First Ebola Case Coming to America- TIME magazine article

[heymeg]

.

---

Members don't see this ad.

 

[medicalmnt]

You gotta feel for the family whose kid wasn't allowed re-entry into the USA only 5days ago. He died from an unrelated illness and was not allowed despite testing negative for Ebola...
so sad

http://www.nbcwashington.com/video/...-in-Liberia-During-Ebola-Quarantine/269316361

You can't help but think "what if only he was from an affluent white family" (went to Liberia for one of those 1-2week mission trips)

 

[NickNaylor]

Of course the chances are not zero even with these precautions. The chances are also not zero that Ebola will spread to the US even without bringing these two patients home for treatment. Even if a doctor or other caregiver at Emory gets Ebola, they'll likely be isolated immediately and only have the potential to pass the disease to very close contacts (e.g. immediate family). The virus is pretty self-limiting, with fairly rapid onset of severe, obvious symptoms. Considering the characteristics of the disease in combination with the superior healthcare and public health infrastructure in the US, even if a few people get Ebola in the US, the public health risk overall is exceedingly minimal and it's not worth freaking out over a couple patients coming home for treatment.

I agree that it's not worth panicking over. But why even increase the risk when there is absolutely zero that can be done here but not in Africa? Treatment is strictly supportive. You and others have made claims that we can "learn" by having them here. I'm curious what that consists of.

 

[medicalmnt]

I agree that it's not worth panicking over. But why even increase the risk when there is absolutely zero that can be done here but not in Africa? Treatment is strictly supportive. You and others have made claims that we can "learn" by having them here. I'm curious what that consists of.

thats assuming it isn't going to become something like malaria. as dangerous and terrible it may be, the victims are from poor countries and there isn't a market benevolent enough to find a cure. I'm sure the patient will recover and people will talk about it for about ~1month then everything will go back to normal.. war, politics, scandals, sports, crime, celebrities, and super-PACs.

 

[heymeg]

.

 

[wholeheartedly]

Well, at least this thread isn't as bad as reading the comments on the news articles....

Precautions HAVE been taken. Just take a look at some of the media from the region. Since the infection is spread via contact, all you need is full body coverings. These resources are available, as are disinfectants.

You don't need a level 4 biolevel lab to institute contact precautions.

There are quite a few other factors at play here that need be taken into consideration with respect to trained healthcare workers being infected. And other with respect to the ability of the disease to spread in a setting like the U.S.

"Just take a look at some of the media from the region."
Really?!

The media doesn't accurately portray anything these days and you pretty much have to read multiple sites, articles, press briefs from the CDC and global news sites to get a thorough appreciation of all the information available on this outbreak. They show pictures of people fully suited up because that captures an audience, that doesn't mean that's the norm. Gloves, full body coverings, goggles, and disinfectants are NOT available most places. I've had friends working in some of these regions express their surprise that people wash gloves and reuse them in a lot of places. They are available in Ebola treatment centers once it's identified that that's the problem and they are set up for intake. But a lot of the infected healthcare workers become infected before they know what they're dealing with, or trying to make do the best they can with the resources they have while knowing what they're dealing with (ie knowingly risking their safety for greater benefit).

Now with respect to how the two Americans who are being brought here contracted the virus:

MSF has been the main group dealing with managing Ebola outbreaks since shortly after Ebola was first identified. In that time they have not had single Ebola death in their staff. Effective contact precautions in a highly trained group works.

One big problem is, there aren't enough highly trained staff to manage an outbreak of this size and geographical distribution. They are having to train new and inexperienced staff on the fly. Some of these are folks who don't have the scientific background to fully understand what's going on here. It is simple to glove and gown in theory, but requires practice to get the hang of the routine and do it properly, in the right order. Think about getting trained to scrub properly for the OR. In those media pictures, you can see that gloves, boots, goggles are being dried out in the sun after being sprayed down with bleach. That's not an ideal practice.

Buried in the news reports is information reporting that the two American workers were infected by a local staff member who later died and the exposure occurred outside the isolation unit when they weren't gowned and geared up.

When you are in an environment like this, with an outbreak of this size, there are going to be exposures healthcare workers face that don't occur inside the isolation units, or even in their role as a provider. They are living in these places and while you can control what you do to protect yourself, you can't control what other people do.

