Ebola Outbreak 2014
In a related outbreak highly qualified Australian Chairperson suspects MERS is a bioweapon:
When I google Mers bioweapon I get articles from 2003 and from conspiracy sites.
Look at this woman's credentials and you will understand why she is so well qualified to make this interpretation (she has devoted her career to being able to answer this question)
"She has won numerous awards for her research including the Sir Henry Wellcome Medal from the US Association of Military Surgeons for her work on risk analysis of bioterrorism;"
If this really breaks out please get lots of sources for your info…..
An obligatory phase of all disasters seems to be when representatives of the status quo try to keep the game going without interruptions by issuing authoritative statements that "there is nothing to worry about." Too bad that these statements cannot be relied on to offer realistic risk assessments. Alas, we are forced to think for ourselves. (Or to wait for Chris' report!)
This morning Zerohedge reports:
Limitation of my summary: I am not an expert in tropical diseases, travel medicine and have never seen anyone with Ebola, so my summary here is entirely "book knowledge," gathered from articles and studies that are a couple of years old, and is the perspective of a non-specialist.
GeoSentinal (and here) is a network that tries to keep track of international movement of infectious diseases. UpToDate Online is a subscription text service with a chapter on evaluating sick travelers returning from sub-Saharan Africa. I'll hit the high points of my understanding of Ebola risk at this point in time. [PM me if you'd like me to send you the pdf of this UpToDate chapter–SP] And I'd love to hear from others.
1. Ebola is a viral infection that presents with a "flu-like illness" very much like hundreds of other viral and bacterial infections. Fever, chills, headache, body aches, weakness (and sometimes vomiting, diarrhea and sore throat). But, those infected quickly become too weak to get out of bed (prostration, sepsis). They LOOK SICK.
2. In a GeoSentinal 2006 report of some 4,000+ sick travelers, someone returning to the US from Sub-Saharan Africa with a fever, 62% have malaria, 6% Dengue, and 28% could not be identified. In those returning with diarrhea, the parasites giardia and ameba were tops, and bacteria camphylobacter, shigella and salmonella, next, and unidentified viruses about 30%.
3. At this moment, a febrile, sick person who just came in from Africa probably has one of these common infections, not Ebola. (Like 6-8 orders of magnitude more likely!)
4. Despite its scariness, the transmissibility of Ebola seems pretty low. The best information I find is that you can sit in the same room with an infected person and not catch it. Latex gloves, a mask that covers nose and mouth and an eye shield would protect against minor splashes of bodily fluids in a social proximity contact type of situation like sitting on the same bus or in the same doctors waiting room. However, a healthcare worker who was starting an IV, giving a bed bath or cleaning up diarrheal stool would need a full suit and face shield–like right out of a movie. Routes of infection: One vet who did an autopsy on an infected monkey, people eating poorly cooked monkey meat, eating fruit that fruit bats had salivated on. Mostly though, Ebola is passed to the family members of the sick person who have intimate contact with bodily secretions as they care for their loved one. [Much sadness here.]
5. The hemorrhage part. Very scary imagery, but only about 50% of Ebola cases have hemorrhages and most of those are not terribly dramatic. Bleeding from an IV site, easy bruising of the skin and conjunctival hemorrhages were most common manifestations of "hemorrhage." And the hemorrhages were late stage developments in people already feverish and profoundly weak. Very few actually vomit blood or pass lots of bloody diarrhea.
Some of the infectious diseases mess with the clotting system so that oozing capillaries keep oozing. (Technically, DIC). With conjunctival hemorrhage, pictured above, a few drops of blood collect on the outside of the sclera (the white rubbery part of the eyeball), and under the conjunctival membrane (the thin transparent membrane covering the sclera.) This gives a very visible bloody eye. Under ordinary conditions in the US, conjunctival hemorrhages are common and are considered entirely benign and simply result from a forceful sneeze, or rubbing an itchy eye. They go away in 7 days. In a healthy person, conjunctival hemorrhages have no medical significance at all. But, in the setting of a high fever and prostration (too weak to get out of bed) in someone just back from Sierra Leone, a hemorrhagic fever like Ebola would be considered.
6. Hemorrhage during an Ebola infection was not predictive of mortality. Some died without hemorrhage and some that hemorrhaged recovered. However, the rare, massive bleeding from the rectum case would be fatal.
