Tag Archives: Outbreak

First person in US to catch Ebola: The Meaning of Ebola Patient Two (updated)

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.)

More on Ebola:

Two Ways Hollywood and Literature Have Confused The Ebola Problem

According to popular literature (some fiction, some not) and movies, Ebola can cause havoc, infecting thousands of people, killing over half of them, and threatening an entire nation if it were to become airborne. Turns out that’s not true. Ebola can do all those things without becoming airborne. In several nations.

The confusion caused by this misconception is further enhanced in a more subtle way. Since the Hollywood version of Ebola (or some other similar disease) indicates that it is dangerous because it becomes airborne, we see constant claims today on the Internet that Ebola must be airborne because it is out of control in West Africa. And, of course, we see claims that it is only a matter of time before it becomes airborne. But an examination of the disease from an evolutionary perspective suggests that this is extremely unlikely. It is almost as though people have to believe that Ebola will eventually become airborne (or already is) to take it seriously. It wont’ become airborne. You must still take it seriously.

So that is the first area of confusion, about what Ebola is and what it does and does not do.

To this confusion, by the way, we may add the already mentioned hyperbolic reaction to Ebola, often of a rather tin-hat variety and the equally incorrect hyperskepticism that has made claims like Ebola is not that big of a deal because it is not malaria. That is also demonstrably false.

The second area of confusion is what is normally done when something like Ebola shows up in the US, as it has in Dallas, Texas. The Hollywood and Literature version is that a big silver truck shows up at the site, people with protective gear jump out of the back, individuals are taken away to Level 4 containment facilities that are handily available nearby, the site is sterilized using high tech devices (or imploded or burned down with flame throwers?), and if there are a lot of possibly infected people, everybody is quickly rounded up and moved in large green trucks to a containment camp run by the Army, with Morgan Freeman in charge whom you think at first is a nice guy but turns out to be evil.

Well, some of that is sort of happening, but slowly and clumsily and with no has-mat suits and no containment camp. As I write this I’m watching the live briefing on Ebola in Dallas. We have just learned that pretty soon some guys are going to go over to the apartment where the family of the patient lives. They will do the laundry when they get there because there might be Ebola kooties on the sheets and pillows. The CDC went grocery shopping for them, and they are being told they can’t leave. So in a way this is a little like what Hollywood says would happen, but with much, much lower production value and pretty much as a post-hoc set of reactions rather than a clear plan always in place just in case.

We are also learning at the news conference that there is not a current plan for where to take a second or third Ebola case. No playbook in place. Having said that, the authorities are confident that they can handle the problem.

None of this is surprising. After all, fiction is fiction. That’s why they call it fiction. What is also not surprising, but disappointing, is the low level of thought behind the questions the press are asking, and the highly unprofessional approach taken by some reporters. Pro tip: Don’t ask only dumb questions, or questions that have already been answered, then be all mad and stuff when the press conference ends sooner than you thought it should.

More on Ebola: