[Health] The Infectious Diseases Thread

[$iljanus]

Where is Smoove? I want him to hold me.

In the coming pandemic, approaching someone for a hug is a killing offense. So keep your dirty hugs to yourself.

[Isgrimnur]

Also, having a child in school I think I'm starting to get more concerned about this entovirus thingy floating around. Apparently the vast majority get the sniffles but there are some cases coming out now where kids are getting polio-like symptoms? WTF?

Enterovirus. The group also contains, surprise, surprise, the poliovirus. To be fare, it also contains the rhinovirus, source of the common cold.

[Captain Caveman]

Results for the Frisco case: Negative!

I can't wait to eat his poop now.

[Isgrimnur]

You need a better hobby. Come to the boardgaming thing in Plano this month.

[Captain Caveman]

You need a better hobby. Come to the boardgaming thing in Plano this month.

I'm not a boardgamer. I could be convinced to play poker, or engage in some consensual poop-eating.

[Holman]

Results for the Frisco case: Negative!

I was happy to see this too. It's nice that he's not sick, and anything that throws water on inflated public panic is a good thing.

[Isgrimnur]

You need a better hobby. Come to the boardgaming thing in Plano this month.

I'm not a boardgamer. I could be convinced to play poker, or engage in some consensual poop-eating.

I could almost guarantee myself and a +1 for poker night. I don't know if coop's sociopathy would let him run the tables on us or prevent him from showing.

In either case, I'm not exactly set up to host anything.

[Pyperkub]

You need a better hobby. Come to the boardgaming thing in Plano this month.

I'm not a boardgamer. I could be convinced to play poker, or engage in some consensual poop-eating.

I could almost guarantee myself and a +1 for poker night. I don't know if coop's sociopathy would let him run the tables on us or prevent him from showing.

In either case, I'm not exactly set up to host anything.

You're going to be nesting for months, of course you will

[Captain Caveman]

Second confirmed case. A health care worker who was treating Duncan. You'd think such a person would have taken all the necessary precautions... I'm curious how this happened.

[J.D.]

Wait, so a trained health care worker with all the proper procedures and equipment gets sick, but the family living in his apartment using the same bathroom and using the same sheets and towels are still OK?

[Captain Caveman]

Wait, so a trained health care worker with all the proper procedures and equipment gets sick, but the family living in his apartment using the same bathroom and using the same sheets and towels are still OK?

Yep. I assume the health care worker was somehow careless, but they aren't giving any details about that... But I already anticipate massive panic around the "not even the CDC protocols can protect us" meme.

[msduncan]

Is it possible for the virus to go through a brief period when it's airborne? Maybe sometime towards the middle or end of the symptoms?

We have two health care workers in two first world hospitals that have now come down with it while at least trying to follow western medical protocols.

Per NBC:

The worker became infected despite wearing full protective gear while treating Duncan, who later died from the disease, during his second visit to the hospital.

[Smoove_B]

Ok, so I guess I'll share the article:

"I will tell you that the fact that we identified this individual so quickly is actually to me a sign that the system is working," he added.

I'd like to counter that if the system was working, he wouldn't have been initially turned away, but that would probably be judged as harsh.

Wait, so a trained health care worker with all the proper procedures and equipment gets sick, but the family living in his apartment using the same bathroom and using the same sheets and towels are still OK?

I'm guessing there's a gap between what she was told to do, versus what she actually did. I don't want to imply laziness or ignorance, here either. So now contact tracing starts for her and this is extended out into November.

If nothing else, the amount of work involved and to see what U.S. medical and epidemiological investigation staff are doing for a single case, it should give everyone an appreciation for the mess they're dealing with in Africa with thousands of infected people.

[Kraken]

it should give everyone an appreciation for the mess they're dealing with in Africa with thousands of infected people.

I read an article a week or two ago explaining that most people in Africa don't have addresses, even in the cities, and even beyond the shantytowns. Makes them wicked hard to track, not to mention preventing them from participating in much of modern society (getting bank accounts, registering to vote, etc). The story was about somebody who's using modern technology to impose addresses on huge swaths of the world that have never had them before. Science News? MIT Technology Review? My internet connection is flaking out so I can't look for it right now.

