Disease Detectives of Lebanon

“When we do this, we also cover our shoes, and when we leave the caves, we destroy everything we had on,” Kayali says. “It all goes into biohazard bags.” 

It’s an expedition that, as an epidemiologist, Kayali has carried out at least once a month until the covid-19 pandemic. 

“Whenever you go sampling bats, you know you’re going to come back with a positive sample,” he says. “You can go into a bat cave and all the bats look healthy, but when you examine them in the lab, you find viruses.”

Kayali, 44, is cofounder and chief executive of Human Link, a nongovernmental organization based in Lebanon and devoted to discovering the sources of viruses capable of spreading to humans. 

Now, “in the coronavirus world,” says Dr. William Karesh, an executive vice president of the New York-based EcoHealth Alliance, which has worked jointly with Kayali over the past four years, “Human Link is very highly respected, and at a regional scale, they’re best in class.”

Together the organizations assess the ongoing and future risks of spillover of infectious diseases, such as Middle East Respiratory Syndrome (mers), from animals to humans. 

“We did anthropological studies to understand why some people are at more risk of catching disease than others. We tried to peel away the layers of the onion to understand what causes these diseases, and why not everyone gets sick,” says Karesh, who calls Kayali an “ultimate professional” among a handful of world experts on both coronaviruses and influenzas. “His science is first-rate cutting edge,” he adds. “People trust him.”

Human Link is currently part of the global search for a covid-19 vaccine, a role similar to the one it played in 2012 when mers emerged in Saudi Arabia. Because Kayali is somewhat of a disease-expert celebrity, he is often invited to speak or appear on disease-related documentaries and news segments. Earlier this year he was featured in the Netflix docuseries, Pandemic: How to Prevent an Outbreak, which aired mere months before covid-19 spread worldwide. In the film he spoke about measures virologists and epidemiologists had in place to combat the next global disease outbreak when—not if—such an event occurred. He was one of the many epidemiologists around the world predicting the imminence of a catastrophic pandemic. Kayali also appeared in a March segment of the abc program 20/20, examining global efforts to identify sources of covid-19. 

Human Link’s work has always been significant, Kayali says, but now its efforts to investigate and secure a vaccine are paramount.

Becoming an expert on infectious disease was not on Kayali’s radar growing up. Lebanon’s civil war erupted in 1975, the year he was born, and it made survival and “new normal” part of the daily conversation. It also stirred a feeling inside that he one day would serve his people, to help those who lost much, to leave the world a better place. 

“My initial idea was to go into medicine, so when I was picking majors for my undergraduate degree, environmental health caught my attention,” he says, remembering how he then felt a larger calling to serve large populations. “I started learning about public health, epidemiology and biostatistics, and then I thought that was a better way to go.”

Kayali earned a master’s degree in public health from the American University of Beirut, and he then served in the Lebanese army for several years. In 2008 he earned a doctorate in epidemiology from the University of Iowa, and he joined St. Jude Children’s Research Hospital in Memphis, Tennessee, which was receiving funding from the National Institutes of Health (nih) to research avian flu in the Middle East. At St. Jude, Kayali’s mentor was infectious disease specialist Richard Webby, director of the World Health Organization’s Collaborating Center for Studies on the Ecology of Influenza in Animals.

“I came back from the States and set up a virology lab in Cairo with the Egyptian National Research Centre because at the time avian flu was a big thing,” he recalls. “We studied how frequently h5n1 [avian flu] can jump from wild birds to poultry to humans. Then in 2012, when mers emerged in Saudi Arabia, we started working on that too.”

Human Link also collaborated with a group of Dutch disease detectives who proved that archived camel serum had antibodies against mers. Kayali says the joint effort led to key findings and more trips into the field. 

“We got the hint that camels might be involved and went out sampling. We were the first to show the virus in contemporary camels,” he says.

The discovery allowed medical authorities to identify people exposed to camels as an at-risk population and go on to create targeted public health campaigns.

