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Vol. LXVI, No. 23
November 7, 2014
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Week of Drama
NIH’s First Ebola Patient Recovers, Visits White House

On the front page...

Recovered Ebola patient Nina Pham is led out of the Clinical Center by NIH director Dr. Francis Collins (l) and NIAID director Dr. Anthony Fauci.
Recovered Ebola patient Nina Pham is led out of the Clinical Center by NIH director Dr. Francis Collins (l) and NIAID director Dr. Anthony Fauci.
In the 8 days between the arrival of NIH’s first confirmed Ebola patient—nurse Nina Pham—and her subsequent release, virus-free, from the Clinical Center on Oct. 24, the campus became a magnet for national media attention and a fevered crucible of self-evaluation: could NIH deal successfully with both a challenging medical case and a workforce worried about exposure to a deadly virus?

Between two mid-autumn Fridays, the campus went from apprehension to jubilation as Pham, 26, stepped to the microphone at a press conference in front of Bldg. 10 to announce, “I feel fortunate and blessed to be standing here today. I would first and foremost like to thank God, my family and my friends…Throughout this ordeal, I put my trust in God and my medical team.”

Continued...

Before Pham—who was joined by her caregivers, her mother Diana and her sister Cathy—spoke, NIAID director Dr. Anthony Fauci declared her virus-free on the strength of 5 negative PCR (polymerase chain reaction) tests. “What a great pleasure and privilege it is for me and the staff here, to have the opportunity to treat and care for—and to get to know—such an extraordinarily courageous and lovely person,” said Fauci.

In honor of Pham’s nursing alma mater, Texas Christian University, Fauci wore on his lab coat ribbons with the TCU colors. He predicted for her “a normal, healthy, happy life,” once the fatigue of dealing with Ebola infection subsides.

“I am now on my way back to recovery,” said Pham, “even as I reflect on many others who have not been so fortunate.” She especially thanked recovered Ebola victim Dr. Kent Brantly, from whom she had received a transfusion of plasma. It is believed, but not proven, that antibodies circulating in those who have recovered from Ebola offer protection to patients with a current infection.

“I believe in the power of prayer,” Pham continued, “because so many people all over the world have been praying for me.”

Pham, flanked by her sister Cathy (l) and mother Diana (r) accepts a round of applause from CC director Dr. John Gallin (l) and NIAID clinical director Dr. H. Clifford Lane (r). Fauci leads a Special Grand Rounds session on the “perfect storm” of Ebola in West Africa.

Pham, flanked by her sister Cathy (l) and mother Diana (r) accepts a round of applause from CC director Dr. John Gallin (l) and NIAID clinical director Dr. H. Clifford Lane (r).

Fauci leads a Special Grand Rounds session on the “perfect storm” of Ebola in West Africa.

NIH director Dr. Francis Collins opened the impromptu press conference, calling it “a special moment in the life of this remarkable institution. We like to call ourselves ‘the National Institutes of Hope.’ Hope just went up a notch today.”

Gallin holds up an Ebola fact sheet at an employee all-hands session on Oct. 17 in Masur Auditorium.

Gallin holds up an Ebola fact sheet at an employee all-hands session on Oct. 17 in Masur Auditorium.

Answering media questions, Fauci reiterated, “She is cured of Ebola, that’s for sure. She will get full strength back—she’s such an incredible lady—and she’ll do it quickly.”

Asked how Pham communicated with family and caregivers during her ordeal in isolation, Fauci enumerated ways including the iPhone FaceTime video application: “She taught me how to use it,” he quipped.

As the 20-minute press conference wrapped up on a blustery noontime, someone asked if Fauci would miss Pham. Returning to the mic he had just left, Fauci declared, “I’m gonna miss her a lot. I gave her my cell phone number, just in case I get lonely.”

Someone in the crowd shouted, “We love you Nina!” and the conference ended in applause as Pham headed to the White House for a meeting with the President before going home to Texas.

But that’s not how the week had begun.

Helicopters Herald Drama
Lane (l) and Fauci (c) are joined by NIAID’s Dr. Richard Davey (r), who runs the hospital’s special clinical studies unit.

Lane (l) and Fauci (c) are joined by NIAID’s Dr. Richard Davey (r), who runs the hospital’s special clinical studies unit.

Photos: Bill Branson, Ernie Branson

The news helicopters that hovered over campus on the afternoon of Oct. 16, when word of Pham’s impending arrival became public, offered a hint of things to come. The following morning, a convoy of satellite trucks queued up along Center Dr. in front of the Clinical Center, where the first of the week’s two outdoor news conferences was hastily arranged.

