Doctor in New York City Is Sick with Ebola
nytimes.com
nytimes.com
This is sort of misleading in this context, unfortunately. The WHO considers (sustained presence) within 1 meter of EBV carrier to be ~physical exposure. The young doctor appears to have been on a NYC subway within 12 hours of having a fever of 103. Creating a potential group of exposures that may be un-traceable.
Maybe someone can correct me if I'm wrong. But this would be highly unfortunate if these reports are correct. Presumably the uber driver is also in this group now, but records should be able to provide some data on that one much easier.
Though the growth of number of patients with Ebola is definitely exponential. Please note it takes 21 days for the each multiplication to happen. It started in March and has been been spreading since, 10K is pretty large for a 7 month period.
>>but the sky isn't falling just yet.
In things like this you won't know when the sky will start falling apart. And generally when that happens its already too late, and you would be staring at a pretty big damage.
No body knows how many people have been infected, or will be infected in the next multiplication.
Which is why WHO suspects ~1.4 million could get infected by January. By then it would be too late.
Was the bowling alley public subway trip really a must-do thing, for someone who had just directly worked with ebola patients? Could this kind of thinking not be part of the training for this kind of work, I wonder?
In my experience with experts I'd say especially someone who "knows better" can end up thinking that the bad thing can't happen to them right up until they, in a fit of being human, have an oops and it does.
Like enforced isolation of some kind? The thing that people have been asking for since the beginning, but is a bad idea for some reason that nobody can explain?
Also, in this case and many like it, imprisoning this man would have been much more expensive than simply testing him for the disease.
There you go; one reason it's a bad idea to imprison someone you think might be carrying ebola is that you can just test their blood and know for sure if they are. Seems a lot cheaper and better all round than imprisoning people.
The point here is that it's not clear that there's a reason to enforce a quarantine- yet. But if it becomes clear, then we need to have the balls to do it.
Are they free to leave whenever they wish? No? Sure sounds like imprisonment. Maybe it's for the best, but that doesn't mean it's not imprisonment. It's on the same moral spectrum as conscription and forced labour; the removal of fundamental rights from an individual for the betterment of a great many other people. I'm not saying it shouldn't be done, but it should be recognised that under the social system the country in question (USA) subscribes to, it's a fundamentally evil act.
While not illegal there should be comprehensive legal safeguards around it. And, if it's not illegal, what are the laws that regulate quarantine in the US?
http://www.cdc.gov/quarantine/index.html
The sub pages are lengthy and cite specific laws and so on.
Skimming, CDC has broad authority to detain travelers and states and local health departments usually have the power to enforce a quarantine (with violation of the quarantine being a misdemeanor).
Accounts of how he was found are a bit odd. In some articles the fire department was sent to retrieve him. According to another article, a tenant in his building claims police broke down the door to get into his apartment.
It could be the case that he was infected 2-3 weeks ago, but since the average time of symptoms showing up is 8-10 days because he was symptom-free before leaving for nyc, he might have thought he was fine.
http://www.cdc.gov/vhf/ebola/symptoms/index.html
"A 21 day period for quarantine may result in the release of individuals with a 0.2 – 12% risk of release prior to full opportunity for the incubation to proceed."
http://currents.plos.org/outbreaks/article/on-the-quarantine...
I wonder how feasible this is. Its not just the bowling alley, using public rest rooms, subway, or utensils at a restaurant. Its almost impossible to find every thing he came in contact with and disinfect it. Plus in case of stuff like utensils, whats to guarantee that they were not mixed with each other and used by other people already.
If some one has been infected due to this by now. It will become impossible to get a realistic perspective of how far this thing would have spread.
In short you are dealing with a exponential growth scenario.Which is why these sort of things are so dangerous.
Even the NY Times got it right this time: "People infected with Ebola cannot spread the disease until they begin to display symptoms, and it cannot be spread through the air."
Prior to this outbreak, this Ziare strain of Ebolavirus, now formally known as "Ebola virus", has never infected more than 318 people at a time, and not a whole lot more than a thousand total: https://en.wikipedia.org/wiki/List_of_Ebola_outbreaks#List_o...
I guarantee that at least one of the things the usual suspects like the CDC "know" about its transmission is wrong. Consequentially wrong? Well, we'll see.
As for this case, he was not feeling well (also described as "sluggish") for a couple of days before his self-monitored temperature spiked. Which is prompting the usual suspects to say that that wasn't a "symptom" ... which is open to question.
Meanwhile, the transmissions in Dallas have all been in keeping with the things the usual suspects were saying (health care workers did become infected there, but they are known to be at higher risk, PPE is known not to be 100% safe, the hospital did not have great PPE procedures in place).
