Dallas health worker who tested positive for Ebola wore ‘full’ protective gear
washingtonpost.com
washingtonpost.com
I say this not to incite panic, but to provide insight that many might not have. It is more likely that during the thousands of interactions that this patient saw, the messiness led to a breach, instead of the virus infecting via a vector we've not yet realized.
I've had 2 relatives who were submitted to different local hospitals for different things, but they both contracted secondary infections, which nearly killed one of them.
At the end of the day, we should feel lucky that a complete stranger made an honest effort to help you or your loved one in their time of need, and not focus exclusively on the complications and accidents that may have happened along the way.
To anyone who works in healthcare, if you don't already, I would strongly encourage the use of checklists for any and every important task. Checklists save lives. [0]
[0] http://www.who.int/bulletin/volumes/86/7/08-010708/en/
http://news.bbc.co.uk/2/hi/health/7825780.stm
http://www.hsph.harvard.edu/news/magazine/fall08checklist/
Edit: Typo.
Edit 2: These hospital visits were covered by Canadian healthcare so we didn't have to pay hundreds of thousands of dollars. I can see how it would be very difficult to overlook complications and accidents when the bill will likely bankrupt you.
For the first 10 years or so of my working life, my only experience of paperwork was top-down controlling bullshit. Pointless timesheets. Useless reports. Data collected and never looked at again. It was managers imposing mandates in ways that rarely helped the business, and often hurt it.
But in getting into the Lean movement, I came to realize there's another approach. If you are a team that wants to do well, there's only so far you can go on implicit work practices. Eventually variation becomes the biggest barrier to improvement. The solution is to collaboratively create a standard way of getting a job done. With variation minimized, you can then start to rigorously test improvements, increasing quality and reducing waste.
This is easiest to see when you're working solo. A while back I was struggling to go running in the mornings. I was always forgetting something: keys, money, headphones. Now near the door is a simple list I can run down to make sure I have everything. Less stress, less wasted time in the mornings, more runs. I love it.
But groups can do the same thing. Can and should, really. Top-down imposition of quality practices rarely works. The people doing the work are the best ones to create and tune the way a job gets done. Might as well do it before some manager gets a bright idea and inflicts the wrong approach on you.
Then when you grow older you realise that just like in every aspect of the world, everything is super messy and no one, except for a very few, know what they're doing.
More people should understand that hospitals are messy.
If you exclude the Cleveland Clinics, Cedar Sinais, Beth Israels & Stanford Meds of the hospital world, most American hospitals are woefully bad for patients, in terms of HAI rates(Hospital Acquired Infections).
Buried in a pile of books, surveys and studies during the passing of the Affordable Care Act (ACA) a few years ago, was an eminently readable book called
Catastrophic Care: How American Health Care Killed
My Father--and How We Can Fix It by David Goldhill.
Here's an Atlantic piece by Mr. Goldhill
http://www.theatlantic.com/magazine/archive/2009/09/how-amer...
A Reason TV discussion with him
https://www.youtube.com/watch?v=GvSa9nC4JcQ
I think his points are still relevant, even after the passage of the ACA.
In a few years, I am certain that we will have to revisit the issue of how little we get as consumers of healthcare in America, for how much we spend as a nation, all over again.
If anybody has a link for stats comparing local hospitals in the US versus Europe, I would love to read them.
http://www.dailymail.co.uk/news/article-1327766/Mid-Stafford...
1200 dead because of avoidable cleanliness problems
It depends when she became infected though - was it Duncan's first visit or after they admitted him as an Ebola patient? I'm not sure if this has been established yet or if so, can't find a good source.
One thing is for sure, that hospital is going to get the SHIT sued out of it.
Thats why its nice to live in a place that requires HAI (Healthcare Acquired Infections) to be reported. In the state I live in (US/AZ), this is only voluntary for the hospitals. As a patient, it makes it almost impossible to make an educated decision on what facilities to avoid.
Now, we see that Western medical workers with education, resources, and the focus of single patients in Western hospitals are catching it. And now I feel like the message is shifting toward something like: "It's impossible for doctors to do their job without a high risk of transmitting Ebola, and even if the protocols work, it's impossible to follow them. But still: Ebola is nothing to worry about, and any significant response is counterproductive panic."
