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October 26, 2014

Commentary: First US-Contracted Ebola Patient Declared Disease-Free

Filed under: Ebola — Tags: , , — dr steve @ 10:18 am

To the panicky-Petes out there…Mr Thomas Eric Duncan was SYMPTOMATIC and in the community for approximately 4 days after he was sent home from the Emergency Room the first time with fever and gastroenteritis (and given antibiotics, which is another subject altogether).   Despite this, only Nurses Nina Pham and Amber Vinson are known to have contracted the illness from him.   The 3 week deadline from his ultimate isolation on Sept 28 is over.  There has been no great outbreak of Ebola in Dallas, and one is not expected in NYC from Dr Craig Allen Spencer’s “Big Day Out” as he was not symptomatic at any time and isolated himself within hours of becoming febrile.

I don’t agree with Quarantine, at least not the way it is being done to Kaci Hickox…but the lack of self-isolation by people like Nancy Snyderman and Dr Spencer create significant issues with contact tracing and increase societal anxiety.   We should not relieve people of their personal liberties just because people don’t understand the science behind Ebola transmission, but on the other hand we must do what we can as medical professionals to allay these fears.   If Dr Spencer had self-isolated and then became symptomatic, I’m quite convinced none of this mandatory quarantine business would have happened…until the next case, of course.

The CDC  has specific recommendations for asymptomatic people who have come into contact with Ebola virus:

  • Conditional release and controlled movement until 21 days after last known potential exposure
    • By “conditional release” they mean “people are monitored by a public health authority for 21 days after the last known potential Ebola virus exposure to ensure that immediate actions are taken if they develop symptoms consistent with EVD during this period. People conditionally released should self-monitor for fever twice daily and notify the public health authority if they develop fever or other symptoms.”
  • Controlled Movement “requires people to notify the public health authority about their intended travel for 21 days after their last known potential Ebola virus exposure. These individuals should not travel by commercial conveyances (e.g. airplane, ship, long-distance bus, or train). Local use of public transportation (e.g. taxi, bus) by asymptomatic individuals should be discussed with the public health authority. If travel is approved, the exposed person must have timely access to appropriate medical care if symptoms develop during travel. Approved long-distance travel should be by chartered flight or private vehicle; if local public transportation is used, the individual must be able to exit quickly.”

So the CDC so far does not recommend quarantine, even if a person has:

  • Direct skin contact with, or exposure to blood or body fluids of, an EVD patient without appropriate personal protective equipment (PPE)
  • AND is asymptomatic

If governments are going to quarantine people who return from close contact with the Ebola virus despite the CDC’s recommendations, and despite what we know about Ebola transmission, how about an ankle bracelet and home monitoring?   At least then they could binge-watch “Breaking Bad” or “Sons of Anarchy” (or “The Strain”!  Horrors!)  And if we’re going to mandate a 21 day quarantine, compensation for lost time at work needs to be part of the equation.  The government has the right to require quarantine;  it doesn’t appear to be necessary to prevent the spread of disease, but some politicians feel it’s necessary to prevent the spread of panic. If they’re going to do this, it should be done as humanely and as comfortably as possible.  These health care workers are heroes and need to be treated as such.

Some have proposed quarantine before people LEAVE the area;  this would certainly work, but it needs it be in at least 4 star surroundings, with access to food, electricity, clean water, and communications.  We need health care providers to travel to Ebola-stricken areas to stop this at the source;  giving them a well-earned 3 week vacation at the end of their tour sounds better than “quarantine”, doesn’t it?

More on this story as it evolves.  See the CNN article below. 

yr obt svt,

Dr Steve

============================================

 

CNN — Nina Pham was the first person to catch Ebola on U.S. soil, and now, 13 days after testing positive, she has been declared free of the deadly disease.

Her first order of business will be to hug her dog, Bentley, she said Friday.

She invoked God and science in expressing gratitude for her ongoing recovery from a disease that has no established cure.

“I feel fortunate and blessed to be standing here today,” she said. “Throughout this ordeal, I have put my faith in God and my medical team.”

Nurse cured of Ebola: I’m so fortunate

Where is the Ebola dog Bentley?

After being greeted by her father, Peter, Nina Pham is presented with scrubs signed with well wishes by her colleagues at Texas Health Presbyterian Hospital Dallas.
After being greeted by her father, Peter, Nina Pham is presented with scrubs signed with well wishes by her colleagues at Texas Health Presbyterian Hospital Dallas.

Later Friday, President Barack Obama met Pham in the Oval Office and gave her a big hug.