[Smoove_B]

Waaaaaaay back in April right when this was starting, yes, there was an article about crowd-sourcing disease maps.

[Holman]

it should give everyone an appreciation for the mess they're dealing with in Africa with thousands of infected people.

I read an article a week or two ago explaining that most people in Africa don't have addresses, even in the cities, and even beyond the shantytowns. Makes them wicked hard to track, not to mention preventing them from participating in much of modern society (getting bank accounts, registering to vote, etc). The story was about somebody who's using modern technology to impose addresses on huge swaths of the world that have never had them before. Science News? MIT Technology Review? My internet connection is flaking out so I can't look for it right now.

I was just reading about how social customs in West Africa often make quarantine difficult. In the West, we think nothing of parking ill family members in the hospital for days or weeks on end. In Liberia and elsewhere, abandoning a sick person to the care of strangers is considered almost heartless, and families will do everything they can to take care of their own. Obviously this makes it easy for highly contagious diseases to spread, but it's very strongly ingrained in the culture.

[Stefan Stirzaker]

On the decision to Euthanise the Spanish nurses dog.

Dr D'Alterio refers to OIE's document as a reference according to which the nurse's dog should not have been euthanized. Most likely, he refers specifically to the following statement in the said document:
"There is no evidence that domestic animals play an active epidemiological role in the transmission of the disease to humans."

It will be interesting to note whether the Spanish health authorities, while aware of the scarce scientific knowledge on the issue, may have based their difficult decision to euthanize the dog upon the "precautionary principle" or "precautionary approach." In short, the "precautionary principle" is a notion which supports taking protective action before there is complete scientific proof of a risk; that is, action should not be delayed simply because full scientific information is lacking. This principle has been an essential part of the international agreement (Agreement on the Application of Sanitary and Phytosanitary Measures, the "SPS Agreement"), of which OIE is a signatory, an essential part thereof being the precautionary principle.

In some legal systems, as in the law of the European Union, the application of the precautionary principle has been made a statutory requirement in some areas of law.

The Spanish authorities could have been cognizant of OIE's document when discussing the dog issue before action was taken. OIE issued the document, "technical information sheet on Ebola virus disease outlining epidemiological observations and scientific knowledge of the disease including the animal reservoir," on 6 Oct 2014, the very day when the nurse was found positive for Ebola virus.

The potential role of dogs in Ebola epidemiology has been subject to a study, the results of which were published in 2005. For subscribers'
convenience, its abstract is copied below:

"Ebola Virus Antibody Prevalence in Dogs and Human Risk. Lois Allela, Olivier Bourry, Regis Pouillot, Andre Delicat et al. (2005). Emerging Infectious Diseases 11 (3) pp 385-390.

Abstract
During the 2001-2002 outbreak in Gabon, we observed that several dogs were highly exposed to Ebola virus by eating infected dead animals. To examine whether these animals became infected with Ebola virus, we sampled 439 dogs and screened them by Ebola virus-specific immunoglobulin (Ig) G assay, antigen detection, and viral polymerase chain reaction amplification. Seven (8.9 percent) of 79 samples from the 2 main towns, 15 (15.2 percent) of 99 samples from Mekambo, and 40
(25.2 percent) of 159 samples from villages in the Ebola virus-epidemic area had detectable Ebola virus-IgG, compared to only 2
(2 percent) of 102 samples from France. Among dogs from villages with both infected animal carcasses and human cases, seroprevalence was
31.8 percent. A significant positive direct association existed between seroprevalence and the distances to the Ebola virus-epidemic area. This study suggests that dogs can be infected by Ebola virus and that the putative infection is asymptomatic.

The full paper is available (free) on line at <http://wwwnc.cdc.gov/eid/article/11/3/pdfs/04-0981.pdf>. - Mod.AS

[Stefan Stirzaker]

Another interesting thing about Ebola and screening (which I hadn't realised) is that infectiousness is proportional to fever temp.

This is a discussion of Ebola outbreaks in Africa where up to 15 percent of confirmed cases were afebrile (without fever). But the amount of virus excreted increases in proportion to a fever, so at less than 101.5 degrees F, transmission is probably not very efficient. - Mod.JW]

[soulbringer]

Wait, so a trained health care worker with all the proper procedures and equipment gets sick, but the family living in his apartment using the same bathroom and using the same sheets and towels are still OK?

