More people should understand that hospitals are messy. Really messy. From wiping vomit to feces to rolling over patients to changing chucks to wiping down monitor cables to handling bottles of saline that you may inadvertently leave out in the open for others to touch to not disposing spare gauze that may be contaminated to forgetting to wipe down your stethoscope to tearing your gown off as you rush to see another patient, etc etc etc. There are any number of people going in and out of a patient's room, performing a wide array of tasks, handling an even wider array of objects. Add to that the often hurried nature of hospitals and you get an environment prone to breaches of protocol.
I say this not to incite panic, but to provide insight that many might not have. It is more likely that during the thousands of interactions that this patient saw, the messiness led to a breach, instead of the virus infecting via a vector we've not yet realized.
More people should understand that hospitals are messy.
American hospitals are messy. It gives me no pleasure to uniquely qualify that. The fact is that, the more you read on the topic, the more you will learn that this is an uniquely American thing, at least among the industrialized advanced nations.
If you exclude the Cleveland Clinics, Cedar Sinais, Beth Israels & Stanford Meds of the hospital world, most American hospitals are woefully bad for patients, in terms of HAI rates(Hospital Acquired Infections).
Buried in a pile of books, surveys and studies during the passing of the Affordable Care Act (ACA) a few years ago, was an eminently readable book called
Catastrophic Care: How American Health Care Killed
My Father--and How We Can Fix It by David Goldhill.
In 2007, David Goldhill's father, in good overall health,
checked into the hospital with a minor case of pneumonia.
Within a few days, he developed sepsis, then a wave of
secondary infections. A few weeks after entering the
hospital and the day after his 83rd birthday, he died.
I think his points are still relevant, even after the passage of the ACA.
In a few years, I am certain that we will have to revisit the issue of how little we get as consumers of healthcare in America, for how much we spend as a nation, all over again.
Yeah, when my mom was dealing with a brain tumor, she was treated at both her local hospital and a more distant university hospital (University of Michigan). The difference in quality between the two was jaw-dropping to me.
If anybody has a link for stats comparing local hospitals in the US versus Europe, I would love to read them.
It's amazing how dangerous hospitals actually are, though it's also important to note that everyone working there is doing their best to keep your loved ones alive but at the end of the day, accidents will happen whenever and where ever they are allowed to.
I've had 2 relatives who were submitted to different local hospitals for different things, but they both contracted secondary infections, which nearly killed one of them.
At the end of the day, we should feel lucky that a complete stranger made an honest effort to help you or your loved one in their time of need, and not focus exclusively on the complications and accidents that may have happened along the way.
To anyone who works in healthcare, if you don't already, I would strongly encourage the use of checklists for any and every important task. Checklists save lives. [0]
Edit 2: These hospital visits were covered by Canadian healthcare so we didn't have to pay hundreds of thousands of dollars. I can see how it would be very difficult to overlook complications and accidents when the bill will likely bankrupt you.
For further reading on the subject, I recommend taking a look at The Checklist Manifesto (http://amzn.com/0312430000), written by Atul Gawande, one of the doctors mentioned in the articles.
For those skeptical of checklists as a symptom of bureaucracy, I wanted to suggest a distinction between top-down (or controlling) bureaucracy and bottom-up (or supportive) bureaucracy.
For the first 10 years or so of my working life, my only experience of paperwork was top-down controlling bullshit. Pointless timesheets. Useless reports. Data collected and never looked at again. It was managers imposing mandates in ways that rarely helped the business, and often hurt it.
But in getting into the Lean movement, I came to realize there's another approach. If you are a team that wants to do well, there's only so far you can go on implicit work practices. Eventually variation becomes the biggest barrier to improvement. The solution is to collaboratively create a standard way of getting a job done. With variation minimized, you can then start to rigorously test improvements, increasing quality and reducing waste.
This is easiest to see when you're working solo. A while back I was struggling to go running in the mornings. I was always forgetting something: keys, money, headphones. Now near the door is a simple list I can run down to make sure I have everything. Less stress, less wasted time in the mornings, more runs. I love it.
But groups can do the same thing. Can and should, really. Top-down imposition of quality practices rarely works. The people doing the work are the best ones to create and tune the way a job gets done. Might as well do it before some manager gets a bright idea and inflicts the wrong approach on you.
First, everyone was saying that only backwards people doing backwards things in backwards places could possibly get Ebola (paraphrasing; and I am not condoning the message, just repeating it).