So yes, this is the first time that healthcare providers have dealt with Ebola in the U.S. and an abundance of caution is necessary. However, regular old community hospitals have dealt with several cases of imported Marburg and Lassa fever without issue (other than the CDC missing the Marburg diagnosis the first time in one of the Marburg cases). No transmission to other people occurred even though these places didn't initially know the seriousness of what they were dealing with. So the panic for a situation where we do know what we're dealing with and have a completely separate unit and and specially trained staff and separate diagnostic facility for laboratory work, etc. is a bit overblown.

 

[NickNaylor]

My point is that it's really not increasing the risk by any significant amount because of the healthcare and public health infrastructure we have in the US that isn't in Africa, and cultural practices and ideas in Africa that aren't in the US.
When you say there's nothing that can be done here but not in Africa, are you suggesting that the care provided in crowded, resource-limited African field hospitals staffed by emergency aid volunteers are equivalent to the care here in the US, with the resources of a nationally ranked hospital and the CDC at its disposal?
And it's a chance to do more sophisticated research on the virus than is doable in Africa. Experimental medicines can be tried there, certainly, but it's a more controlled environment here that would probably yield more useful results.

I'm saying that pumping someone full of fluids is pumping someone full of fluids. That is not something limited to the US. Though you argue that bringing someone to the US adds negligible risk, my counter is that there is even less risk to not bring them here - particularly when there doesn't seem to be a real reason to do so.

What kinds of experimental medicines? What kind of "research?" These are nice claims but are vaguely dubious.

 

[NickNaylor]

Well, at least this thread isn't as bad as reading the comments on the news articles....




There are quite a few other factors at play here that need be taken into consideration with respect to trained healthcare workers being infected. And other with respect to the ability of the disease to spread in a setting like the U.S.

"Just take a look at some of the media from the region."
Really?!

The media doesn't accurately portray anything these days and you pretty much have to read multiple sites, articles, press briefs from the CDC and global news sites to get a thorough appreciation of all the information available on this outbreak. They show pictures of people fully suited up because that captures an audience, that doesn't mean that's the norm. Gloves, full body coverings, goggles, and disinfectants are NOT available most places. I've had friends working in some of these regions express their surprise that people wash gloves and reuse them in a lot of places. They are available in Ebola treatment centers once it's identified that that's the problem and they are set up for intake. But a lot of the infected healthcare workers become infected before they know what they're dealing with, or trying to make do the best they can with the resources they have while knowing what they're dealing with (ie knowingly risking their safety for greater benefit).

Now with respect to how the two Americans who are being brought here contracted the virus:

MSF has been the main group dealing with managing Ebola outbreaks since shortly after Ebola was first identified. In that time they have not had single Ebola death in their staff. Effective contact precautions in a highly trained group works.

One big problem is, there aren't enough highly trained staff to manage an outbreak of this size and geographical distribution. They are having to train new and inexperienced staff on the fly. Some of these are folks who don't have the scientific background to fully understand what's going on here. It is simple to glove and gown in theory, but requires practice to get the hang of the routine and do it properly, in the right order. Think about getting trained to scrub properly for the OR. In those media pictures, you can see that gloves, boots, goggles are being dried out in the sun after being sprayed down with bleach. That's not an ideal practice.

Buried in the news reports is information reporting that the two American workers were infected by a local staff member who later died and the exposure occurred outside the isolation unit when they weren't gowned and geared up.

When you are in an environment like this, with an outbreak of this size, there are going to be exposures healthcare workers face that don't occur inside the isolation units, or even in their role as a provider. They are living in these places and while you can control what you do to protect yourself, you can't control what other people do.

So yes, this is the first time that healthcare providers have dealt with Ebola in the U.S. and an abundance of caution is necessary. However, regular old community hospitals have dealt with several cases of imported Marburg and Lassa fever without issue (other than the CDC missing the Marburg diagnosis the first time in one of the Marburg cases). No transmission to other people occurred even though these places didn't initially know the seriousness of what they were dealing with. So the panic for a situation where we do know what we're dealing with and have a completely separate unit and and specially trained staff and separate diagnostic facility for laboratory work, etc. is a bit overblown.

