Less Guts and More Brains

The worst-case scenario for the Ebola epidemic spreading in West Africa predicts about 1.4 million cases by early 2015 according to the W.H.O.  In a quote from the N.Y. Times, Thomas R. Frieden, the C.D.C. director, said, “My gut feeling is, the actions we’re taking now are going to make that worst-case scenario not come to pass. But it’s important to understand that it could happen.”  Lets do the math.

Right now we have about 10,000 cases of Ebola infection in West Africa, and thanks to our Federal non-response to the Ebola epidemic, 5 or 6 people with Ebola have made their way into the United States.  This has resulted in spending about 12 million dollars on health care, and quarantining or supervised monitoring approximately 1,000 contacts.  Furthermore, 2 nurses have been infected by Ebola treating one Ebola infected “tourist” let into our country.  Lets “scale up” these numbers to reflect the “worst case scenario”.  If we do not change our national policy of letting in everyone without a current fever, we could predict that approximately 700 Ebola patients would make their way into the U.S. The cost to our health care system--16.8 billion dollars, quarantining 1.4 million people, and we could expect 3,000 infected nurses. 

But we can rest easy--our head of the CDC has a gut feeling that this is not going to happen.  I also believe that this will not happen, but I am not tasked with the protection of our citizens against deadly viruses.  However, President Obama and Director Frieden are responsible for our security and are gambling with our healthcare infrastructure and the lives of our nurses, doctors and citizens.  Why?? so that they can be seen as doing the politically correct actions by allowing free travel between the epidemic and the U.S.?  This simply makes no sense--a little less guts and a bit more brains are called for.

Steven Keller, Ph.D.

Professor New Jersey Medical School-Rutgers University

Our Public Medical Leaders Must Speak Out Concerning Governor Christi’s Ebola Policies

Rutgers Medical Chancellor Brian Strom, M.D., Deans Robert Johnson, M.D., New Jersey Medical School, Vicente H. Gracias, M.D. RWJ School of Medicine; and Thomas A Cavalieri, DO, Rowan University School of Osteopathic Medicine, why don't you speak out concerning the medical response to the Ebola epidemic and what steps we need to take to protect people outside the epidemic area and to help treat and manage the epidemic in West Africa?  You are the leaders of academic medicine in New Jersey and we have not heard a single statement on containment or treatment of the Ebola epidemic from you. 

The President and the Democrats just suffered a major electoral defeat with all of the Democratic candidates “running” from the President’s policies and distancing themselves from him.  In New Jersey, with respect to the Ebola response, do we have a very similar phenomenon occurring—all of our healthcare leaders staying silent with regard to Governor Christi’s Ebola isolation policy?  I have said many times that I believe the Governor is scientifically correct and politically brave for taking the stand on forced isolation to protect the people living in N.J.  But who am I—just a professor at the New Jersey Medical School-Rutgers University.  Where are the voices of our medical public health leaders—Drs. Strom, Johnson, Gracias and Cavalieri?

I am not talking about freedom of speech, which is something we all enjoy in our country; I am speaking of one of the obligations of being an academic leader—can you stay silent when we, the people of your State need your opinions.  Is this not an integral part of your position?  With opinions coming from the Federal healthcare leaders and the President contradicting our Governor’s position, aren’t you obliged to speak out?  Or, do you disagree with the Governor and are simply remaining silent?  You are accomplished public health officials and academics who have an obligation to speak out—support or disagree with our Governor, but remaining silent is shirking your responsibility to your academic community and the people of our State.

Steven Keller, Ph.D.

Tenured Professor New Jersey Medical School—Rutgers University

“Nurse in a Tent” and Dr. Spencer Take 2: The Best evidence for Mandatory Isolation and Quarantine

So you know the beginning of the story once the nurse returned from West Africa--she was placed into forced isolation/quarantine by N.J. Governor Christi’s executive order.  University Hospital in Newark set up a tent to receive such persons and for several days the Nurse resided in this facility, and became the “Nurse in a Tent”.   After fussing about the conditions of her quarantine and making noise concerning her rights she was allowed to “escape” to her home state of Maine, where she was again placed under supervised quarantine by executive order of the Governor of Maine.  Vowing to ignore the forced quarantine the “Nurse in a Tent” did in fact leave her quarantine and went bicycling in her community, held several news conferences, hired several lawyers, and, in general became the poster child for quarantine disobedience.  Her lawyers’ argued that her civil rights were being violated, and so convinced a judge to allow her to break quarantine.  Listening to the “Nurse in a Tent”, her lawyers, and the judge, and the potential damage they could have caused through a manipulation of our legal system, provides the very best evidence that we need a strong Federal policy of forced isolation and quarantine for those returning from West Africa during the Ebola epidemic.  An even better practice would be to have the quarantine take place before the persons board an aircraft for the U.S. 

