As the collective and cable news freakouts begin with the second Dallas health worker having been diagnosed with Ebola, with more data, our collective ignorance level seems to be increasing. Yes, there are important issues wrt to this second health care worker, but the odds that anyone contracted Ebola from her are close to zero. A hedge because there is no public information on the range of behaviors that primary Ebola victims engaged in during the asymptomatic and early symptomatic stages of their infections. Only that they seem not to have infected anyone else during that stage. A closer look at Nigeria is informative.
On September 24, 2014 Forbes reported Nigeria Free of Ebola as Final Surveillance Contacts are Released
AFP then added, “Nigeria has not reported any new cases since September 8, the WHO said. If there are no further cases, Nigeria could be declared Ebola-free on October 20.”
Dr. Chukwu provided further details, saying, “No cases are under treatment, no suspected cases. There are no contacts in Lagos that are still under surveillance, having completed a minimum of 21 days of observation.”
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This was just over two months since Patrick Sawyer, a Liberian-American, had flown to Lagos from Liberia on July 20th. Sawyer collapsed at the airport and was immediately admitted to hospital. It was approximately a day before it was suspected that he was infected with Ebola and suffering Ebola Virus Disease (EVD). At that time he was isolated, tested, and treated. Contract tracing, quarantine, and monitoring began quickly after that. Unfortunately, Sawyer died five days later on July 25th. It appears that he was well into the symptomatic phase of Ebola, “acutely ill” per CDC, when he arrived in Lagos. (Day 10-16 since infected.)
In total there were nineteen to twenty-one reported Ebola cases and eight deaths (a 38% to 42% fatality rate if case reports are correct). The CDC has issued a report, Ebola Virus Disease Outbreak — Nigeria, July-September 2014 that details the events and government and medical community actions that contained this outbreak.
The first significant fact in this report is that Mr. Sawyer was under observation for Ebola at a hospital in Monrovia and developed a fever on July 17th and was advised not to travel. With airport screening for fever, Mr. Sawyer would have been denied a boarding pass. Second fact, he denied any exposure to Ebola during his admission process to the hospital in Lagos. Third, Lagos public health authorities were immediately alerted to a possible Ebola case.
Port Health Services conducted early contact tracing at the airport and worked with airlines and partners to ensure notification of the outbreak through International Health Regulations (IHR 2005) mechanisms (3). The EOC case-management team took over management of each laboratory-confirmed or suspected case, triaged potential patients, and decontaminated areas inhabited by them. …Having the capacity to conduct Ebola laboratory diagnosis in-country at the Lagos University Teaching Hospital facilitated rapid identification of confirmed cases and quick discharge of persons with suspected Ebola who tested Ebola negative.
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As of September 24, 19 laboratory-confirmed Ebola cases and one probable case had been identified (Figure 1). A total of 894 contacts were identified, and approximately 18,500 face-to-face visits were conducted by contact tracers to assess Ebola symptom development.
Makes the initial public health response in Dallas look a bit shabby. On the other hand, Duncan likely received a higher level of care in the Dallas hospital than Sawyer had in Lagos, and the health workers in Dallas were better protected. Of the twenty confirmed or probable cases in Nigeria, thirteen had been in direct contact with Sawyer, three had second order contact, and three had third order contact. The task for the medical community was complicated by an ECOWAS colleague of Mr. Stewart’s who had met him at the airport in Lagos. (Can we assume that the greeting included very close contact such as hugging?) He broke his quarantine order and sought private medical care in a hotel in Port Harcourt He survived, but his doctor, Dr. Ikechukwu Enemuo, didn’t. Enemuo was one of the second order contacts and he was the contact for at least one third order, his wife who has survived. Enemuo wasn’t diagnosed with EVD while he was alive, seems not to have received any specific EVD care, and died 8/22 before being admitted to hospital.
The first health worker death in Lagos was on August 6, 2014. Seventeen days from possible first contact on 7/20. By August 4, that nurse and one doctor had been confirmed with EVD and another three workers at the hospital were being tested. By August 19, Ebola had claimed the lives of two doctors, one nurse, and two health workers that had treated Sawyer. While those numbers don’t look great, it’s not known how quickly they were put under care after the first symptoms appeared. Those in Nigeria with EVD that survived, received the standard hydration and palliative care and none of the yet to be proven experimental treatments. It has been demonstrated that quality standard care seems to reduce the fatality rate from 70% to closer to 40%. Not yet clear how much the survival odds increase based on when in the course of the disease the care is initiated.
What’s shocking is that TX Presbyterian Hospital, TX public health agencies, and/or the CDC didn’t quarantine all those that treated Duncan. Freaking Nigeria did better than that. Based on this update, Amber Vinson, the second healthcare worker to be diagnosed with Ebola, will be transferred to a special bio-containment unit in Atlanta for care. The US has four units of the CDC’s highest calibre, wouldn’t be confident that Vinson sought medical attention at the first sign of a low-grade fever as Pham did. Still, within three to four days she likely put her own health at more risk than anyone else.
White House press secretary Josh Earnest is talking to reporters …
This is completely unacceptable and inadequate. What is so freaking difficult about designating a lead, medical professional, spokesperson for the Executive branch of the USG? Should have been done two months ago. It’s not as if the federal government doesn’t employ plenty of people that would be qualified for this assignment. My preference, for reasons not interesting enough to recite, would be the Acting Surgeon General, Rear Admiral Boris Lushniak. It’s why you don’t have political appointees like Salazar running Interior when BP has a catastrophic blowout and like Burwell running HHS when an epidemic emerges.
Then maybe the CDC wouldn’t make statements such as this one without more evidence/proof:
“The first several days before the patient was diagnosed appear to be the highest risk period,” the director of the CDC has said.
My colleague Lauren Gambino has more:
The two infected nurses had `extensive’ contact with Thomas Eric Duncan in the days before he was diagnosed with Ebola and was extremely ill, excreting large quantities of highly-contagious body fluids.
Prior official statements said that Pham only came into contact with Duncan AFTER he’d been diagnosed. That was on 9/30. And it does seem odd that someone with EVD would be more contagious when his/her viral load is lower instead of later when it’s higher.
The CDC continues to report that the incubation period for Ebola is two to twenty-one days. If by “incubation” the CDC means from infection to the earliest objective symptom, a low-grade fever, the two day period would be encouraging and comforting. The twenty-one days would be troubling. It’s still looks to me as if the asymptomatic incubation phase is a week +/ – 2 days. However, from the reported cases it looks more like twenty-one days from infection to death and not twenty-one days from infection to first symptoms.
Early detection and isolation saves lives. Can it still be done quickly enough in Liberia, Sierra Leone, and Guinea to slow down the epidemic?