Claims of malfeasance by the media are long on occurrence but short on demonstrable proof and strangely seem to always happen to support the claimer's argument. With all due respect, you'll have to forgive me for not taking that claim seriously.

All of the claims you're making could be similarly made about workers in the US. Do you think facility staff, janitors, etc. have this knowledge? All it takes is one mistake and you have a pandemic. That's my point. Mistakes and carelessness are not unique to Africa.

 

[wholeheartedly]

I agree that it's not worth panicking over. But why even increase the risk when there is absolutely zero that can be done here but not in Africa? Treatment is strictly supportive. You and others have made claims that we can "learn" by having them here. I'm curious what that consists of.

I'm going to be cynical as hell here and suggest that it's not entirely altruistic or patriotic on the part of the CDC to bring this here.

Treatment is in theory strictly supportive, but in places that can institute transfusions, regularly laboratory monitory of coagulations status, rehydration, and so on in a person who has a higher baseline health status, it's not futile care. We have a better likelihood of saving these people here in the U.S. than we would there.

That said, there is discussion of experimental therapies and treatments that are available that have been discussed and in a state of the art environment, they can do real time tracking of how both supportive care and treatments impacts the body.

There's wide variability in the case fatality rate in the outbreaks that have occurred. These are often attributed to the strain of the virus, but in Guinea right now the fatality rate is markedly different from that in Liberia for the same strain of the virus. What's potentially different is the quality and timeliness of care available. From a management strategy it's important to know how case fatality changes in different environments. Knowing we can drop fatality from 80% to 30% with high level care might free up some funding resources for early intervention, instead of like this outbreak where calls for help have been going on for awhile and WHO is just now ponying up a 100 M to deal with it.

 

[AMEHigh]

As mentioned above, this provides some explanation as to why the endemic developed but says nothing about the fact that healthcare workers who have been taking these precautions with a virus that is "nearly impossible to spread" have contracted the infection. I'm aware of these things. They aren't related to my point.

Oh ok, I must've misunderstood you. Since we don't know exactly how these Americans contracted the disease I think it's completely relevant to discuss the differences in cultural norms there. That means they were in contact with more sick people in general (not just while doing their jobs) and they were surrounded by more people that might not have gone to the doctor if they were showing signs of illness. To my knowledge people aren't walking around 24/7 completely covered so I was taking in the fact that people have to understand the differences in cultural norms and different environment to possibly explain why these doctors were infected.

The precautions taken there, resources and cultural norms are different there than they are here, so I think it's directly relevant to the point of how health care workers have contracted Ebola.

 

[heymeg]

.

 

[AMEHigh]

I'm saying that pumping someone full of fluids is pumping someone full of fluids. That is not something limited to the US. Though you argue that bringing someone to the US adds negligible risk, my counter is that there is even less risk to not bring them here - particularly when there doesn't seem to be a real reason to do so.

What kinds of experimental medicines? What kind of "research?" These are nice claims but are vaguely dubious.

http://www.usatoday.com/story/news/nation/2014/07/31/ebola-vaccine-trial/13404609/

 

[BestDoctorEver]

I'm saying that pumping someone full of fluids is pumping someone full of fluids. That is not something limited to the US. Though you argue that bringing someone to the US adds negligible risk, my counter is that there is even less risk to not bring them here - particularly when there doesn't seem to be a real reason to do so.

What kinds of experimental medicines? What kind of "research?" These are nice claims but are vaguely dubious.

You are not serious! You think the kind of care an Ebola infected patient will receive at Emory is the same as if they were in Liberia...

 

[wholeheartedly]

Claims of malfeasance by the media are long on occurrence but short on demonstrable proof and strangely seem to always happen to support the claimer's argument. With all due respect, you'll have to forgive me for not taking that claim seriously.

All of the claims you're making could be similarly made about workers in the US. Do you think facility staff, janitors, etc. have this knowledge? All it takes is one mistake and you have a pandemic. That's my point. Mistakes and carelessness are not unique to Africa.

So me saying experienced public health workers I personally know saying that the resources aren't there and people currently on the ground in this outbreak saying the resources aren't there and that they need more gloves and masks isn't accurate because the media is throwing around a few pictures of people gowned and gloved up?