Now, we see that Western medical workers with education, resources, and the focus of single patients in Western hospitals are catching it. And now I feel like the message is shifting toward something like: "It's impossible for doctors to do their job without a high risk of transmitting Ebola, and even if the protocols work, it's impossible to follow them. But still: Ebola is nothing to worry about, and any significant response is counterproductive panic."
I don't know whether that's what you're saying or not. But I am done hearing about how Ebola is not really a problem[1][2]. We just don't know anywhere near enough to be confident that it won't spread.
Even if you grant that modern rich areas can control it, that still leaves an awful lot of people exposed.
Having worked in a hospital for a whole year I can agree. Hospitals are the perfect example for something that you thought as a kid would be handled by ultra-smart people, doctors who love their jobs and who know best how to take care of patients.
Then when you grow older you realise that just like in every aspect of the world, everything is super messy and no one, except for a very few, know what they're doing.
Not to mention HCWs are the ones treating patients at their most infectious stage. As the viral load increases, so do the odds of transmission. Unfortunately it sounds like this was probably the result of improper PPE doffing :(
It depends when she became infected though - was it Duncan's first visit or after they admitted him as an Ebola patient? I'm not sure if this has been established yet or if so, can't find a good source.
One thing is for sure, that hospital is going to get the SHIT sued out of it.
> More people should understand that hospitals are messy.
Thats why its nice to live in a place that requires HAI (Healthcare Acquired Infections) to be reported. In the state I live in (US/AZ), this is only voluntary for the hospitals. As a patient, it makes it almost impossible to make an educated decision on what facilities to avoid.
looks like During Duncan's first visit, he wasn't being treated as an Ebola patient (he was given antibiotics and painkillers, and sent home). Once he was readmitted - that's a different story, but his initial interactions could have infected a lot of people.
PPE is hard... Every time you take it off is an opportunity for infection. It's very easy to get complacent and not be as careful as you should be (yes, even when dealing with something like Ebola). When you're donning and doffing dozens of times a day, mistakes happen. It's very likely she wasn't the only one to be exposed, but hopefully she's the only one that was infected.
Military contamination rates for Decon are considered to be 25%. That number is just the projection for unit effectiveness after an event, but it is rooted in the fact that even the most well trained people will still cut corners in decon. Mostly due to heat and fatigue. Overconfidence and repetition weariness can also be issues for those that decon too much.
Remove humans from the equation? Humans make mistakes. Humans working in high stress situations are at a greater risk for making mistakes. Humans working in high stress situations, while wearing PPE that traps heat and moisture are at a tremendous risk for making mistakes.
This seems to be a viable target - for people in quarantine, if we can replace x% of actions that need to be done by humans with devices that can be sterilized, then that's a x% decrease in number of infections.
We don't need any AI for this - remote control would work just as well. Can't we get a pair of robotic hands on wheels + Oculus Rift and controller gloves for a small fraction of what an MRI device costs?
While I agree with you overall, this statement is just plain wrong from a statistical perspective:
> if we can replace x% of actions that need to be done by humans with devices that can be sterilized, then that's a x% decrease in number of infections.
There are no public citations that I could dig up. That number is the number used for planning with persistent agents. It varies quite a lot by agent.
For further context look up the health worker mortality in West Africa due to Ebola. Even if those people are not all highly trained they are trained. The reality is that people simply cut corners, even when they know the risk, and the margin for error is obnoxiously low.
The prevalent culture in medicine still assumes that people can do things correctly all the time. Contrast that to aviation where every interaction has been designed around the fallibility of human beings for decades.
You can't change a culture on a moment's notice, just because the threat is more significant.
Showers can actually do more harm than good if the equipment is permeable, or the individual did not follow protocol when donning. Meaning even little things like not cuffing your gloves.
The can cause overconfidence in regards to contamination.
Maybe? I'm a firefighter/paramedic (with training and experience in hazmat operations). I don't know anything about the specific procedures used in this case.
I doubt they do in this case though. Probably at the end of the shift, but when you are in and out of a patient's room a dozen times a day, it's not likely they do a full decon each time.
EDIT: Just reread your post after seeing frankydp's reply. I thought you were asking about decon showers _after_ removing PPE. frankydp is absolutely correct that showering while wearing most styles of PPE is a bad idea.
I was wondering the same. Clearly this wouldn't work with permeable cloths as that would just rinse possible virus into the suit (assuming water). UV exposure perhaps, there are a lot of these (http://www.sott.net/article/287166-Ultraviolet-light-robot-k...) things going around.