I don't know whether that's what you're saying or not. But I am done hearing about how Ebola is not really a problem[1][2]. We just don't know anywhere near enough to be confident that it won't spread.
Even if you grant that modern rich areas can control it, that still leaves an awful lot of people exposed.
[1] https://news.ycombinator.com/item?id=8161937 [2] https://news.ycombinator.com/item?id=8429867
I doubt they do in this case though. Probably at the end of the shift, but when you are in and out of a patient's room a dozen times a day, it's not likely they do a full decon each time.
EDIT: Just reread your post after seeing frankydp's reply. I thought you were asking about decon showers _after_ removing PPE. frankydp is absolutely correct that showering while wearing most styles of PPE is a bad idea.
The can cause overconfidence in regards to contamination.
Military contamination rates for Decon are considered to be 25%. That number is just the projection for unit effectiveness after an event, but it is rooted in the fact that even the most well trained people will still cut corners in decon. Mostly due to heat and fatigue. Overconfidence and repetition weariness can also be issues for those that decon too much.
We don't need any AI for this - remote control would work just as well. Can't we get a pair of robotic hands on wheels + Oculus Rift and controller gloves for a small fraction of what an MRI device costs?
> if we can replace x% of actions that need to be done by humans with devices that can be sterilized, then that's a x% decrease in number of infections.
The Miasma theory is always an issue even for the most educated/trained. By that I mean what I can't see can't hurt me.
Just curious, do you have any citations for this?
For further context look up the health worker mortality in West Africa due to Ebola. Even if those people are not all highly trained they are trained. The reality is that people simply cut corners, even when they know the risk, and the margin for error is obnoxiously low.
You can't change a culture on a moment's notice, just because the threat is more significant.
Frankly, this hospital mismanaged the index patient from the beginning and though the woman infected now wasn't on the initial list...the list itself wasn't complete because they didn't properly diagnose the index patient ebola to begin with.
[1] http://www.cbsnews.com/news/cdc-chief-on-second-ebola-case-t...
"Only 15 BSL-4 facilities were identified in the U.S. in 2007, including nine at federal labs."
There are 4 hospitals in the nation that have a total of less than 20 beds that are set up for diseases like this. Emory (CDC), the NIH in Bethesda, the biggest with 10 beds is in Omaha, Nebraska, and there's one in Missoula, Montana, not far from one of those BSL4 labs.
3 at Emory: http://www.emory.edu/EMORY_REPORT/erarchive/2005/July/July%2...
3 in Montana, and they've never used them or put their protocols to the test: http://missoulian.com/news/local/st-patrick-hospital-of-site...
7 at the NIH, and it sounds like they've gotten some use: http://clinicalcenter.nih.gov/translational-research-resourc...
As mentioned before, 10 in Nebraska, and they don't have a BSL-4 lab handy; hopefully they have, or are setting up, a mini-lab there, for as Emory realized, it's not practical to send samples from Ebola patients to the hospital's main lab: http://www.nebraskamed.com/biocontainment-unit
"Frieden also promised that protocols at the hospital would be reexamined to find out how the disease was apparently transmitted." Other patients with quite advanced cases of ebola, who were on the brink of death, have been successfully treated in United States hospitals without any health care workers in those hospitals being infected so far. The Dallas hospital where this latest incident happened will definitely have to review its infection control protocols, but we know already that other United States hospitals are doing things right.
Terrifying news like this came out when SARS was first spreading around the world in 2003. SARS is especially easy to transmit from one person to another because it is an airborne virus. No doubt there will be other cases of ebola infection spreading in the developed world, even in hospital settings, now that the first few cases have been discovered. But SARS transmission decreased a lot once people in China started taking precautions like self-isolation and masks to cover coughs. West Africa has a lower availability of equipment, supplies, trained personnel, and even information today than rural China had in 2003, but with sufficient outside help the transmission of ebola can also decrease a lot, until numbers of new cases start falling instead of rising.
