Ebola in Dallas Texas: Is our response adequate?

First, let’s look at the situation in West Africa, because that is way more important than anything going on in the US right now. The WHO has said two things about this. First, if there is not a full intervention, there may be hundreds of thousands or even millions of cases of Ebola several months from now (cumulatively). Second, with full intervention they can stop this epidemic.

What is full intervention? They say that full intervention is the development and manufacture of an effective vaccine, and the deployment of that vaccine to a very large percentage of the affected population.

Putting this another way, the current response has been inadequate, and while it can be improved, it can’t be made adequate. Things are pretty bad, are going to get enormously worse, and there is little hope for any other outcome, unless full deployment of a vaccine that does not exist over the next six months is realistic.

Now let’s look at the US. Public health officials and public health experts have been saying the same thing for months. Don’t worry about an Ebola outbreak in the US. We can handle it. We know what we are doing, and we have the systems in place to take care of this. So just don’t worry.

I’m going to tell you now why this is probably both true and untrue.

It is probably true at the large scale. We are not going to have an outbreak of Ebola in the US that involves hundreds of people getting the disease. Probably not even dozens. But, it is not true that we have the capacity to fully handle Ebola coming to the US in the way most people assume this is meant. It is very possible for Ebola to some to the US and make a bunch of people sick with about half of them dying. How many is a bunch? Five, maybe eight, something along those lines, but possibly a few times, in a few places, adding to a couple of dozen. (Totally guessing here, feel free to make your own guess.) That may not happen at all, but given the current situation it is absolutely possible. However, it is not necessary. If our public health system was truly able to handle an Ebola intrusion, the only people who would have Ebola in the US would be those who arrive with it, and possibly a very small number of additional people, not a bunch. In other words, unless changes are made, the inadequacy of our system, said to be fully adequate, will allow several people in the US to become ill, some will die, over the next year.

Here is why.

First, consider the travel problem, which is probably the smallest part of this. When Patient X came to Dallas with no Ebola symptoms, he was almost certainly not a risk. But he did get on an aircraft with the disease, and took a long trip the US. If this event happens 100 times over the next several months, how many times will the patient become symptomatic on the plane, possibly exposing others? 10% of the time? 5%? 20%? Hard to say, but often enough that over the next several months hundreds of travelers and airline workers will be exposed, but, the chance of them contracting the disease is low. So, with the current expanding outbreak and current policies, a very small number of people may get Ebola in a system that claims to be totally able to handle it. That’s small change compared to what is going on in West Africa, and it is probably the least of our worries here in First World Land.

Second, we have the problem of reporting and identification. Patient X became symptomatic and then for something like a day did not seek medical help, during which time various individuals were potentially exposed. Again, since Ebola is not airborne, the chances of them getting the disease is low, but it is real. The problem is that when people get sick, there is almost always going to be a window of time from a few hours to a couple of days during which the most prepared health care system in the world has no control over what happens because the person does not show up at a hospital or clinic. There may be no way to avoid this, but the risks can be reduced. If the West African epidemic continues members of the communities that overlap between the US and West Africa will be at risk, albeit low risk, of exposure to those who travel back and forth on a regular basis. What needs to happen is that those communities take special care to address this issue internally. All it is going to take is one or two Americans catching the disease from a person living part time in West Africa to shut down air connections between the two regions. If we want to avoid this, there needs to be self-monitoring in the communities.

Third, we have the unconscionable thing that happened in Dallas. A patient who had been in Liberia showed up with Ebola like symptoms in a hospital and was sent home. Holy moly. Why did that happen? Well if you’ve been recently in the hospital for anything that required testing and such, you may already know. Hospitals and clinics, but especially emergency rooms, are run like those steak houses that became popular back in the 1980s. You arrive at the steak house, and a nice person with a big smile seats your group. Then a server comes over and takes drink orders. A second server brings the drinks. A third server comes by for your meal order. A fourth server brings the appetizers, and a fifth server brings your meal. Eventually somebody comes by with the check. (Remember those?)

In an emergency room, there will probably be a physician taking care of you but all the tests that are run are done by different individuals, if there is some kind of treatment you need, the person who cues you in on that (tells you how to take the pill or use the device they are going to give you) is different still. The person who checks you out is different still. What is the possibility that a concern you address to the physical will be responded to by that physician later during your visit? It depends on how fast the person who check you out and sends you home arrives on the scene. Maybe 50–50.

