Ebola - prevention and mitigation

The technology and tactics of Ebola detection, prevention and mitigation of infected spaces. What stops Ebola? What should stop it but does not? What operational tactics are effective?

I was going to post this on our other thread, but it seems more relevant here.

A research organization, the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota has found evidence that Ebola may be airborne, and that the N95 masks/respirators that are commonly used are ineffective, and "recommends the minimum protection for healthcare professionals in high-risk settings is a “powered air-purifying respirator (PAPR) with a hood or helmet” that will filter 99.97% of all particles down to 0.3 microns in diameter."

http://www.breitbart.com/Big-Government/2014/10/14/CIDRAP-Confirms-Ebola-Transmittable-by-Air

Early disgnosis, minimal contact with infected person, rehydration, and a strong will to live appear to be a factor for some.

Dr. Ada Igonoh, one of the surviving doctors in Nigeria, shared her harrowing first-hand account a month or so ago: http://www.bellanaija.com/2014/09/15/mus...s-is-her-story/


Also, here's what they learned from treating the first two American health care workers transported to Emory, as explained by Dr. Bruce Ribner:

http://www.idweek.org/ebola_idweek_2014/

One interesting takeaway on Personal Protective Equipment (PPE) is why they upgraded from impermeable body protection to Powered & Supplied Air Respirators (PAPRs) --


--M

any chance you could find the citation from the organization itself, not the media outlet? I am crazy busy at work at the moment and can't do it.

Here it is:

http://www.cidrap.umn.edu/news-perspecti...rotection-ebola

Powered air-purifying respirator are somewhat pricey, but will be much more comfortable than the standard S-10.

http://www.amazon.co.uk/gp/product/B00IEHZPBK

If you need one, it is probably best to get one now before they become unavailable.

No people for the virus to replicate in or a lack of people i.e. mean distance for the virus to transfer to another person from an infected person. So population density in a critical factor for the scale and speed of its deadly progression.

The virus has come and gone for years in Africa. When "gone" it must be in a reservoir somewhere so it can come back later...

Stopping an outbreak may not be the same as stopping the disease. Are there articles describing where virus has been between outbreaks?

According to the Wikipedia article: "Fruit bats are believed to be the normal carrier in nature, able to spread the virus without being affected."

Other mammals are known to become infected, including Gorillas and Chimps, and some monkeys. Various strains have infected pigs.

http://en.wikipedia.org/wiki/Ebola_virus_disease

With news that both Texas nurses, Pham and Vinson, will be treated at the biocontainment ward at Emory University, it seems like EMU is the place to be if you have Ebola.

Yesterday, there was finally a press release regarding the third mystery patient at Emory, a WHO doctor who contracted Ebola in Sierra Leone, and who is recovering. So, with Dr Kent Brantly, Nancy Writebol, and this third patient, Emory is 3 for 3. I would want to go there if I had Ebola.

I sense that there has been a shift in policy now. Before, the CDC's Dr Frieden said any US hospital should be able to safely treat an Ebola patient, but we've just seen in Madrid and Dallas that reality does not always live up to theory.

I'm curious to see if future Ebola patients are also transported to one the national biocontainment wards, which would confirm a shift in policy. There is some additional risk of contamination in transport, but the cumulative risk to healthcare workers treating someone over time seems to be worth the risk based on experience so far.

Edit: And in testimony before Congress this morning, a top official from Texas Health Presbyterian Hospital says there was no hands-on training for the staff for Ebola before Mr Duncan came to their hospital.

So, all the more reason to transport Ebola patients to facilities that have specifically drilled for just such a situation for years.

Much like Smallpox I suppose. You will find Ebola and Smallpox reservoirs in US and Russian Government Military Bio weapons research establishments.

There is some good science (at least, it looks good to my layman's eyes) suggesting that fruit bats are immune carriers. Pigs and non-human primates have also been infected in the past.

I hope this is not too much of a silly question, but here it is.

I have read several reports that one of the Doctors who survived Ebola donated his blood so that the plasma (which contains anti-Ebola antibodies) can be extracted and was used to treat other patients. I have been wondering about this for the past week or so.

If this is actually an effective treatment (is it?), then would it not make sense to collect blood from Ebola survivors in Africa (perhaps paying for it as is done in many blood donation centers), extract the plasma, and use it to treat the Ebola patients?

