First person in US to catch Ebola: The Meaning of Ebola Patient Two (updated)

My biggest concern is that ebola gets into the bat populations in North America and Europe. That may make it much more difficult to deal with in the short term.

What would likely happen then is that vaccines for ebola would be developed and administered to bats, likely via GMOs. That would probably be pretty effective because bats have a low population growth, ~1 per year, and immunity would likely be long lasting.

It should be noted that rabies is endemic in Bat populations in the US already. Although it does take a bit to spread, clearly the risk of rabies is low enough that only those involved in animal health (vets animal services etc) get the vaccine.

Remember, though, there are two kinds of bats and they are very different. Both Rabies (in the US) and Ebola (in Central/West Africa) is found in fruit bats. There are no fruit bats in the US or the New World. I am not certain that non-fruit bats have been tested for Ebola in Africa, but a lot of animals were and to my knowledge only fruit bats are regular hosts (and even there, it is spotty, found in many species, but the average sampled fruit bat may show no evidence or only evidence of prior infection, not active infections).

Microchioptra and Megachioptra diversified a long time ago, probably the early Eocene. They are really different. Mega do not echolocate and are less nocturnal (though this is probably derived, but in antiquity). Ebola is a filovirus, suggesting that fruit bats originally acquired it from plants (in antiquity through a long history, likely). I don't think it is especially likely that the insectivorous (or blood drinking) microbats are carriers of ebola.

But, after all, a lot of mammals can catch it. Dogs seem to have it but not get sick from it. The idea of Ebola taking up a new host is not at all outrageous. Probably it would be a mammal, and it would likely be gregarious (given the way ebola probably gets round in bats). So microbats are a possibility, as well as a wide range of rodents, I suppose.

One also has to wonder how much training the workers had had with these procedures (or is that a stupid thought?)

"Perhaps care workers should be demasked, degloved, and degowned by a masked/gloved/gowned coworker who has just suited up in a space away from the patient. (I don’t think that is done now.)"
What level of concern would there be for these people's risk of exposure?

If I'm not mistaken, the issue in West African bats and ebola is that the bats are a common form of bushmeat. Transmission comes from handling and eating the infected animals.

Just guessing, but I think ebola would have to become widespread in humans before being transmitted to North American bats, and even then, Americans have very limited contact with bats.

Bats are bushmeat but most outbreaks probably have involved primates or ground mammals. The a west African outbreak may not have been bushmeat at all.

Until now this hasn't really been a west African problem

I am thinking a big threat now is terrorists deliberately spreading the virus using their own bodies. Ie if someone were to get themselves infected and travel to a populated area, deliberately mingling into crowded places. I hope the authorities have attention on that angle.

That tactic goes back to the Middle Ages. And before that, too, I believe. (In the form of, e.g., livestock infected with anthrax being flung into walled towns to spread contagion.)

I'm not aware that it's been done with human beings, although I wouldn't put it past some ethno-religious groups to do so...

(Yes, yes, we're all now thinking about the castle scene in Monty Python and the Search for the Holy Grail...)

We're told that the chance of catching Ebola on a plane is very small. However I thought I heard that either the case in the US or in Spain was transmitted via a third surface, i.e. from the infected patient, to some surface, to the new patient, possibly from perspiration. If that is the case, then I would have thought the chance of catching Ebola is somewhat higher than we are being led to believe.

Can anyone clarify this?

Thanks.

Alistair, it is my opinion that if a person with advanced Ebola, exhibiting multiple symptoms, is a regular passenger on a commercial airline for several house, there is a very high probability of transmission.

Thanks Greg, that aligns with my thoughts.

So, to first approximation, our current estimate (with some margin of error!) of R0 in the US is now 1?

Karsten, yes, a very small sample size, but yes. Or, greater than or equal to, I suppose.

