Monday, August 4, 2014

Ebola - Truth, Misinformation and Paranoia

In the last week or so, we've seen a health crisis that most Americans didn't care a bit about become something that they are obsessed with. All because two people currently fighting Ebola are being flown here (or have arrived already) to receive care.

The fact that there has been an outbreak ongoing in Africa for a while now didn't seem to bother most people until the news that two individuals would be brought back here. Suddenly, it seems like everyone is a physician and everyone is an expert and everyone is collectively losing their minds. 

Let's all just calm down for a hot second, please?

Before I go any further with this post, let me tell you a little bit about my qualifications to discuss this subject. I did exhaustive medical research and studied epidemiology in grad school. Epidemiology is the study of disease patterns, where they come from, how they can be treated, how they can be prevented and contained. For a little over a year, I worked in risk management for a major metropolitan hospital and was charged with drafting many of the policies and procedures for physicians and nurses practicing on the campus. One of the many topics I covered had to do with infectious disease controls and management. Though I've been officially out of the field for a while now, I maintain my subscriptions to several industry journals and stay up to date on medical news, both from the internal legal/management side and from the larger public health side.

Basically, I know what I'm talking about. I'm not a foremost expert on the topic, I have not studied virology and haven't worked in the field with an outbreak like this one, but I'm more equipped to discuss the subject than Donald Trump ever will be. 

My intention with this post is to clear up some of the misinformation out there, answer questions that I have been asked and discuss the larger global issues involved with diseases like this one. Yesterday, I asked my fans and friends if they had specific questions and I will do my best to cover them all here.

Ebola virus, courtesy of the CDC
What is Ebola?
Ebola is a zoonotic virus, meaning that it is one that can be transmitted between animals and humans. There are five known strains of the virus, each with slightly different characteristics and varying mortality rates. The strain involved currently is believed to be the Zaire strain. In the past, it has carried a 90% mortality rate, meaning that 90% of those infected have died. The mortality rate in the current epidemic is closer to 60% because of the availability of supportive care in the field, which makes sense. The more professionals available to help, the better chance patients have.

It is believed that Ebola is a latent virus present in certain animal populations all the time, and that it only crosses over into human infections when there is some incident in which a human is exposed to the blood or bodily fluid of that particular animal.

The mortality rate would almost certainly be lower if an outbreak occurred in an area with sufficient health care resources, supplies and infection controls. 

The current outbreak began in February in Guinea.

What are the symptoms?
As it affects humans, it is referred to as Ebola hemorrhagic fever. The symptoms begin usually with a sore throat, fever, headache and muscle pain, followed by the development of more severe symptoms. It presents like many other regional diseases in Africa such as malaria in the initial period. Nausea, diarrhea and vomiting then set in. Once liver and kidney function become impaired, some patients experience bleeding. Bleeding is often a sign of a more severe immunologic reaction to the virus. 

How is it transmitted?
Ebola is transmitted through contact with the blood or bodily fluid of an infected animal or person to another or through contact with contaminated surfaces. This makes transmission rapid in the case of caregivers charged with cleaning up vomit, diarrhea and blood of patients. It is not an airborne virus, though it's theoretically possible to transmit it if an infected patient coughed large droplets on an uninfected person. 

That type of transmission would be short in distance and only to people within a range that they could be coughed on (assuming there was an open portal in the person being coughed on in the first place). This does not mean the disease is airborne. 

Airborne diseases are those that can be easily (not large droplets, but microscopic ones) spread through coughing, sneezing, etc. Ebola isn't going to get to the back of the plane through the ventilation system or be picked up by a breeze.

None of the strains of Ebola have ever been known to mutate to an airborne form and there is absolutely no evidence to support any claims that there have been. It's a bit of a semantic argument, yes, but an important one. Bodily fluids can become airborne and reach other people, but the disease itself is not considered airborne.

Universal precautions employed in hospitals here are considered effective at preventing transmission.

The virus can live quite a long time outside the host patient, even after death. Contact with any blood or bodily fluids, even after recovery or death can result in transmission. 

How is it treated?
Ebola is a viral infection, meaning that it isn't something we can "cure". We can primarily provide supportive care, meaning we can keep patients hydrated and treat symptoms, but whether they survive the virus itself is largely something outside human control. This is the case with all viruses. There is some promise in the development of antiviral medications that may help patients fight it off.  Dr. Ken Brantly, the physician brought back already, has been treated with an experimental serum and currently is showing signs of improvement. In 1999, 7 of 8 patients transfused with the blood of survivors of prior epidemics survived, though this is not routine practice. 

When a patient survives an Ebola viral infection, they generally recover quickly and completely, though some may experience lingering complications. The virus is known to remain in the semen of male survivors for up to seven weeks which can result in further transmission. 

There is evidence to support the theory that survivors carry immunity against the virus, at least in the short term period. It does not recur in survivors without additional exposure. Studying this issue has been made complicated by the fact that the mortality rate is so high and the areas where outbreaks have occurred don't have adequate resources to study long term effects of the disease. 

An NIH developed vaccine is slated for testing this fall. If trials are successful, it could be made available by next year, though researchers caution that it would only be one weapon in the fight against the disease.

How long does the virus take to cause symptoms?
The incubation period of the virus is the period of time between exposure to the virus and the development of symptoms. An infected person will carry the disease for between 2-21 days before they show evidence of the disease. During this period of time, they are not contagious. Dr. Brantly's family returned to the United States from the region before he became sick. They have not shown any signs of disease and are currently being monitored.

Anyone exposed to the patients involved who begins to display symptoms here would be quarantined immediately.