Prayer sustained her, and she thanked people around the world who prayed for her, Pham told reporters Friday at a National Institutes of Health hospital in Bethesda, Maryland.

The nation saw a cheerful and composed Pham, dressed in a bright turquoise top and matching necklace, when she strode to a bank of microphones moments after Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said she was free of the virus.

Complete coverage of Ebola

She thanked Dr. Kent Brantly, the American physician who also survived Ebola, for donating his plasma to her while she was sick.

But she’s not entirely out of the woods, she said.

“Although I no longer have Ebola, I know that it may be awhile before I have my strength back,” Pham said. “So with gratitude and respect for everyone’s concern, I ask for my privacy and for my family’s privacy to be respected as I return to Texas and try to get back to a normal life and reunite with my dog, Bentley.”

Bentley, a Cavalier King Charles spaniel, remains in quarantine until the end of the month in Texas, but Pham “will be able to visit, hold and play with him tomorrow,” Dallas County Judge Clay Jenkins said Friday.

“I know that will be good for both of them,” said Jenkins, who oversees the Ebola response in Dallas.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, hugs Nina Pham outside the National Institutes of Health in Bethesda, Maryland.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, hugs Nina Pham outside the National Institutes of Health in Bethesda, Maryland.

A ‘stressful and challenging’ time

Pham, 26, who grew up in a Vietnamese family in Fort Worth, Texas, graduated with a nursing degree in 2010 and just months ago received a certification in critical care nursing, which deals with life-threatening problems.

The Ebola experience, she said, was a “very stressful and challenging” time for her.

Without direct reference to the continent, she alluded to how Ebola has ravaged West Africa in an unprecedented outbreak that the World Health Organization says has caused almost 10,000 confirmed or probable cases of infection and 4,877 deaths as of this week.

“I am on my way back to recovery even as I reflect on how many others have not been so fortunate,” she said.

White House press secretary Josh Earnest called Pham’s case “a pretty apt reminder that we do have the best medical infrastructure in the world.”

“The track record of treating Ebola patients in this country is very strong, particularly for those who are quickly diagnosed,” Earnest said. “The fact that she has been treated and released I think is terrific news.”

The first to catch virus on U.S. soil

Can pets get or spread Ebola?

Pham was among the doctors and nurses in Dallas who treated Thomas Eric Duncan, the first person to be diagnosed with Ebola in the United States. His diagnosis came after he returned from a trip to West Africa, and he died on October 8.

Three days later, Pham tested positive for the Ebola virus, becoming the first person in the United States to contract Ebola on American soil. That sent waves of anxiety through the network of health care workers — and beyond.

Latest Ebola developments

Those anxieties deepened on October 15 when a second nurse in Dallas, Amber Vinson, tested positive for Ebola. Vinson had flown from Dallas to Cleveland and back, prompting an airline to warn passengers on both legs of her trip as well as passengers who took subsequent flights on an aircraft she used. Some schools closed. Health departments monitored dozens of people.

None of them has tested positive for Ebola.

Pham said Friday that her thoughts are with Vinson, who is getting treatment for Ebola at Atlanta’s Emory University Hospital.

Vinson is steadily regaining her strength, and her spirits are high, her family has said. Doctors can no longer detect the virus in her body, but they have not yet determined when she will be discharged, the hospital in Atlanta said Friday.

October 18, 2014

Why We Know Ebola Still Isn’t Easy to Contract (Commentary)

Filed under: Ebola,Steve's Blog — dr steve @ 4:22 pm

Just some quick math to set your mind at ease:

If Ebola were EASY to transmit, there would be a MUCH larger burden of cases in the world right now. Let me show you with math.

Let’s be conservative and say this outbreak started January 1st with one patient. Let’s say this person infected 10 other people, who then infected 10 other people, and so on. With an incubation period of 21 days, and assuming that people can’t transmit the disease until they are symptomatic, it’s pretty easy to calculate where we would be if the above were anywhere close to reality.  (Remember, I’m oversimplifying how this all works, but the answer will still be right enough to make my point).

On Day 21 there would be 10 cases. (1×10)
On Day 42 there would be 100 cases (1x10x10)
On Day 63 there would be 1000 cases (1x10x10x10)
and so on. You’ll notice that with every incubation period, we simply add another exponent to the pile. Period 3 is 1×103, period 4 is 1 x 104, etc.

So for an outbreak that started on January 1st, there have been 290 days (today is Oct 18th, 2014), or 13.8 incubation periods. Let’s round that to 14 to show that a perfectly transmissible virus under these idealized conditions would have caused:

1 x 1014 cases, or 100,000,000,000,000 cases. That’s ONE HUNDRED TRILLION (in American parlay, where a billion is known as a “thousand million” everywhere else) cases, or enough to wipe us all out several times over.