Without knowing exactly what the break in procedure was its hard to speculate, however The risk of any disease that is carried by bodily fluids is much higher in a healthcare setting where they were trying to save his life with dialysis, intubation, starting IVs(probably large ones), arterial sticks to measure oxygen in the blood etc. vs just dealing with potentially sweat on sheets or saliva from drinking glasses etc.

[PLW]

Wait, so a trained health care worker with all the proper procedures and equipment gets sick, but the family living in his apartment using the same bathroom and using the same sheets and towels are still OK?

There is some question about whether proper procedures were followed. The nurses are blaming poor administration.

The nurses' statement alleged that when Duncan was brought to Texas Health Presbyterian by ambulance with Ebola-like symptoms, he was “left for several hours, not in isolation, in an area” where up to seven other patients were. “Subsequently, a nurse supervisor arrived and demanded that he be moved to an isolation unit, yet faced stiff resistance from other hospital authorities,” they alleged.

[Ralph-Wiggum]

There's now a second case of Ebola in a Dallas hospital worker. Clearly the hospital's precautionary procedures weren't up-to-snuff.

[Captain Caveman]

People around here are starting to freak out... I'd be surprised, given 2 cases already, if several more health care workers dont come down with it too over the next few days. It's obvious they were ill-equipped to deal with Duncan.

My son has a doctors appointment across the street from there tomorrow.

[coopasonic]

The geeks heading to BGG.CON are starting to talk about this. 2500 sweaty geeks in close space in Dallas for 5 days. They are going to need to crank up the AC for all the folks in hazmat suits. Pandemic may see more play than usual at the con this year.

[Smoove_B]

I'd be surprised, given 2 cases already, if several more health care workers dont come down with it too over the next few days. It's obvious they were ill-equipped to deal with Duncan.

Yup. I still believe we're looking at a failure to follow PPE protocols and not some type of misunderstanding with how the virus is transmitted. I also don't blame the nursing staff in any way as I would not expect them to be prepared to handle this type of treatment.

Don't be surprised if the CDC ultimately recommends that when an Ebola patient is diagnosed, they're immediately isolated and transferred to a treatment facility where you have people specifically trained to deal with it.

We have a NJ resident (part of an NBC news team) that was put into voluntary quarantine (essentially you stay at home for 3 weeks) after being exposed. Well, she decided getting coffee was more important than hanging out at home, so she visited a public place to get some and violated her agreement with the local health department. She's not symptomatic, but this is how things get crazy.

Anyway, the take home for me was learning that a part-time public health department employee was tasked with going to this woman's house 2x a day to take her temperature. That's how serious we're taking this - tasking someone that is paid hourly with monitoring whether or not this NBC employee is sick. I have nothing but the utmost respect for public health nurses, but this is a perfect example of just how low we prioritize these types of things. You're monitoring someone for symptoms of Ebola and your best plan is to send a part-time worker over to her house? Get the hell out of here.

[Zarathud]

Well, we can't have all that government bureaucracy, you know. The private sector will provide a solution.

[Jeff V]

There's now a second case of Ebola in a Dallas hospital worker. Clearly the hospital's precautionary procedures weren't up-to-snuff.

I'm awaiting word of a major bloodbath affecting the entire upper management at that hospital. They had an opportunity to shine in the national spotlight and chose utter failure instead. This morning, some group that was representing nurses at the hospital (they are not unionized) cited anonymous complaints along the lines of "there were no protocols breached -- because there are no protocols in place."

When I worked for a hospital, we had regular exercises covering a range of scenarios. I participated in a large one that was held on a Saturday that included a hazmat component. We received good marks from the observers from the Illinois Department of Public Health, but I have no idea if the processes were adequate for this sort of thing. We (hospital management) were trained in emergency management. Now, I think that system (developed by FEMA FWIW) is more designed for finite events: mass casualties caused by a blown up building, transit incident, etc. Implementing it from the start would have helped the hospital staff focus on the problem at hand and not rely on potentially (now confirmed) inadequate SOP.

