Wednesday 8 October 2014

Spanish Nurse Ebola “should not have happened”


Perhaps I have over-estimated the influence of my blog on world governments. In various posts I have tried to point out to West African governments the steps they ought to take to control the Ebola outbreak. Things like distributing rubber gloves, soap, disinfectant, instituting barrier nursing and proper disposal of bodies and contaminated wastes. I simply passed on WHO and CDC advice, and in that spirit, here is the latest from the Centre for Disease Control:

As regard the virus itself, Gire et al. have shown that the current outbreak probably arose from those involved in funeral rituals for a traditional healer who had come into contact with an Ebola patient. They suggest that diagnostic tests need to be sensitive to the changing character of the virus so as to detect it with specificity and sensitivity.

In former posts I also suggested that West Africans do not have very caring governments. They are not very well organised, apt to forget to pay their health workers, and far better at making grandiose pronouncements than carrying out basic health care. I didn’t really think that any West African politician would read my blog, but I hoped that I was part of a general swell of opinion, and that one of my readers might pass on the links to someone else in their health professions, and in an infinitesimal way this might have a positive influence on some part of the Ebola control program. Delusional, I know, but why should delusion be a governmental monopoly?

I also had another theme, which was to link the poor performance of these nations when facing a practical threat with their poor performance on simpler tests of problem solving. I have been drawing a parallel between the low measured ability of sub-Saharan Africans and the low ability of their politicians to gather their own resources to protect their citizens.

Pursuing that aim, I would like to broaden my canvas, and try to estimate the intelligence of Western governments, by which I mean the Governments of Europe and the USA. So far, I have been touting them as brighter and better organised governments, able to do simple, basic things like providing rubber gloves, disinfectant, relevant information in general, and barrier nursing in particular.

Now that I look more closely at these governments, I have to confess my mistake. Western African governments are hopeless, but Western European/American governments are less brilliant than expected. They are certainly not one or two standard deviations better than their poorer West African colleagues. These Western workers are well resourced, well paid, and presumably well trained professionals, working in mild climates, with democracy and proper drains. However, the authorities appear to be over-confident about their strategy: screening at airports does not work, they say; quarantine should not even be considered; and the outbreak can be dealt with by prompt tracing of contacts and good treatment for all infected persons.

In Texas a man who flew in from Liberia for what appears to have been a courting visit went to hospital feeling unwell and was sent home, where he then most probably infected his host family and a number of other persons before he was admitted again and diagnosed with Ebola. Now the hunt is on for his “contacts” at which point it becomes apparent that many contacts do not know they have that status. The problem of the Liberian (who had reportedly arrived with documents asserting that he was healthy) has been multiplied perhaps 100 times, though the infected number may be much lower, but this is unknown at this stage. Say it is 1 person, consistent with the minimal estimate of 1 in 100 contacts being missed by the health services. This would double the number of Ebola cases in Texas.

In Spain a nurse at a leading Madrid hospital has managed to catch Ebola from one of the two returned infected Spanish priest she treated. She is said to have entered the Ebola treatment room only twice, once to remove soiled diapers and once to get the dead patient’s belongings, each time in full protective clothing. The hospital is carrying out an enquiry, and in the meantime, yes you guessed it, contacts are being traced. That includes her husband and a number of people she met on her annual holiday, or at least the end part of it when she was symptomatic and infectious, plus the 21 members of staff that attended her on admission before her Ebola status was confirmed. The hospital has said it followed the correct protocols.  Photos show rather primitive makeshift barriers in corridors, and wastes were taken downstairs in the public lift. I think what they actually mean is that they think their staff followed what they imagine were the correct protocols, but now they know that either the procedures or the protocols were wrong, perhaps both. The Press is talking about the training to use the protection suits being perfunctory, and the suits not being suitable, with too much permeability. If that is so, then it may explain why Ebola is spreading so rapidly among far less well protected West African health workers, and that it is easier to catch than formerly stated.