Not to mention SARS is spread from respiratory droplets. This thing is spread by: A) vomit B) saliva C) sweat and if you are running a high grade fever you are going to be sweating and transmitting this thing from every pore in your body.
So no, this is not going to be as easy to contain as SARS especially once it hits somewhere like India.
Of course he was wearing protective gear (it would have been news if he hadn't).
He may have worn it, but what procedures did he follow for removing it? That's where infections are likely to occur - the article even notes at the very end that the nurse in Spain who was infected was probably infected this way.
Make them a different colour on the inside.
People have likened Ebola to HIV, but HIV does not transmit this easily. Even during seroconversion (which is when you might get vomiting and such with heightened viral load) I've never heard of anyone contracting HIV in a hospital.
I feel like the information on transmission has been poor. For example, is skin a barrier for the virus?
We don't know. It's strongly suspected broken skin is not a barrier.
So you touch the surface with the virus then you wipe your nose, rub your eyes, eat with your hands.... and you could get infected.
is skin a barrier for the virus?
@kenjackson: "Is skin a barrier for Ebola?"
Yes. According to Bausch et al.
"Taken together, our results support the conventional assumptions and field observations that most EBOV transmission comes from direct contact with blood or bodily fluids of an infected patient during the acute phase of illness. The risk of casual contacts with the skin, such as shaking hands, is likely to be low."
In the same paper, they note that:
"We found [Ebola] to be shed in a wide variety of bodily fluids during the acute phase of illness, including saliva, breast milk, stool, and tears. In most cases, the infected bodily fluid was not visibly contaminated by blood."
This lends credence to Kyro and JshWright's assertions that hospital and PPE protocol are hard to exactly follow, every time (I'm certainly guilty sometimes). Even if the equipment or chucks aren't stained with blood, there is a possibility that the patient's tears have leaked onto the material and remain unseen.
http://jid.oxfordjournals.org/content/196/Supplement_2/S142....
According to several sources, it may take up to an hour for the virus to be invalidated by UV light. That makes it not really practical for the patient or the HCP involved.
Not only that, but I suspect at the energies required, the amount of UV radiation would be quite harmful to the patient as well.
"Inactivation of virus stocks.Virus stocks were inactivated by exposure to UV light for 1 h. Proper inactivation was controlled by the incubation of Vero E6 cells with the inactivated virus particles and subsequent screening for the presence of viral proteins (immunofluorescence) and viral RNA (reverse transcription [RT]-PCR targeting virus-specific transcripts). The UV-inactivated stocks were used at the same dilutions as the noninactivated stocks."
http://jvi.asm.org/content/75/22/11025.full http://link.springer.com/article/10.1007%2Fs00705-010-0847-1
> ...
> This reflects an incorrect and outmoded understanding of infectious aerosols, which has been institutionalized in policies, language, culture, and approaches to infection control. We will address this below. Briefly, however, the important points are that virus-laden bodily fluids may be aerosolized and inhaled while a person is in proximity to an infectious person and that a wide range of particle sizes can be inhaled and deposited throughout the respiratory tract.
> ...
> Modern research, using more sensitive instruments and analytic methods, has shown that aerosols emitted from the respiratory tract contain a wide distribution of particle sizes—including many that are small enough to be inhaled. Thus, both small and large particles will be present near an infectious person.
> The current paradigm also assumes that only "small" particles (less than 5 micrometers [mcm]) can be inhaled and deposited in the respiratory tract. This is not true. Particles as large as 100 mcm (and perhaps even larger) can be inhaled into the mouth and nose. Larger particles are deposited in the nasal passages, pharynx, and upper regions of the lungs, while smaller particles are more likely to deposit in the lower, alveolar regions. And for many pathogens, infection is possible regardless of the particle size or deposition site.
> It's time to abandon the old paradigm of three mutually exclusive transmission routes for a new one that considers the full range of particle sizes both near and far from a source. In addition, we need to factor in other important features of infectivity, such as the ability of a pathogen to remain viable in air at room temperature and humidity and the likelihood that systemic disease can result from deposition of infectious particles in the respiratory system or their transfer to the gastrointestinal tract.