[Blackhawk]

Like I said earlier, I'm glad that we have a relatively non-communicable disease like this to show us the holes in our system rather than finding them during an outbreak of something really, really contagious.

(Not saying I'm happy ebola is here.)

[$iljanus]

What horrified me was this story in today Washington Post, specifically this portion:

“They kept adding more protective equipment as the patient [Duncan] deteriorated. They had masks first, then face shields, then the positive-pressure respirator. They added a second pair of gloves,” said Pierre Rollin, a CDC epidemiologist.

From my biosafety research training there are specific guidelines when working with certain agents requiring specific protocols and protective gear. What they seemed to have had was a rolling standard of protection seemingly based on the patient's condition rather than the nature of the virus. And this part made me angry:

CDC Director Thomas Frieden expressed regret Tuesday that his agency had not done more to help the hospital control the infection. He said that, from now on, “Ebola response teams” will travel within hours to any hospital in the United States with a confirmed Ebola case. Already, one of those teams is in Texas and has put in place a site-manager system, requiring that someone monitor the use of personal protective equipment.

“I wish we had put a team like this on the ground the day the first patient was diagnosed,” he said. “That might have prevented this infection.”

In the Duncan case, the CDC sent disease detectives to help track down people who might have been exposed, but the agency largely let the hospital handle its own infection control.

I realize bad things happen sometimes even with the most stringent precautions. But really CDC? You thought that letting the local neighborhood hospital manage this while giving advice from a distance would be enough? There was only one patient with Ebola so it's not like the resources of the CDC would be stretched. Was it a turf battle between the hospital or the CDC or did they just not think that the hospital needed any further advice?

[LawBeefaroni]

When I worked for a hospital, we had regular exercises covering a range of scenarios. I participated in a large one that was held on a Saturday that included a hazmat component. We received good marks from the observers from the Illinois Department of Public Health, but I have no idea if the processes were adequate for this sort of thing. We (hospital management) were trained in emergency management. Now, I think that system (developed by FEMA FWIW) is more designed for finite events: mass casualties caused by a blown up building, transit incident, etc. Implementing it from the start would have helped the hospital staff focus on the problem at hand and not rely on potentially (now confirmed) inadequate SOP.

We do an Nuclear/Biological/Chemical and Terrorism/Disaster drill every year. Some of that is federal and some of that is state. No idea what it's like in Texas.

Dallas Texas Health Presbyterian did have Magnet status, for whatever that's worth, as recently as 2011. So it's not like they wre running a completely fly-by-night operation. Granted they could have just "prepped for the test" and not really put good practices into place, but who knows. I thought we went through it every 2 years but maybe it's longer than that. If it is two, they may have lost their status. Leapfrog graded them an "A" in safety.

OTOH, it was an ER. Unless you quarantine everyone upon entering, which would probably lead to a bunch of dead paitents awaiting triage, you're going to have multiple staff exposures if someone walks into an ER with unknown ebola.


Whether this hospital was negligent or not I don't know yet but their faililng has certainly highlighted the issue for everyone else. Hopefully all other hospitals and staff take it to heart.

[Smoove_B]

Was it a turf battle between the hospital or the CDC or did they just not think that the hospital needed any further advice?

Not quite. Because public health is not mentioned explicitly in our Federal Constitution, primary responsibility (under the 10th Amendment) falls on the backs of the States. Essentially, the Texas State Health Department is the lead agency here and they ideally should have had plans in place on a county and local level to deal with this. Whether that looks like policies, training, gear, specialized teams, relationships with hospitals and clinics - it doesn't matter - Texas is responsible for "being ready".

The State Health Department would need to directly request assistance from the CDC (though I'm sure they offered it) and then coordinate with those federal agents. Pressure to do so would likely come from state and local elected officials, but I don't pretend to understand how Texas politics work in this situation; I can only comment on NJ and what would happen here.

All that being said, the federal government does have emergency-level powers of response but that would have probably required the President and/or Congress to step forward and task the CDC with something specific, assuming this was declared an "Emergency". Given our political situation, it doesn't surprise me this didn't happen.