I expect there would be many practical problems in implementing such a plan, but IMO it seems a potentially useful treatment resource is being ignored. What am I missing or not understanding?

A very good question. The short answer is that it is not known if the use of convalescent antibodies (or convalescent serum) is effective with Ebola. But since there is no effective treatment for Ebola, doctors have resorted to still-experimental treatment, but that is at their discretion. Zmapp or the drug by Tekmira would be other examples of still experimental treatments that have been tried.

This case series from a prior Ebola outbreak indicates that a transfusion of convalescent serum shows promise. However, the article does mention that animal experiments did not show effectiveness.

Another mainstream article about this topic is this one.

Donors must meet a number of criteria according to the WHO guidelines. Age 18-60, must wait 4 weeks since discharge and have two negative RT-PCR tests for Ebola, plus be screened for a number of diseases like HIV and hepatitis. The usual blood typing rules between donors and recipients also applies. Anyway, all these criteria limits the donor pool even further.

But putting aside the effectiveness question, I'm not sure that there are enough trained personnel or equipment to do this procedure properly in most of the regions in West Africa where Ebola is raging. There aren't enough resources to give people even basic nursing and supportive care. You also need survivors of Ebola to get the antibodies from and unfortunately, there aren't that many in this outbreak.

It seems that Dr Kent Brantly is giving a lot more transfusions than guidelines would recommend. Kudos to him for his generosity, but that's likely not going to be feasible among most West Africans donors either.

I think there are only four facilities in the US equipped to handle patients at level 4 (Max) isolation. I'll try to source this tonight, but it may be if that you need to move patients, EMU is one of few places available with highest-grade isolation.


I doubt the patients have a choice. Time there probably makes ICU look cheap.


There are a lot of hospitals in the US. I'd wonder just how many had such Ebola-specific training prior to Mr. Duncan, especially those not regional facilities.


Texas Health Presbyterian Hospital is set up to handle three cases at once at Ebola-class isolation, not more. When transferring Nina Pham they specifically stated that the problem was that there might be more cases in the Dallas area and they needed to clear space to be ready, just in case.

Without an effective treatment, the cornerstone of the fight against Ebola is isolation and contact tracing. Despite the mistakes and disorganization in Dallas, the contact tracing part of the response seems to have worked as intended. However, in West Africa, it seems that contact tracing is becoming increasingly rare.

This article discusses the issue directly.


A different article focuses on how thinly stretched healthcare workers are and how patients enter the medical system and just disappear. Patients may die, be transferred, or be recovering, but many/most are not accounted for. If they can't keep track of patients in their care, finding and keeping track of contacts is a daunting task. Family members often have no idea what condition or even where their family members are.


It does not seem that recent pledges of aid from Western countries has made any sort of dent over there yet.

A couple of thoughts about the current Ebola.
I have been following pretty closely.
These are offered in the vein of promoting common sense, rather than fear.

A number of infected travelers have gone thru intl. airports and flown on airplanes. As far as we can tell, NO-ONE in those airports or planes was infected by the traveler. The only secondary infections have been to health care workers in direct contact with the infected people. So this piece of news should be reassuring. The current strain of ebola, while serious, cannot be said to be highly transmissible through very casual contact.

Next, this ebola is NOT airborne in the sense that it is being carried by coughs and sneezes. If it was, most of Africa would have it by now. And probably a lot of other places. If Ebola ever gets to that stage - the world has got a serious problem.

However, there is some medical research that the virus can stay alive on dust and other fine contaminants for a few days. Hence it would not be good to be caring for a patient (in close proximity) and not have breathing protection.

It seems to me that the West is getting its act together now ... the initial response was certainly fraught with problems. The big concern remains about how far ebola will spread in West Africa. And THAT is a real concern. We should be praying - or expressing concern - for the US troops that have been sent there. And also all the health care workers who are active down there. That is a much higher risk zone.

Just my $0.02

Pete

Ebola isn't very contagious:

http://www.npr.org/blogs/health/2014/10/02/352983774/no-seriously-how-contagious-is-ebola

I have heard (randomly) that Ebola can be present in peoples' sweat, for example. But during the incubation process, the viral load in someone's body is fairly low. So the chances of getting it from a glancing contact from the perspiration of an infected person ... is pretty small. And by the time the viral load becomes high in an infected person - they fell like "death warmed over" anyway. They are not going to be walking around, or going down to the local fitness clinic. They will be desperately seeking medical attention.

