I just watched, at a the Twin Cities Science Film Festival, a film called Nzara ’76, which is about the first known Ebola outbreak, the one that gave it its name, in southern Sudan. That’s about 150 miles, as the Mvo-Mvo flies, north of my long term project area in the Ituri Forest, an impassable distance over an unforgiving terrain if you are a person, well within the migratory range of an Ebola carrying fruit bat.
Back in the day, when Ebola would strike here and there, killing dozens, then disappearing back into the wild as quickly as it came, there was not much movement to get a vaccine. Then, one day, a fruit bat, carrying ebola, dropped some bat spit covered fruit bits to the ground, which were later picked up and mouthed by a toddler, who became patient zero in a pandemic that would ultimately kill over 11,000 people and sicken nearly 30,000. That would be a good argument to get a damn vaccine.
But, one could argue that even though Ebola is known to have been around since the 1970s, and may have been around before that (entire villages falling to a deadly disease is known historically in the region, with no understanding of what the disease was), it only arose as an epidemic once, so really, what’s the big deal? Next epidemic we’ll attack much more efficiently and quickly, and only hundreds, if that, will die.
Aside from the fact that the morbidity and mortality tolls in the tens of thousands should not inure us to the death of dozens or hundreds, we should also consider that the conditions that allowed this pandemic to occur arose only recently, so a pandemic is actually more likely in the near future than it was in the near past. Also, and this is from new research, now that Ebola has infected tens of thousands, it has a temporary reservoir in the post-infection population.
Research that could not have been conducted before has now been conduced (and is ongoing) in the pandemic region. It is now understood that survivors can have ebola in their systems for long periods of time after infection, and that in some cases, they can pass this on. It can be passed on through both breast milk and semen. I assume it could be passed on through blood.
It is simply NOT the case that thousands of post pandemic West Africans are restarting ebola epidemics wherever they go. Post pandemic transmission has been rare, and quickly managed. It is probably true that ebola will eventually leave all the post pandemic people. Humans are not really a reservoir, long term, for ebola.
But, consider the fruit bats. The story I gave above about the start of the pandemic is almost certainly true, but at the same time, fruit bats in the region came up empty when tested for Ebola. There are a lot of reasons that would happen, beyond the scope of this post, but it serves as a model for a near future West Africa. Perhaps ebola will last a long time in some individuals. Perhaps previously infected individuals will become reinfected, but not get sick, and be carriers for a year, or six months.
An ebola pandemic is not going to resurface easily, or form this source, in this population, because of post pandemic harboring. But, here and there, some people may get the disease, and if there is another outbreak somewhere else, we now know that the public health problems are even more complicated than previously thought.
The obvious way to solve this problem is with a good vaccine that is widespread and regularly administered.
The research I’m referring to hear was reported at a conference in Antwerp, Belgium, on September 12, and is briefly written up here, in Nature.
A few highlights, and a caveat, from that work:
Researchers will soon publish the first confirmed report of a person without obvious Ebola symptoms infecting another person. A seemingly healthy mother in Guinea passed the virus to her nine-month-old daughter in breast milk, and the child died from Ebola-virus infection in August 2015…
…some people who became infected during the recent outbreak escaped detection. Miles Carroll… tracked 80 people who had contact with Ebola patients in Guinea but did not themselves become noticeably ill. Yet 15–20% of these contacts developed immune responses capable of neutralizing Ebola viruses, suggesting that they had contracted mild infections that went undetected.
[Researchers] traced a cluster of new Ebola cases to a man who transmitted the virus to a sexual partner 17 months after recovering from his infection…
Researchers must show sensitivity in communicating such findings, says virologist Stephan Günther of the Bernhard Nocht Institute, and take care not to make life more difficult than it already is for Ebola survivors, who face discrimination and lingering health problems. “We have to be careful to stress that these are very, very rare events.”
Here’s a question for you: Historical records show that another pandemic will occur, but no one knows when. How do we create a mind shift among world leaders and people in general to start planning for the next one now?
My first two encounters with Ebola might not have been encounters with Ebola, but might have been.
