United Kingdom - Scottish nurse treated for Ebola 'complication' - full recovery from Ebola , discharged

[Gert van der Hoek]

See also:
[h=2]NHS Scotland - Confirmed case of Ebola diagnosed in Glasgow - Nurse Pauline Cafferkey treated at Royal Free London hospital - free of the virus - discharged[/h]


A Scottish nurse who contracted Ebola in Sierra Leone has been readmitted to an isolation unit in London following an "unusual late complication".

NHS Greater Glasgow and Clyde confirmed that the virus is present in Pauline Cafferkey but said it was left over from the original infection.
It is not thought to be contagious.

The 39-year-old, from Cambuslang, South Lanarkshire, has been flown back the isolation unit at the Royal Free Hospital in London.
Ms Cafferkey spent almost a month in the unit at the beginning of the year after contracting the virus in December 2014.

MORE:

 

[Gert van der Hoek]

Ebola nurse Pauline Cafferkey 'in serious condition'

A Scottish nurse who contracted Ebola in Sierra Leone last year is in a "serious condition" after being readmitted to an isolation unit in London.

NHS Greater Glasgow and Clyde confirmed that the virus is still present in Pauline Cafferkey's body after being left over from the original infection.
She is not thought to be contagious.

The 39-year-old has been flown back to the isolation unit at the Royal Free Hospital in London.

Bodily tissues can harbour the Ebola infection months after the person appears to have fully recovered.

 

[FrenchieGirl]

Pauline Cafferkey case shows we still know little of Ebola's long-term effects

Last week the Scottish nurse Pauline Cafferkey was in celebratory mood as she met the prime minister?s wife, Samantha Cameron. She flew down to London after being selected for a Pride of Britain award by the Daily Mirror and joined other winners and families for a reception at No 10 Downing Street.

 

[FrenchieGirl]

Alarm over Ebola nurse's school visit: Parents express worry over victim's trip to primary only 24 hours before she suffered a relapse

Information extracted from the article:

Nurse Cafferkey visited pupils at Mossneuk Primary on Monday 5th October 2015 but she fell ill hours afterwards

Dr Ben Neuman, a lecturer in virology at the University of Reading, said:

... the chances of it [Ebola] being passed on to others were slim, but added:

...?It has never happened, but that doesn?t mean it can?t happen. Eventually, ideally, you would want to see anybody coming into contact with an ebola survivor, like pupils at Mossneuk School, being vaccinated for ebola. It is not the kind of virus you mess around with.?...

...It was claimed she had come into close contact with eight to 12-year-olds, even letting them try on an ebola suit...

 

[alert]

The story that is being widely reported as above seems incredibly unlikely, and potentially disastrous. If this nurse has relapsed as reported almost a year after recovering, the response might indeed need to be the reaction above: vaccinating everyone who has come into contact with Ebola survivors. That might mean vaccinating the entire populations of Liberia, Sierra Leone, and Guinea, as well as many people in the United States, UK, Spain, etc. I'm not sure the world is ready to have to vaccinate that many people against Ebola, or for that matter, to quarantine all the Ebola survivors.

The fact that this might happen in the only Ebola case in Scotland, but in none of the thousands of cases in West Africa(the majority having an earlier onset date than her), seems odd.

Given that there are now thousands of Ebola survivors, and no previous reports like this have happened, I can think of several more likely scenarios than what the media is assuming has happened:

1. Something extraordinary and not directly Ebola related (perhaps a drug interaction from some medicine she was on to deal with post-Ebola syndrome?) suppressed her immune system and caused the virus to re-emerge into the bloodstream. Thus the reason we've never seen this before is because that extraordinary event has never happened to an Ebola survivor.

2. This is actually a new Ebola infection, unrelated to her previous one. The virus has been passaging H2H for the past year since she was infected, and it is conceivable to me that her previous infection might not protect her against currently circulating virus. She is continuing to campaign against the virus. Perhaps her last 21 days of exposure before taking ill should be investigated for links to recent Ebola cases, to animals, or to a laboratory.

3. This is an unrelated infection, causing Ebola-like symptoms only because of damage to her body from the Ebola infection. Thus the Ebola genetic material in her blood is a red herring caused by the first infection, and something else is making her ill.