The case of the NY doctor, Craig Spencer, more so demonstrates the real need for forced isolation—as of today, November 5, 2014, over 350 people are in semi-quarantine in New York City because of Spencer’s disregard of his potential for harboring the Ebola virus—which as it turns out-he was infected!  I continue to hope that we luck-out and no one catches the Ebola infection due to Spencer’s poor judgment or gross denial.  In our society we often must balance one set of rights against another set of rights.  In the Spencer case we need to make a judgment on his right to move freely about New York vs the rights of all of New York people to be free of the fear of infection or actually free of being infected—even if the absolute risk of infection is very low.  Spencer made a very bad decision and many are suffering.  Our governments’ inaction has enabled this bad behavior.

This situation of poor individual decisions having bad consequences cannot be allowed to continue.  In the case of Ebola we have been very fortunate/lucky in that this deadly virus in its current form is not very contagious.  I am concerned about possible mutations of the Ebola virus or the next deadly virus that could be air transmitted.  We should not kid ourselves—next time we may not be so lucky.

Steven Keller, Ph.D.

Professor, New Jersey Medical School—Rutgers University

Public is being mislead by misinformation about Ebola

By Wendy A. Epstein, M.D., F.A.A.D, Adjunct Assistant Professor, NYU School of Medicine, Health Commissioner, Village of Grand View-on-Hudson, NY

Statements and guidelines have been made so often about Ebola that we come to accept them as fact based.  We have been told that all people infected with Ebola are symptomatic. We have been told that if, after 21 days of isolation, a person remains asymptomatic they can no longer come down with or infect others with Ebola.  We are told that the Ebola virus cannot be transmitted through the air, but only by direct contact with infected bodily fluids. We have been told that temperatures taken once in airports to screen for potential sick travelers from West Africa are an effective way to screen. Before we accept any statement about a disease that most of us have had no experience with, let us look at the evidence and change our protocols accordingly.

The designation of a 21 day period of isolation of people exposed to the Ebola virus is based upon a 95% chance that someone, exposed to Ebola, won’t have Ebola after 21 days. That means that if 100 people exit quarantine after 21 days, five may still become sick with Ebola. However, a 25 day period isolation means there is a 99% chance that someone exposed to Ebola won’t have Ebola, or only one person in a hundred may still become sick with Ebola after 25 days of isolation. [Sources: Transmission dynamics and control of Ebola virus disease (EVD): a review Gerardo Chowell^12* and Hiroshi Nishiura³ BMC Medicine 2014, 12:196 and Osong Public Health Res Perspect. 2011 Jun;2(1):3-7. doi: 10.1016/j.phrp.2011.04.001. Epub 2011 Apr 12. Incubation period of ebola hemorrhagic virus subtype zaire. Eichner M¹, Dowell SF, Firese N].

While fever is an early symptom of being infected with Ebola, it is possible to be infected and have no symptoms whatsoever. In a study [Source: Lancet. 2000 Jun 24;355(9222):2210-5.Human asymptomatic Ebola infection and strong inflammatory response. Leroy et al.] Clinicians checked the blood for evidence of Ebola infection in individuals who were family members of symptomatic patients, and who lived continuously with them taking care of them without any physical protection such as gloves. The study showed that asymptomatic, replicative Ebola infection can and does occur in human beings. It seems that people who get infected with Ebola and either are asymptomatic or symptomatic and recover have a different immune response than people who get infected and become very ill and die. The issue then is whether asymptomatic individuals infected with Ebola can infect others. The risk of transmission via blood products donated by such individuals or via semen should be taken into consideration in public-health policy since infectious filovirus have already been found in semen from symptomatic patients 2–3 months after symptoms [Source: Lancet. 2000 Jun 24;355(9222):2210-5].

Taking temperatures at an airport is giving the public a false sense of security. Fever is not specific, as it is an early manifestation of Ebola and many other infections. Someone infected with Ebola may never have a fever. Fevers are not constant throughout the course of the day, but go up and down. Inexpensive temperature dots could be placed on the wrist of travellers as they check in for flight, and checked prior to boarding and disembarking. Should they get a temperature in flight, they could be isolated in one of the plane’s bathrooms, equipped with hazmat suit and respirator with an intercom.  Although healthcare workers are at greater risk for being infected with Ebola, I see no reason not to quarantine all travellers from West African countries where Ebola is present. Furthermore, why not restrict travel to and from West Africa to those risking their lives trying to stop the epidemic there?

Let’s look at the assumption that Ebola cannot be transmitted through the air. Evidence exists that Ebola Zaire virus infects pig’s lungs, and that pigs can infect non-human primates through respiratory transmission of the virus.. Therefore, pigs could theoretically be a source of aerosolized transmission of Ebola to humans in West Africa. This study also showed that the non-human primates did not infect each other through respiratory tracts, i.e., the air. [Source: Transmission of Ebola virus from pigs to non-human primates. Sci Rep 2012, 2:811]. Weingartl et al].  Another study demonstrated there was evidence of possible aerosol route of transmission between non-human primates (Transmission of Ebola virus (Zaire strain) to uninfected control monkeys in a biocontainment laboratory ,[Source: N.Jaax et al, The Lancet, Volume 346, Issue 8991, Pages 1669 - 1671, 30 December 1995]. What this underscores is that we don’t know enough about Ebola to make sweeping generalizations about whether it can or cannot be transmitted through the air.