That is probably how Patient X was let go with Ebola. The system has too many places to break. How likely is that to happen again in other emergency rooms or clinics in the US? Not zero.

So, the bad news is that our system does not really put the lid on Patient Zeros that may show up in clinics or hospital, reliably. The system we have been assured would not allow an outbreak probably won’t allow an outbreak, but it may well allow dozens of people to be needlessly exposed, among whom some may contract the disease.

Now here’s the good news. It is said (though the information is spotty) that between 80–100 people who may have had even minimal contact with Patient X are being checked twice a day for fever, and a smaller number are being looked at more closely, even quarantined. The several schools attended by some kids Patient X had contact with are being sterilized. And so on. Frankly, this is more than necessary, but that’s irrelevant. If you only have a few tiny “hot zones” (in this case, one, and not that hot) an abundance of caution is not overkill. If over-cautious reactions eventually emerge whenever an Ebola patient shows up in the US, the larger scale outbreak will be avoided. But the handful of people initially at risk will not be safe by virtue of our system.

Perhaps that is unavoidable, but I think most people will look at the Dallas event and say that sending the patient home clearly should not have happened, and now every hospital and clinic in the country will be extra cautious. Like, remember that one time a surgeon accidentally amputated the wrong leg, and after that one time, it never happened ever again anywhere?

What, you don’t remember that? Hmm… me neither.

(Also, consider this: Imagine implementing the level of caution now being implemented in Dallas in the affected areas of West Africa? Can you imagine implementing this only half way, or a quarter of the effort? That would a) stop Ebola and b) be impossible. That is why the outbreak continues there. We have a lot to be thankful here in the US.)

Conclusion: The communities that have regular interaction with the affected countries are already in many cases somewhat organized as communities. These communities need to develop humane and thoughtful ways of making sure travelers are properly watched after. Everyone who works in any clinic or hospital has to double check what they are doing and not mess up again. The initial conditions that led to the current situation in Dallas are going to become more common over time.

And, remember, so far everything in Dallas is under control, but it will take 27 days to be sure (the incubation period is about 27 days, despite the “21 day” number you keep hearing). Also, while Ebola can manifest in an infected patient as quickly as two days after exposure, it is more typical to show up 8-10 days later. So the first week to 10 days of October is a fairly likely time, perhaps, to see a second case in Dallas, if there is in fact, further infection.

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The reason quarantine doesn't work, aside from savage medieval approaches like boarding up houses with families inside - which also ultimately didn't work - is that inadequate provision is made for people quarantined to survive without breaking quarantine. Healthy people will go where they must, regulations notwithstanding, to keep themselves and their kids alive. African Ebola patients have fled "treatment" centers in search of food and water (thus, it's fair to presume that the case fatality rate would be significantly lower if some services beyond "lock 'em in and leave 'em to die" were on offer.)

With that in mind, it's very disturbing that the four people quarantined in Texas were served with papers one day, and only on the next day did the authorities say oh, yeah, we will think about bringing them some food so they don't starve in the next three weeks. I've seen no mention of guaranteeing any quarantined workers an income, or just payment of rent and utilities, or return to employment, so a family might emerge healthy after three weeks to find an eviction notice on the door. If you hear about that happening to someone, will you be eager to admit that you might have been exposed to the same disease?

Many workers in the U.S., including, for example, many of those who handle and serve food, get no paid sick days; at best, if they have to take time off they have no income. (In more civilized nations, this is illegal.) At worst, they can be summarily fired for ever being too sick to work; thus they have to come to work with flu and rotavirus. Or maybe, a few months from now, early-stage Ebola. That is what you could call a society's chickens coming home to roost.

Reports say that in Dallas the patient's screener was told on his first visit (by him) that he had just returned from Liberia. That information was never passed on to his main team. Boom.

How many is a bunch? Five, maybe eight, something along those lines, but possibly a few times, in a few places, adding to a couple of dozen

How many deaths from Ebola would it take for the public to begin acting irrationally? My guess is fewer than 10. Managing public perception will be a big job if anything along the lines of what is laid out in your post comes to fruition.

Possibly. I hope the evidence needed to decide one way or the other never materializes.

Thank you for this article. Trying to make sense of all of this and I think this article does just that...makes a lot of sense. People are freaking out...we need to breath....watch thins closely and be prepared.