Entering panic mode too fast, according to the chief of the CDC "there was a breach in protocol"[1]
Frankly, this hospital mismanaged the index patient from the beginning and though the woman infected now wasn't on the initial list...the list itself wasn't complete because they didn't properly diagnose the index patient ebola to begin with.
Isn't the breach in protocol using anything under BSL 4? The problem is there is no way to ensure BSL 4 outside of a couple specialist labs. So the protocols are basically dumbed down to the lowest common denominator.
"Only 15 BSL-4 facilities were identified in the U.S. in 2007, including nine at federal labs."
Those are labs, and there's some surge capability, that count of 15 either includes some that can move to BSL4, or there are a few that can do that.
There are 4 hospitals in the nation that have a total of less than 20 beds that are set up for diseases like this. Emory (CDC), the NIH in Bethesda, the biggest with 10 beds is in Omaha, Nebraska, and there's one in Missoula, Montana, not far from one of those BSL4 labs.
As mentioned before, 10 in Nebraska, and they don't have a BSL-4 lab handy; hopefully they have, or are setting up, a mini-lab there, for as Emory realized, it's not practical to send samples from Ebola patients to the hospital's main lab: http://www.nebraskamed.com/biocontainment-unit
As reported in this news story, "'Clearly there was a breach in protocol. We have the ability to prevent the spread of Ebola by caring safely for patients,' [Thomas Frieden, head of the Centers for Disease Control and Prevention] said in an interview Sunday on CBS’s Face the Nation.
"Frieden also promised that protocols at the hospital would be reexamined to find out how the disease was apparently transmitted." Other patients with quite advanced cases of ebola, who were on the brink of death, have been successfully treated in United States hospitals without any health care workers in those hospitals being infected so far. The Dallas hospital where this latest incident happened will definitely have to review its infection control protocols, but we know already that other United States hospitals are doing things right.
Terrifying news like this came out when SARS was first spreading around the world in 2003. SARS is especially easy to transmit from one person to another because it is an airborne virus. No doubt there will be other cases of ebola infection spreading in the developed world, even in hospital settings, now that the first few cases have been discovered. But SARS transmission decreased a lot once people in China started taking precautions like self-isolation and masks to cover coughs. West Africa has a lower availability of equipment, supplies, trained personnel, and even information today than rural China had in 2003, but with sufficient outside help the transmission of ebola can also decrease a lot, until numbers of new cases start falling instead of rising.
You can't compare this thing to SARS at all. Not only does it have a longer incubation period, but SARS lives outside the host for up to 6 hours (4 days in poop). Filoviruses can live up to weeks outside of the host.
Not to mention SARS is spread from respiratory droplets. This thing is spread by: A) vomit B) saliva C) sweat and if you are running a high grade fever you are going to be sweating and transmitting this thing from every pore in your body.
So no, this is not going to be as easy to contain as SARS especially once it hits somewhere like India.
Of course he was wearing protective gear (it would have been news if he hadn't).
He may have worn it, but what procedures did he follow for removing it? That's where infections are likely to occur - the article even notes at the very end that the nurse in Spain who was infected was probably infected this way.
This is the critical question. She probably dons and doffs protective gear a few dozen times per day, as do most of us who work in a hospital, but we rarely practice doing so correctly. The topological distinction between in and out becomes totally blurred when most people remove their gowns. Therefore, it is probable that many people would think they are correctly removing full protective gear, but have never or rarely correctly removed such gear and therefore got themselves contaminated in the process. Less likely, we don't understand the transmission vector and some fomite is at play. Ideally, in an unusual situation such as this, there should be observers closely eying all contact including de-gowning.
Somewhere I read that if you're really serious about this, you get yourself sprayed with something that glows in ultraviolet light, remove the protective gear, and then look for spots where the agent made its way onto you.
I'm not sure if that's standard practice but if not it seems like a very good idea. They could use it to find errors or potential errors, refine the protocols and make the information available to all medical workers worldwide.
It's a bit late for that to be a solution for the current epidemic. And that'll cost more ... calls for a hack, putting tape on the insides or outsides where you need to distinguish between the two. Or a magic marker ... after you determine ones that won't break down the plastic too quickly.
There was an Ebola documentary on PBS a few nights ago and one of the people noted that he touched a need and that's how he contracted Ebola.