Brainstorms, would those be the "ethno-religious groups" who aren't equipped to just bomb or starve the ethno-religious groups they don't like? Yes, it's theoretically possible that A Terrist would infect himself, come here, and perhaps make a few people sick who might make a few more people sick. (When you're shedding huge amounts of virus, it's because you are experiencing constant vomiting and diarrhea, and as Greg points out above, this doesn't make it easy for you to walk around town rubbing your hands on things.) This pales in comparison to the hundreds of people who are being infected every single day by accident - though some of the racist right seem to think that this too is a plot against them.

I wonder what is the estimate of R0 of the CDC. If 0.1, with some reasonable uncertainty, this first data point ought to cause a significant upward shift in their posterior. It might not shift a prior of 0.5 very much, but then if their prior is 0.5, surely they can't be *that* confident that it couldn't be above 1. I for one, am not reassured by the logic of their communications. I want them to tell me the mean and standard deviation of their current posterior distribution for R0 in the U.S. Surely they've thought about this, no?

Jane, viruses aren't racist, they're more like opportunists. So any opportunistic group that wants to create mayhem could, theoretically, send infected-but-not-yet-symptomatic individuals abroad to mingle with groups they have it out for. They would not be vomiting, et al -- yet. And wouldn't need to go around town rubbing their hands on things. Which is exactly why this is so worrisome. They will eventually end up in the ERs (spreading as they are assisted in getting there) and that's all they require. Nature (human & viral) will do the rest -- as both have already combined & done in West Africa. Which is exactly why this is so worrisome.

@bob #8

... And all I'm thinking now is "we're all fucked."

Tim, we could just close the borders to save ourselves. Only, then Big Business would be screwed. So, since Big Business always gets its interests put first, they'll pull political strings to keep the borders open. THEN we'll all be f'd.

(Ironically, then Big Business will be f'd, too. But "it must be this way", since Big Business' intellect inevitably follows its morals.)

Feel free to substitute AGW into the above and find that it computes the same...

I'm thinking more of little business, which is what would be hurt most when the communities that sit astride the border from each of these African countries and the US is cut in two.

Yes, but I can't see any way to deal with this other than to partition/quarantine and deprive the virus of new hosts. It's too easily spread, and there are many cultural norms that only help to spread it. (E.g., the W African custom of handling the deceased seems tailor-made for Ebola propagation.)

Of course, all that assumes that a vaccine either can't/won't be produced, or that it will be "held hostage" to make its developers rich. Time is of the essence when you're dealing with exponential growth...

It hasn't hurt the black markets moving 'ill-advised' things, Greg Laden #20. -- They don't seem to always follow protocal. Or respect their own reputations when fake and deadly 'K2' happens to accidentally get on their shit, weed-killed, compressed-half-biodiesel glop of what passes for 'weed' when *they* turn off the domestic pipes.

'Insipid {... fill insomething here... my thoughts have turned to glop} L-glopamine(™)...

Brainstorms, if you're not actively sick, you're not likely to be shedding so much virus that just strolling by and breathing on people will give it to them. If you are sick, as soon as you go to the bathroom you'll have virus on your hands, which you can spread by touch, but you will soon be feeling too lousy to do much of that. Experts have said that Ebola is not a "rational" bioweapon - as if there is such a thing - for this reason.

There are thousands of currently infected, soon to be sick innocent citizens in these three countries, and very few "terrorists" indeed. The former group poses a much greater risk for significant spread out of the region, because even the tiny fraction of them who will innocently travel while incubating the virus outnumber any plausible number of - so far completely imaginary - disease terrorists. If we wall them off and try to pretend they aren't there, by the end of the year there will be hundreds of thousands, and the risk of unintentional spread will go through the roof.

Meanwhile, to shut down unintentional community transmission outside that region quickly, it's essential that anyone who might possibly be infected has access to care and does not have good reason to fear seeking it. If the local level of paranoid discourse is so high that a traveling foreigner or returned citizen from an "ethno-religious group" targeted for scapegoating thinks that going to a hospital might get him treated as a "suspected ebola terrorist" and thrown in a locked room with substandard if any care and no phone, he might rationally decide to stay home a couple more days and see if whatever is making him sick gets better. And you don't want that.