The Ebola virus seems to be "tougher" than the AIDS virus, for example. AIDS really cannot survive outside the warm moist confines of the human body - it dies rapidly. Ebola seems to be able to last for a few days on some surfaces. But more info is needed on this.

If Ebola mutates so that it can survive for longer times in the environment - that would not be helpful. The risk would be that if, for example, you picked up a plastic water bottle that was held by an Ebola patient, and then wiped your eyes, some real risk of infection would exist.

I think they are trying to stop Ebola now in West Africa. The last thing the world needs is a huge expansion in the numbers of people infected with this illness (which would happen if the virus got out of control in places like Ghana and the Ivory Coast). The concern would be that eventually new mutations of ebola could develop.

Pete

Back to the convalescent serum issue. This article is skimpy on details, but the WHO is reporting that there are plans to start using convalescent serum more widely in West Africa.

It's an experimental treatment, so we will see how it goes. Once a larger number of patients start getting it, we may get a clearer idea of its effectiveness. The article doesn't say if any clinical trials will be conducted at the same time, although it does mention vaccine trials. I think the popular perception is that blood transfusions can help, so the political pressure may be too great to deny the treatment to Ebola patients in the form of a placebo.

One side story to this new strategy is that there do appear to be asymptomatic survivors of Ebola, too, who also have antibodies to the virus. I referred to it in another post but there's no telling how small or large that number is. That may expand the pool of potential donors, but that's just conjecture for the time being.

Its being downplayed ... but the possibility exists that "Ebola Mary's" are out there. These would be people who actively carry ebola, but show no symptoms of the disease. Just like "Typhoid Mary" in New York, such folks could cause a bunch of problems. They probably DO exist. We have NO IDEA how to spot them. And any one of them can get on an airplane and go anywhere in the world. They will never be detected because they have no signs of fever.

Pete

New York and New Jersey have announced their own mandatory quarantines, using their own (State) authority.

http://newyork.cbslocal.com/2014/10/24/n...d-ebola-threat/

We can add Illinois to that last, too.

Here is a short firsthand account from one of the first people put under mandatory quarantine, a nurse returning to NJ from Sierra Leone.

By the way, this is the same unnamed person that Gov Christie had announced that returned from West Africa with a fever. The article explains how the infrared temperture "gun" can easily be fooled into displaying a higher temperature.

While I agree with a quarantine, the medical personnel returning to the US (NY, NJ, IL) should be treated as victims rather than as perps. Since most of these peeps will probably not test positive for Ebola, supervised isolation in a non-medical facility (I still like my resort/upscale hotel idea) would be better. If/when they do test positive they can be moved, but since most shouldn't, there's no need to waste a hospital bed when a hotel room would be more comfortable.

Hopefully the treatment of returning doctors and nurses will improve.

All people should be less worried about their feelings being hurt than about preventing contagion. While the people interacting with them should absolutely be professional and polite, I think that the individuals in question should not take it personally and give their full cooperation. If they have a complaint, give the feedback to the people or their supervisors, not to the press.

If one has traveled abroad to help treat--and save--victims of Ebola, one should be just as cognizant of the need to NOT infect others. If one has a problem with a 21 day quarantine, one should not put oneself in a position where one might take 21 days to exhibit contagion of Ebola: walk the walk, talk the talk, or take a hike: I don't need you to infect me, because you want to "save the world."

I've read arguments against quarantine for those who have come in contact with the infected and not found them persuasive. Is there an argument for quarantine besides potentially dissuading medical personnel from volunteering in Africa?

Quarantine everyone who works in that hospital in Texas! Also, isn't there a doctor in NY being treated for ebola? We've gotta quarantine that hospital, too. Don't infect me just because doctors "want to save the world." If we're going to quarantine, we've got to do it right -- don't quarantine just people who've been to Africa. We've gotta quarantine anyone with any possibility of coming into contact with this dreadful disease. And don't forget the whole of CDC. In fact, they come into contact with diseases so often, I don't understand why we don't keep them under quarantine all the time.

The nurse in NJ is being or has been released today.
nbcnews.com/storyline/ebola-virus-outbreak/New Jersey releases quarantined nurse.

I find the constitutional arguments against quite persuasive.