Read today that he came in contact (first or second person) with around 80 people.

Why uninfected countries are letting anyone enter from Liberia or any of the other nations where the disease is not being controlled I do not understand. Yes the risk any one person will be ill is low but hey it just happened, and now it's perhaps loose in North America.

By Doug Alder (not verified) on 02 Oct 2014 #permalink

Because a lot of people rely majorly on travel back and forth. It would be a small scale version of, say, no travel between NY and California. Thousands of lost jobs, would probably lead to civil unrest, etc.

Thanks Greg, thats roughly what I've figured. There will be a trickle of new patient zeroes, due to travel. In terms of preventing a largescale outbreak all thats needed is that the average number of new infections, per infected is less than one. With Ebola I don't think thats a very high bar -in fact I read Nigeria had contained its small cluster, and our system is much better than theirs.
But, as long as there is a substantial reservoir somewhere, you have to expect a trickle of new patient-zeroes to keep happening, and we have to have a system thats good enough that they are contained.

I doubt a perfect system is possible, especially if you figure in cost, including the cost of false positives. It makes more sense to expect we will just have to deal with occasional infections, and get on with it. As long as we don't, as a people treat this like terrorist attacks we should be fine.

So the more important issue, is can we contain and eliminate it in the less developed places? I suspect that isn't too difficult, perhaps without the epidemiologically bad burial practices in west Africa, perhaps major outbreaks couldn't happen. By know those populations must realize the issue. Its not unlikely that the animal reservoir from which it occasionally jumps to man has been around for hundreds or thousands of years, and it hasn't become endemic..

By Omega Centauri (not verified) on 02 Oct 2014 #permalink

Can you tell me where you got the 27 day incubation? We are still using 21 days, verified with our ID folks last night after I read your piece.

By Jill Morgan (not verified) on 03 Oct 2014 #permalink

I don't expect you to predict the future, of course, but I can't help but wonder what "enormously worse" entails in Africa. A spread into the Middle East, Europe or India? If so, we may not have a large outbreak in the US now, but what about when people try to fly in from a lot more infected nations?

Jill: I think almost all of the 21 day estimates we see in the literature and secondary sources can be traced back to one or two studies. Meanwhile this study indicates a small percentage post 21 days, with 1% at 25 days. Maybe 27 isn't the correct number, but 21 is not, if this study is valid. To my knowledge there isn't a replicate study.

http://www.kcdc-phrp.org/article/S2210-9099(11)00002-6/abstract

I note that at least one or two studies used the 21 day mark as the study length, and so missed the opportunity, possibly, to identify cases after 2 weeks.

Donal, by "enormously worse" I simply mean that the number of people infected in the current outbreak countries may become very high, and possibly but not necessarily other countries.

We are never going to have a large outbreak in the US. Think of it this way. There are several stages of development of an Ebola outbreak that stems off from the current West African outbreak.

Stage 1: Someone with Ebola leaves the outbreak area. They infect someone en route. Probability: very low.

Stage 2: The infected person becomes symptomatic in the new potentially host country and infects a small number of other people: Probability: Higher.

Stage 3: The infected person seeks help and is quickly quarantined and treated. But, infects ambulance drivers, other health care workers, etc. Probability of passing on the infection: Lower than Stage 2.

Stage 4: While in hospital, infected individual infects others. Probability: Probably lowest of all of these.

That's the scenario in the US. We saw a temporary breakdown in Stage 3 in the US, essentially doubling the time of Stage 2, which is probably the highest risk stage. Hopefully that is not a common thing!

One thing that concerns me is flu season, which is presumably underway and growing and will peak in the US about the time that we may see some very large numbers from West Africa. Almost no one is going to properly diagnose themselves. Some will assume a headache and fever is the flu, others will have the flu and think it is Ebola.

That study didn't actually report any cases in which people took 27 days to get sick; it presents mathematical modeling that "assumes a log-normally distributed incubation period." I don't know that that's a valid approach. Many natural phenomena will not precisely fit the curve that someone happens to want to shove them into. If the mean incubation time were shorter, so that the mathematical model claimed the 99% level of certainty should be reached at only 18 days, yet actual cases at 21 days were known, we wouldn't say exposed people should be freed from monitoring at 18 days because that's what the model says. Quarantining people has serious consequences for them and should be based on what is actually known about the disease in the real world.

