Ebola in CONUS (Ebola #3 thread)

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Strongsidejedi
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Ebola in CONUS (Ebola #3 thread)

The first thread was closed due to disruptive behavior from a few individuals.

The second thread was behind the pay wall.

I am activating this third thread in front of the pay wall in order to permit public review and google scanning of the thread.

Earlier today, 30 Sept 2014, US Centers of Disease Control confirmed positive diagnosis of Ebola in an index patient in Dallas.

The patient travelled to the United States on 19 Sept to 20 Sept and began showing symptoms on 24 Sept.

There has not been a full disclosure of the index patient's travel and flight itinerary.

This thread is for the discussion of confirmed medical information between certified medical professionals.  Discussion of unproven and untested hypothetical treatments should be moved to a different thread.

This thread is to discuss contagion, public policy, and risk mitigation.

Edited by admin on 11/08/2014 - 05:01
Strongsidejedi
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On the issue of index case in Dallas

There is no clear publication of the index case's travel history.

CDC and reporters need to publish the exact itinerary of the index case.

He did not fly nonstop from Liberia to DFW.  There are no such flights.

The questions are what flight, what airline, and which airports....

cris
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@ssj

Let's we how long this thread can last.  If it weren't such an important issue, I would have given up already.

rather than focus on the flight info, I think they should be having a dragnet much like the one they used in Boston for the two bombers.

this is really serious stuff, and we are only going to get one opportunity to get this right.

hippa needs to be thrown out the window here.  The public needs to be told in as much detail as possible where this guy was between the 24th and the 28th.  Even the CDC is admitting he was infectious during that entire period.

Did he work?  Did he go to a sporting event or a movie?

i saw one unconfirmed report this morning  that a family member is sick.  Once this starts to get past a dozen or so cases, it will be exponentially harder to "contain".  The really big difference between the US and Africa is that this population is highly mobile.  And think about how many possible fomites we come in contact with every day.

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DISCLAIMER AND WARNING

THIS THREAD IS ABOUT EBOLA AND THE CONTINUING GLOBAL OUTBREAK. IT IS NOT ABOUT:

  • Bill Gates
  • The Gold Cartel
  • nano-silver
  • the FDA
  • the United Nations
  • the Kennedy assassination
  • Pete Rose's exclusion from the HoF
  • 9/11
  • UFOs
  • the meaning of life
  • this year's Super Bowl winner

This is my site and I want this forum thread to serve as a public service for all who read it. Any comments I see that, in my opinion only, distract and/or enflame the overall discussion will be "moderated." Anyone wishing to discuss any of the alternative topics listed above should do so in a different forum thread.

Turd Ferguson
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Former CDC guy

"More will be infected". From the article: "Don't panic but prepare for the worst".

http://washingtonexaminer.com/top-doc-several-people-were-exposed...more-will-be-infected-by-dallas-ebola-case/article/2554213

cris
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Possible (probable?) 2nd patient

http://www.wfaa.com/story/news/health/2014/10/01/thompson-dallas-county-ebola-patient-cases/16524303/

cris
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Constructive discussion points

I would love to hear the accumulated wisdom of all TURDITES on two specific topics:

1.  Our vulnerability in the CONUS to a biological attack.  I posted a comment last night that this event in Dallas provides proof of concept that someone can get on a plane, come to the US, walk around a major city, and be proven to have Ebola.  This would be the ultimate asymmetric weapon if pursued by a radical.

2.  The ramifications on the economy.  Fear is a horrible thing.  Even IF this is ultimately contained successfully, we are now in a three to four week window of significant uncertainty.  If word of other cases starts to trickle out, heaven forbid in a child, or in a different city, the response could become disproportionate and irrational.  

We could certainly see a decrease in mall traffic, a decrease in airline or other mass travel, a decrease in restaurant and/or hotel use.  All of these would have profound economic effects, especially as we enter that increasingly important holiday season, which now seems to start earlier and earlier.