One could, for example, *test* them. I know it costs money, but we generally require the government to go to great lengths, and expense, before imprisoning people. The only reason for the quarantine is to avoid paying for tests, and to let an-abundance-of-ignorance masquerade as an-abundance-of-caution.

Requiring blood tests every 24-48 hours poses no insurmountable constitutional hurdles and would likely be welcomed by those being tested - Mr. Duncan might be alive today with a testing requirement, but not a quarantine requirement.

It's generally a good idea to require society to try hard before violating civil rights this badly, yet New York and Illinois seem to have put no thought into this at all. Who pays for damages? Is the state prepared to provide as much support to someone imprisoned in their home as they do to a serial killer in the penitentiary?

PS. Does the number 21 actually have any scientific standing?

IMO, some form of quarantine is reasonable and legal.

But perhaps we need to be smarter about the "self monitoring" and tracking of the individuals.

It seems to me that much of the problems stem from the couple of folks (Doctors), at least one who was supposed to be in quarantine, running around in public places.

Maybe we should put the "ankle bracelet" that is used to keep track of folks on parole on the quarantined folks, let them stay at home, require that they stay there, and if the bracelet says they go out, then they get to go to a more restricted and supervised facility.

We might also be able to check that their temperatures are normal by having them do it over a video link.

If the test is very good, and detects infection long before symptoms become apparent, then I would find myself entirely on this side of the argument. Is the test very good? How long must someone be infected before it works?

Found this:

http://well.blogs.nytimes.com/2014/10/25...=blogs&_r=0

Here's a short primer from the American Bar Association on the legal aspects of quarantine/isolation orders. IMHO, the scientific basis of a quarantine can be argued either way, although the experience in Madrid and Dallas seem to support the argument that Ebola does not spread easily in First World conditions before symptoms appear.

No secondary contacts of any of the nurses in Madrid or Dallas came down with Ebola, and even the people in the same apartment with Thomas Eric Duncan when he was quite ill did not contract Ebola either. Dr Nancy Snyderman and members of her camera crew did not infect anyone and almost certainly Dr Spencer did not either (although it's still early in his case). But forcibly putting people in a tent with a port-a-potty and no shower makes no sense to me. There is no reason why people who are not symptomatic could not be quarantined safely at home.

While I think an argument could be made for the medical necessity of some sort of quarantine, from Hickox's description of her experience, sounds like her due process rights outlined in the ABA article were not respected, at least not for a while.

Gov Cuomo has modified NY's quarantine procedures, and although Gov Christie has not, he has already backtracked by allowing Hickox to leave quarantine and return to Maine.

Real-time PCR is quite good at detecting Ebola, but it's not 100%, and I think people are looking for 100% when it comes to Ebola.

If a person has Ebola, then PCR will most likely detect it, unless the viral load is too low to detect in the blood. Someone who is infected but not yet symptomatic could have too low a viral load to detect. Therefore, a single negative PCR results may be erroneous, which is why repeat tests after a couple days are recommended.

But, if a person who is infected has a viral load too low to detect with PCR, they are not going to be infectious anyway. It is best to run the test against people who recently came from an Ebola region or had contact with an Ebola patient and is starting to show symptoms. Actually, even after symptoms appear, the viral load can still be too low for the first 48 hours.

For reference, here's a flowchart for determining whether an Ebola case is "laboratory confirmed." (This is a European protocol but I believe the CDC uses something similar)

The 21 days is the longest observed incubation period for Ebola. There have not been that many cases of Ebola before this current outbreak, so that number may change as more cases appear and more data is collected.

I think a balance between constitutional rights and protecting the public can be found. If the nurse in NJ was asymptomatic and had negative results from PCR testing, sending her home was the right thing to do. Ongoing surveillance and periodic PCR testing of people who were treating Ebola victims seems pretty reasonable.

From the WHO:

"Recent studies conducted in West Africa have demonstrated that 95% of confirmed cases have an incubation period in the range of 1 to 21 days; 98% have an incubation period that falls within the 1 to 42 day interval. WHO is therefore confident that detection of no new cases, with active surveillance in place, throughout this 42-day period means that an Ebola outbreak is indeed over."

http://www.who.int/mediacentre/news/ebola/14-october-2014/en/

bws48,

Make sure you take this document in its full context. Note that the 42 days without an ebola case in a region is the WHO criteria for declaring an outbreak is over.