Having been up all night caring for Pham, who became the first resident of the CC’s special clinical studies unit (SCSU), Fauci spent a half hour answering questions from TV news reporters before going inside to the medical board room to brief print media on how NIH would handle its first Ebola patient. That same day, NIH staff packed Masur Auditorium, Lipsett Amphitheater and overflow rooms for two all-hands information sessions. The crowds returned to the same locales on Oct. 22 for a Special Grand Rounds session on Ebola.

Accompanying Fauci at the press events, and at the all-hands sessions for CC employees, were Dr. Richard Davey of NIAID, who runs the SCSU, NIAID clinical director Dr. H. Clifford Lane and CC director Dr. John Gallin, who explained to the media the special nature of “the world’s largest hospital dedicated to biomedical research.” Also on hand for the employee sessions was Dr. Tara Palmore of the CC’s hospital epidemiology service, who explained the rigors involved in safely caring for an Ebola patient.

At the All-Hands Session

“The Clinical Center has always been a place that has responded to public health emergencies,” said Gallin, at the second of two all-hands sessions to share facts and dispel rumors among Bldg. 10 employees. He remembered when the hospital accepted its first AIDS patients more than 30 years ago, adding, “Now we have another challenge with Ebola…Hopefully, when we’re done, you’ll feel as comfortable [about safety precautions] as I feel.”

“I can’t tell you how very, very proud I am of this institution, which once again has risen to the occasion,” said Fauci. He reminded the audience that, 33 years ago, when the CC first hosted AIDS patients, people crossed the hall to avoid him and wouldn’t ride the elevator with patients infected with HIV.

Davey explained that the SCSU, located on the fifth floor of the Clinical Research Center, opened in 2011 as part of a biodefense initiative, in order to respond to the possibility of a worker at Ft. Detrick becoming infected at its BSL-4 laboratory. The unit got its first test in September, when a physician suspected of having Ebola was admitted to the SCSU. The patient did not have Ebola, but the unit passed with flying colors.
NCI’s Dr. Wyndham Wilson asks a question at the all-hands session Oct. 17.

NCI’s Dr. Wyndham Wilson asks a question at the all-hands session Oct. 17.

“We were thoroughly convinced that the policies at the highest levels of safe containment were effective,” said Davey, who said a cast of dozens “all pulled together in an amazing way. I can’t compliment them enough. The esprit was overwhelming. Our infection control measures exceed the guidelines and have been thoroughly tested.”

NIAID’s Lane emphasized that patient care comes first with CC patients, but a research component is also essential—what did we learn scientifically to improve future care?

“This is our first opportunity to study a patient with Ebola,” he said. “There’s an enormous amount we think we’ll be able to learn with one patient…Even though this is a tiny percent of what’s going on in West Africa, it could extend the benefits of our research there.”

Lane said NIH is “fairly optimistic we can develop a vaccine” against Ebola, and mentioned two candidates, both in phase 1 trials. “Our hope is that we can rapidly extend phase 2 and 3 trials to Liberia…This patient [Pham] is part of a substantial research program.”

Palmore reviewed extensive SCSU safety protocols, insisting repeatedly that the disease can only be acquired through direct contact with the body fluids of an infected person, or a deceased Ebola victim.

“There is no airborne transmission,” she emphasized. Palmore is the coauthor, along with CC deputy director for clinical care Dr. David Henderson, of a 12-page white paper—Ebola Virus Disease Information for NIH Clinical Center Staff—that was made available to everyone in the hospital, and online. Gallin noted that all CC inpatients had received a letter, in both Spanish and English, the night before Pham arrived, assuring that patient safety is paramount.

“Our redundancies and strict procedures help protect staff from exposures, and everyone else, too,” Palmore said.
Portion of the media presence at the CC. Dr. Tara Palmore and Gallin handle questions from the audience.

Portion of the media presence at the CC.

Dr. Tara Palmore and Gallin handle questions from the audience.

During an extensive Q&A session moderated by Gallin, at least one attendee was not sure that NIH is doing enough to protect health care workers and other patients. Dr. Wyndham Wilson, head of NCI’s lymphoma therapeutics section, argued that NIH’s Ebola precautions should exactly match those of Médecins Sans Frontières (MSF, Doctors Without Borders), a group that has been successfully dealing with Ebola in Africa for more than 30 years.

Palmore explained that the extra step MSF takes in Africa—involving hosing down health care workers as they doff personal protective equipment—is practical only in outdoor facilities and would not work indoors. She is confident that NIH’s protective measures, which match those at Emory University, Rocky Mountain Laboratories (St. Patrick’s Hospital, Missoula, Mont.) and the University of Nebraska, are more than adequate.