People have likened Ebola to HIV, but HIV does not transmit this easily. Even during seroconversion (which is when you might get vomiting and such with heightened viral load) I've never heard of anyone contracting HIV in a hospital.
I feel like the information on transmission has been poor. For example, is skin a barrier for the virus?
I'd expect broken skin isn't, but what about intact skin? With HIV we can answer a bunch of questions about transmission. With Ebola I can answer very few. I think this increases the anxiety.
On Sky News earlier today an expert was saying that intact 'regular' skin is indeed a barrier, but that thinner types of skin such as that found inside the mouth, the eyes, and the nose is definitely not a barrier.
A lot of this thread is speculation. Let me interject by actually citing some research which may answer some questions.
@kenjackson: "Is skin a barrier for Ebola?"
Yes. According to Bausch et al.
"Taken together, our results support the conventional assumptions and field observations that most EBOV transmission comes from direct contact with blood or bodily fluids of an infected patient during the acute phase of illness. The risk of casual contacts with the skin, such as shaking hands, is likely to be low."
In the same paper, they note that:
"We found [Ebola] to be shed in a wide variety of bodily fluids during the acute phase of illness, including saliva, breast milk, stool, and tears. In most cases, the infected bodily fluid was not visibly contaminated by blood."
This lends credence to Kyro and JshWright's assertions that hospital and PPE protocol are hard to exactly follow, every time (I'm certainly guilty sometimes). Even if the equipment or chucks aren't stained with blood, there is a possibility that the patient's tears have leaked onto the material and remain unseen.
Would UV lights kill the virus, if, for example, it were to be sneezed out from a patient. Assuming the patient room was awash in UV light, would that kill the virus if it found airborne/aerosol method of transport from an infected patient?
According to several sources, it may take up to an hour for the virus to be invalidated by UV light. That makes it not really practical for the patient or the HCP involved.
Not only that, but I suspect at the energies required, the amount of UV radiation would be quite harmful to the patient as well.
"Inactivation of virus stocks.Virus stocks were inactivated by exposure to UV light for 1 h. Proper inactivation was controlled by the incubation of Vero E6 cells with the inactivated virus particles and subsequent screening for the presence of viral proteins (immunofluorescence) and viral RNA (reverse transcription [RT]-PCR targeting virus-specific transcripts). The UV-inactivated stocks were used at the same dilutions as the noninactivated stocks."
> We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks.
> ...
> This reflects an incorrect and outmoded understanding of infectious aerosols, which has been institutionalized in policies, language, culture, and approaches to infection control. We will address this below. Briefly, however, the important points are that virus-laden bodily fluids may be aerosolized and inhaled while a person is in proximity to an infectious person and that a wide range of particle sizes can be inhaled and deposited throughout the respiratory tract.
> ...
> Modern research, using more sensitive instruments and analytic methods, has shown that aerosols emitted from the respiratory tract contain a wide distribution of particle sizes—including many that are small enough to be inhaled. Thus, both small and large particles will be present near an infectious person.
> The current paradigm also assumes that only "small" particles (less than 5 micrometers [mcm]) can be inhaled and deposited in the respiratory tract. This is not true. Particles as large as 100 mcm (and perhaps even larger) can be inhaled into the mouth and nose. Larger particles are deposited in the nasal passages, pharynx, and upper regions of the lungs, while smaller particles are more likely to deposit in the lower, alveolar regions. And for many pathogens, infection is possible regardless of the particle size or deposition site.
> It's time to abandon the old paradigm of three mutually exclusive transmission routes for a new one that considers the full range of particle sizes both near and far from a source. In addition, we need to factor in other important features of infectivity, such as the ability of a pathogen to remain viable in air at room temperature and humidity and the likelihood that systemic disease can result from deposition of infectious particles in the respiratory system or their transfer to the gastrointestinal tract.
> We recommend using "aerosol transmissible" rather than the outmoded terms "droplet" or "airborne" to describe pathogens that can transmit disease via infectious particles suspended in air.
> Here, we provide data on the stability and viability of MARV and ZEBOV in both liquid media and on a range of solid substrates at various temperatures, over time. In addition, the stability and decay rate of MARV, ZEBOV and Reston ebolavirus (REBOV) within small-particle aerosols held within a modified version of the Goldberg drum system (Goldberg et al. 1958) was investigated.
Completely right! As was theorized since the first modern recorded index case was recorded in Africa (a Dutch coffee farm owner?), several healthcare providers were infected who had not even touched the patient or any of the patient's secretions.
