UPDATE: The first health worker to have been affected with Ebola in Texas may not be moved to Maryland.

From NBC:

Nina Pham, one of the two nurses who contracted Ebola in Dallas, is expected to be moved to a National Institutes of Health isolation unit in Bethesda, Maryland, a federal official with direct knowledge of the plans told NBC News on Thursday.

The transfer could happen later Thursday, but the official cautioned that plans were evolving. Pham, 26, was diagnosed with the virus on Sunday after treating Thomas Eric Duncan, who contracted Ebola in Liberia, flew to Dallas and later died.

The other nurse who contracted Ebola in Dallas, Amber Vinson, was flown on Wednesday to Emory University Hospital in Atlanta. The Emory and NIH units are two of the four facilities in the United States that are specially equipped to handle Ebola.

UPDATE: The second infected health worker will be transferred from Dallas to Emory.

This is a second health worker, who reported in with at fever on Tuesday. The worker is one of the 76 who had been self monitoring, who were thought to be most likely beyond the most likely period for infection.

(This might be a good time to point out that while the CDC uses 21 days, which is probably usually good, one study showed that a small percent of individuals might develop the disease after 21 days following exposure.

Yesterday, Tom Frieden, head of the CDC, noted “CDC Director on Ebola: ‘Even a Single Infection is Unacceptable'” Also, yesterday, Dallas nurses complained about the situation at the beginning of the treatment period for the Index patient who died there.

There was a briefing in Dallas.

During the briefing, it is confirmed that this new patient was involved in care for the Index patient.

We’re a great hospital, we always have been, we want to get this right, we fell really bad, we’re doing fine, etc. etc. (that was the hospital representative)

Teams have swooped in and started cleaning common areas near the new patient’s apartment, neighbors have been or are being interviewed.

The patient lived alone and with no pets. Inside cleaning and cleaning of the car will happen later today.

Question for hospital rep: Does a second case indicate systematic institutional problem. Answer: No. We know what we are doing and handling it and we are looking at everything.

Was this person a nurse? We won’t tell you that.

Question: When did this patient come forward and get a blood test in relation to yesterday’s press conference? Answer. Hipaa.

Question: There are three isolation rooms at the hospital. What will you do when you fill up? Answer: Working on that. Also, there are actually is more room than that, a little.

Question: Timeline? Answer, got confirmation about 1:00 AM. Then we started doing stuff, press release at 4:00.

Question: Allegations from the nurses?? Answer: I can’t comment. We have the proper protected gear.

Question (breathless): Are steps being taken to isolate the other workers? Answer. There are 75 hospital workers. They are asymptomatic, the are not contagious. Please try to avoid community panic with those questions (I paraphrase, he didn’t say that). When people get symptomatic they report in, like happened twice, the system is working.

By the way, the are not coming in to work.

Perspective:

On preparedness of the hospital. There is evidence that the Dallas hospital that treated Thomas Duncan was not prepared to handle an Ebola case, and initially, nurses were not well protected. It is also clear that the clean, crisp, rapid response we may have expected from the CDC was not there. However, it is probably the case that that hospital is now managing the two cases they have properly, and that the monitoring program for other contacts is good.

To me, this means that the repeated, near universal statement by the US health community that the US can handle Ebola was overstated. Let’s take a look at the overall problem. I previously divided the Ebola exposure problem into several phases. Here is an updated version of that:

1: An infected individual arrives in the US, becomes (or already is) symptomatic, and is not yet admitted to a hospital. At this point we rely on that person’s decisions to seek treatment. There can be several hours to several days of time of potential exposure, but even so, the person is ambulatory and less symptomatic, and probably is an infection risk but a low(ish) one.

2: The infected individual either becomes very sick and is brought to the hospital or self admits. At this point there is a risk of infection to other people at the hospital including other patients and hospital workers, as well as ambulance drivers, etc. During this second phase it is up to the hospital to quickly identify a possible Ebola case and isolate the patient, and start safe procedures for care. In the case of the Index patient in Dallas, this took several days (and the patient was sent back into Stage 1). This inadequacy conflicted with what the public was being told by experts. However, now that the very first actual case of Ebola emerging in the US happened, and those who were not expected to mess it up did mess it up, everyone is on their toes and the chances of a repeat of that are lower. The CDC has also developed an improved method of addressing this (their ready teams).