My impression here is to not overrate the "hemorrhage" aspect of Ebola infection. It shows up late, is only seen in 50%, and doesn't predict outcome. Major hemorrhage though, is a rare pre-terminal event.
8. Medical treatment is supportive: IV fluids if dehydrated, oxygen if low on oxygen. Much less often: blood transfusion and clotting factors if hemorrhaging, heparin if clotting. Mostly though, quarantine.
Viruses change and adapt. As Aaron mentioned in an earlier post, Ebola has historically killed its hosts quickly limiting the extent of epidemics. A virus becomes more evolutionarily successful as it gets "less ferocious," incubates longer and gives a milder illness so that the host can travel and spread it farther. A model for "evolutionary success" in the viral world might be the chicken pox virus, VZV. It kills almost no-one and has spread to nearly every member of the host population.
What to look for in the news: most important will be the transmissibility issue. Can you catch the virus by being in a crowded social gathering with an unknown infected person. Right now the best answer available is "no."
I have been reading the platitudes from the health officials and while I see their point, I am coming across some faulty logic or unanswered questions. It doesn't make them wrong – I'm not credentialed to question the experts on the matter, and have no special knowledge, but I do have some thoughts I'd like your opinion on.
"It's not easy to catch Ebola"
Well, sure, not in a rural African village which doesn't have a door, sits in the open air and sunlight and lacks business centers, public transportation and cell phones. But how about in an environment in which people are sneezing and coughing and then touching door handles on buildings and cars, sweating in seats and sharing utensils and glasses at diners (that may or may not be properly washed/sterilized)?
Doesn't this change the nature of how we should map the disease?
In short – why are we using the "what we know" template from a situation that is entirely dissimilar?
People live in much closer proximity in the city.
This is unprecedented in Ebola's saga and shouldn't be dismissed…
"The doctor who was in Sierra Leone…"
Was young and healthy.
He used all the proper protocols to avoid it, and was described as "meticulous" and very detail oriented.
So how did he get it – alongside the top doc (now deceased) and another American Aid worker?
Furthermore, he self-quarantined and send his family, who was living with him in Sierra Leone, back to Abilene, Texas about 5 days ago. His family is said to be 'self-monitoring' for symptoms, but "very unlikely to be infected". I do believe that if they are infected, local powers will quickly and easily quarantine the disease. But I'm interested in hearing about the epidemiology involved…
"It's unlikely it'll make it to the U.S."
I'm as Amerocentric as the next guy, but this is like watching a fire in a town upwind and the firefighters saying "we've got it covered", while picking at their fingernails leaning up against the light post. My hope, and I'm sure a lot of others as well, is that the 'keep calm' attitude is prevailing, and there are actually people working on keeping this as quarantined as possible. It might have a few houses to burn down before it reaches the U.S., but that is still a possibility.
What's the bottom line, Sand_Puppy?
Do you think these elements make it worth keeping a close eye on, or is it another SARS/H1N1 type disease, that lacks communicability and will die out organically within a couple months?
The fact that this seems to have only 60% mortality rate seems to me to make it more likely to spread.
The previous outbreaks seem to have been jumped all over and contained very quickly. This one has not.
I read several of the Ebola/pandemic books a few years ago, but that is the extent of my knowledge on the subject.
An e-book I was reading last week by some doctor regarding scavenging medical supplies mentioned that latex gloves do not block viruses, only bacteria. The ZH article above mentioned using latex gloves. The e-book said that when protecting against viruses you need nitrile gloves.
I agree with what AM said regarding the difference between containing in a small rural village and in large cities possibly connected by air travel.
There is still lots not known about how ebola is transmitted. It seems reasonable to stay at least moderately worried while hard numbers on transmissibility come in.
And the BIG question is aerosol transmission.
1. In some non-human primates, it IS possible to infect an animal with an aerosolized spray delivered into the trachea.
2. But it was NOT possible to infect mice with aerosolized EBOV unless the mice were first bred to have a genetic defect in immunity. http://www.ncbi.nlm.nih.gov/pubmed/21852521
3. And epidemiological evidence (that I read but can't locate quickly) says that aerosol transmission is not the normal mode of spread.
So there is lots just not known.
Let me know what you are hearing, Aaron.