It was in 2014 that Kayali, along with longtime friend and colleague Jimi Goldstein, launched Human Link. Although its headquarters is in Beirut and it has a lab in nearby Zahle, most of its lab research is carried out in Egypt, where Kayali supervises 50 employees in the Cairo district of Dokki. In addition, Human Link also has done fieldwork in Morocco, Algeria, Tunisia, Saudi Arabia, Iraq and Jordan, as well as Togo and Benin.

At present, the nih provides 95 percent of Human Link’s funding through a research contract under the umbrella of the nih’s Centers for Excellence for Influenza Research and Surveillance. The research also overlaps with the World Health Organization on efforts to develop pandemic preparedness for the Eastern Mediterranean.

“Conducting my line of work is very expensive. We’re not only working with the virus, but with thousands of samples,” says Kayali. 

But Kayali and his team suspended field work in late January. On their last outing, they extracted virus samples from snakes, lizards and tortoises in the Cairo suburb of Giza.

“Right now, because of the restrictions, we’re not going out to the fields,” he says. “But as soon as the restrictions are lifted, we’ll be hitting the field, because we have lost valuable time.”

Justin Bahl, an associate professor of epidemiology and biostatistics at the University of Georgia, has worked with Kayali since 2015 on avian influenza viruses. Much of Bahl’s work focused on Kayali’s field research in Egypt, when Bahl was enrolled at the University of Texas. More recently, the two have been looking at how mers emerged and comparing findings to both sars and the current novel coronavirus.

“One reason our collaboration works so well is that Ghazi [Kayali] is trained as an epidemiologist, whereas with virologists, the science is very reductionist. So if you’re a virologist working on influenza, you often work on one virus and one host,” Bahl explains. Kayali, however, “is focused on how viruses transmit and persist within a population. Therefore, his strategies for surveillance and collection are really well-informed, with a solid study design.”

Epidemiology fieldwork is not for the squeamish, Kayali says. Though bats rarely come into direct contact with humans, people are more likely to be exposed to the potentially lethal diseases they carry through remnants of urine and feces. And with fruit bats, like the ones Kayali researches, exposure to saliva on partially eaten fruits is another risk. The relationship among bats, viruses and the spread of disease, Kayali says, is “very intimate” and can begin in food markets. 

“We’ve seen this happen multiple times before. People go into the field hunting for bats as food. In Africa as well, flying foxes are sold for meat in the markets. This is definitely how Ebola got started,” he says, mentioning that while bats are not on the menu in the Middle East, they are in some areas of China, for example. The diseases they carry cause no problems for the bats, “but when you hunt for bats and you’re exposed to their blood and carcasses, you’re providing a chance for exposure.”

All viruses that have caused trouble in modern times—Ebola, mers, h1n1 or Swine Influenza (siv)—he says, have already existed in wild animal reservoirs.

“Before h5n1, it was wild birds, and coronaviruses existed in bats. The virus jumps species occasionally, from bats to another animal reservoir,” he adds.

Coronaviruses have already caused two major epidemics in the last two decades. In 2003, Severe Acute Respiratory Syndrome (sars) infected 8,098 people and killed 774 around the world; in 2012, mers infected 2,506 people and 862 died. 

“In sars-1, it jumped into civet cats, and in mers, camels. In covid, it jumped into some other animal, but we’re not absolutely sure which,” he says. “In the Middle East, and especially in the Arabian Peninsula, we have an intimate relationship with camels, which are treated more as prizes and pets. For covid-19, it would be something similar.”

These experiences explain in part why, this time around, the Middle East appears to be somewhat better prepared, Kayali says. In Lebanon the covid-19 infection rate was relatively low, in part due to the government’s swift closures of schools, restaurants and other public venues, according to the Arab Center Washington DC. In June Lebanon reported 1,495 cases of the virus and 32 deaths, according to Worldometer.

“Because they took people off the streets at an early stage and banned all gatherings, the virus didn’t really have a chance to spread,” says Kayali.

For now, Human Link’s labs are working daily toward a vaccine for covid-19—as it did for mers—while looking at general immunity in the population.

“We’re working with the Egyptian Ministry of Health,” he says. “The initial steps start in labs like mine. You develop a vaccine, you test it in your lab animals, and if you see potential there, you produce a bigger batch and start human testing. Hopefully, we’ll have some results in a couple of months.”