[LawBeefaroni]

What horrified me was this story in today Washington Post, specifically this portion:

“They kept adding more protective equipment as the patient [Duncan] deteriorated. They had masks first, then face shields, then the positive-pressure respirator. They added a second pair of gloves,” said Pierre Rollin, a CDC epidemiologist.

From my biosafety research training there are specific guidelines when working with certain agents requiring specific protocols and protective gear. What they seemed to have had was a rolling standard of protection seemingly based on the patient's condition rather than the nature of the virus. And this part made me angry:

Hospital PPE protocols are (should be, anyway) based on the disease and risk of exposure/type of procedure, not the patient's symptoms.

Here are the CDC recommendations for ebola.
Note that they don't require positive pressure respirators, only N95 masks. The hospital started way below the standard and then overcompensated beyond it.

[$iljanus]

Was it a turf battle between the hospital or the CDC or did they just not think that the hospital needed any further advice?

Not quite. Because public health is not mentioned explicitly in our Federal Constitution, primary responsibility (under the 10th Amendment) falls on the backs of the States. Essentially, the Texas State Health Department is the lead agency here and they ideally should have had plans in place on a county and local level to deal with this. Whether that looks like policies, training, gear, specialized teams, relationships with hospitals and clinics - it doesn't matter - Texas is responsible for "being ready".

The State Health Department would need to directly request assistance from the CDC (though I'm sure they offered it) and then coordinate with those federal agents. Pressure to do so would likely come from state and local elected officials, but I don't pretend to understand how Texas politics work in this situation; I can only comment on NJ and what would happen here.

All that being said, the federal government does have emergency-level powers of response but that would have probably required the President and/or Congress to step forward and task the CDC with something specific, assuming this was declared an "Emergency". Given our political situation, it doesn't surprise me this didn't happen.

The unfortunate thing about biology is that pathogens don't recognize state sovereignty. I certainly see how states have this fear of onerous and costly Federal regulations so would like to manage their own affairs as much as possible but a patchwork response just won't cut it for certain things.

[Smoove_B]

The unfortunate thing about biology is that pathogens don't recognize state sovereignty. I certainly see how states have this fear of onerous and costly Federal regulations so would like to manage their own affairs as much as possible but a patchwork response just won't cut it for certain things.

Why do you hate the framers of the Constitution? What type of liberal-communist agenda are you trying to promote?

Over the weekend there was an article in USA Today (of all places) about our patchwork response problem:

Murphy says some of the issues in Texas stem from a "system problem" in the way public health care is managed in the USA. The Centers for Disease Control provides only guidance for infection prevention and management. "What they do in Texas, what they do in Illinois, it's up to the state," he says.

"The question is, who's in charge?" Murphy says. "The states can follow all the guidelines and take the advice, which they usually do, but they don't have to. It's not a legal requirement. So there really is no one entity that's controlling things."

I have no doubts this single event will be researched, discussed, dissected and re-examined repeatedly for years to come. It's already provided me with more material than I can possible deal with.

[$iljanus]

The unfortunate thing about biology is that pathogens don't recognize state sovereignty. I certainly see how states have this fear of onerous and costly Federal regulations so would like to manage their own affairs as much as possible but a patchwork response just won't cut it for certain things.

Why do you hate the framers of the Constitution? What type of liberal-communist agenda are you trying to promote?

Over the weekend there was an article in USA Today (of all places) about our patchwork response problem:

Murphy says some of the issues in Texas stem from a "system problem" in the way public health care is managed in the USA. The Centers for Disease Control provides only guidance for infection prevention and management. "What they do in Texas, what they do in Illinois, it's up to the state," he says.

"The question is, who's in charge?" Murphy says. "The states can follow all the guidelines and take the advice, which they usually do, but they don't have to. It's not a legal requirement. So there really is no one entity that's controlling things."

I have no doubts this single event will be researched, discussed, dissected and re-examined repeatedly for years to come. It's already provided me with more material than I can possible deal with.

Heh, I'm sure Laurie Garrett is getting her next book ready as I type.

Why do you hate the framers of the Constitution? What type of liberal-communist agenda are you trying to promote?

LOL, I think Cuba's health care system would be well poised to handle this problem. They've also sent a large number of clinicians over to Africa.

