Obama made Ebola the subject of his weekly address. He emphasizes some unique concepts: Science and facts.
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.”
UPDATE: The first health worker to have been affected with Ebola in Texas may not be moved to Maryland.
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.
Yesterday, Tom Frieden, head of the CDC, noted “CDC Director on Ebola: ‘Even a Single Infection is Unacceptable'” Also, yesterday, Dallas nurses complained about the situation at the beginning of the treatment period for the Index patient who died there.
There was a briefing in Dallas.
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.
The hospital has not responded.
The first person ever to catch Ebola in the United States is now in isolation at Texas Health Presbyterian Hospital.
Don’t panic, even if you live in Dallas. But also, don’t fall into the hyperskeptical trap of assuming that because scientific authorities tell you everything is fine that concern is irrational. There are very rational reasons to be concerned. But you need to be smart about what to be concerned about.
A couple of weeks ago, as you know, a man came to Dallas with pre-symptomatic Ebola, and became symptomatic there. This was the first case of a person being diagnosed with Ebola in the US. The case was botched. The hospital sent home a man with pre-Ebola symptoms who had come from West Africa. He was later admitted after he got a bit sicker and tried a second time to get treatment. There were other ways in which the case was not handled too well, mainly from a public relations and messaging standpoint, but the CDC and the hospital involved seemed to be doing a good job and getting their acts together.
Now, the situation has developed in a rather disturbing way. A health worker that had been caring for Patient 0 has now been diagnosed with Ebola. This happened overnight. The patient was under self monitoring, had a mild fever, went to the hospital, was tested, and the reasonably reliable preliminary test indicated Ebola. A second much more reliable test is being done now but it is expected to be positive.
I just watched the news conference and from this I gathered the following important bits about the new patient.
<li>The patient was in the low risk pool. Among Patient 0's contacts, there were higher risk and lower risk. Higher risk individuals were being isolated and/or monitored very closely, lower risk individuals were self monitoring. This patient was self monitoring.</li> <li>The person cared for Patient 0 during his treatment prior to his death at Texas Presbyterian; there was no contact during the initial botched visit. </li> <li>The new Ebola patient used protective procedures (gown, mask, gloves) in that care. The exact nature of the care beyond that is being kept secret at the moment owing to HIPAA rules. (But see below to see how absurd the HIPAA rules are in this case.)</li> <li>The new patient seems to have lived with a second person who is now also in isolation.</li>
Hazmat suit wearing teams arrived during the night at the apartment complex of the new patient, and decontaminated public areas such as the lobby of the apartment building, and the interior of the patient’s car. It is thought that there is a pet inside the person’s apartment, but teams, as of this writing have not entered the apartment. They plan to do that soon. Local police doorknocked everyone in the “immediate area” to explain to them that they should not panic, did a “reverse 911” call for the area, and are re-door knocking this morning. So, the identity of the patient will be known any moment now because you can’t really do all that without that happening. (Which, frankly isn’t too relevant. I’m not sure if HIPAA rules should protect health care workers in quite the same way as patients, though they may in fact do so.)
So, what is the meaning of this all?
First it means that when hundreds of administrators, police, government officials, hospital employees, health workers, etc. are tasked with the job in the US of making sure no one gets Ebola from a person who has Ebola, and also tasked with the care of that person, a) one person gets Ebola anyway, and b) the first patient dies.
I very quickly add that this is a TINY SAMPLE SIZE OF N=1 and I’m being a bit cynical here. But it is still true that all these resources failed to prevent what every one feared, and what the authorities said would not likely happen.
Second, note that this new patient did not get Ebola from Patient 0 prior to his first visit to the hospital, or after that first botched visit. Again, small sample size, but it points out something important. When we say that a human with Ebola can spread the disease only when they are symptomatic, that probably doesn’t even count the initial fever period. Infectiousness is probably correlated to the severity of the symptoms. The family members or heath workers who deal with the bodily fluids randomly coming out of a person who is dying of Ebola, bed ridden and very sick, are at the highest risk, even those in the lower risk pool like this new patient. (This is why the HIPAA rules need to be set aside. We actually need to know what this person’s role in the process was, what this person did exactly. That is important information that the public has a right to know. If this reveals the name of the worker by deduction, then so be it. The person’s name has already been effectively revealed by deduction form the activities at the person’s home.) But, importantly, once a person is really infectious, they are really, really, infectious. See my quick note below on spread of Ebola.