I was doing archaeology in a remote part of the Congo, not far from some of the earlier known outbreaks, in a region where later outbreaks occurred as well. In researching abandoned villages, one of which I partially excavated, I found out that there were settlements that had been struck with a terrible disease that killed many of the residents and made many others very ill. These events, of the previous decade or two, were so tragic and traumatic that those village sites were abandoned, and everyone I talked to claimed that they would never use those village sites again, even though re-occupation of villages previously abandoned as part of the swidden agricultural system was common. Ebola? Maybe.
Around the same time I was reading through a 1950s vintage travel guide to Uganda and the Belgian Congo, owned by my then father-in-law, Neil Tappen. Neil and his wife, Ardith, had worked there in the early 1960s, where Neil produced the first comprehensive survey of the rich primate fauna. They had acquired the book used, so they could not explain the marginal notes added by a previous owner, tallying the death rates of some group or another, with a mortality rate of about 60%. Ebola? Maybe.
If I had told those stories to an Ebola expert five years ago, I’d probably be told this was unlikely to have been that particular disease because it wasn’t around then. Now, we might be thinking Ebola has a longer history in the region. That is one of the many ways in which Ebola is being re-conceived in light of both the experience of the Ebola pandemic, and research spurred by that horrible chapter in West African history.
This and other events were enough to spark a long term interest in Ebola, and years ago I was able to contribute a couple of ideas to help in the hunt for a natural non-human reservoir. That was when fruit bats were first being given a hard look, and today, they are still suspect.
So what about the question at hand?
The first thing that comes to my mind is how do we put in place the resources needed to come immediately up to speed when a new pandemic seems to be starting. This would include monitoring in order to get on top of the problem as quickly as possible, infrastructure to transport good and people where they need to be, trained personnel to take on the various on the ground roles needed to isolate and treat patients and stop the spread of the disease.
However, these things are both obvious and outside my area of expertise. I’m pretty sure there are people at the UN’s WHO, the CDC, and other major health related organizations, thinking about these things.
But there is another aspect of preparation that I think is important. This is the way in which we misconceive Ebola or other diseases, because of a combination of incorrect thinking (about diseases), lack of information, and lack of experience. These misconceptions are usually found among the general public, and result from simply not knowing the science. But sometimes they arise among the medical researchers themselves, and result from not having enough research done, and not having enough experience with a disease.
For example, during the Ebola pandemic, many people were on the edge of panic because they somehow knew that it was only a matter of time before Ebola became fully airborne, like horrid diseases seem to do rather quickly in their fictional form, in novels, in movies, or on TV. In fact, Ebola is highly unlikely to become easily transmitted by air for reasons I go in to here.
That is an example of uninformed but concerned non-experts getting it wrong. But, the “airborne” nature of of Ebola, or lack thereof, is actually less than perfectly understood by many in the health business. For example, we often think of Influenza as an airborne disease because it can be spread by coughing and sneezing. However, this common disease is probably almost never spread that way. Rather, it is spread by physical contact, with bodily fluids (which may have been coughed or sneezed at the start) from the nose or mouth going to the hand, then to another person’s hand, then to the recipient’s nose or mouth, possibly with some intervening step such as an object handled by the patient. So, while many may be concerned that Ebola could turn into something like the flu, if it did that, it still would not be especially airborne. If you want to look at an airborne disease, check out measles, which can apparently travel down the hall from one patient examining room to another, through the air, resulting in a new infection.
It turns out that the categorization of modes of spread has been revised now and then and some feel that further revision would be appropriate, or at least, that everyone should be using a more nuanced and detailed method of describing how diseases can spread. A disease can spread through the air, in a sense, but not be truly airborne. But the distinction is critically important in dealing with a pandemic situation, or even a minor outbreak.
The accepted belief at the start of the Ebola pandemic was that Ebola would not persist in a survivor beyond a certain number of days, so post-infection quarantine periods needed to be just so long. Even then, however, it was known that Ebola could persist in the sperm of infected males for a much longer period. This should have been a clue. By the end of the pandemic, it was understood that Ebola could actually persist in an infected individual for a much longer time. Long enough, perhaps, to attribute an outbreak to a person who had harbored the disease rather than a novel infection from its wild reservoir. This is a significant finding that not only changes how we address quarantine, but also, how we ask questions about the wild reservoir.