4. This is merely a post-Ebola syndrome, caused by damage done during her acute Ebola infection, such as Dr. Spencer and many in West Africa suffered, and the media is misreporting her present illness.

I would like to see if any virus can be cultured from her current blood, and if so, whether it matches that of her previous illness, as well as also whether it is potentially infectious in, say, laboratory animals.

To me, this story seems unlikely to be correct as is being reported.

 

[alert]

VDU blog is reporting Tweets that show (via case #4 above):

http://virologydownunder.blogspot.com/

The complication may be meningitis caused by replicating virus in her CSF. That would be unlikely to be spread, as the virus would not be in her blood (nor would she have hemorrhagic symptoms).

(I am posting Ian's fulll blog here since he is giving quite a bit of background. FT has permission to copy his blogs in their entirety.)

[h=2]SATURDAY, 10 OCTOBER 2015[/h] [h=3]Is the next Ebola virus revelation...reactivating infection?[/h]

​

Great. Are members of the Zaire ebolavirus (EBOV) species the most educational viruses of modern times or what? I mean, we've "known" about EBOV since 1976, but the West Africa Ebola virus disease (EVD) epidemic is the epidemic that keeps on giving - we seem to learn a brand new thing every few months.

And the latest is a doozy although we don't know many of the details yet.

So what do we know about this new finding of a seeming return of infection in a former EVD case? Or is this new disease because of damage from the old infection?

1. A 39 year old nurse, PC, was originally infected with EBOV while working for 3 weeks in the Save the Children?s Kerry Town Treatment Centre in Sierra Leone. She did not show signs of illness until after arriving home in Scotland [1]
2. PC was believed to have become infected while treating EVD patients in some way related to her use of a visor as part of her personal protective equipment, rather than goggles, [10]
3. PC entered a Gartnavel Hospital isolation unit on 29-DEC-2014, and was subsequently flown to the Royal Free Hospital (RFH) in Hampstead, North London on 30-DEC-2015. She stayed there for around a month [2,4]
4. During her time in the RFH, PC was treated with convalescent blood plasma and an experimental antiviral drug
5. PC was declared free of EBOV in January 2015 but continued to report thyroid problems afterwards as she described just a week ago [3,4]
6. On Tuesday 06-OCT-2015, PC was admitted to the Queen Elizabeth University Hospital (QEUH) in Glasgow, Scotland after feeling ill. She was then readmitted to the RFH, 06-OCT-2015, 9 months and 7 days after being declared free of Ebola virus.
7. She is described as being in serious condition. However, it is unclear what her signs and symptoms were at presentation, or have become since.[4]

Descriptions note that PC is "not thought to be contagious". Presumably this means she is not symptomatic with EVD and if so the testing that must have identified EBOV somewhere in her system must have does so from a part of her system that is not readily in contact with the environment. Nonetheless, she is once again isolated at one of the world's best infectious diseases hospitals.[4]

There are also recent reports of PC having had thyroid problems after recovering-perhaps virus has been replicating in this tissue. PC's "condition is a complication of a previous infection with the Ebola virus".[4] Which leaves a lot of room for idle speculation but could just be that she is ill because of what the fallout from what EBOV previously did to a tissue/organ rather than because of EVD itself. Perhaps follicles in the scalp have been a site for virus replication, relating to her earlier hair loss. Another site may be the central nervous system...
All speculation. Again, nothing is known about PC's signs and symptoms of disease when she presented herself to the QEUH, what tissue(s) are involved in her current illness, which samples tested positive first and where the virus may have been replicating all this time. While we understand that some tissues are sites for EBOV persistence, there is clearly much more to learn about the frequency and full range of tissues that harbour infectious EBOV once it becomes undetectable in the blood.

Apart from how shocking and scary this must be for PC herself, another issue is how this will impact on the fragile processes of accepting of EVD survivors back into their West African communities. Extending the length of time that some male survivors are known to harbour EBOV already put pressure on their acceptance by some, but the potential for virus to return to the blood or other tissues - if indeed that is what has happened here - even after that time frame, will require a lot of communication to explain. It will be vitally important for this process that the facts underpinning what's happened here are deduced soon and communicated in ways that can be understood in West Africa. This is a chance for the World Health Organization to show off their shiny new intent to do better at communicating and reacting.