3: The infected individual is in an isolation unit and being cared for. At this point it is up to the hospital and the health workers to minimize the chance of infection of others, and those at risk are, theoretically, the health workers. In the case of the Index patient at Dallas, according to nurses who worked there, the risk of infection of health workers was not minimized fully at least initially, and it is even possible that risks beyond the care staff continued. Eventually, we assume this was fixed. But, the fact that two health workers have been infected does amply demonstrate that whatever was going on was not adequate, though at this point we don’t yet know in what way, or when, things were done improperly and we need to take the word of the same hospital and health system spokespeople that earlier assured us that things are fine. Since the system representatives have yet to fully acknowledge there were inadequate procedures or care, and describe that inadequacy openly, we really don’t know. I suspect they really have cleaned up their acts, because they are strongly motivated to, but we are starting to see the edges of an Orwellian response where information is being cleaned or withheld, sometimes under cover of HIPAA rules.

1: During the first three stages, exposure of others may happen, and those individuals need to be identified and managed. Individuals who do end up being infected during that period are now in Stage 1, but if there is an effective monitoring program, stage 1 is very short (hours?). Because the system is ready for secondary cases, stage 2 is minimized (or does not even exist), and the patient is now in Stage 3. In the case of Dallas, we can guess that the two patients who have cycled into Stage 1 (both health workers) are in Stage 3 and Stage 3 is being done properly.

At a later time, if there are too many additional cases, the revamped and updated Stage 3 response may break down again due to lack of isolation facilities. The authorities seem to be aware of this possibility.

We don’t have a lot of control over what happens during Stage 1 for newly arriving patients, though the system has demonstrated that it can handle Stage 1 for those of known risk who are in a monitoring pool. But for the system to be like various spokespeople claimed it was, a great deal of effort has to be put into training, procedure, and dispersal of equipment. Dallas demonstrates that for a hospital that should have been ready, this was not the case. But, the CDC response, of having ready teams (like we learned from movies and literature to be how the CDC operates, in fiction!) should make the transformation from inadequate response to adequate response more likely if there are other cases.

Many thousands of people in West Africa have gotten Ebola, about half have died. Our problems here in the US are tiny. But, everyone is concerned about the possibility of spread outside of West Africa. One consequence of the small leakage that may occur being handled poorly is a stricter response in the form of travel restrictions. This would have multiple negative consequences. The Dallas Index patient got past the system, but the international travel problem is being tightened up a little (we have no idea if that is adequate). If infections beyond Stage 1 continue to happen, as they have in the US and Spain, people will demand a closure of borders. And, perhaps, that is what should happen.

Timing of infections vis-a-vis the Index patient

Ebola is thought to manifest in as little as four days after exposure, with most cases showing up prior to 17 days after exposure, but as late as 25 days, using very liberal estimates of exposure time. The Dallas Index patient, Thomas Duncan, was cared for in the hospital staring on September 25th, and died on October 8. The most recent secondary infection was identified last night, so let’s round up and say that was 7 days after possible exposure. If we assume for the moment (we have no basis for this, this is a rough guess) that the first half of that care period was as suggested by nurses being handled inadequately, and the last half was managed well, to split the difference, perhaps the most likely period of exposure ended around the second of October. So, perhaps today is about two weeks post dating likely exposure. So, a roughly optimistic guess would be that the chances of another health worker ending up with Ebola is not small for the next three or four days. A fully pessimistic estimate is that we have ten or so days over which this could happen. Stay tuned.

Comments

  1. #1 dean
    October 15, 2014

    Have you seen the new darling of Fox News, Dr. David Sanders, “World renowned Ebola expert”, expounding on the fact that Ebola can be spread through the air and that it has “the inherent capacity to get into the lung”.

    My email box has been full of references (I have a good number of conservative relatives) to his comments. Strangely, all have been to Fox, Breitbart, Infowars, and similar spots referencing him, no ordinary sites. I can’t get to those from school so can’t tell anything about him.

  2. #2 proximity1
    October 15, 2014

    “Nurses at Texas hospital: ‘There were no protocols’ about Ebola”
    By Catherine E. Shoichet, CNN
    October 15, 2014 — Updated 0236 GMT

    (CNN) — A union made troubling allegations Tuesday about the Texas hospital where a nurse contracted Ebola, claiming “guidelines were constantly changing” and “there were no protocols” about how to deal with the deadly virus.”