As for Dallas, the plural of anecdote is not data. We just don't know yet; for example, in 1st World conditions where IV saline etc. are standard, the death rate may be well below the 70% currently estimated in West Africa. Although your points about the Dallas Ebola Magnet Hospital of Excellence's, are correct: while following the then current CDC "protocols" (scare quotes since the CDC and others invested so much into their sanctity vs. health care workers following them), were inadequate, e.g. no neck coverage.
Heck, look at the standard Bellevue Hospital PPE picture that's been floating around for many days, e.g. http://www.nydailynews.com/life-style/health/bellevue-hospit... Based on what we suspect the person on the right would stand a serious chance of getting Ebola, and that's no longer the protocol.
Or look at this gem from the U.K. press: http://www.dailymail.co.uk/news/article-2805930/Should-Offic...
You don't suppose there's some environmental, population density, etc. differences that might make NYC's experience different than Dallas'?
That doesn't mean chickens need to start running at axes the second a known case is identified and isolated.
Which is being advocated by precisely who?
My major theme here is that people, and most especially "authorities" should not be lying, e.g. not making absolute statements about things which aren't. So fat that that has resulted in a constantly changing the party line as preceding versions have turned out to be lies. But there's worse, in the most brazen example I know of, http://cnsnews.com/news/article/brittany-m-hughes/cdc-you-ca... contradicting yourself in consecutive sentences.
You want "panic"? Convince the American people the authorities responsible for keeping us from getting an epidemic of Biblical proportions are systematically, even routinely lying to us. We're well along the road to that.
He wasn't very clear there. But the CDC statements have been reasonably consistent and clear, especially in the face of the ridiculous questions they get from reporters. A softer reading is that transmission from an asymptomatic person who is later found to be infected is not believed to be possible at the time they are asymptomatic. Health workers with exposure should still, out of an abundance of cation, avoid contact with large groups of hard to trace people.
My main takeaways were (starting 25 minutes in): - There's a lot we don't know, especially about the current strain
- He's heard of patients that did not have a fever through the entire infection
- There have been incidents/experiments where we do not understand how ebola, this strain in particular, passed between animals
Why are you sure?
It's a bit like saying, "Hey I've saved lives over here so I have earned the right to be irresponsible over here". Because you know, karma balances out. No, the world doesn't work like that. And you aren't doing any good propagating this idea either because it encourages this privileged way of thinking.
As much as this guy isn't being vilified (and say what you want about the government spinning its story of ebola being hard to transmit), lets think clearly and rationally. He knew the risks that he could possibly be infected and decided to endanger others when he could have easily stayed home or gone anywhere to a more isolated environment (upstate NY is calling). It is well known symptoms generally show up by the 10th day. Today is his day 10.
It's very interesting that the government has locked down this guys apartment, yet if you need contact with bodily fluids to contract the disease why quarantine the apartment and surroundings? Could it be that droplets are a transmission method as many people are starting to suspect. Sneezing and coughing may spread these droplets to the floors and walls? And if that is the case, what about other objects that come in contact with saliva and other fluids like utensils, door handles, glasses...
The government is using semantics and spin to their advantage by saying it isn't airborne via dried viral transmission. The WHO agrees[1] that it also isn't airborne, but also admits surfaces can transmit the virus.
Most officials omit this detailed explanation since they have no adequate explanation of how to decontaminate the urban environment en masse if an outbreak does occur.
In the end we all have to assess our own risk profiles. Will I stand or sit next to somebody coughing? I doubt it. Or will I take mass transit if I can easily walk to where I need to be by leaving a bit earlier? Nope.
[1] - http://www.who.int/mediacentre/news/ebola/06-october-2014/en...
I would suggest to everyone: Don't comment on questions like this one (how Ebola spreads) unless you know for certain what you are saying and can back it up. We have complete saturation of rumors and bad information; adding to it won't improve the situation.
I don't mean to criticize the commenter above; they just happened to have the top-most comment of this kind.
EDIT: What a strong signal of over-reaction when a post that says you should know what you are talking about, on HN, is modded down. (I don't care how it's modded, it's just depressing to see this response here.)
