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Is it time to think about Ebola again?

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  • Sat, Jun 15, 2019 - 09:42pm

    #31

    davefairtex

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    MSF managed to keep its people mostly-safe

How did MSF manage to keep its people mostly safe at an Ebola Treatment Center – with no vaccine – in the depths of Africa during the last epidemic, when the fancy hospital in America ran into difficulty?

This story shows it is entirely possible to run an ETC without all your staff – or even most of them – dying from Ebola.  The care is necessarily primitive, but for the patient the survival rate in these centers is better than what the patient will get in the community, and this way the patient won’t end up infecting (and likely killing off) their friends and family.

MSF’s priority: protect the staff at all costs.

https://www.latimes.com/world/africa/la-fg-ebola-doctors-without-borders-20141016-story.html

  • Sun, Jun 16, 2019 - 04:54am

    #32

    sand_puppy

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    How MSF managed EBV patient

It has been 2 years since I read closely the accounts, but the care rendered by MSF was absolutely unlike any medical systems (hospitals or clinics) in the USA or Europe.

They were basically a simple roof over a fenced in field with plastic fencing to limit mixing of those infected and not infected.  Contact between health care workers and patients was almost nothing.  No IVs, no blood tests, no chest x-rays.  The only meds given were Tylenol pills, Compazine pills and Imodium AD pills.  And lots of oral electrolyte solution.  Bathroom was buckets or a porta-potty-like device that the patient managed themselves.  No one checked blood electrolyte tests and did chest x-rays or CT scans, or gave IV antibiotics when a secondary pneumonia set in.

Everything in the patient room was designed to be hosed down with water/bleach mixture several times a day, including the mat that they lay on and the floor around their bed.

No sheets and blankets.  (Warm climate)

No turning on the call light to get a kindly nurse to help you to the bathroom.  It was get yourself to the bathroom.  If you can’t make it and have an accident, the 3 PM hosing of you, your bed and the floor will clean most of it up.

The best I could imagine in the USA would be a converted industrial warehouse with a cement floor, plastic furniture/beds aligned in rows, tarps hung on overhead wires to separate sections, and porta-potties.

MSF Health care workers gowned up and went in for 30 – 45 min at a time, then were out for 2 hours to recover.  Heat and humidity made protective gear difficult to tolerate.  (Think of the high school wrestling team wearing a plastic sweat suit trying to get down to weight prior to a match.)

All of the “standards of care” that restrict operations in US hospital systems (to ensure high quality) would need to be discarded.  And all job descriptions.

MSF lived and operated in a very different world than the US

  • Sun, Jun 16, 2019 - 06:47am

    #33

    davefairtex

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    standard of care

My sense is that the standard of care for an Ebola epidemic should be much different than for normal situations.  The standard of care must prioritize the lives of the staff over the lives of the patients.  Otherwise – as your doctor friend points out – the staff will vanish overnight.

But my point is, Ebola doesn’t need to be a civilization-ending gotterdammerung.  There is a solution, and MSF has it nailed, at least for Africa anyway.  We just need the will to put it into action.  If we all die because of “standard of care” rules that are fine for the normal situations, but are fatal for an Ebola epidemic, its a totally self-inflicted wound.

So – no mystery here.  MSF has the answer – or at least an answer that worked in the tropics.  We just need to use a little creativity (and the will) to enact a roughly similar regime here in the US.  With the focus on protecting the staff at all costs, with a treatment regime dumbed down to very basic care that minimizes risk to the team over everything else.

Which, I think, is at the core of what that doctor is really saying.

The paper I found really bears out his viewpoint.  Caring for someone in the last week is incredibly dangerous.  That’s when most people end up getting infected – and then dying – is caring for someone who is in that last week.  And/or burying them after they die.

If you don’t do everything you can to protect those last-week caregivers, all sorts of things go wrong, and in a real hurry too.

That’s my sense anyway.

  • Sun, Jun 16, 2019 - 12:46pm   (Reply to #33)

    #34

    thc0655

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    re: standard of care

But my point is, Ebola doesn’t need to be a civilization-ending gotterdammerung.  There is a solution, and MSF has it nailed, at least for Africa anyway.  We just need the will to put it into action.  If we all die because of “standard of care” rules that are fine for the normal situations, but are fatal for an Ebola epidemic, its a totally self-inflicted wound.