> We recommend using "aerosol transmissible" rather than the outmoded terms "droplet" or "airborne" to describe pathogens that can transmit disease via infectious particles suspended in air.
http://www.cidrap.umn.edu/news-perspective/2014/09/commentar...
> Here, we provide data on the stability and viability of MARV and ZEBOV in both liquid media and on a range of solid substrates at various temperatures, over time. In addition, the stability and decay rate of MARV, ZEBOV and Reston ebolavirus (REBOV) within small-particle aerosols held within a modified version of the Goldberg drum system (Goldberg et al. 1958) was investigated.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2672.2010....
However, note in the paper I cited:
"However, the isolation of EBOV from only 1 saliva specimen, in contrast to the 8 that were RT-PCR positive, could suggest that the virus is rapidly inactivated by salivary enzymes or other factors in the oral cavity that are unfavorable to virus persistence and replication."
That plus the fact that standard precaution PPE for diseases with high rates of transmission (at least in CA) calls for goggles and a mask makes this story all the more interesting.
As many commentators undoubtedly will say, additional cases are to be expected. However, it's a problem that both in Texas and Spain, the people infected have been health workers. Health workers that are supposedly well-protected and well-informed about Ebola specifically (at least the spanish nurse was, it's not clear in this case yet).
Now it's true that there are more bodily fluids in a hospital than outside, but given all the protection and procedures, is the difference so big that a health worker is at a much bigger risk than a person who happen to sit next to someone infected on a bus?
There are two cases as I see it. Either it's likely that other people, non-health workers, have been infected. We just don't know about it yet, or it has been decided that it's not in the public's interest to know. Or the protective measures are so bad, the disease so misunderstood or hard to protect against, that health workers effectively can't protect themselves against the risk.
Either case, it's a big problem. In the west too.
In that thread people were saying the health worker was infected before they knew Duncan had Ebola. In this thread, when it turns out that the health worker did know Duncan had Ebola, people are saying that it's obvious. Funny how these things work.
No one except mainstream US media is advocating panic. That doesn't mean it's not a serious issue that requires our attention. Saying "Ebola is overrated, more people die of X every year, don't panic ffs" doesn't add anything to the debate - it's neither controversial nor insightful.
To guide the discussion, here's a suggestion for people who disagree with me. Either argue why there are more than the two cases that I outlined, or argue for why either of the two cases aren't a problem in the coming weeks and months.
Going one step further, none of the comments that were posted at the time you made that summary really said much about whether the worker knew that Duncan had Ebola.
Even in family contacts the main vector of Ebola seems to be caregiving - you're likely not touching someone sitting next to you on a bus, much less wiping their bottom or cleaning their face from vomit.
Yes, that's abolsutely true. Ebola spreads through contact with bodily fluids. Someone who not syptomatic (or in the early stages of their symptoms) does not produce much in the way of 'extra' bodily fluids, so the risk is quite small in terms of casual contacts. It's only when they become quite sick that they start produce massive amounts of infectious fluids, and that's when healthcare workers are most likely to come into contact with them. In fact, the sicker they become, the more fluids they produce, and the more care they need...
> There are two cases as I see it. Either it's likely that other people, non-health workers, have been infected. We just don't know about it yet, or it has been decided that it's not in the public's interest to know. Or the protective measures are so bad, the disease so misunderstood or hard to protect against, that health workers effectively can't protect themselves against the risk.
The third option (and the most likely one) is that people make mistakes. The protective measures work if used properly, but they have to be used properly _every time_. With half a dozen cases being treated in the US, I'm somewhat surprised we've only had one lapse leading to an infection so far. However, as long as the average number of healthcare workers infected per patient stays well below 1, we've got nothing to worry about.
Like when they blamed the computer system then later denied it was a problem or when they said the initial patient's fever was 101 and it later turned out to be 104 we may have to wait for the truth to come out, if it ever does.
This is why Ebola is such a threat. It takes time to incubate, it looks like other less harmful health problems early on, and it spreads. Yet air travel goes on impeded and borders are open. SARS led to more restrictions that Ebola.
Honestly it really seems we are trying to rationalize away the problem. We are coming up with excuses for cases that go against what people were told to expect. This is not how you contain a problem, its how you create a bigger one.