A third area in which individuals making wrong assumptions can negatively impact an effort to address a new pandemic is in the locally variable beliefs about where infections come from, along side various mortuary practices that may be important to someone’s religion or belief system, but that enhance spread of the disease. I can not honestly characterize this set of local beliefs because, as an anthropologist who has worked in the Ebola region, I can tell you that belief systems are extremely variable there, with many different systems overlapping in space, within individual villages, and that even within the context of households or families, there is a great deal of individual variation.
I have known families where five or six people living together had three or four entirely different sets of beliefs about important (and unimportant) things. You know this too. Does everyone at a major family gathering, or a get together at work or in your community, share all their basic beliefs? That is highly unlikely. Yet we tend to see people living in other lands, more often than not in developing regions, as being far more homogeneous than they really are. Then, when someone points out a belief system interfering with a scientifically based endeavor (such as a major public health disaster), the assumption is that this is a widespread, intractable, universal problem. There is, though, more diversity than that around your Thanksgiving table and in a typical West or Central African village.
Sometimes these diverse beliefs emerge simply because different “tribal” groups all live near each other and traditional beliefs get thrown together when people, and this is very common, marry across those relatively artificial boundaries. But the most dramatic divergences in beliefs have to do with local reaction to systems, technologies, and practices, that come from the outside. This can be something simple like the best way to restore life to a nearly dead battery you were hoping to use in a radio, something more important like the best way to catch fish or wild game given the availability of key western goods like fishhooks and wire, to somewhat more bizarre arguments (in more remote areas) about what really is in those cans of foodstuffs that sometimes trickle in from Western sources.
When a “traditional” population sticks firmly to their beliefs even though it harms them, that’s a story and it may get reported in the New York Times. We saw reports like that during the Ebola pandemic, reports about people refusing to go to clinics because they believed something about Ebola that simply wasn’t true. But, it is also possible for people to put aside their traditional beliefs and accept new knowledge, and change their minds. In my experience, this is the much more common result of interaction between traditional indigenous thinking and intrusive Western thinking. But those stories, where people learn new stuff, change their minds, and change their practices, usually don’t make news. So, our Western conception of the West African peoples who were afflicted with this pandemic is that a huge problem arises from folks sticking to their old and incorrect folklore. Maybe that is true at times, but I strongly suspect that this aspect of the problem was way overplayed by the press.
So, here is what we have to do, aside from all that logistical planning (and fund raising) noted above.
More research. After many smaller outbreaks of Ebola over many years, the scientific and medical community was left with a number of important misconceptions about Ebola that might have been better known had there been more prior research. This must be assumed to be true of any disease that has pandemic potential but that has not developed to such a level so far. There needs to be a well funded, ongoing, international research program addressing emerging diseases that is proactive, addresses whatever research questions come along in good scientific tradition, as pure research rather than as a reaction to untoward events.
More education of the general public. Part of the problem in addressing a pandemic is the inappropriate response, often time and resource wasting, of the press and the public. This happens because the basic, and often rather simple, science needs to be taught fresh to reporters and those who consume the news each time something like this happens. After a decade and a half of major news agencies removing science bureaus, and the spread of anti-science sentiment largely for political reasons, we are paying a cost. If you watched any of the CDD or state health department press conferences at the time Ebola cases were popping up in the US, you will remember the difficulty officials and medical experts had in explaining the science to the reporters, and the often breathless and, frankly, foolish way many reporters were acting at those events. Those events were hardly remarked upon at the time, but the need to explain basic stuff to the reporters, and their poor level of preparation to understand these things, was shameful. But it is also fixable.
More education on the ground in areas that may be affected. Pandemics of this type may be thought of as more likely to emerge in tropical areas, but in fact, they can emerge elsewhere as well. Part of public health education should be to address proper public, community, family, and personal response to an infectious disease crisis, balancing between urgency and sensibility, to avoid undue panic or inappropriate responses when something does happen.