Wait! What? In what sense does MSF have Ebola care nailed? The outbreak in 2014 burned itself out. It was not contained, cured or stopped by the medical response. We don’t know why it stopped but we do know WE didn’t stop it. The current outbreak is still going strong, spreading and doubling pretty much on schedule. MSF is providing what we here call hospice care which is the best they can do with limited resources and primitive conditions. I give them props but I wouldn’t crow about “success.” Hospice-type care for Ebola patients in the US or anywhere in the developed world might eventually be the dominant model but it would be catastrophically disruptive socially and economically. In fact the social and economic implications would probably be worse than the mere deaths and lingering illness caused by the disease.  Aesop’s main points in writing about this include: 1) our preparations are woefully, even criminally, inadequate, 2) TPTB seem more focused on keeping people calm and obedient rather than prepared, 3) the medical system probably will eventually make some necessary triage adjustments like shunting most patients into MSF-style hospice care but by the time they do the disease will have spread far and fast, and 4) since the medical system is sooo unprepared individuals should be thinking for themselves and developing their own plans and supplies. I agree when you said Ebola doesn’t have to be a civilization ending disaster but I apparently have less hope than you that “THEY” will do the right things and keep it “under control.” It will be waaay worse than it has to be.

And I can tell you from personal professional experience that the same kinds of problems are lying around in plain sight when it comes to law enforcement’s preparations. My big city police department has made valiant efforts to be ready to provide police services in the case of CBRNE emergencies (like Ebola), but they too are woefully under prepared, staffed and equipped. I guess the reasons come down to the First and Second Laws of Engineering: #1) Given enough time and money we can solve any problem, and #2) There’s never enough time or money. Police will be required to provide ordinary and extraordinary police services in hot and warm zones during an Ebola outbreak. That means operating in the same kinds of protective equipment and procedures medical personnel would use in an Ebola outbreak. Imagine SWAT having to respond to an active shooter in “spacesuits” and respirators. Imagine patrol officers in those unrespirated plastic suits doing everything from crowd control, to protecting medical personnel administering the scarce vaccine to certain targeted groups but not to the general public, to security at medical facilities, to border control, and so forth. I can tell you it will be too little, too late even though those of us who were trained and equipped to do it will be among the last in the police department to refuse to come to work.

Years ago I saw an HBO movie called “Dirty War” about terrorists who detonate a dirty bomb in London and thought it could’ve been a documentary it was so accurate. I recommend watching it while focusing on how inadequate the police and fire departments’ preparations really are, how the politicians and fire/police brass focus on reassuring the public about how great their preps are, how the firefighters on the line complained they were no where near well prepared enough (and are shushed up), and how when the real thing happens the inadequacies are obvious and deadly.

We would all do well not to drink the Kool Aid of Reassurance and come up with our plans for a worst case scenario. We might even survive.

“Happy Hunger Games! And may the odds be ever in your favor.”

  • Sun, Jun 16, 2019 - 11:51pm   (Reply to #33)

    #35

    davefairtex

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    re: re: standard of care

So, first of all, MSF has the last-week care nailed in the sense that very few of their staff die doing the job of caring for people in the most dangerous phase.  As I read it, that’s one key objection of your ER doc: he doesn’t want to die.  The MSF care structure prioritizes his survival, while the current US structure does not.

Ebola is very deadly, but not very transmissible.  In spite of the experiment that showed that Ebola virons can float around in the air, the epidemiological data strongly suggests (Law of Big Numbers) that it is contact with a late-stage patient’s body fluids that is the primary culprit for transmission.  Compare the R0 for Ebola (2.5) vs Measles (18) – this supports the claim that it isn’t easy to become infected.  How many people are actually caring for a late-stage patient?  Not that many.  Visitors to the house, people even sharing a meal – very unlikely to get infected.  That’s what the data tells us anyway.

https://en.wikipedia.org/wiki/Basic_reproduction_number

[Related: do we believe the data in the published papers here at this site?  Are these numbers all just lies from the CDC?  More on that later.]