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Well, this looks terrible

Cris or SSJ please comment on this:

 

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The Problem Is

When, where and how long has the guy had this. How many people has he come in contact with. How many public areas has he been in, how many cities, how many planes, how many has he infected and where are they now and who will they infect.

Did he catch it in an airport, in a plane, by touching something.....everything he touched is contaminated including the ambulance he was transported in which others were transported in after he was and what about the ambulance attendants who came in contact with him, ambulances do go to multiple hospitals not just one ....

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Speculation

TF regarding the speculation.

1. If an airline flight was the source of infection overwhelmingly it would have been the flight from Liberia and not the flight to Dallas.

2. If this speculation is correct then other cases from that flight should be showing up at the destination and beyond.

3. Until these other cases show up worldwide then DO NOT PANIC.

EDIT: (Had to rush out to meet wife.) If the speculation is correct then patient zero whom became ill and infectious on the flight from Liberia should have, by now, shown up with the disease.

COMMENT: This looks like another case of a little knowledge is a dangerous thing. Perhaps the author of the video has the best of intentions and does not intend to spread panic. He has the data from CDC regarding time of onset of illness from infection. He uses this data to create a hypothesis that the Dallas case is not the index case for the current spread to Dallas. Having created  a hypothesis (speculation) the next thing is to look for data to verify or reject the hypothesis. The hypothesis predicts a patient zero who was infectious and ill on a flight on September 19th. This hypothetical patient would be expected to have been diagnosed outside Liberia by now. This has not occurred, hence the hypothesis is rejected.

A lengthy comment but illustrative of scientific procedure.

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Another Possible Ebola Case in Dallas

http://www.infowars.com/official-admits-another-possible-ebola-case-in-dallas/

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@Turd Ferguson - OK I"m in - Here's your answer Craig

@Craig,
Thanks for putting the site on notice for this thread.  Seriously, Craig, this thing has the potential to neutralize a significant portion of our economy in the next 90 days.

Last night, I sent Cris a private email where I raised the concern that MENA radicals could intentionally infect themselves in Sierra Leone, Guinea, or Liberia; board a flight to the US; land in the US; spread the Ebola virus among the civilian population; and then leave the US after spreading the germ for one week; and then watch as our health system copes with a major national disaster.

The national security apparatus of this nation is set up to handle military threat and not biologic.

I have privately warned people in my area about the instability caused by HMO managed care type of medicine.  I stand by that concern to this day.

The reason the patient was turned away from the Dallas area hospital on 9-26 needs to be explored in great detail.  My guess is that the ER and primary care physicians were following established protocol for any feverish patient.  Details need to be stated on his presentation and management on that day.  But, they won't.  The reason is that the medical center is on the hook legally.

The situation in Dallas is serious because (a) CDC is not stating conclusive information the index case's travel history and (b) US FDA has not prepared the nation's healthcare system with diagnostic test kits to quantify on a regular basis the presence or absence of the virus in a patient.

In the first Ebola thread, SteveW chimed in with significant lab experience.  SteveW and I figured out that you can at best run possibly 100 separate samples in an afternoon.  We concluded in that thread that the US had to push pack the diagnostic kits to local jurisdictions in August.

As we were continuing to monitor the outbreak and behavior of the virus in Africa, we had interference in that original thread.  My view is that the interference was from individuals who are not trained in infectious disease, do not know the epidemiologic protocols to intervene, and only had delusional views to block discussion.  I am troubled by these individuals because they stopped our discussion before we could position policy and recommendations to prevent the current situation today.

Had we been able to continue the discussion publicly, it would have been clear to the national journalists who were frequenting the prior thread that the CONUS was at risk.

In the prior thread, Cris and I both concluded that a military option was required to secure travel from Liberia, Sierra Leone, and Guinea to other nations.  Initially, I disagreed with Cris' reaction but he had successfully predicted the behavior of the epidemic in the three nations.  I noted that Nigeria had a shot at containment.  This is where the 12 case tipping point observation originates.