Those of you suggesting a bio-terrorism approach lack imagination. Guinea pig terrorists (or prisoners) would be infected by the virus from the fluids of an infected corpse that was smuggled out of west Africa. The infection would be allowed to proceed until copious infectious fluids were gathered. The fluids would be sent to terrorists in locations around the world who would spread them on surfaces in public places, while contracting the disease themselves. Then as long as possible they would infect as many individuals as possible. In other words, you don't need to be infected yet to start spreading the cheer.

Jane, Dan-- You needn't make this complicated: If someone infected goes to another country while they're asymptomatic, then gets sick later, then even if incapacitated, someone (multiple Good Samaritans?) will "help" by seeing to it that such "people in need" end up in an ER or medical office.

While that's occurring, everyone involved will be in contact with bodily fluids, touching surfaces, and causing what Jane refers to as "unintentional community transmission".

With 3 weeks from exposure to symptoms, that means a lot of chances for incidental exposure that goes unaware + travel before symptoms appear, leading to the culturally-expected assistance ... that all leads to exponential growth of exposure.

This would be different, if, say, an exposed person turns purple and oozes slime within minutes of being infected/infectious. Only then would repugnance lead to consciously avoiding contact.

We don't have that. We have "Oh you're sick, you need to see a doctor.. Let me help you..." Cultural norms and social pressures of "Polite Society" lead us to do things that lead to bodily contact and that's all it takes...

Brainstorm... Greg can probably verify whether this is correct, but I think there's a big difference in cultural aspects in west Africa and here that would likely prevent similar rapid spread of the disease.

On of the big problems in Africa has been that most of this has occurred in small villages where people have a limited capacity to comprehend what is actually happening. I've watched a Frontline piece and a NOVA special about this outbreak (and if I'm getting things right) it sounds like a lot of people have been infected there due to the tradition of washing the bodies of their dead. That, and the fact that, rather than having the option to go to a hospital, ebola victims are often cared for in their homes. It's only when medical workers get word of an outbreak in a village that the go their to try to locate them. By then you have entire extended families who've been in close contact with a symptomatic victim.

Then, on top of everything else, you have these foreigners who show up in the village, speaking strange languages (English), putting on space suits, then carrying their loved ones off, and then returning them a week later when they've died. Just tragic and awful for everyone involved over there.

It's definitely a big concern over here, but I kind of doubt we would see anything similar as what's been seen there. (I hope I'm right.)

You all lack imagination. While everyone is looking for Ebola is not the time to spread Ebola. Marburg. Spread that around, and the confusion will be immense and the fear will be ten fold. Throw in a little Lassa for good measure.

Oh, and welcome to our new friends at the NSA!

Rob, I hope you're right, too. OTOH, history of brain-dead Americans reacting to something they're scared of and don't understand; patients being sent home incorrectly; hysteria over the airborne tope; nurses getting infected after supposedly following procedures; etc. And I hope you're right, too.

Greg, you're just too damn intelligent not to have been on their radar the entire time...

I use linux.

Truly a radical, and probably a subversive... But at least you're protected.

Actually the authorities (and others in the know) being alarmingly Orwellian about it brought this outbreak on my radar in the first place.
Without having seen any sign of imminent panic, getting constantly told not to panic, that makes me nervous. You know, like when someone tells you not to call the police, you should call the police.

You guys tell us a lot about what didn't and probably won't go go wrong (mostly obsolete 2 weeks later).
What you aren't quite as verbose about is what went wrong in the first place, why the virus has pushed the fast-forward button in Africa real hard. It didn't start as much last year, did it?
Has anything changed there, say reproduction rate or infectiousness or is this just a random freak ocurrence?

Greg, What differentiates the Reston ebolavirus from Zaire ebolavirus? How was Reston able to become airborne (or communicable by that exposure pathway) and Zaire cannot? I read your blog on why ebola [Zaire] will not become airborne, and accept your assertions. Also, why is Zaire able to infect humans and Reston cannot? Cellular receptors?