I provide the conclusion from the study I referenced:

We have shown that risk of acquisition of filovirus infections primarily follows from only close personal contact and generally only in later stages of illness. By making this statement, in no way do we deny that filovirus infections are dangerous. The EVD transmission paradox (colloquially summarized as ‘Hard to catch, Easy to die from’) has been discussed previously 84 but never summarized with as much quantitative and documentary evidence as we provide. Caring for patients until death is particularly risky, especially within domestic settings. Among people experiencing only indirect contact, even when living in the same house, the risk of contracting disease is actually quite low. There is little evidence that more distant contact or that contact with people incubating the disease poses any risks. More studies are needed that correlate context, timing and intimacy of contact with days after disease onset and external symptoms or severity of illness. There is evidence that transmission from non-intimate contact is low during early illness, but there is no simple indicator for the transition to late illness when disease transmission is highly likely from any contact without adequate protective measures. Meta-analysis showed that transmission is very unlikely without direct physical contact. Once an outbreak has been identified, care for patients in well-equipped health care facilities cuts transmission rates. There is wide variation in the confidence intervals and magnitude, in many suggested risk factors even when adjusted for confounders, suggesting that understanding of community filovirus transmission could be greatly improved.

https://academic.oup.com/ije/article/45/1/102/2363618

Lastly, I’m going to give you a link to the CDC’s history page on Ebola outbreaks.  There have been a large number of outbreaks.

https://www.cdc.gov/vhf/ebola/history/chronology.html

Go through the trouble of reviewing each outbreak.  Many have occurred in large cities in Africa.  Those with adequate medical systems have managed to corral the infection reasonably quickly.  It sure sucks for those who were unlucky enough to be infected (mostly, they die) but the epidemic is definitely stamped out.

Ok, so is the CDC lying?  Is the published data all just fakery and hopium and we’re all just doomed?

I’m going to use the law of big numbers here again.  There have been 22 outbreaks.  They have all been stopped – fairly quickly – minus the one in play now in the DRC where there is a low-intensity civil war going on and they are shooting healthcare workers, and the one before where the healthcare system sucked and it was still recovering from a civil war and there was very little trust in anything the government said.

It seems, from reviewing the macro evidence, that if the society is reasonably cohesive, and the number of initial cases are relatively small, the system acts quickly to stamp out the problem.  It really, really sucks if you are the one to be infected (which accounts for our ER doc’s high level of irritation), but if we imagine we can do as well as one of the larger African cities, as a society we can probably deal with it.

BTW – the epidemic in West Africa didn’t “burn itself out”.  That would involve almost everyone catching the disease, 70% of whom would die.  It was stopped because people changed behavior, and stopped taking care of late-stage patients at home, instead sending them off to the isolation centers run by the MSF.  In the papers I read, that’s called a change of R0 to Rt – a change in human behavior results in a change in transmission rates in the affected population.

So Tom.  I have a request.  I encourage you to read the materials I’ve provided.  Then come back and tell me where I’m wrong.  Your primary source is very worried because he is at the point of the spear on this matter.  His life is on the line.  Stupidity by the establishment – which as you say, is practically guaranteed prior to any crisis – will get him killed, and this does not make him happy.

But even in Africa, once the system changed how it dealt with the crisis, it got solved.  That’s what the history suggests.  There are still some “doom” scenarios possible, but they are not yet in play.

  • Mon, Jun 17, 2019 - 07:15am

    #36

    sand_puppy

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    Awesome Job Finding the Ebola Numbers!

Very nice and very appreciated research effort DaveF.  Great summary and very perceptive analysis of this information.

Most Helpful Stuff

You found the “reproduction number” (the average number of people that a sick person will infect) for EBV.  This is very helpful.    R(o) = 2.5.  R(o) is > 1 meaning that an outbreak will continue to spread without intervention.

I love the historical review of the worlds Ebola outbreaks and the map.  I did not know that it had flared up and died out so many times.

Ebola History

Nice to have confirmation that the infective phase is the late phase of the illness and just after death and is (almost?) entirely by direct physical contact with bodily fluids of the severely ill or recently deceased.