It is especially important that populations in regions that may be affected by pandemics can prepare by laying a groundwork of education and new new thinking about what these diseases are and how to spot them and cope with them.
Finally, Ebola is not the only pandemic causing horrid disease in the tropics, so the question at hand needs to be addressed generally. Moist equatorial Africa is not the only region where this sort of pandemic can develop. And, with climate change, the warmer regions of the world, where certain kinds of diseases seem to do better, are getting larger.
Jim Moore and I were both students in the PhD Program in Anthropology at Harvard a few years ago. He graduated about the time I entered the program. To give a rough historical touchstone, I remember the day he needed to get his thesis off to the Registrar, and there was a delay because it was taking longer than expected to deburst the pages fresh out of the printer. Anyway, Jim is Professor of Anthropology at UC San Diego, and has done a great deal of work with Old World Primates, the evolution of social systems, and related topics. A while back Jim wrote an important piece for American Scientist which was a summary of his intensive research on the complex origin of HIV in Africa. Jim and I got to talking the other day about that topic in relation to the current West African Ebola outbreak (though this really relates to Ebola across the region in West and Central Africa). I invited Jim to write a guest blog post on the topic, he did, and that post is below. The graphic above accompanies the post and is used with permission from Jim’s earlier American Scientist article.
Ebola and “the French Disease”
The origin of AIDS
By comparing the degree of variation among samples of HIV 1 group M (the virus responsible for the pandemic), we can estimate how long it has been since the original variant existed; that gives us a time for the most recent common ancestor (TMRCA) of between 1908 and 1920 (depending on which recent analysis you like). For group O (which has not spread far), the TMRCA is a few years later, about 1920 to 1926. Put in the error estimates for these dates, and the range is about 1903 to 1948. Group N, with fewer than 20 patients known, is thought to have originated between 1948 – 1977 and the range for group P (2 patients) spans more than a century.
By comparing HIV 1 with different strains of SIVcpz and SIVgor (simian immunodeficiency virus of chimpanzees and gorillas), we find the closest match for group M comes from chimpanzee groups in SE Cameroon, just over the border from RP Congo (“Congo Brazzaville” to distinguish it from the Democratic Republic of Congo [DRC], ex-Zaire, ex-Belgian Congo). Group O appears to be derived from SIVgor, most likely someplace in southwest Cameroon. That discovery involved collecting thousands of samples of ape feces from all over Africa and screening them for SIV, a prodigious project overseen by Beatrice Hahn. And a recent paper in Science makes a good case that for HIV 1 group M, after initially becoming established in someone in northern RP Congo/SE Cameroon, the virus traveled down the Sangha River to Kinshasa (personally, I don’t think they can meaningfully separate Kinshasa and Brazzaville at this stage) around 1920, where it was maintained at a low prevalence until about 1960 when the pandemic began.
Do the same exercises for HIV 2, and the two epidemic groups (A & B) most likely originated around 1940 – 1945 (1924 to 1959) from SIVsm (sooty mangabey) someplace in or near Ivory Coast. Like HIV1 group M, the virus seems to have travelled from its point of origin (sooty mangabeys in the Tai Forest, Ivory Coast, have the closest SIV matches to both groups) to where they caught on and eventually became pandemic (Guinea-Bissau, where the war of independence seems to have facilitated the process).
Now here’s the thing: people in both areas have eaten primates, and so been exposed to SIVs, for millennia. And as a sexually transmitted disease, well, sex has been going on for even longer. Massively increased promiscuity in the context of commercial sex workers in rapidly urbanizing and poor populations? That’s more a twentieth century thing, starting early in the century but really taking off after World War Two and ongoing today. Furthermore, in around 1960 disposable plastic syringes became widely available and, in poor areas, were often reused and/or easily available to traditional healers and charlatans, making unsterile injections more common. And of course travel by trains, cars, and planes has increased through the 20th century (with an important caveat that in parts of Africa such as the DRC, many railroads and roads weren’t maintained after independence and fell apart post–1960s).