Yes, urban outbreak, that much is obvious from the news.
But why urban outbreak? That's what my question boils down to. Didn't it start quite seperate and did nothing uncommon for many months or are those two seperate outbreaks.

@28. Greg Laden : Would a test for ebola also pick up marburg?

Also, while thinking gee thanks, about giving 'em possible ideas, I do wonder whether the Islamic ritual bathing practices* - among other things - would be a preventative factor -and I think they'd realise how likely a tactic like that would be to be backfire on them? Maybe?

* Apparently as I understand it, not a Muslim so don't really know) Muslims have to ritually wash their hands and faces before each prayer (5x daily if devout) and I think also on entering a mosque yeah? Communal facilities there make the implications for ebola infective folks rather obvious don't they? Also aren't Muslim burial practices similar to West African ones and thus also would risk infection spreading too so they probably wouldn't use this method.

Final thought :I know some Mullahs /Ayatollahs / islmaic leaders have put a Fatwah on nuclear weapons (read somewhere a few times) so wonder if they've done the same for bioweapons like this speculative one? Of course there's also apparently fatwahs (bans) on suicide too and that hasn't stopped the homicide-suicide bombing practices so , yeah, who knows? (Not me - hence asking!)

Greg, I found a paper saying that R0 for Norovirus is 2.62:

http://journals.lww.com/eurojgh/Abstract/2014/10000/Person_to_person_tr…

If your comparison is viable, then yes there is cause for considerable worry, given the rapidity of spread of Norovirus.

I recall seeing R0 = 1.38 for Ebola from more than one credible source, possibly including in this blog. I'm inclined to think that 1.38 may be low, and the actual number would be a little above 2 in the US and a little above 4 in Africa, but that's my "intuition" speaking, _not_ a science-based estimate. (I came up with those numbers before I found the paper on Norovirus for comparison.)

(For those who don't know this: R0 = the number of new patients that can be expected to catch a disease from any given patient. For example Alice has a bug that has an R0 of 1.5: we can expect one more person to catch it from her, and a 50/50 chance of a second person catching it from her. Bill has a bug with an R0 of 2: we can expect two more people to catch it from him. Etc.)

Re. Ebola terrorism: (Bob and others):

I've been making noise about the risk of Ebola suicide terrorism for well over ten years, including in a couple of places that had/have good to excellent channels to the TLAs (three-letter agencies). I've also seen indications that they have been thinking along similar lines independently. So I would say it's highly likely that the scenarios are convergent: anyone who thinks about this comes to similar conclusions. I'm confident that the TLAs are on alert for this, including looking out for suicide terrorists, smuggled animals, bedding, clothing, bodily fluids, etc. And I'm also confident that the methods available, are up to the task.

Seriously: with all the bad press about the TLAs, what you don't hear about are their successes, but there are many. For example TSA catches over 100 firearms a month that would otherwise have gotten onto airplanes. If you assume that 99.9% are innocent mistakes (e.g. someone left their legal firearm in a travel bag after a car trip), that's still two potentially fatal hijacks per year prevented. And yet all you see in the media & the blogs are complaints about having to take our shoes off.

To characterize the Ebola terrorism risk in terms of "rational actors" is a mistake: rational actors are by definition death-averse and this-world-oriented. Contrast to "irrational actors" who are death-seeking and other-world-oriented, for example motivated by martyrdom ideologies. (These are not limited to Islam: there are segments of Dominionist Christianity in the US that promote martyrdom.) It is precisely the "irrational actors" that we have to worry about. And as the activities of ISIL have shown, their capacity for evil deeds is limited only by the available opportunities.

The fact that other viruses e.g. Marburg, may also be used by bioterrorists, only increases the total risk. However, again, I am confident that the TLAs are aware & alert about all of this.

Re. animal vectors:

Let us not forget common rodents: mice and rats. There are two risks here: One, mice or rats in housing occupied by patients. Two, mice or rats getting into contaminated wastes, either at patients' homes (e.g. apartment dumpsters) or at hospitals.