You're saying that most media reports leaving out the fact that this country has treated equally deadly, identically transmitted Marburg and similar Lassa fever, without issue in less than ideal situations in regular old community hospitals without special containment facilities, while emphasizing that the is the "First time this country has ever treated a patient with Ebola" over and over again isn't skewed for scare tactic, headline grabbing?

As to your second statement, that's a weak argument. No one going into that containment facility is going to have been trained on the fly or lacking in science knowledge about that facility. There aren't going to be regularly trained janitors or facility staff going in and out of that unit. I had questioned how laboratory testing would be handled, but the Emory staff has stated that this unit has it's own laboratory facility as well for the diagnostic testing and management.

I'm not saying an abundance of caution isn't warranted.

But you state in one sentence that you agree panic isn't warranted and in the next breath talk about one careless person starting a pandemic.

I agree one careless person could cause trouble, but the CDC has stated that it's taking precautions learned from multiple other places after incidents occurred during SARs. One of those was putting monitors outside patient rooms to ensure that providers followed procedures exactly.

If there's an Ebola outbreak in this country you can pretty much bet it'll be from either an intentional bioterrorism type event, or someone coming with the disease under the radar and subsequently infecting people before being quarantined.

 

[AMEHigh]

I'm saying that pumping someone full of fluids is pumping someone full of fluids. That is not something limited to the US. Though you argue that bringing someone to the US adds negligible risk, my counter is that there is even less risk to not bring them here - particularly when there doesn't seem to be a real reason to do so.

What kinds of experimental medicines? What kind of "research?" These are nice claims but are vaguely dubious.

Also, I'm not saying that I'm happy that Americans have Ebola, but I do think it's possible it will help with research. Quite frankly pharmaceutical companies aren't invested in certain meds/vaccines purely from an economic standpoint. I bet if 1000 people were infected with Ebola in the U.S. vs in Africa there would be 100 times more effort being put in to testing and treatment.

Here's an interesting thought provoking article:
http://www.vox.com/2014/7/31/595266...k&utm_campaign=voxdotcom&utm_content=thursday

 

[wholeheartedly]

@NickNaylor I'm really surprised by this.

Things you can't do easily in West Africa that you can do at Emory:
Plasma, platelet, and cryoprecipitate transfusion
Administration of various coagulation factors
Real time monitoring of coagulation status with things like TEG that probably aren't available even in most university hospitals in Africa.
Real time monitoring of electrolytes and other labs

There are some experimental treatments, usually monoclonal antibodies approved for testing in humans in other countries. Nothing FDA approved here, but that doesn't mean they might not try it. Studies have shown antibodies derived from certain species of monkey, mice, and goats have prevented death in those animals.

Just because you feel like being skeptical of everything without sufficient background in the disease doesn't make you right.

 

[AMEHigh]

I'm saying that pumping someone full of fluids is pumping someone full of fluids.

Lets be real here. Liberia didn't even have a blood back until a few years ago. I don't know a lot of the details about the hospital that the Americans were receiving care through in Liberia, but I'm about 100% sure it wasn't as equipped as Emory. As someone who has been in hospitals in other countries, it's not always the same. Hell, there are obviously some hospitals in the US that I wouldn't even want to be treated in!

 

[NickNaylor]

So me saying experienced public health workers I personally know saying that the resources aren't there and people currently on the ground in this outbreak saying the resources aren't there and that they need more gloves and masks isn't accurate because the media is throwing around a few pictures of people gowned and gloved up?

You're saying that most media reports leaving out the fact that this country has treated equally deadly, identically transmitted Marburg and similar Lassa fever, without issue in less than ideal situations in regular old community hospitals without special containment facilities, while emphasizing that the is the "First time this country has ever treated a patient with Ebola" over and over again isn't skewed for scare tactic, headline grabbing?

As to your second statement, that's a weak argument. No one going into that containment facility is going to have been trained on the fly or lacking in science knowledge about that facility. There aren't going to be regularly trained janitors or facility staff going in and out of that unit. I had questioned how laboratory testing would be handled, but the Emory staff has stated that this unit has it's own laboratory facility as well for the diagnostic testing and management.

I'm not saying an abundance of caution isn't warranted.