I am not an American nor have I ever been to the US so this may be nonsense.

It is OK talking about Dallas - even I have heard of that. But the US is a big place. What are the medical facilities like on an Indian (am I allowed to use that word?) Reservation?

Imagine an American returning from an infected area. He has returned by air so we must assume that he has the wherewithal to access the medical system and the education to realise the need to do so. However, he has no symptoms and has no knowedge of contact with an infected person so he passes through the airport and continues on his journey home to some perfectly respectable but rather remote location. On the way he stops off for a meal at some roadside establishment. He throws up all over the place and leaves some minimum wage waitress to clean up. The waitress becomes ill and is fired. She gets the bus home, let's say to that Indian Reservation, where she starts an outbreak of Ebola.

The State Senate declares the outbreak to be the judgement of God on these evil pagans and does nothing. The general population cites the Second Ammendment and attacks the Reservation driving the Indians into the next state where they are met by the usual care and compassion generally shown to refugees, that is, none.

There now follows a breakdown of law and order which the police try to subdue in their acustomed manner. Hospitals are overwhelmed with with casulties with bullet wounds who may or may not be carrying Ebola. Then the first white nurse falls ill. The troops are sent in.

Is this plausible? Will hospitals turn away patients on the grounds that they do not specialise in tropical diseases? Does the government have enough power over privately owned medical facilities? Who pays the bills?

Alan, actually, I've heard but am not sure that the medical facilities in the area of Dallas where this has played out suck. It is a poor area. But I'm not sure about the specific hospital, many urban hospitals in poor areas are pretty good.

The scenario you are describing, with the guy throwing up and the bus ride to the reservation, etc, is Stage 2 in comment #12. Depending on the circumstances, as you suggest, that could involve a fair number of people, but max in the dozens, probably fewer (who would actually get infected). Anywhere in the US, the next stage would not develop, not plausible, I would say.

I think the part about sending in the troops has already happened in Ferguson!

I posted #14 before I read #12.

What I cannot understand is how a country like the US which has no state health service, and particularly a state like Texas which would fight to prevent getting one, could tackle an outbreak. The victims are likely to be those who are destitute anyway and living on the fringes of society, those who have every reason to keep away from the attention of the authorities.

Unless a hospital is equipped with isolation facilities and ambulances and crew able to deal with these cases, it will merely refer the request to another hospital. Probably, a hospital accountant's worst nightmare is having an Ebola case just turning up in the emergency room.

In the event of an outbreak, would all the best medical facilities will be taken up by the rich and powerful who think that they will go for a check-up to be on the safe side - the hospitals will know that such people have generous insurance to cover the cost?

Not quite vomiting in a diner, but we just had a case of a passenger on an international flight to the states vomiting and causing a bit of a fuss. (And I'm sure the other folks on the plane were in various states of dismay, depending on how paranoid they are: can't imagine the state the flight attendants must have been in.)
http://www.nydailynews.com/news/national/sick-passenger-examined-ebola-…

The person has been cleared, and while there was likely a rise in nerves there wasn't a major problem on board. That's comforting.

Well no, Tim, the pictures you link to are a crock of crap. The first clue is that they are at WND, known by sane people everywhere to be published by congenital liars. Second - as has been noted almost everywhere else, those pictures were
a) Taken 4 days after the actual cleanup
b) Taken from a news site where the caption was

HD Chopper 8 caught crews cleaning the sidewalk outside the Ivy Apartments where the #Ebola patient stayed.

Notice the distinct lack of the word "vomit" in that caption, from the original source? No mention of vomit was in the rest of the short article either.
There are enough lies about this problem (the cranks at Natural News are going full on dishonestly stupid about it) without crap like this getting distributed.

I guess I see your point, dean... the parking lot, where they are seen cleaning, is not the street.

Jane #1 –
Thanks for adding some important social context to the discussion.

By cosmicomics (not verified) on 04 Oct 2014 #permalink

And thanks to Greg for his persistence and perspectives.