This is not the first time EBOV has been found to persist in a convalescent former EVD case.[5,6,7,8,9] But this may be the first documented time that the virus has re-emerged into the blood and caused symptoms in the same former EVD case (correct me if I'm wrong - are there other examples?).

Shingles has been thrown up today as an example of a similar disease that results from a virus recurring but it's not the same thing at all. Although, we don't know that with absolute certainty. The viruses are very different - that we know for certain. Varicella Zoster virus (VZV) is the herpesvirus that first causes chickenpox, usually in childhood,. Decades later after lying dormant and not exciting our immune system, VZV can reactivate to produce whole virus that results in shingles. As far as we know, EBOV does not go dormant, but remains active at some sites, like the testes and the eyeball,[5,7] where our immune system is programmed not to venture in full force, so as to protect those sites from unwanted inflammation (in a nutshell).

Hopefully, some key information will be made clear soon (as opposed to in the scientific literature weeks or months from now) as it will be vitally important for the continued management and support of EVD survivors in West Africa. It is also important knowledge for communicating real risks, and informing and toning down perceived but unrealistic ones. What falls into which category is however becoming harder and harder to discern.

I'll update this blog post as more information comes to hand.

References...

1. http://www.bmj.com/content/350/bmj.h36.long
2. http://www.bbc.com/news/uk-scotland-30629397
3. http://www.independent.co.uk/news/u...issue-for-months-after-recovery-a6687571.html
4. http://www.bbc.com/news/uk-scotland-34483584
5. http://virologydownunder.blogspot.com.au/2015/08/post-ebola-syndrome-or-just-chronic.html
6. http://virologydownunder.blogspot.com.au/2015/05/ibola-and-speed-of-research-reporting.html
7. http://virologydownunder.blogspot.com.au/2014/08/ebola-virus-in-semen-is-real-deal.html
8. http://virologydownunder.blogspot.com.au/2015/03/liberia-enters-next-phase-of-ebola.html
9. http://virologydownunder.blogspot.com.au/2015/03/catching-ebola-mistakes-messages-and.html
10. http://www.theguardian.com/world/20...-pauline-cafferkey-royal-free-hospital-london

 

[Emily]

. As far as we know, EBOV does not go dormant, but remains active at some sites, like the testes and the eyeball,[5,7] where our immune system is programmed not to venture in full force, so as to protect those sites from unwanted inflammation (in a nutshell).

Herpes also seems to act as a chronic infection in the eye of some human hosts, so maybe not so different than ebola. MSF recommends using the better protection of goggles for good reason, I think.

http://iovs.arvojournals.org/article.aspx?articleid=2122099

Ocular herpes simplex
...
Study of patients
with recurrent herpetic keratitis has
shown persistence of virus in the tear film
and virus antigen within lacrimal gland
and conjunctiva even between clinical episodes.
9 In fact, when cultures are made of
tears or saliva in normal humans, random
herpesvirus isolations are made in 5 to 7
per cent of the individuals.10'12 This random
distribution of herpes isolations is consistent
with chronic low-grade infection resulting
in intermittent shedding of virus.

 

[Pathfinder]

Family condemns hospital failures after medics sent Ebola nurse Pauline Cafferkey home - and mistake could have cost chance of crucial treatment

07:01, 11 OCT 2015 UPDATED 10:56, 11 OCT 2015
BY BRENDAN MCGINTY
...
?She had been slightly under the weather the day before but things really deteriorated and on the Monday night, she phoned NHS24.

?She said, ?I?ve a temperature, my head is splitting and I have a sore neck and photophobia.?

?Pauline gave her name and details. They must have known who she was but she was told to wait and that a nurse would be in touch within the next two to four hours.
...
Pauline took herself to the ?out-of-hours GP service at ?Victoria Hospital, where, Toni said, she was assessed by a female doctor, told she was suffering from a virus and sent home.
...
?Instead of being taken into hospital, she spent the whole of Tuesday very ill, suffering from severe symptoms.

?By the Wednesday, things became even worse.