But you state in one sentence that you agree panic isn't warranted and in the next breath talk about one careless person starting a pandemic.

I agree one careless person could cause trouble, but the CDC has stated that it's taking precautions learned from multiple other places after incidents occurred during SARs. One of those was putting monitors outside patient rooms to ensure that providers followed procedures exactly.

If there's an outbreak in this country you can pretty much bet it'll be from either an intentional bioterrorism type event, or someone coming with the disease under the radar and subsequently infecting people before being quarantined.

I'm saying anecdotes are anecdotes and I'm not liable to trust yours any more than mine. I also don't deny that the media sensationalized stories. I'm not sure how either is relevant to the point in hand.

You seem to have more faith in the CDC than me (the same organization, by the way, with scientists who failed to report an anthrax exposure until weeks after it occurred). I don't doubt the vigor with which people will wax poetic about their quarantine plans. That's great, and they are obviously needed. You do make some good points about monitoring lab values and other diagnostic data that might provide some insight into how we might better manage the compilations of the infection. Unfortunately, though, those plans will be worth nothing if they fail. I tend to be extremely risk averse. In this case I see little benefit with unlikely but potentially significant harm. This is just my own calculus of the situation, and you have your own.

 

[NickNaylor]

Lets be real here. Liberia didn't even have a blood back until a few years ago. I don't know a lot of the details about the hospital that the Americans were receiving care through in Liberia, but I'm about 100% sure it wasn't as equipped as Emory. As someone who has been in hospitals in other countries, it's not always the same. Hell, there are obviously some hospitals in the US that I wouldn't even want to be treated in!

Having a well-equipped hospital is irrelevant when most of that equipment is not needed for patient care.

 

[demayette]

Having a well-equipped hospital is irrelevant when most of that equipment is not needed for patient care.

Are you really that [ ] as a med student? Have you ever traveled outside of the US?

 

[NickNaylor]

Are you really that [ ] as a med student? Have you ever traveled outside of the US?

Diminution - the sign of a solid argument.

 

[wholeheartedly]

You seem to have more faith in the CDC than me (the same organization, by the way, with scientists who failed to report an anthrax exposure until weeks after it occurred). .

Oh I assure you, I don't have that much trust in the CDC. But I do believe they won't let your average joe janitor into that facility. I do believe they will have a monitor for everyone coming into or out of a patient room. I also believe that knowing they have eyes on them tends to make people behave a bit better (and in this case I mean the eyes of the whole darn country).

I agree this is risky, but believe the level of risk is lower than being hyped in the media and panicked about on the interwebs. (I also believe it's a bit higher than the officials are letting on).

 

[wholeheartedly]

Diminution - the sign of a solid argument.

So is disagreeing about a lot of things on a subject you don't have a significant background in...

 

[NickNaylor]

Oh I assure you, I don't have that much trust in the CDC. But I do believe they won't let your average joe janitor into that facility. I do believe they will have a monitor for everyone coming into or out of a patient room. I also believe that knowing they have eyes on them tends to make people behave a bit better (and in this case I mean the eyes of the whole damn country).

I agree this is risky, but believe the level of risk is lower than being hyped in the media and panicked about on the interwebs. (I also believe it's a bit higher than the officials are letting on).

I think we agree. We just have different tolerances for risk.

Regardless, the best outcome would obviously be for nothing serious to happen. Hopefully that's the case.

 

[NickNaylor]

So is disagreeing about a lot of things on a subject you don't have a significant background in...

I haven't resorted to personal attacks. I'm by no means an expert and I haven't claimed to be. No one here is, unless there's some MSF staff or an ID doc that we don't know about.

Regardless, I've been cordial. Getting your panties in a wad because you don't like what someone is saying is the epitome of immaturity.

 

[demayette]

Diminution - the sign of a solid argument.

I thought you were being a troll at the beginning, but apparently you were serious...

@NickNaylor I'm really surprised by this.

Things you can't do easily in West Africa that you can do at Emory:
Plasma, platelet, and cryoprecipitate transfusion
Administration of various coagulation factors
Real time monitoring of coagulation status with things like TEG that probably aren't available even in most university hospitals in Africa.
Real time monitoring of electrolytes and other labs

There are some experimental treatments, usually monoclonal antibodies approved for testing in humans in other countries. Nothing FDA approved here, but that doesn't mean they might not try it. Studies have shown antibodies derived from certain species of monkey, mice, and goats have prevented death in those animals.