    “The protocols that should have been in place in Dallas were not in place, and that those protocols are not in place anywhere in the United States as far as we can tell,” National Nurses United Executive Director RoseAnn DeMoro said. “We’re deeply alarmed.”

    “CNN Chief Medical Correspondent Dr. Sanjay Gupta said the claims, if true, are “startling.” Some of them, he said, could be “important when it comes to possible other infections.” …

    (link: http://edition.cnn.com/2014/10/14/health/texas-ebola-nurses-union-claims/index.html )

  3. #3 Astrostevo
    Adelaide hills, South Australia
    October 15, 2014

    Grim news & this from the local online news ain’t exactly cheery neither :

    http://www.abc.net.au/news/2014-10-15/ebola-cases-could-reach-up-to-ten-thousand-a-week-says-who/5814138

    Hope we get an effective (& chepa and accessible) tretament ASAP!

  4. #4 Karan Richardson
    New Jersey
    October 15, 2014

    Dean,

    Dr. David Sanders is an Associate Professor of Biological Sciences at Purdue University, where he heads up Purdue’s Molecular Virology program.

    He’s done some interesting work. See, for example, this:

    http://informahealthcare.com/doi/abs/10.1517/14712598.4.3.329 (paywalled)

    He’s been on air lately saying that the ebola virus could mutate into an airborne pathogen, and that increased transmission rates can facilitate a mutation like that:

    http://www.theindychannel.com/news/local-news/purdue-professor-says-ebola-primed-to-go-airborne

    Some people listen to something like that, and hear only ‘ebola’ and ‘airborne’. Hence the general freakout.

    Personally, I find this embarrassing. Thousands of people dead in Africa (including many hundreds of healthcare workers) – and this country is in a panic over one death and a very small handful of secondary infections. Sheesh.

  5. #5 Greg Laden
    October 15, 2014

    Yes, it is a little embarrassing. But, at the same time, examining the cases where Ebola gets out of Africa is important because globally it is an issue. But, yes.

  6. #6 dean
    October 15, 2014

    Ok. Any idea how much weight his comments about “going airborne” (and similar) should be given?

  7. #7 jane
    October 15, 2014

    It’s been noted that Duncan was put on dialysis and intubated, and that the procedures for these create more aerosols than most aspects of patient care so may increase the risk of transmission. None of the thousands who have survived Ebola so far, including those few treated in the U.S., are reported to have received these procedures. It is unknown whether those who get bad enough to “need” them would have a substantial chance of recovering if time is bought, or if they will probably just substitute for death from kidney or respiratory failure a slightly slower death from liver failure or shock. Both procedures are often overused in America to extend the dying process, but the victims usually have noncommunicable problems. If there is little chance that these heroic measures will save a given Ebola patient’s life, and they increase the risk of a possibly fatal infection of a nurse, perhaps there should be a policy of not using them. It is a tragic fact of plagues that the normal moral imperative to do everything possible for the sick has to be balanced against the need to keep care providers healthy for the sake of future sick people.

  8. #8 Greg Laden
    October 15, 2014

    Dean, yes. Yes I do.

    http://scienceblogs.com/gregladen/2014/09/30/ebola-will-not-become-airborne-and-here-is-why/

    Jane, I’d agree that dialysis may not be common, but it is a known step in treatment for Ebola.

    There are procedures recommended for dialysis and other similar procedures, this has been studied, and it is not simply “unkown.” in one hantavirus outbreak a large number of patients recieved dialysis, the procedures were followed, and there were not secondary infections.

  9. #9 dean
    October 15, 2014

    Thanks – I’ve read that and will re-read. I didn’t know if anything he said was new.

    Have taken enough of your time and will stop bothering you. I need to finish grading and get home off a bum knee now anyway.

  10. #10 RWood
    October 15, 2014

    Is there a concern about veracity here
    http://www.mcclatchydc.com/2014/10/14/243412_dallas-nurses-describe-ebola-hospital.html?&rh=1
    Or with higher levels of authority?