Nature (link below) and others stress the received wisdom, which is that the key lies in treating the disease at source. Effectively, this means colonialism by Western health services sending in trained teams with physical resources to West Africa. These facilities are being built from scratch, and will concentrate on treating the staff who have been sent out (who may catch Ebola), expatriates who have caught Ebola, and local health workers who have caught Ebola. The latter category includes 382 health staff, of whom 216 have already died. These death rates are similar to the bayonet charges in the early part of the First World War.

It’s important to remember that people with Ebola don’t become infectious until they start showing symptoms, so monitoring of contacts of an Ebola-infected patient for fever is usually considered sufficient, with them being isolated only at the first hint of illness — although some authorities may choose to quarantine high-risk contacts. Such early isolation is crucial to limit the number of people they could come into contact with.

Monitoring “for fever is usually considered sufficient, with the contact being isolated only at the first hint of illness” does not reassure me. Somehow this lacks the necessary sense of urgency commensurate with the lethality of the disease.

The “tracing of contacts” procedure is beginning to look a bit cumbersome. Of course, one has to do that, but it should not be the first line of defence. It is quickly becoming untenable that every Ebola case should effectively be given the chance to infect others, and given leave to test the tracing and treatment hypothesis to destruction. The Spanish doctors group had expressed doubt about their facilities being up to the best standards, and they have been shown to have been right in their fears.

To my mind the Spanish nurse case is the most disturbing news about Ebola so far. Either Ebola is more infectious than admitted, or the safe nursing protocol is so demanding that not even a well-trained nurse in a Western hospital can follow it safely.

Humans make errors. Some even invite errors. In one notorious case of stab injuries leading to HIV there was a footnote in the research paper saying that this patient “had managed to inject himself with infected blood”. So, far from being an accidental stab injury with a sharp, this was a case of deliberate self-contamination. Humans are a funny lot.

We are now being faced by a difficult intelligence test: we need to work out whether, all things considered, the recommended strategy: “wait until people are ill and then trace the contacts” is better than quarantine. Once a case has happened it is not too reassuring to be told “it should not have happened”. The experts are quite clear that screening airline passengers “does not work”. I presume the detection rate is low and the false positives too high, by some calculation, but I don’t know why they are so dismissive about this defensive step.

The Official story is that Western health systems have been through all this before, with AIDS and SARS and so on, and that Ebola will be contained. The rise of Ebola cases in the West may indeed turn out to be easily controlled. HIV was not, but SARS was.

I may be naïve, but I assume that at some level of Ebola infection Western governments have a Plan B in a drawer somewhere. They must have such a plan, must they not?


  1. > "It’s important to remember that people with Ebola don’t become infectious until they start showing symptoms, so monitoring of contacts of an Ebola-infected patient for fever is usually considered sufficient, with them being isolated only at the first hint of illness"

    This quip brings Yogi Berra's bons mots to mind -- "In theory there is no difference between theory and practice. In practice there is."

    People with Ebola becoming infectious only when they start showing symptoms implies a binary virus, with Infectiouness set to Off, then switching to On as mild fever begins. Has this hypothesis been tested, or is it more properly classified as a Wish?

    "Mild fever" and "hints of illness" don't seem like very clearly-defined cutpoints for first-responders and primary care providers to use. Separately or together -- used for screening or diagnosis -- what is the sensitivity and the specificity of this tool?

    The answers matter, since this seems to be the proposed entrance to the health care system's response.

    Mild fever and/or hints of illness
    * No -> no further action, except possibly continuing monitoring (unclear to me).
    * Yes -> Ebola-specific PCR or immunoassay diagnostic. And/or quarantine until test results are returned (unclear to me), and/or initiation of contact tracing (unclear to me).

    Has this SOP been employed in the past for any other highly contagious and highly lethal diseases?


    1. The theory is that the exponential increase in the virus occurs in the spleen and other internal organs, so it should be difficult to spread the virus at that stage, while at the same time the person would be pretty ill. I am with Yogi Berra on whether this works with any degree of specificity.

    2. The notion that all the contacts of an individual can be identified, even for a single day, is preposterous.