?This time, a GP came from the out-of-hours service and immediately phoned an ambulance.?
...
Sam Allen said medical staff caring for the 39-year-old nurse at London?s Royal Free Hospital would be entering ?unknown territory? as they battled to save her from the deadly virus just months after she had been given the all-clear.
...
Dr Allen, an award-winning Ebola specialist based at Crosshouse Hospital in Kilmarnock, said: ?I?ve never treated anyone who?s had a relapse before.
...
Family and friends of the nurse have to be tested for the virus as a precaution...

Dr Ben Neuman, a virologist from the University of Reading, said the effects of Ebola on the body can last for up to two years.

He said: ?Once the virus is removed from the blood once, it tends to retreat into the hard-to-access components of the body. It?ll hide in places like the back of your eye or breast milk.
...

http://www.dailyrecord.co.uk/news/scottish-news/family-condemns-hospital-failures-after-6612236

 

[Pathfinder]

Update on Ebola case close contacts

Monday, October 12, 2015

All close contacts of Pauline Cafferkey since she became symptomatic have now been identified.

A total of 58 close contacts have been confirmed and they are a mixture of healthcare workers and Pauline’s friends, family and community contacts.
Decisions on the management of close contacts have been taken by an expert group including, Health Protection Scotland, Public Health England, Scottish Government, NHS Greater Glasgow and Clyde, and other national experts with experience of Ebola.

This group has agreed that, as a precautionary measure, close contacts who have been established as having had direct contact with any bodily fluids would be offered vaccination. These vaccinations have now taken place.

The rVSV-ZEBOV vaccine offered is currently being trialled in collaboration with the World Health Organisation and has been tested in over 7,000 people during the recent outbreak of Ebola virus infection in Guinea. It is an unlicensed vaccine, currently being trialled.

40 of the 58 close contacts were confirmed as having had direct contact with Pauline’s bodily fluids and were offered the vaccine in line with criteria set out by the expert group:

• 25 of them accepted the vaccine
• 15 have either declined the vaccine or were unable to receive it due to existing medical conditions.

It is known from the existing clinical trials of this vaccine that some one in four recipients are expected to experience a rise in body temperature. Therefore, if anyone who has been vaccinated experiences a raised temperature they will undergo a precautionary Ebola blood test. All blood test samples for Ebola in Scotland are tested at the Scottish National Viral Haemorrhagic Fever Test Centre in Edinburgh.

All 58 close contacts are being closely monitored. This includes a period of 21 days since their last exposure where they will have their temperature taken twice daily, restrictions placed on travel and, in the case of healthcare workers they have been asked not to have direct patient contact during this period.

The 25 who were vaccinated will undergo additional monitoring because the vaccine is still being evaluated.

It is important to stress once again that there is no risk to the general public. Ebola is not spread through ordinary social contact, such as shaking hands or sitting next to someone. Nor is it spread through airborne particles.

http://www.nhsggc.org.uk/about-us/me...lose-contacts/

 

[Pathfinder]

Update on Pauline Cafferkey

14 October 2015
Updated: 1pm

We are sad to announce that Pauline Cafferkey?s condition has deteriorated and she is now critically ill. Pauline is being treated for Ebola in the high level isolation unit at the Royal Free Hospital.

https://www.royalfree.nhs.uk/news-media/news/update-on-pauline-cafferkey/

 

[Pathfinder]

Pauline Cafferkey, Nurse With Ebola Complications, Is 'Critically Ill'

by MAGGIE FOX
...
It's not precisely clear if the Ebola virus has returned to cause a repeat infection. If it has, it would be the first documented case.

"We know that Ebola can linger for many months after visible symptoms have cleared. We also know from outbreaks in the past that survivors can show a variety of symptoms, and the debilitating effect of these can last for a very long time, but this is frankly staggering, " said Jonathan Ball, a virology professor at University of Nottingham.

"I am not aware from the scientific literature of a case where Ebola has been associated with what we can only assume as life-threatening complications after someone has initially recovered, and certainly not so many months after."
...

http://www.nbcnews.com/storyline/eb...se-ebola-complications-critically-ill-n444371

 

[FrenchieGirl]

Comment:

(1) if there were that many contacts identified and now being monitored, this means that the symptoms she exhibited were bodily fluids (diarrhoea or vomit or blood or urine...).
(2) since contacts were offered (experimental) vaccination, this means these fluids were contagious.