So what is the threshold before people should be concerned? five more cases? twenty? A hundred? If it gets to a dozen I am pretty sure people will expect travel to locked down and more.
[1] http://www.nytimes.com/2014/10/13/us/texas-health-worker-tes...
[2] http://www.modbee.com/2014/10/11/3587238_timeline-for-first-...
http://www.nationalreview.com/article/389817/ebola-electroni...
BTW - Epic has my local hospital chain by the balls after a few failed attempts to build alternatives. It looks like something from the 1990s - super modal interface in a remote desktop.
When the outbreak began in Guinea it was RO = 1.5 Early July, the RO in Sierra Leone was 2.5. Today in Liberia, the virus has been spreading so fast that the RO hasn't been computed (and we won't officially know since Liberia has been acting shady and is not reporting all of their statistics).
I think you probably saw some infographic floating around and are citing that, but that RO is a variable number.
Data until Aug 26, 2014. http://www.eurosurveillance.org/images/dynamic/EE/V19N36/art...
Data until mid Aug, 2014. http://arxiv.org/abs/1408.3505
[1] http://www.who.int/mediacentre/factsheets/fs103/en/
[2] http://www.washingtonpost.com/wp-srv/special/health/how-ebol...
It's above 1, by my and many other's estimates around 3 in this outbreak, which, while technically "isn't particularly infectious", is still very bad and quite enough for exponential growth, in this case with an observed doubling time of 3-4 weeks. The CDC's recent worst case estimate is 1.4 million infections by January.
(edit: very predictable downvoting on this. But it's simply a fact that politics and race have played a part here. I don't like posting it any more than you like admitting it to yourselves.)
Using uncorrelated and unrelated events to form race-baiting statements is another.
You just described your entire "pre-edit" opinion as a statement of fact.
> I take exception to you describing my comments as "race-baiting"; that is offensive and uncalled for.
Bringing race into this is what someone might consider as offensive and uncalled for.
But that's okay, you are entitled to your opinion, and I don't downvote anyone I respond to, so you have nothing to lose here from me.
The late diagnosis was absolutely devastating to his prognosis. I think it's quite likely he would have survived if it had been caught during his first ER visit. I think it's a stretch to chalk that up race (or a lack of insurance) though...
But he was black and uninsured, and it's Texas, and they summarily discharged him and took no notice.
Perhaps you are right, and it's "a stretch" to mention the factors that may or may not have played a role in why this man was treated so very callously in the midst of a very very well-publicized epidemic of scare-mongering over Ebola.
I simply disagree. I think it is quite possible indeed that these were factors.
Fever plus pain are not "extraordinarily clear signs"; they're common for a host of diseases, including a host of common to African diseases, like malaria.
Nothing I've seen suggests the hospital egregiously dropped the ball in this first visit, however I'm entirely certain that widely casting blame at generic targets when anything bad happens, like "Republicans", racism and our medical system, does no good and rather a lot of harm.
Based on his review of the medical records,
Dr. Adalja said the diagnosis given to Mr.
Duncan before his discharge included
sinusitis, a sinus infection.
What don't you get?? If Thomas Eric Duncan had stated "I'm a Liberian national who recently helped treat a pregnant Ebola victim just before flying to the US" he would have been isolated immediately. He didn't and now other people might die because of it!
It's the Internet; they're a stranger. Move on.
> Please don't use uppercase for emphasis. If you want to emphasize a word or phrase, put asterisks* around it and it will get italicized.
If Thomas Eric Duncan had not lied at the airport he never would have been allowed onto an airplane. If Thomas Eric Duncan had told the hospital in Dallas that he had cared for a person with Ebola he would have been isolated immediately.
Thomas Eric Duncan isn't dead because he was black. Thomas Eric Duncan isn't dead because he didn't have insurance. Thomas Eric Duncan isn't dead because Republicans. THOMAS ERIC DUNCAN IS DEAD BECAUSE HE LIED!
It's this healthcare worker, and the likely other contacts who are not yet symptomatic, who are sick and statistically going to die who are dead because he lied.
And those who expect people to tell the truth on such forms, which flies in the face of all we know about human nature.