Of these scenarios, to my mind, the "apartment dumpster" route is the most dangerous, followed by single-family residential refuse bins. It's essential to practice proper sanitation here, by making sure that refuse bins are covered with tight-fitting lids, and that lids on dumpsters be checked (and repaired if needed) and used properly as well.

Very often, apartment dumpsters are left wide open all the time, because the lids are noisy and heavy (and frankly because people have forgotten that flies and rodents are serious public health hazards in general). That has to stop, and dumpsters need to be fitted with new strong plastic lids, or small hatches in the metal lids, that are easy for people to open and close.

Someone needs to do some testing ASAP to ascertain a) whether mice or rats can acquire the virus, b) whether it can sicken or kill them, and c) whether they can transmit it via their urine, saliva, droppings, etc. I would assume (a) has already been done and the answer is Yes, since rodent models would likely have been needed in Ebola research to date. But I'm not aware of any findings on (b) and (c): does anyone here know of anything?

Astrostevo: I don't know, it might. That would have to be determined. They are both filovirus.

G(40), my intention was not to say that the R0 value of Ebola and Norovirus was the same. Actually, my experience is that Norvirus has an effective infection rate of "everybody, you can't avoid it!!!!' which is pretty close to 3 in an American suburban setting with daycare. It is probably much more infectious that Ebola, so Ebola is really really infections and Norovirus is don't even ask, you've got it infectious.

Greg, thanks; and I figured you meant something like that, but the question was the axis of comparison. If it's not virulence, it's infectiousness, which translates to R0, so I went and dug it up.

And yes, Noro also scares the hell out of me, having had either it or food poisoning a couple of times, decades ago, and never wanting to repeat that experience as long as I live.

If everyone who went to the hospital for Noro was given a sympathetic but clear talk about hand-washing and food sanitation, they'd come back from the hospital "reborn" with true zeal and fervor, and run around seeking to "convert" all their family members & friends who are still "living in sin" by way of ignorance of how bad it is and how easily prevented. That's one kind of preaching we can all live with;-)

G: I know. All we need now is a virus that loves it when you wash your hands!

Dan: I keep thinking of Rio. Actually wasn't Ebola the virus spread in a Tom Clancy novel using the misters at the Australian olympics?

I'm not going to assume that other concentrated poor areas are just like West Africa in the critical ways that matter. But I don't think we actually know what the key factors are. Certainly, dense, poor, lousy health care system, a certain mix of beliefs about disease, etc. must matter.

It might be true that diaspora are less likely to develop between poor and poor regions than poor and rich regions. There are probably not too many communities spit between Monrovia and Rio, for example. If this was an East African phenomenon I'd worry a LOT about South Asia.

The cultural practices problem does emerge as such, I agree. But on the ground, in its actual form (what happens, with all its variations and actual manifestations) it is a real thing that has to be addressed. For example, in the first few outbreaks, the outbreaks were exacerbated by local burial practices. That had to be addressed, and was addressed. But what emerged from that is the myth that all Africans use burial practices that enhance Ebola spread, and/or that all Africans can't change practices to reduce Ebola spread. Neither of those is true. Burial practices (by which I mean the whole mortuary ritual) vary a lot across the continent and even within communities, and often people are willing to understand the problems and change.

Just think about this, if an R0 of 3 for norovirus translates to "everybody gets it": I've recently seen an R0 of 18 for measles. No, there wasn't a decimal point dropped there. Eighteen means everybody and all their invisible friends get it, which is why earlier generations considered a vaccine so desirable. A couple of the vaccinated-against Western diseases that had more significant death rates, including diphtheria, had an R0 of 4 or 5. Of course, living space, sanitation and nutritional quality were all poorer at the time giving rise to those estimates. Food for thought, though.

G writes: "To characterize the Ebola terrorism risk in terms of “rational actors” is a mistake: rational actors are by definition death-averse and this-world-oriented. Contrast to “irrational actors” who are death-seeking and other-world-oriented, for example motivated by martyrdom ideologies."