Just because you feel like being skeptical of everything without sufficient background in the disease doesn't make you right.

 

[wholeheartedly]

I just prefer to see people making risk assessments based on an extensive evaluation of facts and not media fear mongering nonsense or inaccurate assumptions.

And when you say things to suggest that people dealing with this in Africa have ready access to good protective gear, or that there isn't anything they can get at Emory that they couldn't get in Africa, or imply that regular old janitors are going to be let into a special containment facility, it does suggest that you don't have enough experience or background in these issues. Especially when you're so impassioned about it.

That's not a personal attack. I've found you quite knowledgable about plenty of other topics and issues. I'd just expect a bit more restraint in this type of case. I will admit the whole starting a pandemic statement rubbed me the wrong way.

 

[NickNaylor]

I thought you were being a troll at the beginning, but apparently you were serious...

I missed that post (I'm at a wedding and replying during downtime). Those are all good points, which I mentioned above.

 

[NickNaylor]

I just prefer to see people making risk assessments based on an extensive evaluation of facts and not media fear mongering nonsense or inaccurate assumptions.

I'm not worried about fear mongering nonsense or inaccurate assumptions. You are mischaracterizing my position and then arguing against that straw man. Rookie move.

I said from the start that the likelihood of anything bad happening is low. I'm not sure what your bone to pick is. I would also be interested to know about your extensive expertise since you have been quick to question mine.

 

[wholeheartedly]

I'm not worried about fear mongering nonsense or inaccurate assumptions. You are mischaracterizing my position and then arguing against that straw man. Rookie move.

I said from the start that the likelihood of anything bad happening is low. I'm not sure what your bone to pick is. I would also be interested to know about your extensive expertise since you have been quick to question mine.

I edited my post. You say the likelihood is low and then talk about an extremist and highly unlikely situation of a janitor or someone doing something to spark a pandemic. To me, that seems as though you're contradicting yourself on how worried you are.

I'll admit I'm probably bringing in some frustration with various news reports and comments I've read on those (which is never a good way to start your day) and I'll apologize for that. It just seemed like some of your posts were contradicting themselves. Based on responses by others, it appears I'm not the only one reading them that way.

I'm just about finished with my training in infectious disease epidemiology and viral hemorrhagic fevers are a keen area of interest and academic focus in my graduate program. I'm also doing a global health concentration. Prior to that, I had pretty extensive coursework in medical microbiology as well. It's been frustrating to see some of the nonsense going on with the media in portraying this and I feel like it possibly hampered the initial outbreak response.

 

[NontradCA]

I agree that it's not worth panicking over. But why even increase the risk when there is absolutely zero that can be done here but not in Africa? Treatment is strictly supportive. You and others have made claims that we can "learn" by having them here. I'm curious what that consists of.

Maybe someone wants to not die in Africa, and be surrounded by their loved ones. How is this concept missed?

 

[allojay]

Agreed. I applaud people going to West Africa to help these victims, however they need to sign some sort of no-return clause in case of a possible infection. There is no cure and the best thing to do at this time is to contain the spread of this virus.

You raise a good point, I suppose...but if you were one of those people helping out in West Africa, I'm sure you wouldn't want to be trapped in the place that's having the outbreak. I may be wrong, but I know I wouldn't want to be trapped there! It would be absurd to prevent someone to come back to their home country bc of something like that. At the same time, I strongly believe that there must be some type of quarantine procedure put in place upon their arrival to prevent any spread of a disease/ virus.

 

[radkat101]

I just skimmed the post, so someone may have mentioned this already, but people here seem to be forgetting that the virus has already been in the United States for several decades, being handled by researchers and tested on animals in a similar containment facility to the one at Emory. There is even a lab at UTMB Galveston that has the ebola virus. After about 40 years, we are all still alive.

 

[ForensicOdontology]

No matter what ones opinion is, these two folks who contracted the disease are heroes, so I feel the need to make a point of saying our hearts go out to both of them and their families.