, as a result of two simultaneous outbreaks in Germany and in Serbia; the disease is named for a town north of Frankfurt. (Note: the first Ebola outbreak in 1976 was actually two simultaneous outbreaks as well, though much closer together geographically, such that they were determined not be the same outbreak until several years later.) The German and Serbian outbreaks were similar in that they both involved laboratory workers that had become exposed to the virus after handling African green monkeys that had been imported from the same source in Uganda.[i]
Historically, MVD outbreaks have been fewer than those of Ebola – the CDC recognizes twelve, not including the current outbreak. Similar to the current outbreak, MVD outbreaks tend to be small, with respect to the number of fatalities. Twice, however, MVD outbreaks have been large: 128 died in northeastern Democratic Republic of Congo between 1998-2000, less than 100 miles from the Ugandan border; later, in 2004-2005, 227 died during and outbreak in Angola. The majority of outbreaks have taken place in or stemmed from Uganda or neighboring Kenya; the Angola outbreak and a small outbreak originating in Zimbabwe are outliers.
So, should we be fearful of a large-scale outbreak of Marburg, similar to what we saw in 2014-2016 in West Africa? No… but perhaps yes.
Marburg outbreaks, like Ebola, tend to emerge suddenly. But the mysterious nature of Ebola—its unclear linkage with its not-yet-fully-understood viral reservoir—is a characteristic not shared with its sister, Marburg. As such, health authorities within the Marburg endemic zone, such as in Uganda and Kenya, are able to respond to outbreaks somewhat effectively, using contact tracing to determine the source of the disease. In most cases tends to be a cave where bats roost, where a hiker has unwittingly wandered in and exposed themselves, or where bats have been collected for laboratory use. The regional expertise, public health infrastructure, and the developed understanding of Marburg make outbreaks within its endemic zone more capably dealt with.
However, as we hopefully learned from the West African Ebola outbreak, we should know that, like Ebola, Marburg may emerge outside of its endemic zone, and in places with weak public health infrastructures, microscopic doctor-to-patient ratios, and inexperience with diagnosing the disease. Marburg may be less temperamental or volatile than her sister, but that doesn’t mean we should treat her with kid gloves. She deserves as much attention and respect as her sister.
[i] Siegert R. Marburg Virus. In. Virology. New York: Springer-Verlag; 1972; pp. 98-153.
This World AIDS Day the world is facing perhaps the most complex political and epidemiologic environment in the history of the global AIDS pandemic. To tackle this environment we need an equally sophisticated response that builds new evidence for what’s really working at a macro level, refuses to accept the current funding realities, and mobilizes human rights frameworks in powerful new ways to advance the fight against HIV.
The good news of the moment is that the new UNAIDS report shows that the pace of HIV treatment scale up has increased for the third year in a row—with a net of 2.7 million new people added to treatment and a total of 20.9 million accessing treatment. This reflects shifts in HIV policies across the world toward treatment for all without requiring people living with HIV to wait to reach a certain CD4 level (damage to the immune system) before starting. The more troubling news is that HIV funding is deeply in peril. For the second year in a row the Kaiser Family Foundation found that international aid funding to fight HIV declined—by US$511 million from US$7.5 billion to US$7 billion. While national governments in countries with high HIV burden are increasing their funding to fight AIDS, the pull back in donor funds threatens scale up across the board.
This is an especially perilous moment in the history of the epidemic because things are going right on many fronts—but progress could not be more fragile and the relative success in some areas means that reaching the rest gets harder not easier. For example in many of the countries with the highest rates of HIV in the world a significant portion of people living with HIV know their status. On average in East and Southern Africa UNAIDS reports that 76% of people know their status and in South Africa the estimate is 86%. While this is a huge success, these countries continue to have large numbers of new HIV transmissions. This is in part because many who know their status are not on effective HIV treatment to halt transmission and HIV-negative people have limited access to proven HIV prevention technologies. But it is also likely that many of those who do not know their status—the 25% who are hardest to reach—are among those having sex and experiencing HIV transmission. Younger people in their 20s, for example, are among the most sexually active populations yet have far lower knowledge of their status while key populations such as men who have sex with men are less likely to know their status and successfully suppress the virus than their peers in many countries. So we have to start thinking differently and acting on the epidemic we face in 2018 not the one we faced a decade ago.