Third, note that the medical authorities have said all along that following proper procedures minimizes risk. Note that even when following proper procedures one person was infected anyway. Note that at this morning’s press conferences, the authorities have not changed their story. This is partly your fault, members of the public, because collectively you seem unable to understand that Ebola is both very dangerous and manageable. Your collective insistence that your fear being ramped up is somehow proof that Ebola has gone airborne is an example of that. If you collectively stop being unmitigated morons about this, then the authorities can stop being alarmingly Orwellian about it. Maybe.
Fourth, think about this. A huge effort is made to avert a possible Ebola outbreak. The effort fails in a couple of ways, but we get lucky, those failures don’t cause too many problems other than, possibly, the death of the patient because care was not timely and proper drugs were not administered. But as far as the concern over an outbreak goes, the early screw ups did not cause one. So, proper and resource intensive procedures are in place and everything is going as well as it can be. Then somebody gets ebola anyway. This explains West Africa. Here, in the US, we have 200 people for every Ebola patient. In West Africa, you might have 1 person for every 100 (possible) patients out there. Those numbers are made up, but you get the point. In order to limit Ebola in West Africa we’d have to do what we can do here, and that proves to be of limited utility. Prior outbreaks were stopped because of the high ratio of health workers AND the disease burning out by killing almost everyone in some families or small villages so spread was stopped. So now we have a better sense of what is going on there. Imagine that every person in the US isn’t just someone who heard about Ebola in some other city. Imagine, instead, that everybody in the US lives in an apartment building in which one or two other people in the building have Ebola. And there are no hospitals.
So, collectively, that is all good news and bad news. One more piece of good news: We are near the end of the period during which someone who may have been infected might show up.
On the spread of Ebola
I’ve written about how Ebola is spread before and about the unlikelihood of it “becoming airborne” (see links below). But I keep hearing, again and again, that this or that vague observation someone has made proves that it has already gone airborne. Well, I’ve got a bit more to add to that discussion to help people put it in perspective. The truth is, pretty much every one who is saying it is already airborne or that it is likely to go airborne or that eventually it is inevitable that it will go airborne is an airhead. Sorry for the strong language, but at this point it is simply true that with so much information out there about this being utterly wrong is not acceptable.
Consider Norovirus. It is roughly as infectious as Ebola. Two years ago, for example, we had an outbreak of it here in the Twin Cities. Someone at my son’s daycare had it. Then my son, then everyone else at his daycare, and everyone in our family, and everybody. Had it been fatal, the entire region would be dead. It is not airborne, but it is a disease that there is a good chance all the people crowing about Ebola needing to be airborne have had, have seen in action. Next time you feel the need to insist that Ebola is airborne remember the last time everybody in your family, one by one, got the “stomach virus” (as it is often called). It wasn’t airborne. You got it because germs form someones’ poop or vomit got into your mouth. Perhaps you should not have been licking people’s anuses or drinking their vomit with a straw during that time. Oh, you claim you did neither of these things? OK, fine, you weren’t doing that. But you still got kooties that came from vomit or poop. The way bodily fluids get around, and the opportunities for contact, are much greater with Ebola. With the stomach flu, most of the time most people can make their own way to the bathroom to have diarrhea and vomiting. With Ebola, the sicker patients are lying in bed doing this in a closed room. Everything gets kooties on it. Maybe they were soiling themselves and puking for a few hours in a “taxi” waiting to get into a hospital. Touch touches stuff that touches stuff and bits of Ebola rich feces or Ebola laced vomitus are now on your hands.
Even the flu is only barely spread airborne, but mainly through direct or indirect contact. Ebola is more infectious because it does better with indirect contact.
UPDATE: Major Media is reporting, based on a Sunday AM show interview, that there was a “breach” in protocol in Dallas. But the doctor interviewed did not say that. He said, essentially, that there must have been a breach but they do not know what happened. This is important for media to get right, and it is the media’s job to get these things right. If there was no breach in protocol, then the existing protocol allows for Ebola to cross the boundary. If there was in fact a breach, and we know what it was and can confirm it, that is a very different situation. To be clear: The fact that protocol was in place and used and Ebola got across does NOT mean that Ebola is being transmitted by air or in some other unknown way. It could mean that protocol was breached, but without specific evidence we don’t know that to be true, and we don’t know what went wrong. In between these two is the very high probability that standard protocol has a weakness or two that could be shored up. Personally, based on my own experience (not with Ebola) and based on some reports from the field, I would suggest this has to do with how gowns, masks, and esp. gloves are handled. You have to use the same kind of protocol to remove these things as when you are using these things. Perhaps care workers should be demasked, degloved, and degowned by a masked/gloved/gowned coworker who has just suited up in a space away from the patient. (I don’t think that is done now.)