When Cris is describing a 12 case tipping point, I agree with him.  The number of possible infected contacts requiring screening and testing expands exponentially.  Once you get beyond the 12 case tipping point, the ability of the local system to track the thousands of exposed people becomes nearly impossible.

Nigeria was able to contain their problem because their health system was not functioning on the day Patrick Sawyer arrived in Lagos.  The physicians were on strike due to employment and labor issues in Lagos.  This meant that the number of healthcare workers exposed was actually only 1 or 2 people.  Unfortunately, those people also died 3 weeks later.

Hypothetically, if there are 10 contacts of the index case, then the ten cases might have another ten contacts who were possibly exposed in the "second generation" of the spread of the communicable disease.  Therefore, when you get beyond the second generation to the third; you are talking 1000 contacts who require tracking.

The video that you posted makes ridiculous comments.  The person commenting appears to lack medical experience and has no concept of how infectious disease occurs.  He shows a chart that is a graph of days from hypothetical exposure to initial symptoms.  However, there is seldom a singular event where a patient is exposed.  Usually, there are a number of exposures or a gradual exposure over time.  The person gets sick because the person's immune system is unable to fully neutralize the infectious agent.

It is more appropriate to consider a person's exposure over time and the strength of the person's immune system in a tug of war.  As the exposure builds, the person's specific immunity would take 1 to 2 weeks to catch up.  That is not possible.  This is the reason that we immunize children and adults against infectious diseases.  They can be healthy and react to the vaccine first.  There is little lag in that situation and the person successfully fights off the offending virus or bacteria.

The author in the video suggests that the index case has a 50% chance of contracting the illness on the flight.  That is technically flawed. First, it is impossible to know if another case is on the flight even at this time.  Such an analysis would require the authorities to release the detailed flight itinerary.  They haven't.  Second, if there were another person on the flight who was ill, they would be ill now in the destination city of the person.  There has been no outbreak of Ebola of this sort. 

Cris raised this issue in the original Ebola thread.  I was not yet ready to sign off on the threat.  Cris raised the issue of contagion on the plane flights and in the airports.  Even with the significantly ill Nigerian index case, there were no confirmed cases from any airline flight or the airport itself.  Therefore, the contagion risk in the aircraft cabin is very low.

It is far more likely that the index case became exposed in Liberia, boarded the flight as an asymptomatic person, exited the flight 1 day later with jet lag, never suspected that he was ill until 2 days later when he was getting worse, and then finally got to care four days after arrival.

If a second case is observed in Dallas in the next 72 hours, the President should act via Executive Order to declare a state of emergency nationally

1.  Waive CLIA requirements for primary care, urgent care, and ERs nationally.

2.  Push Ebola diagnostic kits to the ER, primary care, and urgent care settings nationally.

3.  Immediately increase regional staffing at CDC networked testing centers for thousands of the diagnostic kits to be run daily.

4.  Waive HIPPA requirements nationally and until the emergency is over such that national and regional news media can report personal information on the individual patients.  This is a must-do because the speed of identification of the contacts is a critical element.

5.  Set aside funds required for states to react immediately to enhance civilian healthcare systems to comply with pushing diagnostic kits for the seasonal flu.  Because initial symptoms of Ebola can match influenza and other viral illnesses, diagnosis of influenza or other communicable disease is now required in a very timely fashion.  This can only be done with the rapid diagnostic kits in the clinical setting.  Delays in processing by for-profit lab companies will only spread potential contagion to additional carriers and labs.

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More info regarding index patient from the New York Times

The New York Times has been doing extraordinary work on the Ebola outbreak.  It should really be daily reading for information

Today's reporting (excerpt):

The patient was identified by Liberian health officials and The Associated Press as Thomas Eric Duncan, a Liberian national. Mr. Duncan came to the United States on Sept. 20 aboard a commercial airliner and officials said that he had shown no symptoms of the disease while on the flight and that he had posed no threat to other passengers.