For monitoring individual people, the WHO still recommends a 21 day period. From the same WHO document you link, see the following:

Yes, good point.

Here is where I am confused and have concerns (help in understanding this appreciated):

1. 95% in 21 days, and 98% in 42 days. So, does that mean 3% of cases are diagnosed/occur between days 21 to 42? Doesn't that mean that at least 3 out of 100 cases will emerge after 21 days ? And what happened to the last 2 percent? When do they emerge?

2. "health care workers who have attended patients or cleaned their rooms should be considered as “close contacts” and monitored for 21 days after the last exposure, even if their contact with a patient occurred when they were fully protected by wearing personal protective equipment" The "fully protected" qualifier bothers me; what if they weren't "fully protected?" The Dallas nurses apparently were "fully protected" by the standards they had in place at the time---but still became infected (albeit within 21 days). So, no risk despite 3% of the cases emerging between days 21 and 42 or longer?

I hope that I am not being paranoid, but I keep feeling that the positive assurances and certainty I am hearing are not fully supported by complete and fully certain science and experience. IMO there is just too much emphasis on 21 days when there seems to be evidence that there can be up to possibly 5% (3% 21-42 days, 2% unknown) of cases that emerge after 21 days. That seems a big risk to me. The WHO statement says that it is "confident" that after 42 days no more Ebola cases will emerge, e.g. that an "outbreak is over." So, to me this says that up until 42 days, more cases can emerge.

Here is another of my points of confusion; our military are going to be quarantined for 21 days when (or actually before) they return, but apparently civilian travelers will not be, or at least will be let to "self monitor." IMO I simply can't resolve this into a consistent view of the precautions we should be taking.

Maybe I am missing something; I'm not arguing, I'm just trying to read and understand that implications of these statements says to me that there is a risk at least until the 42 day point. So why is 21 days the point at which the "all clear" is being sounded? To me it really sounds like it is a "95% clear" signal.

Science is typically never complete nor fully certain. Science is more of a process, than a destination, particularly when it comes to incredibly complex biological organisms. There's almost something new to learn.

I posted that link to that WHO report in the original Ebola thread and it seems pretty clear that the intent of that passage is to say that there was someone with a confirmed case (although they don't define whether it was laboratory confirmed or just clinically confirmed) with an incubation period greater than 21 days. Also the way they broke down the percentages as 95 and 98%, it seems like it could be a probabilistic breakdown rather than an actual count, which means the 21-42 day group may not have literally been 3 out of 100 cases. Based on a probabilistic distribution, a single extreme outlier could span that 95-98% group (and the other couple percent left over are just missing data).

That said, I have not been able to find any clarifications or verification about that WHO report since I first posted that link, so I'm unsure how much confidence to put into that statement that there were some people with incubation periods beyond 21 days. Just as there is tremendous undercounting going on, I'm sure there are plenty of cases where just the wrong information is recorded, and that could easily turn out to be the explanation once the smoke clears.

But back to a point I just made above--our experience with Ebola in the First World has turned out much differently than most people--including myself--feared, based on what it does in African populations. The track record so far indicates a disease which is serious but which the human immune system can beat even without any proven treatments, and indicates a virus which does not rampage through the populace like the Norovirus on a cruise ship.

Regarding quarantines/isolation policies, the fact is that these policies are a combination of science and other political factors, so it is not surprising that different people in charge (like Gov Cuomo or Christie) come up with different policies. Now that some states have implemented their own quarantine policies, there is a big push to harmonize them but of course there is pushback on many sides. If policy were based solely on good science, in my opinion, we would probably follow something like the MSF guidelines that Dr Spencer was following in NYC when he became symptomatic. Policies based more on theoretical risks and trying to appease the public end up looking like New Jersey's original policy of mandatory 21 day quarantine, no matter what.

Arney,

I think you hit some key aspects of the statistics. One further point regarding your comment ".....and it seems pretty clear that the intent of that passage is to say that there was someone with a confirmed case (although they don't define whether it was laboratory confirmed or just clinically confirmed) with an incubation period greater than 21 days....."