The virologist, Dr. Ian MacKay, who seems to know a great deal about Ebola, said as much in:

(1) https://twitter.com/MackayIM/status/653670293035048960
(2) https://twitter.com/MackayIM/status/654426058981183488

 

[alert]

We are now 9 days post re-isolation. Six contacts have displayed enough symptoms to be tested for Ebola, and all have tested negative:

http://www.thescottishsun.co.uk/sco...1013-_-SunScotNews-_-253249643-_-Imageandlink

We still also have no report on what bodily fluids of the patient have tested positive for Ebola, and most importantly, whether infectious virus has been cultured and sequenced. There is, in my mind, at least some risk that this incident may be related to genetic drift of the virus over the past year within the patient leading to eventual immune "escape", so there is a chance this virus might be somewhat different than the one that originally infected her.

 

[alert]

And her blood?

The article also claims that this has occurred with a small number of survivors in West Africa.

http://www.nytimes.com/2015/10/15/wo...-ill.html?_r=0

[snip]

The Royal Free Hospital, which last Friday referred to Ms. Cafferkey?s illness in a news release as ?an unusual late complication of her previous infection,? said Wednesday that she was being treated for Ebola. The virus, several experts said, managed to somehow persist and apparently re-emerged to cause a severe disorder of her central nervous system. Dr. Aylward said her spinal fluid had tested positive for traces of Ebola.
?This isn?t a recurrence of Ebola hemorrhagic fever; this is clearly a meningitis-like syndrome, a neurological syndrome, which is a result of the lingering of Ebola virus,? said Stuart T. Nichol, chief of the viral special pathogens branch at the Centers for Disease Control and Prevention in Atlanta. He stressed that the complication appeared to be extremely rare.

 

[Pathfinder]

Ailing Ebola Nurse in UK May Be Rare Case of Relapse

By MARIA CHENG, AP MEDICAL WRITER LONDON ? Oct 15, 2015, 9:22 AM ET
...
MacDermott hypothesized that Cafferkey's relapse might have been triggered by her immune system.

"If the immune system is distracted, say by fighting off another infection, that might give the virus a foothold to start replicating again out of control," MacDermott said. "It is unusual that it would be able to spiral out of control and (produce) an acute infection again but it's not impossible."

MacDermott said other diseases like herpes also recur when a person's immune system is weakened, and said it was possible that similar cases to Cafferkey's were going undetected in West Africa.

http://abcnews.go.com/Health/wireStory/ebola-nurse-uk-rare-case-relapse-34489631

 

[sharon sanders]

I am not sure what is going on. Is this a case of a relapse, or a complication from the initial disease phase?

 

[alert]

I'm not sure either, and neither is CIDRAP:

http://www.cidrap.umn.edu/news-perspective/2015/10/neuro-complications-cited-uk-nurses-ebola-case

[snip]

Post-Ebola complications that recently hospitalized a Scottish nurse who had initially recovered from her infection in January include a severe central nervous system (CNS) disorder, and her spinal fluid has tested positive for the virus, an official said.

Scottish health officials said last week that Pauline Cafferkey, sickened by Ebola last December while working in Sierra Leone, was hospitalized and is critical condition after suffering an unusual late complication from the disease. Developments such as the tracing of her contacts, vaccination of those though to have had contact with her body fluids, her treatment in a high-containment unit, and her deteriorating condition, however, have raised concerns about whether her illness involved a full-blown Ebola relapse.

The closely watched case has infection control implications and promises to shed more light on the clinical spectrum of complications in survivors.

 

[Vibrant62]

My understanding is that this is now a full blown relapse. Until an official statement is made however, nothing can be confirmed.

 

[Pathfinder]

UK | Fri Oct 16, 2015 2:54pm BST Related: UK

UK Ebola 'relapse' case takes virus specialists to uncharted waters

LONDON, | BY KATE KELLAND AND HEALTH AND SCIENCE CORRESPONDENT
...
The Scottish nurse's critically ill situation, described as "staggering" by one British virologist, signals just how complex and formidable a foe the Ebola virus may turn out to be now that scientists have the chance to study its survivors.

Previous studies and preliminary data from research in survivors of the vast West African outbreak have detected Ebola virus in semen, breast milk, vaginal secretions, spinal fluid and fluids around the eyes.