So exposure to SIV has been going on for millennia, and “the usual suspects” in terms of STD risk factors became important early in the 20th century but increased dramatically (and have remained high) since the late 1950s, and despite that the only strains of HIV that have “caught on” all date from around 1920 – 1945. What is missing?
The French Connection
Those places, those times: French Equatorial Africa and French West Africa. There are SIV-carrying primates in many parts of Africa, under various colonial powers at various times, but all four zoonotic HIV strains happened under the French. Bad luck?
It is impossible to be sure, but I have argued that for HIV 1 the catalyst was the combination of two things. First comes the unbelievably brutal treatment of Africans in both French Equatorial Africa (FEA) and the Belgian Congo, resulting (among other things) in labor camps where men were overworked, malnourished, and provided with women as a matter of policy to keep the workers – well, “happy” is probably not the best word, but you get the idea. The second element was the effort to cure smallpox and sleeping sickness through aggressive diagnosis/treatment/inoculation campaigns using traveling “mobile clinics” that had inadequate equipment for the scale of the job they were doing. For example, one sleeping sickness expedition in 1916 into what is now Central African Republic diagnosed/treated more than 89,000 people with just 6 syringes (the number of needles isn’t recorded). Over more than a decade, these mobile clinics, pioneered by Dr. Eugene Jamot, reached – and injected – millions of people. The importance of sterile equipment was well understood, but the logistics (I speculate) would have been prohibitive. The campaigns represent a major humanitarian effort that saved many lives, but the combination of widespread use of unsterile needles and stress-induced immunosuppression could not have been better designed for adapting a virus to new hosts.
I do not know the relevant history of French West Africa (FWA) so am cautious about saying the same thing happened there with HIV 2. However, it is worth noting that in 1931 Jamot was held responsible for the accidental blinding of hundreds of people being treated by one of his subordinates (sleeping sickness was treated with an arsenic derivative, and the subordinate apparently tried out a higher dosage, with disastrous results). With a cloud over his reputation, Jamot shifted from FEA to – Ouagadougou, in FWA. There he took charge of the sleeping sickness campaign, again with mobile clinics and again treating thousands of people under difficult conditions over several years before his health deteriorated.
About 20 years between the origins of HIV 1 in FEA and HIV 2 in FWA, and about 15 years between the onset of Jamot’s work in FEA and his move to FWA. Very circumstantial, but it gives one pause.
Why belabor the French?
Eugene Jamot was a genuine hero, and while colonial support for the mobile clinics wasn’t all humanitarian (there were concerns about the loss of [forced] labor if too many died), I am sure the people involved were doing their best to help other people in need. It might seem mean-spirited to point the finger of AIDS at them.
Well, here is one reason. A recent article in Science by Faria et al. examined the history of HIV 1 group M, concluding that the virus arrived in Kinshasa in about 1920 where it barely kept up with population growth until about 1960, when it began rapidly spreading in the pandemic we see today. It is valuable and interesting work. The actual origin of the virus is not their focus, but they summarize it thusly:
After localized transmission, presumably resulting from the hunting of primates, the virus probably traveled via ferry along the Sangha River system to Kinshasa. During the period of German colonization of Cameroon (1884 – 1916), fluvial connections between southern Cameroon and Kinshasa were frequent due to the exploitation of rubber and ivory. (page 58)
German colonization? Well, yes; the Germans were in Cameroon up until 1916 (when French/Belgian forces that had traveled up the Sangha in 1914 finally drove them out; Jamot was a medical officer with the expeditionary force). But traffic on the Sangha River didn’t end in 1916, and most of it was between Brazzaville/Kinshasa and the French towns of Ouesso, Nola, and Carnot anyhow. Why specify the “period of German colonization”?? I do not KNOW, but I note that (1) there is no other mention of any colonial power in the Faria et al. article, and (2) of the 14 authors, 6 are affiliated with institutions in Belgium or France (the rest, UK and USA). It looks to me like there may have been a bit of whitewashing going on there, and using a scientific article to blow historical smoke in our eyes gets my dander up.