Keep in mind that until very recently, all the human data was from W Aftrica, and much of it during a raging epidemic. Since this is a situation where one cannot set up a controlled experiment, all the data that went into those statistics was by nature somewhat anecdotal. The folks compiling the data had to assume that the person became infected during their last known contact with an active ebola case. It is entirely possible that some of those outliers ( > 21 day incubation) actually became infected later, and hence their incubation period was actually within the 21 day period. Remember that infection is rampant in the area, and overall levels of sanitation may not be as good as they could be. It is possible they came into contact with the virus from some other source, either a sick person or some contaminated item, without realizing it. The greater than 21 day incubation data points may in fact be just be inacurate data points.

EDIT: One further bit of info. The New England Journal of Medicine (a very highly respected journal) just came out with an editorial on ebola and quarantines. One quote struck me as summing things up nicely:

Bottom line, we don't know what we don't know, and science is not perfect. A little caution should be tolerated and not be a political weapon. Implementation of policies by poorly trained people is always rough and difficult, but we should err on the side of caution.

Too much of the current policies recommended relies on individual cooperation and honesty. My experience with human beings is that many are not honest and will take a narcissistic attitude to take care of their own desires.

We can take caution and protect civil rights at the same time, they are not mutually exclusive.

This article says that the Joint Chiefs Chairman's suggestion to monitor soldiers for 21 days in Italy is because it is simpler and more efficient to just uniformly order all of them to keep separate from other service members and the public for 3 weeks than it would be to assess each person's risk on a case-by-case basis and to actively monitor the higher risk ones.

Ummm, OK. I guess that makes sense. Just order everyone to stay out of sight and be sure. It's the same thing when trying to import your dog into many countries.

Arney and AKSAR; thanks, that clarifies a lot about the sequence of the disease, especially the editorial from The New England Journal of Medicine.

So my remaining concern is compliance and for want of a better term the "honesty" of the self reporting:


This pretty much sums up where I am at now. I've had the same experiences with humans as Montanero. Besides simple honesty, there is the psychological problem of "denial" when they first get a temperature rise or begin to feel ill.

As someone else pointed out, the quote from Dr. House applies "Everyone lies."

Quite true, which is why quarantine policies tend to be a mix of science and other factors. Was disappointed to read in this article (if true) that Dr Spencer in NYC "lied" about being self-quarantined at home instead of riding the subway, going bowling, etc. (I'd like to hear his side of the story, though, since this is the NY Post reporting)

According to the MSF protocol he was following, it was permissible for him to be out and about before he became symptomatic because he would not be contagious, so it wasn't purely a medical reason for not being honest up front about his movements, if he indeed tried to cover that up. Perhaps the backlash against Dr Nancy Snyderman weighed on his mind.

I read that the folks in Maine are freaking out about nurse Hickox returning there even though she's without any symptoms and already tested negative twice. I still need to read up on the legal aspects of her situation with the Maine authorities. Only scanned some headlines earlier.

According to an article in the NY Times, people who even work in the same hospital where an ebola patient is being treated are now being stigmatized, even if they are not in any way connected with treating the patient.
Closer to home for me, a school district has had dispel ebola fears when a teacher returned from a vacation to South Africa, 3,000 miles from the area of the epidemic.

Unfortunately, the "better safe than sorry" approach is subject to the Law of Unintended Consequences. Quarantining people without good, solid, medically supported reasons only serves to increase the general paranoia about ebola. The unintended consequence is that if people think they are going to be stigmatized just for working in the same huge hospital as an ebola patient, or for traveing anywhere on the continent of Africa (no matter how far from the epidemic), then this just increases the incentive to be less than truthfull about where you have been, what you have done, and who you have been near. Thus your "....experience with human beings is that many are not honest and will take a narcissistic attitude to take care of their own desires" becomes a self fullfilling prophecy.

More (public) information from the CDC via a poster, on how Ebola is spread, highlighting the "airborne" vs "droplet" spread (a sneeze which can spread Ebola is via droplet, not airborne).

IMO, this, while true, is not helpful in reassuring the public; it can appear that the CDC is "lawyering" words. I suspect that the difference between "airborne" and "sneeze" will be lost on most folks; the effect might be to further erode CDC credibility and induce fear.

Here is the poster they have released:

http://yournewswire.com/wp-content/uploads/2014/10/Screen-Shot-2014-10-28-at-2.05.53-PM.png

That editorial is excellent. I thought they started to become contagious as soon as they started showing a fever, but this clearly refutes that.