However, note in the paper I cited:
"However, the isolation of EBOV from only 1 saliva specimen, in contrast to the 8 that were RT-PCR positive, could suggest that the virus is rapidly inactivated by salivary enzymes or other factors in the oral cavity that are unfavorable to virus persistence and replication."
That plus the fact that standard precaution PPE for diseases with high rates of transmission (at least in CA) calls for goggles and a mask makes this story all the more interesting.
As many commentators undoubtedly will say, additional cases are to be expected. However, it's a problem that both in Texas and Spain, the people infected have been health workers. Health workers that are supposedly well-protected and well-informed about Ebola specifically (at least the spanish nurse was, it's not clear in this case yet).
Now it's true that there are more bodily fluids in a hospital than outside, but given all the protection and procedures, is the difference so big that a health worker is at a much bigger risk than a person who happen to sit next to someone infected on a bus?
There are two cases as I see it. Either it's likely that other people, non-health workers, have been infected. We just don't know about it yet, or it has been decided that it's not in the public's interest to know. Or the protective measures are so bad, the disease so misunderstood or hard to protect against, that health workers effectively can't protect themselves against the risk.
Either case, it's a big problem. In the west too.
In that thread people were saying the health worker was infected before they knew Duncan had Ebola. In this thread, when it turns out that the health worker did know Duncan had Ebola, people are saying that it's obvious. Funny how these things work.
No one except mainstream US media is advocating panic. That doesn't mean it's not a serious issue that requires our attention. Saying "Ebola is overrated, more people die of X every year, don't panic ffs" doesn't add anything to the debate - it's neither controversial nor insightful.
To guide the discussion, here's a suggestion for people who disagree with me. Either argue why there are more than the two cases that I outlined, or argue for why either of the two cases aren't a problem in the coming weeks and months.
At the time you posted this, there were 1 or 3 other comments. Yet you still summarize, In this thread, when it turns out that the health worker did know Duncan had Ebola, people are saying that it's obvious.
Going one step further, none of the comments that were posted at the time you made that summary really said much about whether the worker knew that Duncan had Ebola.
> Now it's true that there are more bodily fluids in a hospital than outside, but given all the protection and procedures, is the difference so big that a health worker is at a much bigger risk than a person who happen to sit next to someone infected on a bus?
Yes, that's abolsutely true. Ebola spreads through contact with bodily fluids. Someone who not syptomatic (or in the early stages of their symptoms) does not produce much in the way of 'extra' bodily fluids, so the risk is quite small in terms of casual contacts. It's only when they become quite sick that they start produce massive amounts of infectious fluids, and that's when healthcare workers are most likely to come into contact with them. In fact, the sicker they become, the more fluids they produce, and the more care they need...
> There are two cases as I see it. Either it's likely that other people, non-health workers, have been infected. We just don't know about it yet, or it has been decided that it's not in the public's interest to know. Or the protective measures are so bad, the disease so misunderstood or hard to protect against, that health workers effectively can't protect themselves against the risk.
The third option (and the most likely one) is that people make mistakes. The protective measures work if used properly, but they have to be used properly _every time_. With half a dozen cases being treated in the US, I'm somewhat surprised we've only had one lapse leading to an infection so far. However, as long as the average number of healthcare workers infected per patient stays well below 1, we've got nothing to worry about.
It's less surprising if you factor in that the other cases were known to be Ebola before being medevacuated to one of the 4 hospitals that are set up for these sorts of diseases. Presumably they're more careful, and they had advance warning to get their acts together.
On one hand, health workers are wearing more protection - but on the other hand, they're in much more contact with their bodily fluids than a random passerby.
Even in family contacts the main vector of Ebola seems to be caregiving - you're likely not touching someone sitting next to you on a bus, much less wiping their bottom or cleaning their face from vomit.
So far this hospital has completely screwed up both in providing medical services and explaining what happened. Does it really make sense that an apparent emergency room worker would be wearing full protective gear including a face shield before they had even diagnosed Ebola? And if so how did the virus get through? Magic? No somebody, most likely the infected person, screwed up. All it takes is a touch of your comtaminated gloved hand to your unprotected face.
Like when they blamed the computer system then later denied it was a problem or when they said the initial patient's fever was 101 and it later turned out to be 104 we may have to wait for the truth to come out, if it ever does.
Lets be honest here, the only facilities which did screw it up, Emory being one, are specifically setup and trained for this type of containment. They also knew they had patients coming.