Why is the outbreak so bad and will it be as bad here?
The outbreak is as bad as it is in parts of Africa for a few reasons. First, as in every other part of the world, more people are traveling these days to other areas, unknowingly spreading the disease. Second, there isn't very good access to health care in many of the affected areas. Family members are the primary people caring for infected patients, and are doing so without access to protective equipment to prevent transmission. Access to medical supplies is limited and supportive care as we know it here may not exist at all. Third, it is quite common for families to bury their own dead relatives there. Body preparation involves washing the deceased, and we know that the virus can still be transmitted after death, so these processes are almost certainly increasing transmission.

Here in the United States, we also travel frequently. People traveling anywhere don't usually share bodily fluids with other people on planes, trains and boats. The virus is not airborne, so the likelihood of a subway car full of newly infected people is almost impossible unless an infected person was bleeding profusely (or somehow losing a ton of vomit or diarrhea) and everyone touched it. 

Here, we also have access to doctors and hospitals, and those hospitals and doctors employ universal precautions. Sick patients usually end up in the health care system here, where a health care system in large part doesn't exist there. 

Here, we do not bury our own family members. 

There is no reason to believe that there will be an outbreak here as the result of these two patients returning. If one ever did occur, it would be from an asymptomatic flight passenger, not one of the patients being brought back here by the CDC. The story of the patient zero that almost was, Patrick Sawyer, is an example. He died before he could get on a plane to the United States.

Far larger a threat to public health on any given day in this country are the airborne diseases that could be circulating in airplane cabins.

Why are we bringing them back here for treatment?
The first and most obvious reason is so that they can receive better care. Supportive care is much better here, universal precautions are employed to prevent transmission to health care providers. The patients will be cared for in isolation units. 

There have been many who say that these people assumed the risk of working in outbreak zones and should have to stay there. There have been many who questioned who is paying to have them flown back and why we should pay for it. There have been many who fear an outbreak here as a result of their return. 

Emory hospital is working in conjunction with the CDC to care for Dr. Brantly. The CDC hasn't stated where the other patient will be heading. They are both health care providers who had been working in the outbreak zones.

Incidentally.....doesn't this whole matter raise some huge red flags when it comes to HIPAA protections? Why do we get to know what the patients' names are, what hospitals they are at? How this all isn't a huge HIPAA violation, I'm not sure.

As for who is paying for the transport, I don't know and frankly I don't care. These two individuals were doing something that very few are brave enough to do - risking their lives to try and save other people half a world away. Yes, they were fully aware of the risk they were being exposed to. Yes, they knew that they might contract Ebola. 

I find it a little mind boggling that the same people who believe we should leave them there are often unflinching advocates for military members injured abroad. These people, all of them, are Americans risking their lives to help others. Period. They deserve to be brought back here if it gives them a better chance at survival.

Are we really so selfish that we only worry about the potential threat to ourselves in cases like this? I can promise you that the overreaction doesn't paint a very flattering picture of our citizens.

Their return here presents no threat to the average American citizen. Only those in direct contact with the infected patients are at risk for transmission, and the people in those positions are highly trained in the use of contamination prevention...the very things that don't exist in the outbreak zones and the very reasons these people were infected in the first place. You simply cannot compare our facilities to the ones in the outbreak zones. I have to assume that all bodily fluids, waste and contaminated items will be disposed of safely...most likely incinerated. 

They have a much better chance of surviving here than there. They do not pose a threat to our safety by returning. All possible precautions are being taken.

Addressing the conspiracy theories
It seems like any time something remotely dangerous makes the news, the conspiracy circles start turning. I've heard quite a few of them, my personal favorite being that this outbreak is being manipulated by the US Government so that Obama can institute martial law.

First...can we just collectively get over this idea that Obama is an evil dictator wannabe?

Second...the federal government is in possession of far more dangerous pathogens that could be used for biological warfare. Ebola is dangerous and easily transmitted in places without health care structures in place, but it wouldn't be too effective here. If the government really wanted to wage war on its own citizens, they've got bigger guns in the arsenal. Honest.

Third...even if you wanted to believe that the entirety of the CDC (and the thousands of employees and affiliated researchers and physicians involved) are just pawns of the POTUS, do you think he's somehow controlling the World Health Organization too? Or waging biological warfare on parts of Africa? (nevermind...I'm sure there are people who believe that.)

The ugly truth is that a lot of the conspiracy theories are being generated and perpetuated by people with a vested interest in politics (and who, incidentally, know very little if anything about health care crises like this one). Fear is a great motivator, and making people irrationally afraid of things outside anyone's real control is a phenomenal way to get citizens stirred up. The extreme right has a habit of blaming just about everything on Obama, even when the situation is something he literally has nothing to do with at all. 

The role of the media
The media, all of the media, has been irresponsible in how this has been covered. For those who only obtain their information from slanted news sites, even more so. Uneducated opinions like those of Donald Trump are pitched as news when they are actually pieces of inflammatory misinformation designed to make people sitting in front of the screen afraid. 

Even so-called reputable news sources haven't been the best when it comes to disseminating truthful, accurate facts about this disease and the level of the threat it presents to the average person.

What you need to do
Mostly, nothing. Educate yourself about the disease, be aware of symptoms, don't spread false information. 

The CDC has 20 quarantine stations around the country to screen incoming passengers in the event that a flight carries suspicion of disease. The average citizen can't do much when it comes to prevention of global epidemics. Use good hygiene, hand washing and common sense. If there is a possibility that you have been exposed, contact your physician. 

Unless you have been to certain regions near the outbreaks and/or around people who have and been exposed to blood, bodily fluids or the internal organs of someone who was potentially infected, you don't need to panic. 


I think I addressed all the questions people asked me. If I missed something, my apologies. 

Be well. Breathe. Calm down. 

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