Also, the comments about Duncan's family and the caregivers it was passed to also help shed some light how this propagates and when the most risk of contraction comes into the picture.

That's an excellent article, very balanced. It's important to note the government's obligation to use the method least restrictive of civil rights in order to achieve the goals. That means testing, not quarantine (unless someone refused testing).

I see that the nurse in Maine won her lawsuit. News reports suggest to me that the judge struck a very good balance.


I have seen a of summary of exactly one survey on this outbreak, covering all of 44 cases, which saw an incubation period of between 6 and 12 days. Not much to go on for this outbreak. That survey may have discarded statistical outliers as bad samples.


There are no techniques with 0% false negatives: if nothing else, you're going to have mislabeled sample vials from time to time. Never forget "a chain is no stronger than its weakest link" whenever someone has to scribble a name or ID on a specimen label.

One question with PCR is how many iterations / amplification to use. More is more sensitive but more expensive and subject to more false positives. If the virus is there but was missed, they didn't amplify it enough.

And there's always the question of whether FDA approval is granted yet. This is where PHRASECENSOREDPOSTERSHOULDKNOWBETTER.'s czar could be really helpful: walking paperwork through the FDA process.

(since when has using the President's unembellished name been censored here?)

(I think it take about four hours from when the sample is put in the machine to a result; it may be faster now)

It's an automated system and not under the deputies' control.


chaosmagnet

The ebola patient in New York City seems to be improving: New York Ebola Patient’s Condition Improves. This means that of the nine ebola patients treated in the US, one has died, one is still hospitalized but seems to be recovering, and seven have recovered and been released. For some time, medical people have been saying that the high rate of fatality for ebola patients in W Africa was due at least in part to the poor levels of care they received there. Nine patients is still a very small sample size, but the experience in the US seems to suggest that with advanced treatment, the death rate from ebola will be much lower than has been reported from Africa.

Dr Spencer seems to be a very cool guy, and a highly capable physician, with a strong background in wilderness medicine. See a profile of him in Wilderness Medicine Magazine.

"Dr Spencer seems to be a very cool guy, and a highly capable physician, with a strong background in wilderness medicine. See a profile of him in Wilderness Medicine Magazine."

and gutsy, to boot. What a contrast to the irrational fear and panic displayed by some of our alleged "leaders."

An article in Yahoo! News indicates that it costs an average of $215,00 to fly each Ebola patient from Africa to the US.

Moreover, there is currently only *one* airplane that can do this, and that it can only handle one patient.

That is the method for evacuating anyone in the 4,000 person military contingent, as well as CDC personnel all NGO aid groups. If two people get sick, one waits while the other goes.

This aircraft is the same one to transport Ebola patients within the US.

The military is working on a system that can transport as many as 15 patients at a time in a larger cargo airplane. But that can't be ready for a couple of months at least, and there's a question in my mind if one large flight or three smaller is needed:

The turnaround of one large aircraft might mean a minimum of 3 days betweens flights out of Africa, and that might be too slow, especially if the aircraft needs maintenance or is lost.

Can't blame this on the government alone since even the NGO's didn't have evacuation plans in place before sending people. Nonetheless it in a policy problem that the CDC ought to lead on exploring and coordinating.

Breaking news. Spencer is declared ebola free and in a press conference asked for better, more rational treatment of health care workers volunteering in Africa.

Nurse Hickox also finished her 21-day observation period yesterday. The criticism and stigma she and her boyfriend continue to endure has made them decide to move away from Maine.

Well, technically Phoenix Air has two specially-equipped jets, but one is always used to back up the other one, so only one is available at any given time.

The lack of air transport is given as the primary reason why countries like Canada and Australia have declined to send any healthcare workers to West Africa to help deal with this latest outbreak. Cuba has, and now China will, send a lot of help to West Africa, but I don't think either of them have any proper medical transport capability similar to Phoenix Air.

If suspected Ebola cases are transported soon after symptoms first appear, experience seems to have shown the danger of infecting others appears very low, so if a situation arises where multiple people need evacuation at once, that might come into play. Some special negative-pressure, HEPA-filtered isolation "pod" may not be necessary to safely evacuate those cases.

Of course, the further into the disease a person gets, the higher the risk goes as they become more infectious, so at some point, a pod becomes necessary.