Thus the possibility that Mr. Duncan thought he was only helping a pregnant woman get to the hospital to help with a troubled birth. At that point, the most information he could provide is that he cared for a sick pregnant woman.
Relying on the fact that Liberia would prosecute him is a bad idea, due to the precarious nature of justice in that country. I would imagine that Liberia would say just about anything to prevent public opinion in the US from going sour. Liberia is facing an existential crisis and are in desperate need of all the help the US can give.
Mr Duncan's trip to the US was planned weeks in advance, so he was not fleeing the country in response to his exposure.
Citation for that?
It's easy to find articles talking about him receiving the visa in August (I guess he would have applied for it some weeks or months before that).
http://www.scientificamerican.com/article/world-health-agenc...
Its overall budget was flat -- WHO decided to reduce infectious disease activities to fund other priorities. In complete fairness, the article suggests that WHO intended to shift some detection and emergency response responsibilities to member countries, and put some resources in that new paradigm. But even if so, the management of that transition now seems suspect.
I've seen various press references that the WHO had its budget cut after the financial crisis. But as near as I can tell (its budget transparency is almost zero), its budget in 2006 was $3.3bn, vs $4.0bn in 2014.
The CDC, by the way, has an ample budget, much of it dedicated to non-infectious disease activities like tobacco and chronic disease. A bit goes to gun control. These activities may be worthy, but it isn't clear that they protect public health in the same sense that epidemic control does.
But don't let the facts get in the way of a good race-card rant.
"Some Ebola experts worry that the virus may spread more easily than thought -- through the air in small spaces, for example."
Aerosol transmission is a very real possibility and has been demonstrated in the field and in some experiments, including working its way through the air ducts of a building, from one part to the another, infecting monkeys, and not just through one room.
Though some strains are not as effective in that mode of transmission as others.
edit: To the down-voters, at least make your case. The people that worked with the virus, and in the hot-zones, made theirs.
It's _far_ more likely that those transmissions were due to cross contact from the folks working with the animals. The researchers themselves suggested that was an equally likely vector.
Depending on the drop size and the viral load in those drops, depends on how far it will travel in air, how long it will be suspended in air, what potency it has, and how likely someone other can get infected when it's inhaled.
It's how the most common virus is transmitted...
http://en.wikipedia.org/wiki/Common_cold#Transmission
"The common cold virus is typically transmitted via airborne droplets (aerosols), direct contact with infected nasal secretions, or fomites (contaminated objects)."
A person with Ebola going through a crowded airport and sneezing could infect dozens of other people under the right circumstances (virus strain, load, etc).
The critical distinction here is that Ebola doesn't seem to infect the outer part of the respiratory system like colds or influenza. There's not a huge mass of cells there to be shedding viri and getting into the air, and it would take more than a few mutations for that to change.
Ebola viri have been found in saliva, tears, can come from bleeding in the respiratory system, so it obviously can get airborne that way. Exactly what that means (how big are the droplets, how long do they stay in the air etc.), how significant that is as a mode of transmission (which includes iffy estimates of how many viri (virus particles) are required to make an infective dose) ... we just don't know. But with our current Ebola importation policy, it's very likely we will start to get answers to these questions....
> Although they are not naturally transmitted by aerosol, they are highly infectious as respirable particles under laboratory conditions.
I think the issue is to what degree it can get into the fluid that is sneezed out by humans... Once it's in it, the size of the droplet does not matter to how viable the virus is - it's deadly if inhaled in by someone else.
-9/11 truther articles -racist crap about Ebola spreading over the Mexican border because of insufficient efforts to secure said border -several other non-scientific articles about Ebola -an article about "Obama's Ukrainian stooges"
If you want to make your case, find one cite--just one will do--from a legitimate publication of any kind.
"We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks."
http://virologydownunder.blogspot.co.uk/2014/08/ebola-virus-...
It has legitimate publications inside it so it looks like the possibility is quite justified.
It seems that the term "airborne" is very specific and droplets might exist in the air even if it's not considered airborne. (I'm not saying that droplets can be found in the air, but simply that it's not fully confirmed and that this is the reason why they recommend respiratory masks.)