This falls into the trap of caricaturing Others' actions which we don't like as being due to their evil, irrational beliefs. Studies of terrorists (by dictionary or American definitions) make it clear that most are motivated primarily by political goals. People are probably more willing to give their lives for a cause if they believe in an afterlife, but this does not mean that the purported cause is not actually meaningful. That pretense allows us to ignore the real injustices that often provoke intergroup violence.

Meanwhile, I strongly disagree either that the behavior of outgroup members is much less rationally motivated than that of good Westerners - all humans have a mixture of rational and irrational motivations - or that to be rational is "by definition" to be "death-averse". (On the contrary, to be rational, I must recognize that my own short life is of finite value; therefore I should be willing to risk or sacrifice it for something I consider of greater value, such as my child or my people. The needs of the many outweigh the needs of the few, etc.)

But anyway, when I spoke of a rational bioweapon, I didn't mean "one that a Vulcan would consider it desirable to use", to continue the Star Trek theme. I meant "one that a typical, emotionally motivated human who had already decided to develop or use a bioweapon would think was a good candidate." Both U.S. and Russian researchers who had no qualms about working on potential ways of killing off "enemies" with epidemic disease looked at filoviruses and decided that yes, they are very nasty diseases, but no, they do not make "good" bioweapons. This is not to say that no scuzbag will ever set out to infect another person with one on purpose; the U.S. had a small group of [white] scuzbags some years back who contaminated local salad bars with a diarrhea-inducing bug, causing a few illnesses. But if you're trying to bring about the apocalypse, it's a really stoopid way to go about it.

" if an R0 of 3 for norovirus translates to “everybody gets it”: I’ve recently seen an R0 of 18 for measles."

Exactly. Everybody gets NORO, and for the measles, everybody gets that too, plus the people down the hall in another room. Here, "everybody" is everybody in your household, of course.

"Of course, living space, sanitation and nutritional quality were all poorer at the time giving rise to those estimates. " Right, R0 is context dependent.

"This falls into the trap of caricaturing Others’ actions which we don’t like as being due to their evil, irrational beliefs. " Yes, always a very bad mistake to make!

With respect, Reston ebolavirus is an ebolavirus, as confirmed by the CDC. Hence my curiosity and questions yesterday.

From CDC:
"Tissues from pigs that had died from Porcine Reproductive and Respiratory Syndrome were sent from the Philippines to the USDA Plum Island laboratory for diagnostic analysis. Several viruses known to infect pigs (e.g. circovirus and arterivirus) were detected in some of the tissues. Using new molecular detection assays, Ebola-Reston virus RNA was detected unexpectedly in some of the samples. Ebola-Reston virus has not been shown to infect or cause disease in swine previously.

Although infection with Ebola-Reston virus can cause a hemorrhagic fever with high fatality in non-human primates, the Reston subtype of Ebola virus has not yet been proven pathogenic to humans with antibody evidence of Ebola-Reston infection; however, infection with other Ebola virus species, such as Ebola-Zaire and Ebola-Sudan, usually causes a severe hemorrhagic fever that is often fatal in humans.

In October 2008, the Centers for Disease Control and Prevention (CDC) confirmed that swine from two farms in the Philippines were infected with a filovirus, which was confirmed to be the Reston species of Ebola virus."

Yes, it is called that. It is an Asian virus with an apparently different ecology, host, and infection potential that has little to do with the African Ebola virus but that we know little about. I don't happen to think it is correct to call it a subtype of Ebola. Is rather call it Reston for the very reason we are having this conversation (generally). Reston is not informative of Ebola's potential.

Makes me angry that they bring such a disease here to the u.s. A HUGE part of me knows they have a cure but it's not in the budget to save us and everyone else in the world. Population control. We are screwed. There are things they're not telling us. God help us all. If you pray... pray about this. The end is near if they're precdicting 10000 a week. You do the math.

E[R0]=2.