We need, in 2018, to be far more serious and precise about the impact of international efforts to fight HIV and the intersection of aid dollars and the national health system. Here at Georgetown’s O’Neill Institute we recently launched a new project with South African researchers to look at exactly how donor funded efforts are augmenting the national response at front-line facilities. We hope to start understanding a bit better how policies set at the highest levels, specifically regarding which funding source will support which services, play out by the time those policies trickle down to what people in health facilities experience.If we are serious about achieving global goals on HIV there is no alternative to increasing the efficacy and impact of these funds. Ours is a small contribution to the broader agenda that PEPFAR, the Global Fund, the World Bank, and other HIV financing agencies need to address head on—in an era of still growing needs, how can international funds build synergies in practice, not just in theory, with clear and identifiable benefit for communities affected by HIV?
Even if we succeed in increasing the efficacy of the funding we have there is no way out of the reality that more funds are needed. Recent data have shown, for example, that in the places where funding has been sufficient we have achieved key milestones against HIV. Where it’s not, we are failing. East and Southern Africa, for example, has seen ambitious levels of funding including from international sources like PEPFAR and Global Fund that are driving powerful results—like the recent evidence from the PHIA studies showing remarkable progress toward “epidemic control” in key countries. These striking results mean that HIV could move from a crisis to a manageable epidemic in these countries, but only if resources are sufficient to take scale up through to success. This it stands in stark contrast to West and Central Africa where funding has lagged far behind and, as a result, the region has just 35% of PLHIV on treatment and just 25% of all PLHIV achieving viral suppression.
We have to be serious about where the challenges are. A spate of good news in select East and Southern African countries is showing what’s possible. But over-emphasis on some leading countries—where it must be noted far more work is still required to turn possibility into reality—could blind us to the broader needs. The recent PEFPAR strategy is just one example—setting out what are notably ambitious goals for 13 key countries. But with neither PEPFAR nor Global Fund sufficiently financed for the task at hand, neither has a strategy to address the broader context in which the country facing the largest number of new HIV infections, South Africa (not one of the 13), is not on track to reach “epidemic control” as originally planned, countries in the region like Angola and Mozambique are further from success, and epidemics in West Africa led by those in Nigeria and Cameroon are not being met with anywhere near the level of effective response as in the South. Diagnosing the problem correctly has to be part of the solution in a pandemic that follows trade routes not national borders.
Finally, we need to start treating human rights as a truly integral part of the strategy to attack the HIV pandemic. My research has shown that countries that protect a constitutional right to health perform better on key health indicators—and HIV is a key part of that story. Where rights are well enshrined and, most importantly, where rights-supporting organizations like Section 27 in South Africa, Kelin in Kenya, CEHURD in Uganda, and many more are well funded, there is a real opportunity. In these contexts, policy actors seeking to advance access and equity are better able to break into closed bureaucratic policy cycles and force issues ranging from how budgets are spent to which drugs are available to whom into the open. It holds the potential to make HIV and health policy better than it would otherwise be at tackling real life challenges. The most recent UNAIDS report focused in on the Right to Health and with good reason. In 2018, Human Rights have to move beyond first generation rights and the important role they have played in protecting people living with HIV from discrimination and avarice and take the rights of access to scale—in the court rooms, but most importantly outside in all the venues where policy is made.
All of this comes at a time of rising global populism and weakened international institutions. Yet time and time again the global AIDS response has overcome seemingly intractable contexts—breaking the power of multinational pharmaceutical companies to set high prices and expanding financing for scale up through the global financial crisis are just two examples. The coming years, though, are likely to dictate the course of the epidemic—we can miss this opportunity because it is too complex for easy slogans or we can be real about the challenge and use all the tools of 2018 to halt HIV.
Matthew Kavanagh, PhD is visiting professor at Georgetown University and director of the Global Health Policy and Governance Initiative at the O’Neill Institute.
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We are all well aware of the many attempts made by Congressional Republicans to repeal and replace the Affordable Care Act. It consumed Congress’ time and focus for months, and ultimately fizzled with unsuccessful votes to change the law.