Summary:  And it looks like there are 3 methods to stop the spread of the infection:  1)  physical distance between those who are sick and those who are not,  2)  Plastic protective clothing, and 3) vaccination.

The disagreement

The disagreement is about the capacity of our society to successfully establish a MSF (or better) style of quarantined treatment facility for Ebola.

Asoep says no, our society can’t do it.  You must make and defend your own family’s quarantine lines.

DaveF is saying (if I hear your correctly) Ebola is containable/treatable with MSF style quarantined treatment facilities and we should be able to do at least this well in the USA.

Implementing MSF style clinics in the USA

Those not in medicine cannot imagine the immensity and complexity of the legal constraints placed on the actions of hospitals and medical workers.  We cannot just “not allow” someone to enter our facility or walk its hallways.  Even to tell a vomiting person just arrived from the Congo with a fever during an Ebola epidemic “you cannot come in the door” is absolutely forbidden.  Every step is regulated; from intake, treatment, assessment, registration process is is governed by written department policies, hospital policies, administrative guideline, CMS regulations, state laws, codes of conduct and professional behavior definitions.  Armies of administrators, each with legal counsel, are employed to analyze each possible action.   We operate in a labyrinth of legal constraints and rules.

To respond collectively, would require a multi-disciplinary task force to design a system from the top down, that is medically sound, as compassionate as possible, and legally protected.  Its rules will have to be written, knowing that every patient who is admitted, turned away, held, released, treated and not treated, may  bring a lawsuit.  Every action will be reviewed in court in the decade that follows.  Doctors and nurses will have to fight with state medical boards to not be stripped of their professional licenses for participation.  Security officers risk both infection, and being sued for their actions and non-actions.

I could tell you some stories!!

How long would it take a presidential task force to design and implement a coordinated MSF-type program.   3 months?  A year?

I am not optimistic personally.

And later, will the Ebola legislation be used to imprison political dissidents–you know, people who think that kerosene doesn’t melt steel beams?

Fortunately, Ebola doesn’t seem to me right now to be the biggest risk we are facing.

  • Mon, Jun 17, 2019 - 12:52pm   (Reply to #36)

    #37

    davefairtex

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    re: Awesome Job Finding the Ebola Numbers!

Thanks SP.  I was actually fairly relieved when I saw the information.

The R0 of 2.5 isn’t much fun, but that is driven by the behavior in Africa where family members take care of patients at home.  (Hence: the importance of the “community deaths” statistic; a “community death” means 2.5 new cases on average).  Once people are ok with shipping their loved ones off to the camps – ahem, I mean Ebola Treatment Centers – the Rt drops below 1, and that’s how the epidemic comes to an end.

The epidemic is all really just about human behavior.

And we don’t need ETCs unless we have a large number of patients to treat.

Your hospital bureaucracy sounds…really appalling.  Horrifying.  I had no idea.  No wonder that doc is so cranky.

I suspect if push comes to shove, and things get bad, the contingency plan is for Trump to declare a National Emergency and the teams dealing with Ebola at each hospital will be under federal contract – perhaps under the VA – which means they will be protected from legal liability.  There’s probably even a contingency plan for treatment centers too.  FEMA camps.  🙂

But as you said, I don’t think it is the biggest risk we are facing.  We just need to get those people in the DRC to stop caring for their loved ones through death.  That’s much harder when they don’t believe anything the government says…hmmm…

  • Mon, Jun 17, 2019 - 03:48pm

    #38

    thc0655

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    A lot of slack in which trouble can brew

How about these as working assumptions and temporary conclusions based on the data and observations of previous Ebola outbreaks?

1. We’re a little fuzzy on how contagious Ebola is and the variety of ways it can be transmitted. But it probably gets worse and easier to transmit the closer the patient is to death and certainly easier to transmit if patients aren’t identified as Ebola carriers so that adequate precautions and quarantines can be implemented immediately.