EDIT: The same applies to my other post, which asks serious, legitimate questions in a non-offensive way. How sad.
http://www.ncbi.nlm.nih.gov/pubmed/15588056
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4113787/
Ebola and Marburg viruses are the sole members of the genus Filovirus in the family Filoviridae. There has been considerable media attention and fear generated by outbreaks of filoviruses because they can cause a severe viral hemorrhagic fever (VHF) syndrome that has a rapid onset and high mortality. Although they are not naturally transmitted by aerosol, they are highly infectious as respirable particles under laboratory conditions. For these and other reasons, filoviruses are classified as category A biological weapons. However, there is very little data from animal studies with aerosolized filoviruses. Animal models of filovirus exposure are not well characterized, and there are discrepancies between these models and what has been observed in human outbreaks. Building on published results from aerosol studies, as well as a review of the history, epidemiology, and disease course of naturally occurring outbreaks, we offer an aerobiologist's perspective on the threat posed by aerosolized filoviruses."
or
Our study has shown that Lake Victoria marburgvirus (MARV) and Zaire ebolavirus (ZEBOV) can survive for long periods in different liquid media and can also be recovered from plastic and glass surfaces at low temperatures for over 3 weeks. The decay rates of ZEBOV and Reston ebolavirus (REBOV) plus MARV within a dynamic aerosol were calculated. ZEBOV and MARV had similar decay rates, whilst REBOV showed significantly better survival within an aerosol."
Reston is not Ebola, but a close relative.
We're not qualified to perform our own analysis; what we need are conclusive analyses from experts about the scientific consensus and range of possibilities.
Yes, this is all dangerous thinking. Yes, this is acting from one's gut, rather than waiting on the data. But when it's my life on the line, I'm going to err on the side of caution. When death is on the other side of the decision, I'm going to be a little more skeptical of other people's certainty.
The risk to your life hasn't changed, unless you are writing from West Africa. I would be happy to make a bet with anyone on HN that they will not contract Ebola (assuming they are not posting from West Africa), and that the flu will kill far more Americans this year.
Let's be honest; people are acting on fear. It's very compelling to people in the moment, but I think we all know better and know that it's how people make dumb decisions for themselves and do very bad things to others. The person who stays calm when everyone else is panicking is much safer.
Fear is dangerous and contagious -- much more so than Ebola, because fear can spread over HN. Don't follow the herd; set the example for those around you.
This is part of a popular meme that is showing up on the news. They ask questions like, "True or false, you are more likely to die from ebola than the flu." The mark replies "true", and a doctor (medical doctor, not a statistician) is quoted explaining that "You're actually more likely to die from the flu." This could not be more incorrect.
Mortality rates for diseases like the flu (or any disease) are not homogenous for all members of the population. It's not like a roll of the dice. You simply cannot extrapolate an individual's odds from the broad population mortality rate for the flu (or any disease). It is extremely unlikely that I will die from the flu. I am a middle-aged male in good health and fitness. My chances of dying from the flu are extremely low. The reason the flu kills so many americans is because it is so prevalent. It could be said that flu kills so many precisely because it is so non-lethal. This allows it to fly under our radar and infect people who are at risk. I'm not arguing that we shouldn't take action to prevent the spread of influenza, I'm arguing that the flu presents a different set of problems.
My chances of contracting ebola are also extremely low, but if I do, my chances of dying from it are very high. Across the board (all ages and classes), the mortality rate for ebola are much higher than the flu. Unfortunately, we don't have a strong grasp on ebola mortality rates in the west, because we haven't (thankfully) experienced an outbreak. Even in develping countries, the mortality rate varies widely [1].
I agree that we shouldn't let fear run away with our sensibility, but when dealing with a highly infectious disease [2] with a remarkably high mortality rate, we should be cautious. If not fully quarantined, a period of sensible precaution is a reasonable expectation. When the sun is at its strongest we're advised to wear sunscreen and limit our exposure. When an individual spends time with ebola patients, they should be advised to avoid situations where they would expose a large number of people to the pathogen. Flying, taking public transit, and participating in sports are all activities that put you in direct or indirect contact with large numbers of people. This seems like an unreasonble amount of risk to me.
1: http://www.npr.org/2014/10/23/358363535/why-do-ebola-mortali...
2: Even though ebola must spread through bodily fluids, it is extremely infectious. A small amount of the virus can infect you.
I think that raises a several good points. A few considerations:
1) The 'proper' way to evaluate risk, as I understand it, is (likelihood * cost). A 10% chance you'll lose $100 costs you $10 each time you take that risk, over time.
2) I agree that some costs are so high that the math works poorly even with low likelihoods. A 1% chance of death is far too high a risk to take, unless there is some high payoff such as saving someone else's life -- a risk the infected doctor and nurse took.
3) The cost of Ebola is that high, but the likelihood is so infinitesimally low that it's still not worth worrying about. You'll add more life years exercising or simply reducing other risks with the same time spent thinking about Ebola. It's a complete waste of time (I realize the irony of writing that! :) ).
