View 848 Sunday, October 26, 2014
“I have observed over the years that the unintended consequences of social action are always more important, and usually less agreeable, than the intended consequences.”
“Transparency and the rule of law will be the touchstones of this presidency.”
President Barack Obama, January 31, 2009
The first Ebola crisis is ended. Both nurses who contracted Ebola from the Texas Patient Zero have been pronounced virus free and released from hospital. More on that below, but it appears that the first two people to contract Ebola in the United States have recovered from it, and there are no more infections.
It is not so clear with the New York Patient Zero, but all the authorities are certain that nothing more will come of it. Meanwhile the procedures have been revised, new equipment shipped to various hospitals, and more stringent check on people coming from the plague zones have been ordered.
Apparently our loss of devotion since the days of Bismarck has not entirely changed the situation. God looks out for fools, drunks, and the United States of America. It would be wise not to count on this to the exclusion of using good sense.
Ebola-there is a lot we don’t know
A few points about the Ebola discussion:
Contagion should have nothing to do with symptoms. Symptoms are just a marker of systemic viremia. There are viruses that can be spread from an asymptomatic person. One important aspect of symptoms is that you are less likely to spread a virus present in body fluids if you aren’t sweating profusely, vomiting, etc.
I would not have been quite so sanguine about exposing the President (despite my political persuasion) to Nurse Pham unless they clearly had demonstrated a zero (undetectable) virion count by polymerase chain reaction testing. Just because she has antibodies protecting her and killing the virus in her body does not mean she can’t spread live virus. It is unlikely, as she wasn’t vomiting on the President.
A key point to know is the number of virions necessary to transmit the virus; this is one (1) for Hepatitis B. I don’t know what it is for Ebola (it may not even be the same number for different strains). It may be higher than one as there can be a lot of virus in blood, vomit, etc.
I note the deaths of Medicine Without Borders doctors; Dr. Fauci has stated on television that disease spread can be controlled with proper precautions, citing zero deaths in MWB healthcare workers. I guess he really didn’t know.
I believe we should also be concerned about the US Gov’t mandating established clinical trial regulations on Ebola vaccine and treatment tests in Africa. The possibility of death from treatment would have to be quite high for me not to risk it if I had or were exposed to Ebola in Africa. I have heard that one trial being contemplated is to use three groups: one getting one Ebola vaccine; one getting another Ebola vaccine and one getting a Hepatitis B vaccine as a "control" group. This in a disease that is 40-70% fatal. We don’t even do this in most Oncology studies where death rates are high. Many people in Africa believe the vaccinations cause Ebola; what will they think when they are in the trial, get the Hep B vaccine and then get Ebola.
Michael Montgomery, MD
As to the dog of Nurse Pham. We know Ebola can be carried by (probably originated in) Monkeys. I don’t don’t think we know anything about Ebola and dogs (can they get, do they get symptomatic, what is the incubation period in dogs, etc.).
Blood tests and observation would be prudent.
Interesting to read posts by Interstellar Woman of Mystery and Brian P. I have seen similar numbers re: strains and relative mortality for Ebola, although the mortality for Marburg was closer to 90% (although I read that last epidemic of Ebola). Some brief observations:
1) I don’t think we have a great understanding of virulence/modes of transmission. So far none of the people that lived with Mr. Duncan and presumably had more exposure have developed Ebola. As the others have pointed out, would seem to indicate viral load is much higher in the preterminal phase. And while it is not a true aerosol, I am able to tell you from personal experience vomit and stool travel much farther and deposit in places you would not think possible. And certainly, if a patient had an underlying lung condition such as sarcoidosis or tuberculosis these people will frequently bleed into the alveoli so that a cough can make a true aerosol (even without abnormal clotting). Given that we do not know all the modes, I think CDC was premature declaring that Nina Pham had broken protocol and that was the cause of her infection. They never explained her breech, and they didn’t account for Amber Vinson’s infection.
2) It follows that we cannot be sure that our protocols are as effective as they need to be to prevent wide spread infection from primary cases. Even if they are, the costs of monitoring and testing are prohibitive. It follows logically that we should try to limit the number of index cases, i.e. limit access from people from the epidemic areas. Nigeria is a relatively poor country with limited health care and they have made quarantine work. "If there are no Moties, there will be no Motie problem". If there are no index cases in the US, there can’t be an epidemic. At the very least people from affected areas should have a minimum of 24 day quarentine from the last possible day of exposure, and these plans need to be in place before traveller’s are admitted to the US. Returning citizens should have to meet the same standards.
3) I cannot see how limiting access to the US inhibits our ability to treat Ebola in situ. Médecins Sans Frontières and other NGO’s manage to get access. We can certainly mobilize govermental health care to go there. So far the only effective treatment seems to be plasma transfusion from survivors and possibly a monoclonal antibody cloned into tobacco plant. Neither of those need patients in the US to test or treat. Makes the logistics a little harder, but certainly no harder than trying to identify and track several hundred potential contacts for every index case.
4) Since there appear to be some strains with much lower morbidity and mortality, it begs the question if these could be used as an effective vaccine. I am sure people are investigating but I have not seen anything in the Emergency Medicine or general Internal Medicine literature yet.
Hopefully, we will adopt some realistic control measures. Robert Heinlein had a story line in his book Friday where he postulated spread of plague as a major world wide pandemic largely due to very brief travel time in relationship to incubation times for infections. Might be different if we had a very sensitive and fairly specific point of care (or immigration) test to identify people in their preclinical phase of infection. In then meantime I would suggest we set up a treatment center somewhere between 1600 Pennsylvania Ave. and 1 First St. SE.
Doug Lewis, MD
The real danger of ebola…
Recently you said "Of course the real danger is that the plague will enter the Middle East and South America."
WIth respect, the real danger is that it will enter India. India has a population of a billion, and half of them are chronically malnourished – this means that their immune systems will be running on low and they will be much more susceptible to infection than well-fed people. In addition, the heavy crowding and extremely poor levels of sanitation would be tailor made for Ebola to spread. Ebola seems not to be airborne (for now), but, a few sick people throwing up in the Ganges…
I suspect that the Indian government knows this and is prepared to shoot suspected Ebola immigrants on sight… But you’ll never hear about it in the mainstream press….
Globus Pallidus XI
Bellevue staffers call in ‘sick’ after Ebola arrives http://nypost.com/2014/10/25/many-bellevue-staffers-take-sick-day-in-ebola-panic/
Live long and prosper
h lynn keith
And this sums up the Ebola situation. The crisis is supposedly over, although we do continue to import people from the plague zones, and we are sending soldiers there.
Freedom is not free. Free men are not equal. Equal men are not free.