Mr. Duncan worked at a shipping company in Monrovia, Liberia, but had just quit his job, giving his resignation in early September, his boss said. He had gotten a visa to the United States and had decided to go, his neighbors said. He lived alone, but has family in the United States, they said.

Mr. Duncan may have become infected after his landlord’s daughter fell gravely ill. On Sept 15, Mr. Duncan helped his landlord and his landlord’s son carry the stricken woman to the hospital, his neighbors and the woman’s parents said. She died the next day.

Soon, the landlord’s son also became ill, and he died on Wednesday in an ambulance on the way to the hospital. Two other residents in the neighborhood who may have had contact with the woman have also died. Their bodies were collected on Wednesday as well.

Health officials in Dallas said Wednesday that they believed Mr. Duncan came in contact with at least 12 to 18 people when he was experiencing symptoms. So far, none has been confirmed infected.

The five children, who possibly had contact with Mr. Duncan at a home over the weekend, attended four different schools, which authorities said would remain open. As a precaution, they said all the schools — including one high school, one middle school, and two elementary schools — would undergo a thorough cleaning.

“This case is serious,” Gov. Rick Perry of Texas said at a news conference. “This is all hands on deck.”

Health officials on Wednesday continued to track down other people who might have been exposed to Mr. Duncan after he began showing symptoms, on Sept. 24, and will monitor them every day for 21 days — the full incubation period of the disease. Most people develop symptoms within eight to 10 days. As a patient becomes sicker and the virus replicates in the body, the likelihood of the disease spreading grows.

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@ssj

Excellent recommendations.

we have an opportunity to contain this if we react swiftly and efficiently.

by sheer luck, we may have a situation where it will be self limited.  But as a national security issue, this outbreak should be a "rehearsal" for the types of things necessary should we come under an organized biological attack.  IMHO, this is a scenario which cannot be underestimated.  

Once again, I refer you to the book Biohazard, subtitled The Chilling True Story of the Largest Covert Biological Weapons Program in the World - Told from Inside by the Man Who Ran It, by Ken Alibek.

http://www.nlm.nih.gov/nichsr/esmallpox/biohazard_alibek.pdf

i agree that if there are other cases that are identified in the next 72 hours that the President should act with executive order and exercise emergency powers.  

To a certain extent, we are MORE vulnerable than West Africa because our population is so much more mobile and interconnected.  We obviously have significant advantages in terms of public health infrastructure and resources.

But an ounce of prevention is worth a pound of cure.

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@Cris - thanks for the info from NY Times

Cris,

If you locate a good NY Times story, please post the URL to the story.

Regarding the exposure, it basically matches the description of the exposure of Patrick Sawyer in the Nigerian index case.

Sawyer is believed to be the person noted in Ken Isaac's testimony before the House Committee in August.  Sawyer was said to have been exposed to his dying sister in the 24-48 hours prior to death.  At that time, the Ebola virus creates a viremia that is very contagious.

Since those children were exposed over the weekend to the feverish index case, you can assume that they will be ill.  They were likely in school on Monday.  Hopefully, they were not feverish at that time.

The worst case scenario would be that the index case infected the children on Saturday (Sept 27).  Since he sought care on 9-26 (friday), we know he was feverish already.  The presence of the fever indicates that he is already having the initial stages of viremia.  By this very definition, there is a likelihood that the children are going to test positive in about one week.

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Continuing conjecture on epidemic course

Cris,

continuing the conjecture on the course of the Dallas cases...

Sept 20 arrival

Sept 26 index case seeks care with fever present.   Presumptively, he is shedding virus at the time of the fever with possible contagion to house mates and the children.

With known possibility of 2 to 4 day incubation period, it is possible that the kids could be exposed to Ebola on Sept 24 through 28 with presence in the school on Monday Sept 29.

The classmates of the children need to be tested on Oct 2-3.
If that is a typical public school, the kids are stacked 30 to a class room.