Not correct on the Canadian participation. Canada has not sent any military aid however there are a large number of Canadian medical personnel in West Africa under the auspices of the Red Cross, Unicef, Doctors without Borders and other NGO's.

Also, Canada has 2 (non-military) mobile detection labs along with the requisite staff in Sierra Leone and the last I heard, were ready send more labs and people if called upon. As of about 3 weeks ago, the Canadian government also pledged a further 30 million dollars in direct Ebola aid.

To clarify, yes, Canadians are volunteering as individuals with various aid organizations like MSF, but there are no Canadians sent by Ottawa to West Africa for direct patient care.

To be fair, even the large American military contingent sent over are not there to provide direct patient care, but to provide logistical support for civilian workers. And like Canada, the US military is providing laboratory services but they will have no direct patient contact. However, about 70 volunteers from the uniformed members of the US Public Health Service are there to staff a center in Monrovia built by the US military and reserved for infected healthcare workers (which I'm not sure is up and running yet).

To the best of my knowledge, Canada has ALWAYS contributed to humanitarian endeavors. They have ALWAYS been beside us, when they weren't in front of us, in military expeditions as well.

The Canadian government was asked to send medical workers. which for our country is different in terms of resources, structure and personnel as compared to the USA. Any call for these workers would most likely come from the public and private sector rather then the military. As there is no guarantee that any worker would not get infected with Ebola, and not be able to readily airlifted out, the government would not commit...and rightfully so. Those who volunteer are the probable same type of workers that would be asked by the government. However the difference being (and I will leave the politics out) is that these workers, if they get infected, it would be up to the aid agencies to arrange transport home.

This no different then any government when they are asked to respond to any disaster but do not commit people but other NGO agencies do send people. My wife who has spent a lot of time in Africa with various NGO's will attest to where an NGO would have to fly a person out for medical reasons (at a huge expense) without any government support. BTW, to date, my wife has not brought forth the discussion of her going to any of the affected African countries in a NGO role. I think she is very aware of what my response would be...

At one point, there were calls to send Canada's military DART team to one of the affected areas. Wisely the Government said no. The DART team is not really trained for this type of operation and IMHO, it would been a waste of resources and money for all. Perhaps in a post Ebola outbreak ending, DART could have a role, but not now.

In the US when someone becomes sick and needs to be evacuated the organization that sent them - military, CDC, NGO - has to pay for their transport back.

It appears that this time *nobody* thought of the need to have an evacuation plan until Dr. Brantly got sick. The fact that there is even one aircraft is a result of hindsight from the SARS outbreak, not foresight for Ebola.

The second aircraft is apparently under contract and in Siberia somewhere, and not currently available for evacuation flights from Africa.

Both aircraft can apparently be configured for full BSL-4 containment, including airborne pathogens. Phoenix Air is modifying a third airframe for this, but no more without a paying customer. That means that in the best case, with all three aircraft available and properly configured, the US has the capability to evacuate about one patient per day.

Even that best case seems low to me. In the real world you can probably count on only one or two aircraft unless you're willing to pay to keep them on standby - Phoenix is the business of putting those airplanes to work, not sitting them idle somewhere in case a call comes in.


Is that true of all Ebola outbreaks or only this one?


Also, the Phoenix aircraft must refual a couple of times, in foreign countries, to get to the US. The aircraft might be denied landing rights if an Ebola patient isn't in a POD, even if no one leaves the aircraft.

I am a bit of an aviation buff and previously read up on the Phoenix Air ambulances They are using modified Gulfstream G-III jets to airlift Ebola patients back to the USA. The jet is refueled at Lajes Air Field on the Azore Islands before flying to the USA.

Inside the Flying Quarantine Ward Used to Transport Ebola Patients

Phoenix Air details Ebola flight operations in 'Flying ICU'

Well, the basis for saying that Ebola is not contagious until symptoms appears, and only through direct contact with bodily fluids, is based on prior outbreaks. Granted, First World experience is very limited, but so far, it does seem to support that assertion, too. Early on, these people are not suffering from vomiting, diarrhea, or bleeding out yet, so the risk to others seems minimal in the early stage. The viral load in bodily fluids that early is also relatively low.

The point about countries not accepting planes when Ebola patients are not sealed in a pod is a good point. I can certainly see countries blocking the landing of such flights. Boy, what happens if a plane had to make an emergency landing?