The reality:

Total Cases: 8997

Laboratory-Confirmed Cases: 5006

Total Deaths: 4493

(from cdc.gov)

Ok, this is the worst outbreak of Ebola in recorded history and we need to contain it, and learn how to treat it more effectively.   Every death is a tragedy, and every illness creates anxiety.   I really want you to pay attention to those numbers and understand them, though.  Despite everything, Ebola is hard to catch…this is why in the US (so far, tomorrow could prove me wrong) the only people who have contracted the disease on our soil were health care workers, basically immersed in the stuff.

What’s scary about Ebola is its mortality rate, and the WAY people die from the virus.  We may very soon have some good news on those fronts, too.  People have been discovered who have antibodies to the virus but never got sick.   These people may provide some very important insights into the inflammatory response of the body to the virus which wreaks such havoc.  In addition, there are labs all over the world with mouse-myeloma hybrid cells churning out monoclonal antibodies RIGHT NOW (more on this later if you’re interested) that may very soon give us an unending supply of antibodies to treat infected people.   A vaccine would set people’s minds at ease, particularly if it worked quickly so we don’t have to vaccinate the whole world and only people who have been exposed to the virus (similar to what was done with smallpox).  Ultimately tracking this piece of crap virus down to the animals that harbor it and vaccinating THEM would kick this virus’s ass once and for all.

Anyway, enjoy.  Follow the Ebola story with interest and watch how we defeat it (Nigeria did it, so can we), but don’t panic about it.  Ok?

 

your obt svt,

 

Dr Steve

 

PS: Here’s the CDC’s take on transmission of Ebola virus.  We discussed some of these issues in our podcast last week, and again on the Saturday, Oct 18 episode of “Weird Medicine” on SiriusXM (Sirius 206, XM 103, 10pm Eastern).

October 4, 2014

Finally Some Good Ebola News

Filed under: Ebola — dr steve @ 9:21 am

What Texas can learn from Nigeria when it comes to containing Ebola

By Elahe Izadi October 4 at 7:43 AM

While devastating reports continue to stream out of West Africa, where the deadly virus has overwhelmed already weak public health systems and left thousands of people dead, and anxiety grips the United States over the first case of Ebola diagnosed in the country, one nation serves as an example of hope: Nigeria, which appears to have successfully contained Ebola.

As concerns spread over U.S. hospital readiness, there are some lessons to be learned from Nigeria, where officials managed to get ahead of the fast-moving virus after it was brought into Africa’s most populous country by an Ebola-infected man who’d flown into Lagos. This week, the U.S. Centers for Disease Control and Prevention reported that the outbreak could be coming to an end in Nigeria, with no new Ebola cases since Aug. 31.

As in the U.S. case, Ebola arrived in Nigeria by passenger plane. But unlike Thomas Eric Duncan — who arrived in Dallas before he became symptomatic and was therefore not contagious during his flights from Liberia to Texas through Brussels and Dulles International Airport — Patrick Sawyer was already symptomatic when he landed in Lagos on July 20. At that point, Sawyer, Nigeria’s Patient Zero, was contagious and dying.

It was a nightmare scenario with the potential to spiral out of control, given the bustling city of Lagos, Africa’s largest, is a major transportation hub. As Sawyer was placed in isolation, public health officials had to track down every single person who’d come into contact with him, from the flights he’d boarded to the Lagos airport and the private hospital where he went after landing. And they had to do so quickly, making the process known as contract tracing a priority.

“In the whole system approach in beating the war on Ebola, contact tracing is the key public health activity that needs to be done,” said Gavin MacGregor-Skinner, who helped with the Ebola response in Nigeria with the Elizabeth R. Griffin Research Foundation. “The key is to find all the people that patient had direct close contact with.”

From that single patient came a list of 281 people, MacGregor-Skinner said. Every one of those individuals had to provide health authorities twice-a-day updates about their well-being, often through methods like text-messaging. Anyone who didn’t feel well or failed to respond was checked on, either through a neighborhood network or health workers.

Nigeria took a “whole community approach,” with everyone from military officials to church elders in the same room, discussing how to handle the response to the virus, MacGregor-Skinner said.

Such an approach, and contact tracing in general, requires people be open and forthright about their movements and their health, he said. Stigmatization of patients, their families and contacts could only discourage that, so Nigerian officials sent a message to “really make them look like heroes,” MacGregor-Skinner said.