Asked why Pham had been transported from Texas to the CC, Fauci offered several reasons: NIH has a special unit built for this kind of crisis and trained staff. Plus, “We are a biomedical research institution. Very little research has been done on these patients due to the cataclysmal nature of treating them. We have almost a moral responsibility to step to the plate on this.” He also said the Texas hospital needed room in case any other people fell ill after contact with Thomas Eric Duncan, the patient who infected Pham.

At Special Grand Rounds

The crowds that had attended the two all-hands sessions on Oct. 17 were back on Oct. 22, filling not only Masur and Lipsett but also the FAES classrooms in Bldg. 10, for Fauci’s description of “a perfect storm” of Ebola in West Africa, which is by far the largest of 24 Ebola outbreaks since 1976. Indeed, it is many times larger than all previous outbreaks combined, he said.

Fauci also lamented a perfect storm of media miscommunication on the disease, pausing often to disentangle multiple public misperceptions.

NIH director Dr. Francis Collins opened Special Grand Rounds by saying, “I have never been prouder of this institution than during this international crisis.”

Ebola is a filovirus, meaning it has filaments. “It’s a scary looking virus,” Fauci noted. It is the Zaire strain of Ebola, historically the most virulent, that is causing havoc in West Africa, he said.
Reporters and camera crews crowd the front of Bldg. 10 on Oct. 24, the day Pham was released, virus-free, from the hospital.

Reporters and camera crews crowd the front of Bldg. 10 on Oct. 24, the day Pham was released, virus-free, from the hospital.

Ebola infection is virtually indistinguishable from flu at the outset, but within days can proceed to vomiting and diarrhea on the order of 5 liters per day, causing massive dehydration.

The current outbreak, traceable to last December, but more fulminant in March 2014, is complicated by a number of factors, said Fauci. These include extensive family relations in that part of the world, general poverty, porous borders between nations and poor health care.

The power of NIH sequencing technology has been brought to bear on 99 Ebola virus sequences taken from 78 patients, Fauci said. While the virus does appear to be undergoing many mutations, none have yet occurred in its functional domain; it is still transmissible only by direct contact, not by any airborne route.

More than 3,000 U.S. troops have been commitcommitted to Ebola response, Fauci said. There are 17 100-bed hospitals under construction, “but that may not be enough.” There is also a 25-bed unit set aside for health care workers.

About 50 people arrive daily in the U.S. from countries affected by Ebola, but all are screened both on exit from Africa and entry to the U.S. Fauci said a study of some 36,000 travelers from Africa to the U.S. during August and September turned up 77 individuals with fever, but all had malaria, not Ebola.
Pham reads from a prepared statement on the day of her release. She took no questions from the media at the session. Fauci prepares to hug Pham as she heads to the lectern to speak to the media.

Pham reads from a prepared statement on the day of her release. She took no questions from the media at the session.

Fauci prepares to hug Pham as she heads to the lectern to speak to the media.

He emphasized that when a health care worker such as Pham—“an extraordinarily charming lady, brave and courageous”—becomes infected, that is not an outbreak, but a misfortune.

The audience was riveted by Dr. Daniel Chertow’s account of a volunteer stint at an MSF field hospital in Monrovia, Liberia. The assistant clinical investigator in the CC’s critical care medicine department began with a brief video made by National Geographic on-site at the hospital; though mired in a difficult setting, Chertow exhibited exhilarating satisfaction of a kind that travel ads for places like Jamaica and Hawaii could only dream of evoking.
Dr. Daniel Chertow of the CC’s critical care medicine department volunteered to care for Ebola patients in Liberia.

Dr. Daniel Chertow of the CC’s critical care medicine department volunteered to care for Ebola patients in Liberia.

He took care of more than 200 patients during his stay, about 40 percent of whom survived. “We need to reduce the stigma associated with this disease,” he emphasized. Even when patients go home disease-free, they are still often shunned in their families and communities, Chertow reported.

The session ended with a discussion of ethical issues raised by the Ebola crisis, led by CC bioethicist Dr. David Wendler, who urged that the global public health community take lessons from West Africa for consideration during non-crisis times. He also pointed out that more than 2 million people in sub-Saharan Africa die of diarrheal diseases unrelated to Ebola each year. “Ebola is not the only culprit,” he said.

During a Q&A session, Fauci was asked about news reports of a dog in Spain that had been euthanized after contact with a suspected case of Ebola. “Dogs can become antibody-positive for Ebola, but don’t get sick and die,” he said. “It’s theoretically possible that a dog could transmit Ebola to a person, but there is no evidence of that so far.”

He added, “Nina’s dog is Bentley, and no one’s gonna kill Bentley.”

At the end of her prepared remarks on Oct. 24, Pham asked for privacy as she goes home to her career in Texas, where “I am going to reunite with my dog Bentley.”


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