AIDS and Ebola
Here is a better reason for acknowledging the likelihood that AIDS got its start as an unanticipated consequence of underfunded, understaffed humanitarian efforts to deal with infectious diseases in equatorial/west Africa: history can repeat itself. To ignore ebola in West Africa is not an option, and half-measures have whole risks.
The puzzling origins of AIDS (2004). Jim Moore. American Scientist 92: 540–547. pdf
The early spread and epidemic ignition of HIV–1 in human populations (2014).
Nuno R. Faria, Andrew Rambaut, Marc A. Suchard, Guy Baele, Trevor Bedford, Melissa J.Ward, Andrew J. Tatem, João D. Sousa, Nimalan Arinaminpathy, Jacques Pépin, David Posada, Martine Peeters, Oliver G. Pybus, and Philippe Lemey. Science 346: 56 – 61.
Of the seven Americans who have contracted Ebola, five overseas and two in Texas, all seven have survived. Comments from President Obama, focusing on how we have to be guided by the science:
“Here’s the bottom line. Patients can beat this disease. And we can beat this disease. But we have to stay vigilant. We have to work together at every level — federal, state and local. And we have to keep leading the global response, because the best way to stop this disease, the best way to keep Americans safe, is to stop it at its source — in West Africa.”
Given the current and developing situation in Dallas, where two health workers have become infected with Ebola while caring for a patient, it is reasonable to ask if health workers might decide to call in sick for a few months until this whole highly infectious often fatal disease thing blows over. Daniel Barnett, of the Department of Environmental Health Sciences at the Johns Hopkins Bloomberg School of Public Health, has looked into health workers’ unwillingness to report to work when there is a potential for infectious-disease transmission to themselves and their family members.
The health workers I know tend to run into burning buildings or jump into frozen lakes and such to rescue people, so I can’t see that happening. Apparently it has been an issue in Spain and in West Africa. I can’t explain Spain, but things are so dismal in West Africa that it is not at all unexpected. But what about in the US?
So far there doesn’t seem to be an issue according to Barnett’s research, but he cautions that continued willingness to work with Ebola patients here is not assured. In an earlier study, Barnett and colleagues found that one-third of workers at a large U.S. urban medical center would be unwilling to respond to a severe infectious disease outbreak.
“An individual’s personal perception of the importance of his or her work during the response phase and his or her sense of confidence in performing this role effectively, are among the most powerful determinants of willingness to respond,” notes Dr. Barnett. “Our research also suggests that familiarizing health responders with laws and policies designed to protect their wellbeing in an emergent infectious disease event is important for bolstering response willingness,” Barnett adds.
Barnet notes that for training to be effective it must provide clear guidance on infection control protocols and instill a clear understanding of outbreak response duties. I asked him about the domestic side of this, about training of health workers regarding in relation to thier behavior or decision making when they are off duty. This seems to have arisen as an issue with the second Ebola-infected worker in Dallas, who took an air flight after starting a fever (if reports are accurate) and before diagnosis as having the disease.
“Preparedness and response trainings on emergent infectious diseases need to cover not only work-related protocols,” he told me, “but also address behavioral elements outside of the healthcare setting in the interest of public health. To date, there’s essentially been no research or ‘environmental scan’ on the extent to which such trainings actually encompass behaviors and practices outside of the health care workplace. However, this type of training on precautionary measures outside the workplace is essential. It needs to be imbedded into trainings and harmonized across healthcare institutions to ensure consistency.”
It is now known that the second infected health worker who had cared for Dallas Index Patient Duncan took a Monday air flight from Cleveland to Dallas-Forth Worth after she started to have a fever. It was a Frontier airline flight and it arrived in Dallas at 8:16 PM, was put to bet overnight, received normal cleaning, and resumed service Tuesday. There were more than 130 other people on that plane.
Chances are Ebola is not THAT contagious when it is just staring up. You really need those bodily fluids. There is almost ZERO chance that anyone was infected on that plane, or at the airport, or anywhere else.
“We will, from this moment forward, ensure that no individual monitored for exposure undergoes travel in any way other than controlled movement,” Frieden said Wednesday. He said the agency would work with state and local authorities to enforce this restriction.