I thought this was a fascinating account of the trials of trying to care for suspected Ebola patients in a third world country with minimal resources–a makeshift Ebola ward. The staff is afraid to approach the patients or even enter the ward, the patients are afraid of each other (and rightfully so, it turns out some of those put in the Ebola ward did not have Ebola), and no one has the resources to do anything creative. Minimal food and water were available so the patients are hungry and dehydrated. Some were too sick to clean up their diarrhea and vomit and no one would approach them to help. It took days to weeks for a blood sample to be tested and the diagnosis to be clarified one way or the other. But until cleared, they were told if they left the ward they would be shot.
Ebola: Anticipating challenges and improving patient health and safety measures on makeshift filovirus wards
The WHO offers this document recommending procedures for healthcare workers caring for suspected Ebola patients. So far, I am not finding any discussion of the latex vs nitrile protective gloves issue Joe mentioned.
The question of the transmissibility of Ebola will be clarified most decisively in the next 7 to 14 days.
Patrick Sawyer, an American businessman of Liberian descent, flew to Africa as a part of his work promoting trade. While there, he cared for is sick sister who subsequently died. It turns out, she had Ebola, something not known at the time. Mr Sawyer was apparently infected while caring for her (or preparing her for burial?).
He then flew on 2 flights through 3 airports (Monrovia in Liberia, Lome in Togo, and Lagos in Nigeria) while he was developing worsening symptoms and collapsed in the Lagos airport. He was taken to a hospital where he later died.
Fellow passengers were reportedly given warning about the symptoms of Ebola, but allowed to continue their travels. The names of the exposed passengers (and their destinations) were not released.
So here it is guys: If Ebola is transmissible through casual contact or aerosol we will know this without a doubt in the next 7 to 14 days. If not, we will know that, too. This is the acid test.
I think that I'll top of my rice and beans supply and freshen the water jugs while we wait for resolution of this question.
Obama is continuing on with a summit of African leaders–including leaders from infected countries. Meanwhile, a US senator is calling for us to close the borders to countries where it has already landed.
Me,? I just finished my habitual Summer restocking of our pantry and medicine cabinet. Yes, Sand_puppy, I am (as usual) prepared to shelter in place for a month. But this time, it's with masks, gloves, and antivirals.
We are getting a bunch of XXL (our hand size) nitrile gloves from Grainger. I have to wash the dishes anyhow.
I felt bad for not at least attempting to do the level of background research that most of you do before I made my glove comment. I did a quick search and found three articles that did not rule out latex gloves for stopping viruses. The test for virus blocking is quite elaborate and usually not performed by the manufacturers.
It might be that the quality of the glove rather than the material is the determining factor. They also are concerned with the strength of the glove against ripping or puncture. They seem to advise wearing two gloves in sensitive situations.
It seems to me that the main reason for choosing latex over nitrile is cost, which at the quantities we are talking about should not be an issue.
Here are some of the links.
Thanks for the info and updates, Doc, I'd be curious to know how big your audience among health care workers out here in the pucker brush is. No pressure.
What if Mr. Sawer hadn't become symptomatic for another week and had presented at an ER in Minnesota? How long would it have take before some asked if he'd been traveling in Africa recently? How long would it have taken if he had been white and not spoken with an African accent? What if Dr. Brantley had returned to Texas with his family? What if the reason he became infected was that he was exposed some were out side of the hospital? How many asymptomatic people are wandering all over the planet right now?
How will the US public health care system respond? I remember vividly a hysterical woman I treated in the early stages of the SARS outbreak. She had been in our waiting room for 30 minutes and had been walked right through our department without a mask. She was so upset that it took me ten minutes to figure out (her English was good, but not fluent) that she had just come from Hong Kong. Even years later the memory of that gut punch moment of standing at her bedside and realizing that I might have been exposed, that I might not be allowed to leave the hospital, that I might not get to see my family again, that I might die, packs an emotional charge. I self quarantined with my patient for several hours as charge reassigned the rest of my rooms and the doctor and radiology came and went in full PPE. Eventually, as she was afebrile, had a clear chest X-ray, and the incubation period was too long, the diagnosis was just a bad cold and we were cleared, but so many things could have gone wrong and being on the wrong side of a quarantine line is scary as hell.
Watching this thing play out is going to be fascinating,