“This is the best thing people can do for Nigeria: They are going to protect and save Nigeria by being honest, by doing what they need to do, by reporting to the health commission,” he said. This made people feel like they were a part of something extremely important, he said, and also took into account real community needs. “You got real engagement and compliance from the contacts. They’re not running and hiding.”

Sawyer had come into contact with someone who ended up in Port Harcourt. That person, a regional official, went to a doctor who ended up dying from Ebola in August. Within a week, 70 people were being monitored. It ballooned to an additional 400 people in that one city.

Success stories of people coming through strict Ebola surveillance alive and healthy helped encourage more people to come forward, as they recognized that ending up in a contact tracer’s sights didn’t mean a death sentence.

In the end, contact tracers — trained professionals and volunteers — conducted 18,500 face-to-face visits to assess potential symptoms, according to the CDC, and the list of contacts throughout the country grew to 894. Two months later, Nigeria ended up with a total of 20 confirmed or probable cases and eight deaths.

The CDC also pointed to the robust public health response by Nigerian officials, who have had experience with massive public health crises in the past — namely polio in 2012 and large-scale lead poisoning in 2010.

When someone is on a contact list, that doesn’t mean that person has to stay at home for the entire incubation period of 21 days from the last contact with someone who had Ebola. People on contact lists are not under quarantine or in isolation. They can still go to work and go on with their their lives. But they should take their temperature twice a day for 21 days and check in with health workers.

Officials in Texas began with a list of about 100 names; they have whittled the list down to 50 people who had some contact with Duncan. Of those, 10 are considered high-risk.

The CDC recommends that people without symptoms but who have had direct contact with the bodily fluids of a person sick with Ebola be put under either conditional release, meaning that they self-monitor their health and temperature and check in daily, or controlled movement. People under controlled movement have to notify officials about any intended travel and shouldn’t use commercial planes or trains. Local public transportation use is approved on a case-by-case basis.

When symptoms do develop, that’s when the response kicks into high gear. People with Ebola are contagious only once they begin exhibiting symptoms, which include fever, severe headaches and vomiting.

While four people in Dallas are under government-ordered quarantine, that is not the norm. Those individuals “were non-compliant with the request to stay home. I don’t want to go too far beyond that,” Dallas County Judge Clay Lewis Jenkins said Thursday.
On Friday, the four people were moved to a private residence from the apartment where Duncan had been staying when he became symptomatic.

A law enforcement officer will remain with them to enforce the order, and none of the people are allowed to leave until Oct. 19.

Duncan is the only person with an Ebola diagnosis in Dallas, and no one else is showing symptoms at the moment. But, as Nigeria knows, the work in Dallas has just begun.

August 9, 2014

What’s Scary About Ebola, Reasons Not to Fear It

Filed under: Ebola — dr steve @ 6:18 pm

from abc.com

What’s Scary About Ebola, Reasons Not to Fear It

WASHINGTON — Aug 9, 2014, 9:48 AM ET
By CONNIE CASS Associated Press

 

The United States’ top disease detective calls Ebola a “painful, dreadful, merciless virus.”

The World Health Organization has declared the outbreak in West Africa an international emergency, killing more than 900 people and spreading.

That’s scary and serious. But it also cries out for context.

AIDS alone takes more than a million lives per year in Africa — a thousand times the toll of this Ebola outbreak so far.

Lung infections such as pneumonia are close behind as the No. 2 killer. Malaria and diarrhea claim hundreds of thousands of African children each year.

In the United States, where heart attacks and cancer are the biggest killers, the risk of contracting the Ebola virus is close to zero.

Americans fretting about their own health would be better off focusing on getting a flu shot this fall. Flu is blamed for about 24,000 U.S. deaths per year.

To put the Ebola threat in perspective, here are some reasons to be concerned about the outbreak, and reasons not to fear it:

———

WHY IT’S SCARY

There is no cure for Ebola hemorrhagic fever.

More than half of people infected in this outbreak have died. Death rates in some past outbreaks reached 90 percent.

It’s a cruel end that comes within days. Patients grow feverish and weak, suffering through body aches, vomiting, diarrhea and internal bleeding, sometimes bleeding from the nose and ears.

The damage can spiral far beyond the patients themselves.

Because it’s spread through direct contact with the bodily fluids of sick patients, Ebola takes an especially harsh toll on doctors and nurses, already in short supply in areas of Africa hit by the disease.

Outbreaks spark fear and panic.

Health workers and clinics have come under attack from residents, who sometimes blame foreign doctors for the deaths. People with from Ebola or other illnesses may fear going to a hospital, or may be shunned by friends and neighbors.