This is why Ebola is such a threat. It takes time to incubate, it looks like other less harmful health problems early on, and it spreads. Yet air travel goes on impeded and borders are open. SARS led to more restrictions that Ebola.
Honestly it really seems we are trying to rationalize away the problem. We are coming up with excuses for cases that go against what people were told to expect. This is not how you contain a problem, its how you create a bigger one.
So what is the threshold before people should be concerned? five more cases? twenty? A hundred? If it gets to a dozen I am pretty sure people will expect travel to locked down and more.
From the Post article linked here, "The person treated Duncan, the Ebola patient, after his second visit to the ER, on Sept. 28." This was not an ER worker, and their contact with the patient was after the diagnosis.
I may be wrong that it may be an ER worker but according to the NY Times "it occurred at some point DURING or after his second visit to the hospital on Sept. 28."[1] He tested positive on Sept. 30.[2] We will have to wait to see what the facts turn out to be.
Do you recall if the original alleged computer system problem mentioned a particular EHR? Not sure I read anything except vague references to software error.
According to National Review it was Epic. This makes sense given their market share but keep in mind that National Review have an axe to grind as Epic is a big Obama/Obamacare supporter. Best to find additional confirmation.
BTW - Epic has my local hospital chain by the balls after a few failed attempts to build alternatives. It looks like something from the 1990s - super modal interface in a remote desktop.
It's actually not that contagious. There is a unit of measurement for this called the Ro number (high #=more contagious). Ebola is about 1.8 currently, pandemic flu was 1.9, measles is 15-20.
What? You do realize that a RO can actually grow in size which is exactly what this is doing right?
When the outbreak began in Guinea it was RO = 1.5 Early July, the RO in Sierra Leone was 2.5. Today in Liberia, the virus has been spreading so fast that the RO hasn't been computed (and we won't officially know since Liberia has been acting shady and is not reporting all of their statistics).
I think you probably saw some infographic floating around and are citing that, but that RO is a variable number.
I assumed the inclusion of the word "currently" would have implied that the number is dynamic, my apologies if that wasn't a safe assumption. I haven't seen any data putting the Ro in any country over 3.0. Obviously waiting to see new data that includes September.
I gather that a number of 3 is much more likely than 1.8. Still low compare to what's medically "airborne", especially if you factor in that pandemic flu is probably undercounted.
It's above 1, by my and many other's estimates around 3 in this outbreak, which, while technically "isn't particularly infectious", is still very bad and quite enough for exponential growth, in this case with an observed doubling time of 3-4 weeks. The CDC's recent worst case estimate is 1.4 million infections by January.
That has happened in the past. It's not unique to this outbreak. People make mistakes all the time. Sometimes those mistakes related to how they wear PPE.
At some point, we're going to have to talk about how this black, uninsured man walked into a Dallas hospital, which discharged him and then later lied about his condition when he first went to a hospital. And we're going to need to talk about Republicans slashing CDC funding and every other type of public health funding they could get their hands on. And we're going to need to talk about how the two white Christian missionaries got flown directly to a specialized hospital in Nebraska immediately upon diagnosis, and survived.
(edit: very predictable downvoting on this. But it's simply a fact that politics and race have played a part here. I don't like posting it any more than you like admitting it to yourselves.)
What is your preferred explanation? That a doctor suspected ebola but, because Duncan was an African without insurance, thought it better that he walk around for four more days?
When would you like to talk about the fact that an unmarried unemployed man traveling from the Ebola hot-zone of Liberia (also 5th highest rate of visa overstay) but with Ghanaian citizenship, who had a sister living in the United States, was even allowed into the country to begin with?
By all accounts Mr Duncan got the best care possible once he was diagnosed properly. He had the misfortune of not matching blood types with the earlier U.S. patients whose blood had been used to treat others.
The late diagnosis was absolutely devastating to his prognosis. I think it's quite likely he would have survived if it had been caught during his first ER visit. I think it's a stretch to chalk that up race (or a lack of insurance) though...
But isn't that precisely the point? He was not diagnosed properly when he first presented, despite extraordinarily clear signs. He's a Liberian national who recently helped treat a pregnant Ebola victim just before flying to the US, for chrissakes. He presented with extreme pain and a very high fever.
But he was black and uninsured, and it's Texas, and they summarily discharged him and took no notice.
Perhaps you are right, and it's "a stretch" to mention the factors that may or may not have played a role in why this man was treated so very callously in the midst of a very very well-publicized epidemic of scare-mongering over Ebola.