  11. #11 Greg Laden
    October 15, 2014

    RWood: I wrote about that here:

    http://scienceblogs.com/gregladen/2014/10/14/was-the-texas-health-presbyterian-hospital-prepared-for-ebola-probably-not/

    I don’t know how to evaluate that. If a bunch of nurses express concerns like this I’d take it seriously, but I think the claims also have to be evaluated in detail. As I imply above it is reasonable to assume that things were messed up at the start then got better. But at the same time it is important to question the fact that the authorities (generally, in the health industry and public health) had been saying all along that everything would be managed just fine, as the evidence is clear that this is not the case.

  12. #12 Brainstorms
    October 15, 2014

    And now we find that this nurse was on a plane the day before showing symptoms…

    Must be something about Ebola that it makes its victims want to travel around during the incubation period.

  13. #13 jane
    October 15, 2014

    It should be extremely unlikely that this patient infected anyone on that flight – but unlikely isn’t impossible. However, the nurses caring for Duncan were told only to do self-monitoring, rather than the more intrusive monitoring by health officials, because they were perceived as being “not really at risk.” If they believed they were quite safe and were only monitoring at all out of an abundance of caution, there would be no reason for them to avoid public transportation. It is appearing under American conditions that sharing housing or even a bed with a patient in early stages is less risky than performing some aspects of medical care, with typical protective gear and training, on a patient who has become extremely ill. This is problematic because some of those staff must use public transportation just to get to wok.

    Nurses have said that staff caring for Duncan were actually caring for other patients on the same day. If these two nurses got droplets or aerosol on a suit, say, which then got on their skin during disrobing and eventually infected them, then went to other patients’ rooms, it is not impossible that they could have touched something else with that skin surface and exposed another patient. This seems unwise, and I bet they will change it quickly. But then, if involved nursing staff at a community hospital must be considered semi-high-risk for infection, should they not care for non-Ebola patients until 21 days after their last contact with an Ebola patient? It’s been noted that nurses at this hospital are not unionized and have very little clout with management. Will the hospital pay for them to take three weeks’ vacation (which I would say they have richly earned)?

  14. #14 Omega Centauri
    October 15, 2014

    This whole episode makes me worry about our care-system. In Nigeria, the Replication factor went from an estimated value of two, to about .4 once they got serious. Our system insists on trying its best to save each patient, almost regardless of cost. In the case of patient zero, R is at least 2. Can we give good care, and minimize R at the same time? At least in the unawakened state at one hospital the answer is no.

    Well we are trying a lot harder now, CDC teams ready to swoop in and take over. Hopes its enough.

  15. #15 Greg Laden
    October 15, 2014

    In Nigeria, that happened in the same way it is happening here. A few people got infected by one person arriving from a different country, then it died out. Which is interesting.

  16. #16 Greg Laden
    October 15, 2014

    The nurses are not working in the hospital, and are on paid leave, according to the recent news conference.

  17. #17 Greg Laden
    October 15, 2014

    Or maybe it is unpaid leave….

  18. #18 proximity1
    October 16, 2014

    @ 16 & 17 :

    Think of it this way– those nurses who are union members may be and more likely are on paid leave while those, if any, who aren’t union members are not or are _much_ less likely to be, on paid leave.

    —————–

    Now we know of at least one instance of airborne Ebola :

    “it flew” Frontier Airlines flight 1143 Cleveland to Dallas/Fort Worth Oct. 13 and, as usual, the public is told,

    …”The safety and security of our customers and employees is our primary concern.” (Frontier Airlines)

    …”passengers on Frontier Airlines Flight 1143 are at “extremely low risk” of being exposed.” ( Centers for Disease Control Director Dr. Thomas Frieden )

    This is the equivalent of “no harmful radiation was released.” I don’t think Dr. Frieden’s assurance is more than sheer conjecture on his part. I doubt he has any very good idea of what the likelihood of exposure was during that particular flight–unless he was aboard and seated next to the nurse in question.

  19. #19 Hank Roberts
    hankroberts.wordpress.com
    October 17, 2014

    > at least one instance of airborne Ebola

    One patient flying in an airplane.

    That’s transportation, not transmission.

    Don’t confuse the two.

  20. #20 Jim Schenke
    Purdue
    October 20, 2014

    Do your research and you will see that it was CNN who first ran with Sanders expertise.

  21. #21 Jim Schenke
    Purdue
    October 20, 2014

    If you think that Sander is some sort of FOX NEWS stooge, do your homework and check out his progressive campaigns for office against the likes of conservative Steve Buyer (R-IN).