However, one of the kids is a high school student by your report and another is a junior high student.  Therefore, they move from room to room.  Plus, the high school and junior high students have gym class with possible showers and perspiration.  If either of the two kids were feverish on Monday or yesterday and in gym, that is a public health issue.

There could be 300 or more kids exposed from just the two kids alone...figuring 30 kids to a class, six different classes, and two index cases.  30 x 6 = 180 with a guess of some of the kids being the same in different classrooms.  

Gym class might be a source of spread due to showers being used and perhaps even clothing or towels.

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@ssj - let's be a wee bit optimistic

While I share your concern about gym and showers etc, and certainly it behooves us to err on the side of caution, I think we should also remember your point about the Nigerian experience.

i was very worried that the planes would be fomites and the fact that PS was noted to be visibly ill in the airport would lead to a large number of infections.  An it turns out, the disproportionate number of victims turned out to be the healthcare workers who came in contact with him.

still trying to reconcile the fact that the healthcare workers wore protection and still got infected.  I think we can reasonably conclude that they probably didn't protect themselves well enough and that something more than just brushing against perspiration for instance is needed for transmission.  Some kids taking a shower after gym is very different than cleaning up diarrhea or drawing blood.

hopefully, we won't see any kids being infected.  Not only would that be heartbreaking, it would suggest the threshold for transmission is lower than previously thought.

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@Cris - optimism

Cris,

Optimism is a good thing.  But, hope is not a good motivator in this context.

If the optimism leads to slower response, then the optimism is not helpful.

I would be shocked if a second case did not develop.

The timeline is too suggestive of the possibility of ill contacts.

On the recent "Public Service Announcement" thread started by Craig, a person posted this link:
http://jid.oxfordjournals.org/content/179/Supplement_1/S18.long

The article appears to be a compilation of case reports from a previous outbreak of Ebola in Kikwit, DRC in the early 1990's.  This was also a Zaire strain outbreak.  The case histories of each patient are intriguing.  Patient 7 in particular had very limited exposure to a prior case.  The stories fit with the Zaire strain in this epidemic.  

I would be pleasantly surprised if the children were not infected.

Even if you assign a 10% risk of each child being infected, there are many people in the family.  The odds that one person or possibly two are infected out the entire group are probably around 50/50.

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@Cris on Nigeria

There is a substantial difference between the Lagos, Nigeria situation and Dallas, Texas.

In Lagos, Nigeria, the patient was identified as being ill within hours of arrival to Nigeria.  From the news reports I saw back in July, the patient was taken to the hospital fairly quickly.  I recall there being discussion about taxi rides and hotels, but PS was in the hospital (if memory serves) within 48 hours.  Because there was a lack of clarity, the publication by CDC in the MMWR of the Nigeria experience was important.  It is highly unfortunate that CDC only published these reports last night (after the first cases were identified in the US).

In Dallas, Texas, the patient was mixing in the general populace for several days.  He was also in a condominium project with family, including children.  Because he would be feverish, perspiring, and viremic at the time (presumptively); the odds of transmission in home are actually fairly high.  Had he been admitted on Friday instead, the schools would not have been affected and at risk.

While it appears that the Dallas FD did well with transport of the patient on 9-28, the patient had transport on 9-26 and symptoms for two prior days that has not been discussed publicly.

It is good that the CDC finally worked with United Airlines to release the travel itinerary from Brussels to Dulles and from Dulles to DFW.

Although CDC states that the patient was not contagious at the time, this also presumes that he did not develop the initial signs during the 20 + hour travel time from Liberia to the DFW area.

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All valid points ssj

Lets hope for the best and prepare for the worst.

We will see what tomorrow brings.

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It's still Wednesday in Hawaii

And another possible Ebola case. Doctor quoted at hospital saying "very possible":

http://khon2.com/2014/10/01/patient-in-isolation-in-honolulu-hospital-officials-say-ebola-a-possibility/

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