[Smoove_B]

Heh, I'm sure Laurie Garrett is getting her next book ready as I type.

I would need to go back and review Betray of Trust (a great book and weapon) to see if she predicted this, but my guess is no. She does cover the other Ebola outbreaks in Africa, so who knows. Regardless, it was written at a different point in time, so yes, she is probably gearing up for an update. She's been very active on Twitter, at least. She's merciless in her accounting, so I do hope she's able to come up with something.

Personally, I'm all for it. I really don't think public health is winning the PR battle - now more so than ever. I don't think the average person truly appreciates all the things we're doing behind the scenes to try and keep society healthy. This is a great opportunity to get that information out there and show people why it's important for us to be proactively monitoring, training and preparing for these types of events.

[LawBeefaroni]

The State Health Department would need to directly request assistance from the CDC (though I'm sure they offered it) and then coordinate with those federal agents. Pressure to do so would likely come from state and local elected officials, but I don't pretend to understand how Texas politics work in this situation; I can only comment on NJ and what would happen here.

My admittedly biased observation of Texas is that health care there is a game of political football where they're more concerned with things like shuttering women's health clinics than with emergency preparedness. Hell, up until 2011 rural hospitals in Texas couldn't even employ doctors. Health systems along for the ride just try to focus on profits.

[J.D.]

Good news is that as of Sunday we can assume all the "originals" who came in contact with Duncan (family, ER nurses, etc) are Ebola-free. And the two nurses who have it now were put in quarantine immediately after having symptoms. I'm guessing we'll see a couple more cases from within the hospital from those who were treating Duncan and then hopefully *fingers crossed* that's it from Dallas.

[LawBeefaroni]

Good news is that as of Sunday we can assume all the "originals" who came in contact with Duncan (family, ER nurses, etc) are Ebola-free. And the two nurses who have it now were put in quarantine immediately after having symptoms. I'm guessing we'll see a couple more cases from within the hospital from those who were treating Duncan and then hopefully *fingers crossed* that's it from Dallas.

Forgive me if I don't make the same assumption.

I live to serve. People surviving a hemorrhagic viral infection up until now has been quite rare. However, one of the last times it happened was a researcher that accidentally injected himself with Marburg in the lab waaaaaay back in 1971. Now, Marburg is a close relative of Ebola (not nearly as deadly), so it's not necessarily the same - but the Marburg virus was still found in his semen 61 days after he recovered. In theory this means people *could* be spreading it via semen after being cured and healthy, but we don't know because survival rates for Ebola historically speaking are terrible (< 10%). But I'm willing to bet for those that have been treated here in the United States, they'll be collecting fluid samples for the next year to see if they're still harboring the virus in any capacity.

[Smoove_B]

Health systems along for the ride just try to focus on profits.

You might be on to something. From Scientific American:

The Texas Health Presbyterian Hospital in Dallas next blamed the error on their electronic medical record system (EMR). This is entirely plausible, as the many brands of EMR I am familiar with are seemingly designed to maximize billing and minimize liability, by giving the illusion of comprehensiveness. They are, however, extraordinarily poor for patient care, as they are so cluttered with needless, clinically irrelevant detail.

That might be the single-greatest article I've read on the subject so far.

[Captain Caveman]

Good news is that as of Sunday we can assume all the "originals" who came in contact with Duncan (family, ER nurses, etc) are Ebola-free. And the two nurses who have it now were put in quarantine immediately after having symptoms. I'm guessing we'll see a couple more cases from within the hospital from those who were treating Duncan and then hopefully *fingers crossed* that's it from Dallas.

Yes, this is an important-- and optimistic-- point. No ebola cases among the family members supports the notion that contagion is more difficult when the patient is less symptomatic. Duncan was still very sick prior to being admitted to the hospital, but not at "hemorrhaging fever" levels that the healthcare workers were dealing with. Hopefully, that means that these healthcare workers who contracted ebola are extremely unlikely to pass it on, as they were isolated immediately upon coming down with a low-grade fever.

Not that this will temper the freak-out going on down here.

Edit: and now I just read the Smoove quote above provided by Lawbeef and I'm scared again.