But scientific literature has never documented an Ebola relapse case before, meaning Cafferkey's is likely to generate great fear and anxiety for the 17,000 or so other Ebola survivors across West Africa.

"This is totally unprecedented. We've never seen this, and there's so much uncertainty," said Jeremy Farrar, a specialist in infectious diseases and director of the Wellcome Trust.
...
Doctors at the London Royal Free hospital where Cafferkey is in a high level isolation unit say she is "critically ill" and is being "treated for Ebola".
...
"Even if you don't have the virus in your bloodstream it can be hiding out," said Messaoudi. "And we need to be aware of that because it's setting up the stage for potentially new outbreaks."

For now, she said, the key message amid all the unknowns is "it's not over when we think it's over."
...

http://uk.reuters.com/article/2015/10/16/uk-health-ebola-relapse-idUKKCN0S91ZZ20151016

 

[foxp3]

I am in Glasgow. Anyone interested can read my previous posts last year when ironically I highlighted the inherent dangers to NHS lab staff when treating possible EBOV samples. It saddens me therefore to read the following article, and I know some of the staff involved, but that's not relevant.


LABORATORY staff at a Glasgow hospital have been told not to leave the country.

http://m.eveningtimes.co.uk/news/13...ld_NOT_to_leave_the_country_over_Ebola_fears/


As the article says, The staff in the Queen Elizabeth University Hospital in Glasgow ( locally known as the death star), say they were not made aware that samples may contain Ebola. It is alleged that CSF fluid, Blood, Urine,Faecal, Throat Swabs, etc all went by a common tube system to the labs. Many of the processing was done by hand, and not assigned to senior experienced staff ( as would have happened if EBOV was suspected). The staff said patient details contained name, symptoms, the usual, but no mention anywhere on paperwork for the labs of previous Ebola infection.

The staff have asked for an explanation for this. They have been told that the possibility was raised via a medic dealing with Miss Caferkey, [FONT=Source Sans Pro, sans-serif] [/FONT]the virology consultants initially dismissed the idea. As experts had not deemed Pauline a status of a " probable Ebola case," there was no need to mention the disease on the patient details on the lab work. It is all in the article.

The conclusion the virologists reached was we believe based on data gathered from the West Africa outbreak, and as we have seen many of the links posted in this thread state Pauline Cafferkey is a rare case, one article saying it has left the experts "staggered".

My question is how do the specialists know Pauline's case is rare, what are they basing this information on. In all experimental systems "like " must be compared with " like" and any variables between systems must be considered.

How then can they possibly compare the mechanisms involved in Pauline's initial recovery to all those who survived the virus naturally in West Africa. The only similarity I can see is that they all survived, but Pauline's unlike theirs was an artificially induced survival.

She did not erradicate the virus herself, the Zmap antibodies and donated plasma rich in ant-EBOV antibodies would have literally hoovered the virus out of her body. This was perhaps aided by the various antivirals that they gave. This situation is so far removed from natural recovery from Ebola, where initial strong innate immune responses develop into specific high affinity antibody responses, and lastly generate the all important immunological memory in order to rapidly deal with any future exposure, or reactivation.

Paulines recovery did not follow such a natural physiological process. For all we know Pauline's immune system may have never made a good enough response, perhaps she didn't generate good memory, and so later when virus gets reactivated in immunoprivilaged sites such as CNS, the immune response isnt primed ready and waiting to tackle it when it reappears in the systemic system.

The survivors in West Africa fought the virus and their immune systems won. Pauline was kept from dying by donated antibodies and antivirals, there is a big difference in the end product, and the immunological imprint left. So how can the long term outcome for survivors in West Africa automatically be applied to what Pauline should experience.

Reactivation of virus in Pauline therefore may not be rare because we have nothing to compare it to.

What I find staggering is not Pauline's condition, but the so called experts comparing apples to lemons. If these experts remembered their simple rules of experimental design from their PhD days, they would have perhaps entertained the notion that Pauline may have had Ebola again and not put these medical staff on a 21 day hell marathon, nor have them in a situation where they feel they have to have an experimental vaccine, nor have delayed Pauline's return to London and the treatment she needed.


Foxp3.