Humans sitting or standing within close proximity to each other could transmit Ebola virus by sneezing droplets of infected fluid onto another person. The viral load, or numbers of viral particles in a sample, is extremely high in body fluids of infected individuals when they become symptomatic. It takes as few ten Ebola viruses out of the millions in each airborne droplet of a sneeze to infect those who breathe it in.  

It also is evident that air travel is a major mode of dissemination of airborne illnesses, such as influenza.  A study demonstrated that the post 9/11 restriction of air travel in the United States delayed the dissemination of that year’s influenza by 2 weeks. There were no travel restrictions imposed in France in 2001, and consequently, there was no change in the timing of the arrival of influenza, in France. Given the number of deaths each year from influenza, perhaps it makes sense not to let sick people with fevers fly in general. [Source: PLoS Med. 2006 Sep;3(10):e401.Empirical evidence for the effect of airline travel on inter-regional influenza spread in the United States. Brownstein JS¹, Wolfe CJ, Mandl KD].

One possible explanation for the role of direct physical contact in transmission is the presence of abundant virus particles and antigens in the skin in and around sweat glands. Source: [J Infect Dis. 1999 Feb;179 Suppl 1:S36-47]. The nurses infected with Ebola while caring for Mr. Duncan (the West African patient who flew into Dallas) were said to have made some mistake in protecting themselves.  It is possible that Ebola could have been transmitted through the skin of Mr. Duncan, particularly later in the course of his illness when his viral load was the greatest.  Simply touching a cadaver is an independent risk factor for contracting Ebola.

As yet, we know far too little to presume the following: that 21 days is sufficient to adjudge a person Ebola virus-free; that screening for temperatures at airports protects the American people; that lack of symptoms indicates no possibility of infection; and that Ebola cannot be transmitted through the air. We do know that at least 25 day isolation would add significant protection; that blood tests are the most reliable  way to confirm an infection with Ebola, and that much more research needs to be done on how this virus is spread. Until we know enough, we need to set a much higher bar for containment before we risk further spread of deadly pathogens.

Perhaps, the only way to know if someone is infected with Ebola is to take serial blood samples spaced over one month, 30 days which is 5 days past the 25 days of isolation necessary to eliminate 99% of people, exposed to Ebola, who will become symptomatic. We do not know how many people who are asymptomatic after the period of isolation are not infected with Ebola unless their blood is checked for presence of the viral RNA and/or have specific antibodies to the Ebola virus at the end of their confinement.

Ultimately, the mass vaccination of vulnerable people in West Africa and those brave healthcare volunteers who are risking their lives to save the rest of us is key to ending the spread of Ebola. Until then, public health policy and public trust, must be dictated by the science about what we know and will learn about the mode of transmission of Ebola.

President Obama and his Administration are hurting the Ebola Relief Efforts

The President and his administration are hindering the Ebola relief efforts in West Africa.  I believe that we have a moral and ethical obligation to do what we can to stop the Ebola outbreak in West Africa.  Furthermore, looking at this selfishly, the best way to protect us in the U.S. is to stop the epidemic, eliminating the pool of Ebola Virus, which currently is in West Africa.  President Obama’s approach to the Ebola epidemic is counterproductive--let me explain.  Americans want a strong, intelligent leader who will make smart and courageous decisions and follow through.  The health crisis in West Africa requires a multipronged approach: 1) immediate suspension of all commercial flights from the epidemic; 2) immediately preventing all people with passports from West Africa from entry into the U.S.; 3) immediately require a 21-day quarantine of all persons coming from the epidemic; 4) pressure and enable the governments of the epidemic countries to set up isolation zones throughout each country and ban travel in and out of these isolation zones; 5) set up Ebola supportive therapy stations in each isolation zone that has Ebola patients; 6) encourage and enable U.S. health care workers to fly to the epidemic and participate in the supportive therapy stations; 7) encourage and enable  all of the countries of the world to do the same.  With such a comprehensive and scientifically based approach we stand our best chance of limiting the epidemic to West Africa and ultimately saving thousands of lives in West Africa and around he world.  I think the majority of Americans would enthusiastically back such a plan.  President Obama and his administration are focusing on parts 5 and 6 of the above plan to stop the epidemic, which leave many of us wondering why he and his administration are ignoring other critical components of the plan.  What makes this more puzzling is how indignant the President has been during his recent speeches referring to the quarantine.  Doesn't he realize that his lack of action on isolation and quarantine and his disparaging citizens who advocate such has further eroded our support of his Ebola policy specifically and his leadership in general.  Doesn't he realize that politically, just a few days before the mid-term elections, his Ebola response is further damaging his party and his ability to get anything accomplished over the next 2 years?  Doesn’t he realize that by angering many of us with his weak and seemingly “politically correct” approach to the epidemic, his actions (or lack of such) will ultimately backfire and make the components of the Ebola response he is advocating harder to accomplish?

Steven Keller, Ph.D.

Professor New Jersey Medical School-Rutgers University

http://ebolaresponse.blogspot.com/