I simply disagree. I think it is quite possible indeed that these were factors.
While we're not sure whether he said "West Africa", "Liberia", or what, press reports universally say he never reported his close contact with that pregnant Ebola victim.
Fever plus pain are not "extraordinarily clear signs"; they're common for a host of diseases, including a host of common to African diseases, like malaria.
Nothing I've seen suggests the hospital egregiously dropped the ball in this first visit, however I'm entirely certain that widely casting blame at generic targets when anything bad happens, like "Republicans", racism and our medical system, does no good and rather a lot of harm.
And yet the hospital initially diagnosed him with sinusitis, the symptoms of which clearly do not include abdominal pain.
Based on his review of the medical records,
Dr. Adalja said the diagnosis given to Mr.
Duncan before his discharge included
sinusitis, a sinus infection.
HE WAS NOT DIAGNOSED WHEN HE FIRST PRESENTED BECAUSE HE DIDN'T TELL ANYBODY HE HAD BEEN IN CONTACT WITH SOMEBODY WHO DIED OF EBOLA!
What don't you get?? If Thomas Eric Duncan had stated "I'm a Liberian national who recently helped treat a pregnant Ebola victim just before flying to the US" he would have been isolated immediately. He didn't and now other people might die because of it!
Everything is clear and more evident in hindsight. It seems that as far as Duncan knew, that pregnant woman was suffering from malaria, not ebola. She died while he was in transit or shortly after. He would not have had that knowledge.
"Knew", or very possibly hoped. She died in the house he was living in, and the end symptoms are sufficiently different that if you know which is which, you'd know. But we can't assume he would know to be able to do a differential diagnosis.
That is a nice theory...except that that word did not appear in my original comment; only in the parenthetical edit after it was downvoted. I take exception to you describing my comments as "race-baiting"; that is offensive and uncalled for. It was also certainly not my intention. I think the way we treat the uninsured is criminal in this country, and it's also very dangerous from a public health standpoint, and this example illustrates that problem quite well.
Its overall budget was flat -- WHO decided to reduce infectious disease activities to fund other priorities. In complete fairness, the article suggests that WHO intended to shift some detection and emergency response responsibilities to member countries, and put some resources in that new paradigm. But even if so, the management of that transition now seems suspect.
I've seen various press references that the WHO had its budget cut after the financial crisis. But as near as I can tell (its budget transparency is almost zero), its budget in 2006 was $3.3bn, vs $4.0bn in 2014.
The CDC, by the way, has an ample budget, much of it dedicated to non-infectious disease activities like tobacco and chronic disease. A bit goes to gun control. These activities may be worthy, but it isn't clear that they protect public health in the same sense that epidemic control does.
Thomas Eric Duncan took a pregnant woman who later died of Ebola by taxi to look for treatment. He lied on a questionnaire at the airport in Monrovia that asked if he had been in contact with anybody infected by Ebola. Because he lied his own country said that it would prosecute him if he survived!
If Thomas Eric Duncan had not lied at the airport he never would have been allowed onto an airplane. If Thomas Eric Duncan had told the hospital in Dallas that he had cared for a person with Ebola he would have been isolated immediately.
Thomas Eric Duncan isn't dead because he was black. Thomas Eric Duncan isn't dead because he didn't have insurance. Thomas Eric Duncan isn't dead because Republicans. THOMAS ERIC DUNCAN IS DEAD BECAUSE HE LIED!
Actually, what Mr Duncan did was help his neighbors drive a woman who was 7 months pregnant to the hospital. The woman was presenting symptoms that are not unique to Ebola (fever & convulsions). The woman was not hemorrhagic. The group was turned away at the hospital and so they drove her back home. Mr Duncan then assisted in helping the woman back into the house. This is almost certainly the point at which he was exposed. The woman was not tested for Ebola until after her death, so Mr Duncan could not have known but he could have suspected.
Thus the possibility that Mr. Duncan thought he was only helping a pregnant woman get to the hospital to help with a troubled birth. At that point, the most information he could provide is that he cared for a sick pregnant woman.
Relying on the fact that Liberia would prosecute him is a bad idea, due to the precarious nature of justice in that country. I would imagine that Liberia would say just about anything to prevent public opinion in the US from going sour. Liberia is facing an existential crisis and are in desperate need of all the help the US can give.
Mr Duncan's trip to the US was planned weeks in advance, so he was not fleeing the country in response to his exposure.