2. The later medical intervention occurs the less likely patients are to survive no matter what is done for them. At some as yet undetermined point, survival is basically impossible and the best that can be done for those patients is palliative care (hospice type care focused on comfort, not cure or survival). Steely-eyed triage will be necessary to focus scant medical resources on those who have the highest probability of recovery. Triage decisions are never popular, and they’re tough on those who have to make and enforce them. But not making them properly always degrades the effectiveness of medical interventions.

3. Safety and survival of care-givers is one of the most important goals in order to marshal scant medical personnel AND keep the personnel from revolting and refusing to come to work, or having anything to do with Ebola response.

4. Without any hard numbers in advance it seems safe to predict that Western response to Ebola if it arrives will see a higher survival rate than in Africa and a quicker stopping of the spread of the disease. But how much better will it be? And how bad will it get anyway even though an outbreak here won’t be as bad? “Only” 2,000 dead would be much better than the 2014 outbreak, but what would that cost a Western country besides the deaths? Riots? Economic collapse?

5. Western medical systems are trying to be ready for an Ebola outbreak but those preparations are based on unrealistically rosy assumptions and limited by the amount of time and resources that can be devoted to it before it even arrives. After an outbreak starts we can assume appropriate adjustments will be made but how long will that take and how far will the disease spread until the adjustments are implemented? There’s a lot of slack there that will be in the favor of the disease.

6. Western citizens will probably respond in some ways differently than Africans have. Some Western responses will work in our favor. For instance I think it will be easier to inform Western citizens of the best and worst ways to avoid catching the disease and caring for a sick loved one who may or may not have the disease. And getting their cooperation might be easier too. OTOH Western citizens may respond in ways that make the outbreak worse, or at least the social and economic ramifications worse. For instance, Westerners can afford to be more mobile than poor African villagers so an infected Westerner is more likely to spread the disease faster and farther than simply to a family member or a contact in a village three miles away. It probably wouldn’t take a large percentage of truck drivers, nurses and doctors, and people employed in other jobs refusing to come to work to seriously foul up our complex, just in time systems and have huge impacts socially and economically. I also expect that many Westerners will revolt against quarantines, shelter in place orders, and triaging THEIR loved ones into tents where no attempts are made to saved their loved ones’ lives. How bad will that get, and what effects will it have? (For instance, in police work, the public’s response in dense urban areas to shelter in place orders in office buildings indicates that we can expect about 30% of those people to attempt to defy the orders and sneak out of the building in spite of warnings that a dangerous chemical, biological or radiological threat is waiting for them outside.)

7. Agreed: Ebola in the West doesn’t have to be a total disaster. Agreed: An outbreak in a Western country will probably kill fewer and spread less than outbreaks have in Africa. But can we also agree that it will be much, much worse than it could be under ideal conditions?  Can we also agree there is always an element of luck in these outbreaks, and that BAD luck breaks are a definite possibility here? Can we also agree that TPTB will, as they always do, overemphasize reassuring the public in the early stages while the outbreak is getting away from them and that this dynamic will lead to reduced public trust in the authorities and an outbreak that is worse than it has to be because of that?

  • Mon, Jun 17, 2019 - 06:39pm

    #39

    thc0655

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    More numbers: another spike in cases

http://www.cidrap.umn.edu/news-perspective/2019/06/ebola-case-counts-spike-again-drc

Over the weekend, the ministry of health in the Democratic Republic of the Congo (DRC) recorded 28 new cases of Ebola, and will likely confirm another 20 new cases today. With nearly 50 cases in 3 days, the outbreak is experiencing another spike in activity following the discovery of cases in neighboring Uganda last week.

According to the World Health Organization’s (WHO’s) Ebola dashboard, the outbreak total now stands at 2,168 cases.

In addition to the newly confirmed cases, there were 19 fatalities over the weekend, including 8 that took place in the community.

In total, 1,440 people have died during this outbreak, which began last August in North Kivu and Ituri provinces. Another 319 suspected cases are under investigation.

The new cases come from known hotspots, including 11 in Mabalako, 4 each in Katwa and Mandima, 3 in Kalunguta, 2 in Butembo, and one each in Lubero, Beni, Rwampara, and Musienene.

  • Mon, Jun 17, 2019 - 11:29pm   (Reply to #38)

    #40

    davefairtex

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    traveling while symptomatic

[duplicate]

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