While Republicans were busy trying to take away health insurance from millions of Americans and make it virtually impossible for my child or anyone else with a pre-existing condition to be able to get health insurance, they also neglected many of their pertinent responsibilities, like ensuring that the Children Health Insurance Program (CHIP) continued to be funded. Republicans, who control both houses of Congress, missed the September 30th deadline to keep funding the program, which ensures nearly 9 million American children and 370,000 pregnant women through both Medicaid and separate, state-administered programs. Children depend on adults to act like…well, ADULTS, and make decisions and take actions needed to ensure their safety and well-being. Congressional Republicans have instead thrown a temper tantrum that rivals the antics of the most sugar-infused 2 year old, and could potentially leave our nation’s most vulnerable citizens with no health protection.
Now, without knowing if or when they will receive their federal funding allocations, most states are faced with the possibility of running out of funds to continue their CHIP programs after the new year. Some states, such as Virginia, plan to notify enrollees on December 1st that the program could end when funds are exhausted by late January 2018.
Congress has done little to secure funding for the program. In late October, House Republicans passed a funding extension bill for CHIP that took funds from existing ACA programs in an attempt to undermine their archnemesis, Obamacare. House Democrats resoundingly panned the bill, and the Senate has been too preoccupied with finding tax cuts for the wealthy, so they have ignored CHIP completely and not taken any action.
We elect our political leaders to lead. We send them to Washington, DC to make decisions in the best interest of their constituents. That is not what is currently taking place in Congress. Hubris and personal agendas are the ruling mindsets, and no substantive progress is being made. The citizenry, rather than being the priority, are now collateral damage from the ideological differences and power jockeying taking place a few blocks away on The Hill. Our leaders are not leading. They are not doing their jobs. They are failing us. There was once a time when children would not be used as political pawns, and all could agree to preserve their best interests. Clearly, we are not in those times, and the current leadership cannot seem to get over their personal interests for the sake of protecting the interest of children. If that does not show us, the voting public, that changes need to be made, I am not sure what else will.
As the former director of the White House Office of National AIDS Policy where I helped launch the first comprehensive National HIV/AIDS Strategy to combat the domestic HIV epidemic, I’m often invited to give talks to a variety of groups. I primarily address issues related to the domestic landscape of HIV and I do that with the backdrop of having lived through the rough times of the early AIDS epidemic — a horrible past that has certainly given me a sense of perspective.
Since the 2016 election, we are once again confronted with a turbulent political environment where access to health care and efforts to address health equity are in flux. HIV programs are on the chopping block, and many are questioning whether their elected officials care about them. Rough times may be back. But this time, we’re better equipped than we were in the early years of the epidemic and that is now reflected in my talks.
I am a policy wonk at heart and can talk endlessly about Medicaid policy and how to make the health system work for low-income people, but now I find myself giving talks that might be more akin to what you’d hear on the inspirational talk circuit. That’s not by accident – I am naturally a ‘glass half full’ person. But, there is also much to be positive about.
I recently gave a short talk at a luncheon plenary sponsored by NMAC and Gilead Sciences at the United States Conference on AIDS, the largest annual conference for frontline community-based HIV services providers, which I’d like to encourage you to watch. I think it’s the right message for right now. It reminds us to reflect on how far we have come and aims to bolster us in our collective efforts to support our communities.
World AIDS Day is on Friday, December 1. Indeed, it feels a bit different this year and it should. While many of us are acutely experiencing the pain and are fearful of the difficult political environment that confronts us, there is huge positive progress to be celebrated. Recognizing the storms we have weathered in the past, let’s reimagine our path to ending the HIV epidemic. Let that be a reason for feeling different this year on World AIDS Day.
Jeffrey S. Crowley is a Distinguished Scholar and Program Director of Infectious Disease Initiatives at the O’Neill Institute for National and Global Health Law. From 2009 to 2011, he served as Director of the White House Office of National AIDS Policy. Crowley is also a Returned Peace Corps Volunteer having served in the Kingdom of Swaziland from 1989 to 1991.