Actually, Thomas Eric Duncan is dead because he came in sufficiently close contact with the Ebola virus, and it was fatal as it is for most who contract it.
It's this healthcare worker, and the likely other contacts who are not yet symptomatic, who are sick and statistically going to die who are dead because he lied.
And those who expect people to tell the truth on such forms, which flies in the face of all we know about human nature.
My understanding is that Duncan told the ER staff that he had helped to treat a malaria patient. At the time of his first visit to the hospital, he didn't know, himself, that he had been exposed to Ebola.
But don't let the facts get in the way of a good race-card rant.
"Some Ebola experts worry that the virus may spread more easily than thought -- through the air in small spaces, for example."
Aerosol transmission is a very real possibility and has been demonstrated in the field and in some experiments, including working its way through the air ducts of a building, from one part to the another, infecting monkeys, and not just through one room.
Though some strains are not as effective in that mode of transmission as others.
edit: To the down-voters, at least make your case. The people that worked with the virus, and in the hot-zones, made theirs.
> including working its way through the air ducts of a building
It's _far_ more likely that those transmissions were due to cross contact from the folks working with the animals. The researchers themselves suggested that was an equally likely vector.
Contact is far more likely cause of infection, agreed. But when sneezing we spray a tiny amount of fluids. Are they not enough to get infected even with a low probability? Given an high number of occurrences any low probability yields an event.
The virus still has to be in nasal passages or perhaps lower to get in what's expelled. Here's what I said in a recent discussion in reference to the fear it would evolve to be "airborne" as the term is medically used (https://news.ycombinator.com/item?id=8421982):
The critical distinction here is that Ebola doesn't seem to infect the outer part of the respiratory system like colds or influenza. There's not a huge mass of cells there to be shedding viri and getting into the air, and it would take more than a few mutations for that to change.
Ebola viri have been found in saliva, tears, can come from bleeding in the respiratory system, so it obviously can get airborne that way. Exactly what that means (how big are the droplets, how long do they stay in the air etc.), how significant that is as a mode of transmission (which includes iffy estimates of how many viri (virus particles) are required to make an infective dose) ... we just don't know. But with our current Ebola importation policy, it's very likely we will start to get answers to these questions....
That's the definition of "aerosol transmission" here.
Depending on the drop size and the viral load in those drops, depends on how far it will travel in air, how long it will be suspended in air, what potency it has, and how likely someone other can get infected when it's inhaled.
"The common cold virus is typically transmitted via airborne droplets (aerosols), direct contact with infected nasal secretions, or fomites (contaminated objects)."
A person with Ebola going through a crowded airport and sneezing could infect dozens of other people under the right circumstances (virus strain, load, etc).
Because this is actually a fairly well defined area of research. Sneezing absolutely does produce particles that small. Ebola cannot be transmitted by those particles. The larger droplets that can transmit Ebola are too large to make it through a ventilation system.
> Although they are not naturally transmitted by aerosol, they are highly infectious as respirable particles under laboratory conditions.
I think the issue is to what degree it can get into the fluid that is sneezed out by humans... Once it's in it, the size of the droplet does not matter to how viable the virus is - it's deadly if inhaled in by someone else.
Here's my case: you made your alarmist "case", such as it is, by posting a junk article from a junk, far-right blog whose other charming entries include:
-9/11 truther articles
-racist crap about Ebola spreading over the Mexican border because of insufficient efforts to secure said border
-several other non-scientific articles about Ebola
-an article about "Obama's Ukrainian stooges"
If you want to make your case, find one cite--just one will do--from a legitimate publication of any kind.
"We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks."
It has legitimate publications inside it so it looks like the possibility is quite justified.
It seems that the term "airborne" is very specific and droplets might exist in the air even if it's not considered airborne. (I'm not saying that droplets can be found in the air, but simply that it's not fully confirmed and that this is the reason why they recommend respiratory masks.)
> Or, maybe, this strain is considerably more infectious than initially assumed, and the protocol is inadequate.
It's not magic. There's no amount of 'infectiousness' that will penetrate several millimeters of plastic.
The simplest explanation is that the nurse simply made a mistake. Either touching exposed skin while still in PPE, or screwing up while taking PPE off.
I say this not to incite panic, but to provide insight that many might not have. It is more likely that during the thousands of interactions that this patient saw, the messiness led to a breach, instead of the virus infecting via a vector we've not yet realized.