Two of the worst-hit countries — Liberia and Sierra Leone — sent troops to quarantine areas with Ebola cases. The aim was to stop the disease’s spread but the action also created hardship for many residents.

———

WHERE IT IS

The outbreak began in Guinea in March before spreading to neighboring Sierra Leone and Liberia. A traveler recently carried it farther, to Nigeria, leading to a few cases in the giant city of Lagos.

Ebola emerged in 1976. It has been confirmed in 10 African nations, but never before in the region of West Africa.

Lack of experience with the disease there has contributed to its spread. So has a shortage of medical personnel and supplies, widespread poverty, and political instability.

Sierra Leone still is recovering from a decade of civil war in which children were forced into fighting. Liberia, originally founded by freed American slaves, also endured civil war in the 1990s. Guinea is trying to establish a young and fragile democracy.

Nigeria, Africa’s most populous country, boasts great oil wealth but most of its people are poor. The government is battling Islamic militants in the north who have killed thousands of people and kidnapped more than 200 schoolgirls in April.

This outbreak has proved more difficult to control than previous ones because the disease is crossing national borders, and is spreading in more urban areas.

Tom Frieden, director of the U.S. Centers for Disease Control and Prevention, predicts that within a few weeks, Ebola will sicken more people than all previous occurrences combined. Already more than 1,700 cases have been reported.

Global health officials say it will take months to fully contain the outbreak, even if all goes as well as can be hoped.

———

REASONS NOT TO BE AFRAID

Ebola is devastating for those it affects. But most people don’t need to fear it. Why?

—Ebola doesn’t spread easily, the way a cold virus or the flu does. It is only spread by direct contact with bodily fluids such as blood, saliva, sweat and urine. Family members have contracted it by caring for their relatives or handling an infected body as part of burial practices. People aren’t contagious until they show symptoms, Frieden said. Symptoms may not appear until 21 days after exposure.

“People should not be afraid of casual exposure on a subway or an airplane,” said Dr. Robert Black, professor of international health at Johns Hopkins University.

—Health officials around the developed world know how to stop Ebola. Frieden described tried-and-true measures: find and isolate all possible patients, track down people they may have exposed, and ensure strict infection-control procedures while caring for patients. Every past outbreak of Ebola has been brought under control.

The CDC is sending at least 50 staff members to West Africa to help fight the disease, while more than 200 work on the problem from the agency’s headquarters in Atlanta. The WHO is urging nations worldwide to send money and resources to help.

—It’s true that Ebola could be carried into the United States by a traveler, possibly putting family members or health care workers at risk. It’s never happened before. But if the disease does show up in the U.S., Frieden said, doctors and hospitals know how to contain it quickly.

“We are confident that a large Ebola outbreak in the United States will not occur,” Frieden told a congressional hearing Thursday.

———

OTHER THINGS TO WORRY ABOUT

Ebola’s toll is minuscule compared with other diseases that killing millions of people.

“The difference is the diseases that do kill a lot of people — malaria, diarrhea, pneumonia — they cause their problems over time,” Black said. “They’re not generally epidemic. They’re not the kind of sudden burst of disease and death that creates fear like this.”

The common diseases have far lower mortality rates. They kill so many people because such huge numbers are infected.

In comparison, Ebola is manageable.

“The order of magnitude of the resources to control Ebola in small communities in three or four countries is very small compared to controlling malaria in all of Asia and Africa,” Black said. “I don’t at all think we should hold back on the resources to control Ebola, but we need more resources to control these major killers of children and adults that we’re making too little effort against.”

———

Associated Press writers Lauran Neergaard in Washington, Marcia Chen in London, and Michael Stobbe in New York contributed to this report.

———

Online:

Centers for Disease Control and Prevention: http://www.cdc.gov/vhf/ebola

World Health Organization: http://www.who.int/csr/disease/ebola/en

 

August 5, 2014

Ebola News 08-05-14: Isolating Possible US Cases

Filed under: Ebola — dr steve @ 3:36 pm

From ABC News

 

Hospitals across the country are isolating and testing potential Ebola patients, erring on the side of caution as the largest Ebola outbreak to date rages in West Africa.

A 46-year-old Columbus, Ohio, woman who recently traveled to one of the three countries affected by the outbreak is being held in isolation at a local hospital, the Columbus health department said today. She was hospitalized several days ago but is “doing well” as she awaits Ebola test results from the Centers for Disease Control and Prevention, which are expected today or Wednesday, the health department said.
(more…)

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