Wednesday, 15 October 2014

Ebola: Errata

I need to correct three errors I have made.

Error 1

For some months I have been saying, based on expert advice from various trusted expert sources, that the Ebola virus would be easily contained in Western countries, particularly in Western hospitals. I now recognise that this was an error. Sorry.

It turns out that nurses at Texas Health Presbyterian Hospital in Dallas, according to the director of the National Nurses Union RoseAnn DeMoro, were given inadequate protective clothing; conflicting guidance about treatment protocols; were closely involved in dealing with the patient’s infected projectile vomit and explosive diarrhoea; and worked in rooms where soiled materials were piled up to the ceilings.  All this despite receiving many official directives from the CDC about how Ebola should be handled. It is said that 72 hospital workers may have come into contact with patient zero at some stage.

The nurses' statement (given anonymously, which is probably the best way to find out the truth in these fraught circumstances)  alleged that when Duncan  (US patient zero) was brought to Texas Health Presbyterian Hospital by ambulance with Ebola-like symptoms, he was “left for several hours, not in isolation, in an area” where up to seven other patients were. “Subsequently, a nurse supervisor arrived and demanded that he be moved to an isolation unit, yet faced stiff resistance from other hospital authorities,” they alleged. Duncan's lab samples were sent through the usual hospital tube system “without being specifically sealed and hand-delivered. The result is that the entire tube system … was potentially contaminated,” they said.

48 contacts in the community are being monitored for exposure. Health workers were not part of this group, because it was assumed they were not exposed. Another health worker has tested positive for the virus (announced today), so we have 2 hospital worker infections arising from the index case. This is stupidity of the highest order, and the management of the hospital need to explain themselves quickly. The union representative may be exaggerating, but she doubts that any US hospital is able to deal safely with Ebola at the moment.

Error 2

I said that HIV was easier to spread than Ebola because you can transmit HIV through sex while still looking healthy. I forgot that Ebola can remain in sperm for 60 days, and in one case probably up to 90 days, such that the 30% who survive Ebola  will be in reasonably healthy looking condition and might have unprotected sex. So, in calculating the spread of Ebola we should factor in some sexually transmitted infections.

Error 3

I retained the idea that, in the case of widespread global spread of Ebola, the Authorities had a Plan B somewhere, in which the conventional narrative about disease control would come into question, and stricter quarantine would be recognised as the one option that works, given strict enforcement. Privately, I assumed this might be found somewhere in the World Health Organisation. Now Dr Bruce Aylward, the WHO Assistant Director-General of WHO's work in polio eradication and humanitarian response, is quoted as saying that the 70 per cent death rate made Ebola "a high mortality disease" in any circumstance. The WHO target is to isolate 70 per cent of cases and provide treatment as soon as possible over the next two month in an effort to reverse outbreak, he said. "It would be horrifically unethical to say that we're just going to isolate people," he said, noting that new strategies like handing out protective equipment to families and setting up very basic clinics was a priority.

His comment on ethics seems to hinge on the concept that it would be wrong to “just isolate people”, in that they ought to be isolated (I presume) but provided with protective equipment. That is fine, but the phrase “horrifically unethical” reveals a one-sided approach to ethics. I assume that Dr Aylward would concede that it would be “horrifically unethical” to let infected persons spread the disease by coming into close contact with others. Therefore, ethics must balance the needs of infected persons against the need of other people not to become infected.

A reminder

If the World Health Organisation is in favour of handing out protective equipment to families and setting up very basic clinics it is now coming round to saying in public what just about anyone pointed out much earlier, as I did on 5th August:

If treatment is really unlikely to help victims, then in a big outbreak it might best to avoid attempts at close contact nursing, and rely on quarantine and subsequent disinfection as the best way to save more lives. Perhaps hydration packs distributed to homes under quarantine would be best, but that is for public health specialists to judge.

So, I have quickly corrected 3 errors, and drawn attention to a prior, modest suggestion for Ebola management.

If you detect any further errors in the way that experts are dealing with Ebola, please let me know of them as they arise, daily.

8 comments:

  1. So, this Ebola management problem is not a group IQ problem after all.

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    1. Might explain public reactions in West Africa (for example, denial that Ebola exists) but probably not a good explanation for the small sample of imported Ebola cases in Western countries. However, only the US has been subjected to a real test: a patient flying in having lied about contact with Ebola, so we cannot be sure yet how the not very good US response compares with similarly presenting patients in West Africa. Even on this poor showing, US response is probably better than West Africa collapse of treatment model. Nigeria and Senegal have a good story to tell, and I will try to look into this later.

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  2. According to this blog post (h/t 'Fourth Doorman' in West Hunter comments):

    "[Dallas nurse Nina Pham] was self-monitoring [for fever], because she wasn't even one of the 48 people Dallas officials are checking on twice daily as potential Ebola victims."

    "we're now left with the assurance that a nurse who, from her own professionalism, was monitoring herself without any supervision or oversight, and immediately presented for evaluation, the very evening she spiked a temperature, is supposed to be the one so careless that she infected herself with Ebola [by not properly following protocols]."

    No cite or link is given, but the claim that direct care providers were not being monitored for early signs of infection somehow rings true.

    By the way, the first time I've read the terms "projectile vomiting" and "explosive diarrhea" in an article about Ebola is just now, it this post.

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    1. Yes, read that, and it seems credible. There is usually a big gap between the official accounts and the reality on the ground. A bit like company reports, in fact.

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  3. I didn't cite a source for that, because the information was relayed and repeated on multiple news sites, from NYTimes, AP, Reuters, CNN, NBC, ABC, CBS, and Fox.

    None, I repeat NONE of the 70-odd hospital workers along with Nina Pham were included in the list of people being monitored twice daily by local health authorities after caring for Duncan, because until Pham became symptomatic, there were considered "extremely low-risk" (i.e. "that would be too hard for us to do").

    In yet another case of locking the door after the horses got out, they changed that policy this week. Which is how they caught the second worker's newly symptomatic infection relatively quickly.

    Note also that all these persons, before Pham became known to be infected, were treating other patients, and wandering the community freely, and not on any sort of voluntary isolation.

    This has been a failure at every level: the hospital - from direct supervisors to overall management, the city ,county, and state health authorities, and the CDC, both on-site and at the top.

    As for the vomiting and diarrhea, the descriptions come from descriptions of Ebola survivors, and far too many years in the ED getting vomited on and at, and slinging far too many bedpans full of things I'd rather not think about.

    But thanks for reading.
    Best wishes,

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    1. @ Aesop -- Stopping by your blog was informative. I've been "paying attention" to the Ebola story, but not that much, e.g. half-watching the teevee network news when my wife has it on.

      So it's notable that I (and presumably, many people like me) hadn't realized these unpleasant facts about the course of the disease (projectile vomiting of infectious fluids) and of the response to it (don't worry, everything's under control, we haven't bothered surveilling exposed health care workers since there's no risk).

      Our elites are not notably competent, and/or not notably concerned about the interests of average (i.e. lower-status) Americans.

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  4. Evidence to the above point:
    http://dfw.cbslocal.com/2014/10/15/ebola-patient-traveled-day-before-diagnosis/

    Vinson (patient #3) was flying around the day before she became symptomatic, no isolation suggested whatsoever, and potentially exposed another 132 passengers plus flight crew to Ebola on local flight from Cleveland to DFW. Plus whoever she was around in Cleveland OH.

    And the hits just keep on coming.

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  5. "Our elites are not notably competent, and/or not notably concerned about the interests of average (i.e. lower-status) Americans."

    Sad but so true.

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