Nina Pham, one of the two nurses who contracted Ebola in Dallas, is expected to be moved to a National Institutes of Health isolation unit in Bethesda, Maryland, a federal official with direct knowledge of the plans told NBC News on Thursday.
The transfer could happen later Thursday, but the official cautioned that plans were evolving. Pham, 26, was diagnosed with the virus on Sunday after treating Thomas Eric Duncan, who contracted Ebola in Liberia, flew to Dallas and later died.
The other nurse who contracted Ebola in Dallas, Amber Vinson, was flown on Wednesday to Emory University Hospital in Atlanta. The Emory and NIH units are two of the four facilities in the United States that are specially equipped to handle Ebola.
UPDATE: The second infected health worker will be transferred from Dallas to Emory.
This is a second health worker, who reported in with at fever on Tuesday. The worker is one of the 76 who had been self monitoring, who were thought to be most likely beyond the most likely period for infection.
(This might be a good time to point out that while the CDC uses 21 days, which is probably usually good, one study showed that a small percent of individuals might develop the disease after 21 days following exposure.
During the briefing, it is confirmed that this new patient was involved in care for the Index patient.
We’re a great hospital, we always have been, we want to get this right, we fell really bad, we’re doing fine, etc. etc. (that was the hospital representative)
Teams have swooped in and started cleaning common areas near the new patient’s apartment, neighbors have been or are being interviewed.
The patient lived alone and with no pets. Inside cleaning and cleaning of the car will happen later today.
Question for hospital rep: Does a second case indicate systematic institutional problem. Answer: No. We know what we are doing and handling it and we are looking at everything.
Was this person a nurse? We won’t tell you that.
Question: When did this patient come forward and get a blood test in relation to yesterday’s press conference? Answer. Hipaa.
Question: There are three isolation rooms at the hospital. What will you do when you fill up? Answer: Working on that. Also, there are actually is more room than that, a little.
Question: Timeline? Answer, got confirmation about 1:00 AM. Then we started doing stuff, press release at 4:00.
Question: Allegations from the nurses?? Answer: I can’t comment. We have the proper protected gear.
Question (breathless): Are steps being taken to isolate the other workers? Answer. There are 75 hospital workers. They are asymptomatic, the are not contagious. Please try to avoid community panic with those questions (I paraphrase, he didn’t say that). When people get symptomatic they report in, like happened twice, the system is working.
By the way, the are not coming in to work.
On preparedness of the hospital. There is evidence that the Dallas hospital that treated Thomas Duncan was not prepared to handle an Ebola case, and initially, nurses were not well protected. It is also clear that the clean, crisp, rapid response we may have expected from the CDC was not there. However, it is probably the case that that hospital is now managing the two cases they have properly, and that the monitoring program for other contacts is good.
To me, this means that the repeated, near universal statement by the US health community that the US can handle Ebola was overstated. Let’s take a look at the overall problem. I previously divided the Ebola exposure problem into several phases. Here is an updated version of that:
1: An infected individual arrives in the US, becomes (or already is) symptomatic, and is not yet admitted to a hospital. At this point we rely on that person’s decisions to seek treatment. There can be several hours to several days of time of potential exposure, but even so, the person is ambulatory and less symptomatic, and probably is an infection risk but a low(ish) one.
2: The infected individual either becomes very sick and is brought to the hospital or self admits. At this point there is a risk of infection to other people at the hospital including other patients and hospital workers, as well as ambulance drivers, etc. During this second phase it is up to the hospital to quickly identify a possible Ebola case and isolate the patient, and start safe procedures for care. In the case of the Index patient in Dallas, this took several days (and the patient was sent back into Stage 1). This inadequacy conflicted with what the public was being told by experts. However, now that the very first actual case of Ebola emerging in the US happened, and those who were not expected to mess it up did mess it up, everyone is on their toes and the chances of a repeat of that are lower. The CDC has also developed an improved method of addressing this (their ready teams).