A colleague recently observed that we are addressing one of the most ancient diseases with approaches nearly as ancient, including over-hospitalization, use of involuntary isolation and in some countries, use of discriminatory and punitive laws which violate human rights and impede the fight against TB. Draconian laws are not the only archaic aspect of the response to TB; we are still largely fighting TB with outdated tools and medicines even though there are better, more effective ones that have been developed.
By way of background, Mycobacterium tuberculosis, the bacteria that causes TB, has plagued humanity since antiquity. TB was present in the Neolithic period (5800 BCE) and in ancient Egypt—fragments of mummies from 2400 BCE have shown signs of tuberculosis. Often a killer of characters in historical novels and films, tuberculosis, also referred to as ‘consumption,’ or ‘phthisis’ in past eras, may have killed more people than any other microbial pathogen in human history. The development of TB chemotherapy in the 1940s and 50s was significant, since for the first time TB could be effectively treated, although these medicines included major side effects including killing outer and inner hair cells which can result in hearing loss.
While many countries, particularly higher income countries, were able to significantly reduce TB incident rates by the 1980s, the AIDS epidemic has been a significant contributor to the large increase in incidents and high TB mortality that we see today. This is especially the case in developing countries who have been disproportionately impacted by HIV, particularly in contexts in which there are serious health system challenges and weaknesses.
Today, we are still largely fighting this ancient disease with older diagnostic tools and medicines; the better and more effective medicines are generally unavailable to those who need them. In fact, only 5% of people in need of newer, more effective TB medicines for drug-resistant strains have access to them. This means that people have no choice but to take older, more toxic drugs which cause deafness and psychosis and only cure 50% of people who take them. With regard to diagnostics, sputum smear microscopy is still the most common diagnostic method which only tests for pulmonary TB (not extra-pulmonary), is difficult for children to produce and does not have sufficient specificity. An additional challenge, People Living with HIV often have false negatives in TB tests because they have lower bacteria count than HIV-negative people who have TB (including microscopy and to some extent also in some nucleic acid amplification tests).
photo: MIT Review
While more rapid diagnostic tools and tools that better address gaps have been developed, such as the GeneXpert and LAM test (especially important for TB testing for People Living with HIV with low CD4 counts) these tools are not widely available in many countries and also have diagnostic deficiencies. For example, GeneXpert produces errors when exposed to dust and LAM has very low sensitivity. A significant development, the GeneXpert Ultra (next generation of GeneXpert) has improved sensitivity in TB detection for People Living with HIV and children and was endorsed by WHO in March 2017. This will be a game changer for those who have access to the tool.
In addition to the use of outdated diagnostics and medicines, in some countries public health laws, criminal laws, and treatment protocols are similarly outdated, and lack a human rights-based, participatory and patient-centered approach. For example, several countries have public health or other laws which criminalise or broadly allow for isolation, detention and quarantine in the context of infectious diseases including TB. Criminal laws may be for ‘exposure’ or similar offenses. In extreme cases, patients have been imprisoned for inability to adhere to TB treatment. Even when not TB-specific, such provisions may confer wide legal authority on health workers to involuntarily detain TB patients for long periods. Even when not enforced, provisions of this nature further stigmatise people with TB and tend to have the effect of driving people with TB and key populations underground and away from health facilities.
While there is reasonable concern over the spread of TB, particularly drug-resistant strains, ensuring meaningful access to TB prevention, diagnostics (including for drug resistance), treatment, care and support is the most effective and appropriate approach to stem the spread. Notably, once a patient is on effective treatment for two to three weeks they are typically not contagious. In general and especially in light of this, use of involuntary isolation and coercive treatment raises serious ethical and human rights issues, particularly in contexts in which there is inadequate access to drug resistance testing. For example, some countries have laws which allow for mandatory testing, treatment, hospitalisation and isolation; yet at the same time do not provide comprehensive access to rapid and effective drug-resistance testing or effective medicines for MDR-TB. Improving access to effective and quality community-based treatment, care and support and moving away from coercive and punitive approaches to TB are essential steps to modernise TB care, safeguard medical ethics and human rights, and most certainly to end TB by 2030.
photo: Biospectrum Asia
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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.