Earlier this morning I read an interview with Peter Piot, who was part of the team that discovered the virus in 1976 (and who figured prominently in Laurie Garrett's book, The Coming Plague). The following quote doesn't provide the commenters here with new information, but with some already known information that's important to bear in mind when discussing the outbreaks in west Africa and the ability of the U.S. to avoid nightmare scenarios:

“I think it is what people call a perfect storm: when every individual circumstance is a bit worse than normal and they then combine to create a disaster. And with this epidemic there were many factors that were disadvantageous from the very beginning. Some of the countries involved were just emerging from terrible civil wars, many of their doctors had fled and their healthcare systems had collapsed. In all of Liberia, for example, there were only 51 doctors in 2010, and many of them have since died of Ebola.”
http://www.theguardian.com/world/2014/oct/04/ebola-zaire-peter-piot-out…

By cosmicomics (not verified) on 04 Oct 2014 #permalink

Is a lie tim. There was no vomit there after for days. What is there to be confusing?

Greg, the hospital in question is actually one of the better facilities in Dallas; it's basically the regional facility for neighborhoods like Preston Hollow (where George W. Bush moved to). The neighborhood the patient stayed in is a few miles east, and is a very dense area of multifamily complexes with a large immigrant population (a great many refugees are resettled in that neighborhood by relief agencies).

A key issue here is that, as in most urban areas, facilities in Dallas proper have very little unused or surge capacity. Leaving aside any workflow issues with EHRs like Epic, it's not surprising that a nonspecifically-symptomatic patient, even a Liberian national, slipped through the cracks when there's fifty other patients in line at the ER, with ten of them needing immediate triage.

By RiceAndSalt (not verified) on 05 Oct 2014 #permalink

RiceAndSalt, thanks for the perspective, very informative.

Breaking:

Rice and salt cures ebola.

By The Daily Mail… (not verified) on 05 Oct 2014 #permalink

Dean, this is what I *thought* I saw on CNN friday

A hazmat team finally arrived on scene today to sanitize the contaminated apartment

yes, yes... it's DM

Published: 00:47 EST, 3 October 2014 | Updated: 16:55 EST, 3 October 2014
http://www.dailymail.co.uk/news/article-2779036/Hazmat-team-arrives-Ebo…

Could you please point me to the source/ simple 'splainer of this 'four day' discrepancy? thx.

Frankly, I don' t think the CDC did anything wrong there. You can leave an apartment with Ebola Kooties as long as you want. I do think they should have gotten the family someplace else ASAP for a number of reasons.

But we are not assured that they COULD have jumped in to disinfect the apartment within hours, since they didn't do that; under other conditions that might have been necessary.

Greg,

Would one of those 18 inch quartz envelope hard UV germicidal bulbs be effective/helpful with this particular virus?? (Not for people to be in the same room with it!!) -- I had one way back that I'd play around with.. sticking it down inside the central air intake and whatnot. If it was placed in the bathroom, you could nearly immediately smell the 'germs cooking' off towels and whatnot much like when a septic system is dug up and the dirt exposed to the sun.

{I've a friend that was in the duct cleaning buisness and he was looking to 'invent' something. We came up with maybe it'd be good to have some kind of inner surface of the ducts to refract that light all throughout it.}

I'm thinking sheets, towels, surfaces, that kind of thing.

And now I just 'heard'/learned something new (from CNN, though. So some boulders of sodium chloride overload may be prudent).

Ebola progression is biphasic. That is to say that many get better before suddenly getting back to looking like Death eating a cracker. Now, I don't how common or disseminated this is but, to me, that's a pretty important piece of small print!!

Most viruses do not retain their virulence outside a host, which provides an environment that protects it from oxygen & ionizing radiation. (Your cells need similar protections, which is why you're sheathed in insulative layers of dead skin cells.)

Your UV light would make short work of virus particles... And bacteria. And bugs, etc. But the longer your textiles are exposed, the more they, too, will be damaged & weakened (witness how beach towels fade in the sun).

UV light ionizes molecules, which tends to break them down (or cause them to recombine) -- basically doing the very thing everyone who's afraid of "radiation" freaks out over.

Oxygen in the air does somewhat the same thing -- only it takes longer to "rust" the viral particles into non-activity.

By Brainstorms (not verified) on 06 Oct 2014 #permalink

Proximity1: Yes, I think about the nasty flu season we had a few years ago which included H1N1. Huxley was born at the beginning of that season. Taking him for his first few visits to the pediatrician, the waiting room in the clinic was full of people who all looked really sick and I suspect many had the flue. The procedure for infants was to not even stop at the checkin, just to go right into the exam room area, say who the appointment was for, and then get escorted right to an exam room. They didn't want any proximity between infants and all the sick people.