4) There are many more equally deadly and far more likely risks for healthy middle-aged people: Lightening strikes, natural gas explosions, being shot in the head, carbon monoxide poisoning, food poisoning (of certain kinds), other contagious and non-contagious diseases, etc.
5) > When an individual spends time with ebola patients, they should be advised to avoid situations where they would expose a large number of people to the pathogen ... This seems like an unreasonble amount of risk to me.
Generally I agree that we should minimize risks, but again I'm not sure there is one here:
* It's very possible that it's very safe. Nobody in the United States (in fairness, that we yet know of) has contracted Ebola in this manner from the infected 3, though two of them spent much time around others. Also, wouldn't Ebola be rampant in the hospital where the infected nurse worked, if this was a risk? Wouldn't it be rampant among medical staff in W. Africa, given the prevalence in their environment (higher than flu in those facilities)? * HIV spreads via bodily fluids but we don't quarantine the infected or their caregivers. However when HIV first become known, people were afraid to be near the infected (resulting in a lot of discrimination). I think we should not repeat that mistake. * I would guess that hospital workers encounter many contagious, deadly diseases, yet nobody worries about those spreading.
People want to treat Ebola differently despite many similar and much greater risks. That's why I believe it's fear and not real risk that drives it.
Anyway, I'm approaching redundancy. Good talking to you!
What other BSL-4 pathogen are you referencing here? Or are you suggesting BSL-4 is an unappropriate classification? Maybe you think the scientific and biosafety community erred when they created the BSL-4 designation?
There is plenty of research out there that documents the objectibe risk.
There is very little research that documents supports a strategy of "see no evil, hear no evil, speak no evil".
People don't need to panic.
But that's entirely seperate from lack of comprehension of the actual risks involved. After all, you can't solve problems you don't admit to having.
Trying to deal with a BSL-4 pathogen with BSL-2 safety gear is a fools errand. We might not havy any better options, especially in backcountry settings, but lets not pretend its "not risky".
In densely populated urban areas those risks are simply not tolerable. They are not tolerable for two reasons: (1) we can do better; and (2) the technology that allows for (1) makes the risks of not doing (1) more problematic.
Technology allows us to isolate patients; but it also allows non-isolated patients to spread the pathogen further/faster. People with hemoraggic fever don't walk 1000Ks or cross continents on their own power. They only do so by using technology.
It makes sense that the appropriate technology be dedicated to helping contain these bio-hazards and to compassionately care for the afflicted.
But seriously, what do we have to gain by sticking our heads in the sand? It seems this is a cynical strategy by people who don't want to "get their hands dirty"? Mayb we can continue to provide false confidence to 'volunteers' to go to africa and do our dirty work for us?
Why do we need to play this charade? Lets just give these people the tools they need (including time, money , and gear) and properly de-brief them and the public about the risks and what is at stake from either mistakes or inaction.
http://www.cidrap.umn.edu/news-perspective/2014/09/commentar...
I have to believe the US Government already knows that ebola is capable of this, they've been studying it for decades. If it can spread by aerosol, they're lying to prevent substantially more panic.
Downvoters should start by refuting the linked article - it's a pretty important article. The authors are guaranteed to know a lot more about ebola than anyone here.
> He knew the risks that he could possibly be infected
> and decided to endanger others when he could have
> easily stayed home
In the military service you will hear it as "trust in your training." Basically you believe you won't be the guy that gets shot or steps on a land mine or what ever because you trained really hard and you know you are implementing that training flawlessly.
It is entirely possible this person was so confident in their training, and their own competence in putting that training into action, that they believed it was impossible for them to be infected. They do the self monitoring because that is what you are supposed to do, but it never comes up positive because you did what you were supposed to do. This gets worse the more times you do something and the outcome is exactly as you expect it to be.
So I can believe this guy didn't believe he was at risk. Just like I have foolishly believed this small change I am checking in can't break anything[1]. One hopes he was asymptomatic when he went out. Unlike the guy in Texas who was showing symptoms and went home, or the nurse who had a fever and got on a plane anyway.
Sure you could put anyone coming back from West Africa in an airstream trailer [2] for 21 days but that is impractical if you want to support the process of fighting it in West Africa.
[1] I know, hugely different scale, but illustrative of my fight against my own assumptions in the pursuit of better process.
[2] http://en.wikipedia.org/wiki/Mobile_Quarantine_Facility#medi...