3: The infected individual is in an isolation unit and being cared for. At this point it is up to the hospital and the health workers to minimize the chance of infection of others, and those at risk are, theoretically, the health workers. In the case of the Index patient at Dallas, according to nurses who worked there, the risk of infection of health workers was not minimized fully at least initially, and it is even possible that risks beyond the care staff continued. Eventually, we assume this was fixed. But, the fact that two health workers have been infected does amply demonstrate that whatever was going on was not adequate, though at this point we don’t yet know in what way, or when, things were done improperly and we need to take the word of the same hospital and health system spokespeople that earlier assured us that things are fine. Since the system representatives have yet to fully acknowledge there were inadequate procedures or care, and describe that inadequacy openly, we really don’t know. I suspect they really have cleaned up their acts, because they are strongly motivated to, but we are starting to see the edges of an Orwellian response where information is being cleaned or withheld, sometimes under cover of HIPAA rules.
1: During the first three stages, exposure of others may happen, and those individuals need to be identified and managed. Individuals who do end up being infected during that period are now in Stage 1, but if there is an effective monitoring program, stage 1 is very short (hours?). Because the system is ready for secondary cases, stage 2 is minimized (or does not even exist), and the patient is now in Stage 3. In the case of Dallas, we can guess that the two patients who have cycled into Stage 1 (both health workers) are in Stage 3 and Stage 3 is being done properly.
At a later time, if there are too many additional cases, the revamped and updated Stage 3 response may break down again due to lack of isolation facilities. The authorities seem to be aware of this possibility.
We don’t have a lot of control over what happens during Stage 1 for newly arriving patients, though the system has demonstrated that it can handle Stage 1 for those of known risk who are in a monitoring pool. But for the system to be like various spokespeople claimed it was, a great deal of effort has to be put into training, procedure, and dispersal of equipment. Dallas demonstrates that for a hospital that should have been ready, this was not the case. But, the CDC response, of having ready teams (like we learned from movies and literature to be how the CDC operates, in fiction!) should make the transformation from inadequate response to adequate response more likely if there are other cases.
Many thousands of people in West Africa have gotten Ebola, about half have died. Our problems here in the US are tiny. But, everyone is concerned about the possibility of spread outside of West Africa. One consequence of the small leakage that may occur being handled poorly is a stricter response in the form of travel restrictions. This would have multiple negative consequences. The Dallas Index patient got past the system, but the international travel problem is being tightened up a little (we have no idea if that is adequate). If infections beyond Stage 1 continue to happen, as they have in the US and Spain, people will demand a closure of borders. And, perhaps, that is what should happen.
Timing of infections vis-a-vis the Index patient
Ebola is thought to manifest in as little as four days after exposure, with most cases showing up prior to 17 days after exposure, but as late as 25 days, using very liberal estimates of exposure time. The Dallas Index patient, Thomas Duncan, was cared for in the hospital staring on September 25th, and died on October 8. The most recent secondary infection was identified last night, so let’s round up and say that was 7 days after possible exposure. If we assume for the moment (we have no basis for this, this is a rough guess) that the first half of that care period was as suggested by nurses being handled inadequately, and the last half was managed well, to split the difference, perhaps the most likely period of exposure ended around the second of October. So, perhaps today is about two weeks post dating likely exposure. So, a roughly optimistic guess would be that the chances of another health worker ending up with Ebola is not small for the next three or four days. A fully pessimistic estimate is that we have ten or so days over which this could happen. Stay tuned.
This is breaking news as of Tuesday PM. According to the nurses at the hospital, no, not initially. Anonymous nurses have claimed via their union:
-Patient Zero was left for several hours in a place with up to seven other patients, not in isolation. When a senior nurse attempted to insist he be moved to an isolation unit she was met with “hostile” responses.
-Blood samples were transported through the hospital tube system instead of hand carried.
-Nurses were not entirely covered with protective wear. The gear they had left their necks exposed. To remedy this they were told to wrap tape or gauze (not sure) around their necks.
-People were going in and out of isolation areas without protective equipment.
-Medical waste was not properly handled, with hazardous waste piled nearly to the ceiling as there was no plan to dispose of it.