I wouldn't mind a 21 day quarantine on a beach or camping
Unless you are in proper (BSL-4) lab, the sad reality is there will always be risk. I hope that MSF doctors and volunteers are well protected. But it worries me that they would even contemplate believing that they have zero risk of exposure. That's simply not scientific or a professionally responsible. Although, to be fair, the CDC was guilty of making this same assumption up until about two weeks ago.
It makes more sense for them to spend 21 days self monitoring (in a secluded environmnet) locally in country. There is no need for a complete travel ban, but a staged ingress/egress process would make sense. And certainly we don't need to be issuing sight-seeing or tourist visas etc. Critical business travel could also be easily arranged for with a built in waiting period (most visas take 2-6 weeks anyway to issue).
I would have through the health agencies they volunteer with would enforce these kind of quarantines to prevent international transmission of disease.
On one hand I can't help admire these people risking their lives to help people on the other side of the world. On the other hand some of them seem content to play Russian roulette with their neighbors and family back home, which makes no sense to me. Is it as the OP suggested that doctors make for bad patients?
Please look at this first
That seems pretty unusual, isn't it? How long was he there, a couple months?
"Symptoms usually occur within eight to 10 days of infection and Dr. Spencer had been home nine days when he reported feeling ill." That's not including travel time local and international.
That's a tight schedule!
Instead of quarantining by default, I think it would be interesting to offer a free, relaxing vacation in a low population density region to people who are returning from helping in Africa. i.e. you cannot leave West Africa and return to a major city directly. Instead you fly back to your home country by way of a desirable destination and hang out there for a few weeks.
Methods: The prior estimates for incubation time to EV were examined, along with data on the first 9 months of the current outbreak. These provided estimates of the distribution of incubation times.
Results: A 21 day period for quarantine may result in the release of individuals with a 0.2 – 12% risk of release prior to full opportunity for the incubation to proceed. It is suggested that a detailed cost-benefit assessment, including considering full transmission risks, needs to occur in order to determine the appropriate quarantine period for potentially exposed individuals."
http://currents.plos.org/outbreaks/article/on-the-quarantine...
http://www.who.int/csr/disease/ebola/declaration-ebola-end/e...
Apologies for the cliche 'use technology to solve all the problems' HN comment.
It should be standard practice to give someone returning from West Africa that had contact with ebola a GPS tracking device the records their exact location for 21 days following the last know exposure.
This notion that anyone exposed to ebola is basically responsible for keeping tabs on their own well being voluntarily leaves way too much room for human error.
What is higher risk?: 1) Going to the Ebola zone in W. Africa (EDIT: And taking the proper precautions to protect yourself), 2) Walking as a pedestrian on NY streets, or 3) Sharing a subway car with someone who has been in the Ebola zone?
There are around 3 cases of Ebola in the United States. I expect most of the resultant suffering will be because the public reaction is causing us to divert resources from where they could do more good (including West Africa).
See the first three sources I found about Ebola transmission in sweat: http://well.blogs.nytimes.com/2014/10/03/ebola-ask-well-spre... (claims that sweat doesn't contain Ebola) http://www.afro.who.int/en/clusters-a-programmes/dpc/epidemi... (claims that Ebola can be transmitted through sweat) http://www.cdc.gov/vhf/ebola/transmission/qas.html (hard to tell whether they think sweat is a transmission mechanism or not... they define "body fluids" twice, once including sweat and another excluding it)
I also heard on NPR that sweat contained a lot of the virus (don't have a reference handy).
Real experts don't shoot their mouth off with false assurances about a disease we don't know much about. The "hard to catch Ebola" mantra was going on long after that was discredited[1]. These aren't experts, they have some kind of agenda, and I'm not sure what it is. For some, it's probably just being on TV. For others, it's to feel smug about how the ignorant masses under them are panicking irrationally. As for the rest, probably political.
Again, I'm not panicking about Ebola. We'll have a few isolated cases in the West. It will remain in Africa in all of the hot zone countries until we have a vaccine. And hopefully that happens before it spreads to Nigeria, India, Brazil, or other areas where it might be hard to control.
I am not panicking. I am just mad at the irresponsibility of these "experts" we keep hearing from.
[1] No references here, but I think everyone remembers that the first story was that, unless you were engaging in some unsanitary funeral practices deep in an African village, it was impossible to catch. After doctors began to catch it, the story changed to be that they don't have enough resources to protect themselves. Then several Western doctors got infected while in hospitals in Western countries (Spain and the US at least), and the story changed into something about how the protocols will protect us, but were just not followed properly these few times (despite not knowing the specific protocol violations that lead to infection).
-Harlem
-An Uber car
-The High Line
-A restaurant
-A Train
-Jogged 3 miles
-L Train
-1 Train
-The Gutter
Unbelievable.