Second Ebola Case in Dallas

http://news.yahoo.com/texas-health-care-worker-tests-positive-ebola-095758341.html

A second Ebola case has been reported in Dallas in a health care worker who attended Mr. Duncan and reportedly wore full personal protective equipment (PPE) without a specific breech. When Mr. Duncan returned to the hospital on September 28th he was in day 5 of his illness. Thus far none of his household contacts have become ill and none of them wore PPE. So, what does this tell us about Ebola and how we can attain control?

One, that Ebola patients become more infectious as the illness progresses. The newly reported case in a healthcare worker had onset on October 10th. If we take 9 days as the mean incubation period for Ebola this means the healthcare worker's exposure was sometime around October 1, which was day 8 of Mr. Duncan's illness.  This is similar to what was seen with SARS, that patients become more infectious (and dangerous) with time.

Second, that only hospitals that are well prepared to care for highly infectious patients should be allowed to do so. Standard practice is to have a staff person dedicated to observing the donning (putting on) and doffing (taking off) of PPE. This observation should continue throughout the period of clinical care (from an ante-room with a window).  Perhaps gentle reminders during the doffing can avoid the presumed situation in Spain where the nurse may have touched her face with a gloved hand.

When a patient presents to a hospital early in the illness there is time to transfer to such a facility. That's the plan here in NYC. Bellevue hospital has a specially equipped ward to care for Ebola patients. Their staff are well trained. The number of healthcare workers entering the room should be kept to a minimum, especially after day 7 of the illness.

Still holding my breath.

Ebola in the US: is NYC prepared?

Many of us in public health have been holding our breaths and it is not because Ebola can be transmitted though the air. We’ve been awaiting the outcome in Dallas. We’re not fully out of the woods just yet but there is little cause for additional alarm.

Mr. Duncan left Liberia on September 19^th, four days after he reportedly carried a woman dying from Ebola to and from her apartment.  By one account he had held her legs while the woman’s family held her upper body. Mr. Duncan is said to have ridden in the taxi with the woman to the hospital.  The woman was refused entry at the hospital and has subsequently died.

There aren’t any direct flights from Liberia to the US. Mr. Duncan transferred planes in Brussels, landed in the US at Dulles International Airport in Washington, DC and then continued on to Dallas. He was not yet ill so there wasn't any exposure to his fellow passengers. Nine days after he helped carry the Ebola patient in Liberia, on September 24^th, Mr. Duncan began to feel ill. This is a typical incubation period for Ebola lending further credence to Mr. Duncan's likely exposure to Ebola. His symptoms were fever, stomach pain and severe headache. He presented to the emergency department of Texas Health Presbyterian Hospital on the evening of September 25^th. According to one reporter with access to the medical records Mr. Duncan’s temperature was 103°F. The hospital performed a number of tests and eventually released him with a prescription for antibiotics. After it was later discovered that Mr. Duncan had Ebola the hospital admitted that protocol had not been followed. While it was ascertained that Mr. Duncan had traveled to the US from Liberia in the 21 days preceding his illness this information did not trigger the appropriate response.  The failure was initially blamed on the electronic medical records system and then hospital administrators admitted there had been a serious a miscommunication.

Since this story broke every city in the nation has asked themselves could what have happened in Dallas happen here?  There are over fifty acute care hospitals in NYC and thousands of private practice offices and urgent care centers. Weeks before the case in Dallas left his home in Liberia NYC hospitals received from the health department an alert with instructions on how to screen and isolate sick travelers from the affected countries and posters to alert patients to announce that they had recent travel. Numerous conference calls with hospital leadership have been held. Health Department staff have made the hospital Grand Rounds circuit to spread the word. The task while simple, must be universally applied. Ask patients about travel and immediately isolate those with fever (or worrisome symptoms) who have been in an affected country within the preceding 21 days. The city has a 24-hour hotline for doctors to call and through that mechanism there have been nearly 100 reports (see link below). Most of the travelers had not been to an affected country, which just goes to prove how vigilant the NYC medical community has been. Doctors and nurses aren’t taking any chances opting to consult with the health department rather than risk making a Dallas-type error. And this suits everyone just fine. 

https://a816-health29ssl.nyc.gov/sites/NYCHAN/Lists/AlertUpdateAdvisoryDocuments/2014-10-09%20HAN%20Ebola.pdf

You might be reassured that CDC Director, and former NYC Health Commissioner, Dr. Tom Frieden has said there won’t be an Ebola outbreak in the US, but here’s more reassurance: it has been 16 days since Mr. Duncan’s illness first began and there have been no secondary cases in Dallas. The people at greatest risk, his family and household contacts, are in quarantine. So, even if one of them should become ill there should be no further spread. As I said, we aren’t yet out of the woods. We must wait 21 days after the last exposure date, the moment Mr. Duncan was placed in isolation. That date is October 19^th.

Will another traveler incubating Ebola arrive in the US? It is possible. NYC is more likely than most cities in the US to receive such a traveler. Screening at airports, the latest defense tactic that is starting this weekend, will only catch people who know they had an exposure and are willing to confess this to federal authorities. Yes, we’re dubious too. At least in NYC we are confident that the medical community is aware, vigilant and prepared, despite what a fear mongering, headline grabbing, Professor of Health Policy and Management might otherwise claim.

http://www.thedailybeast.com/articles/2014/10/09/ebola-panic-is-worse-than-the-disease.html

Enterovirus D68. The new polio?

News from CDC is that there have been more cases of a strange paralytic syndrome in children in which limbs go limp following what appears to be an upper respiratory illness (http://emergency.cdc.gov/han/han00370.asp). Some, but not all, of these children have tested positive for Enterovirus D68 (EV-D68). The cluster announced yesterday is in Colorado and involves 9 children. Earlier this year California reported twenty cases of the same illness that had occurred over a 2-year period (http://www.nytimes.com/2014/02/26/health/unknown-form-of-paralysis-strikes-california-children.html?_r=0).

So, has polio returned in a new guise?

I am not old enough to remember polio. I remember receiving the oral vaccine and seeing old black and white newsreels of children in iron lungs, but no one I knew had contracted the disease. Even during my training I didn’t see a case. Although the disease is believed to have been around since Greco-Roman times, it wasn’t until the late 19^th and early 20^th centuries that humanity was plagued by epidemics.  Like EV-D68, polio belongs to the enterovirus family and is transmitted person to person via the fecal-oral route.  Believe it or not the epidemics of last century are attributed to improved hygiene. With less exposure to the virus during infancy there was a decline in immunity that resulted in a more severe illness later in life when exposed. Most polio infections (95%) are inapparent, meaning they don’t result in any symptoms or paralysis, yet the person is capable of transmitting the virus. Among those with symptoms only about 1% get paralysis. To any individual the risk was low, however, on a population scale this was disastrous. During the peak years there were about 20,000 cases of paralytic polio per year in the US. After vaccine was introduced in the 1950s there was a dramatic decline and polio in the United States was all but forgotten.

I was speaking to a public health historian the other day. She told me that when she was in graduate school she was told that infectious diseases had been conquered and that it was pointless to study them. Chronic disease was the new frontier.  Short sighted to say the least. Ebola, Legionnaire’s disease, HIV, Hantavirus, SARS, Nipah and MERS have all emerged since this professor was told to forget about the field. West Nile virus moved into a new hemisphere, we’ve had an influenza pandemic and Chikungunya exploded in the Caribbean. Forget what you were told, infectious diseases will be with us as long as there still is a planet earth.

Consider this. Your 4-digit PIN number has 10,000 possibilities. There are ten options for the first digit, i.e., zero through nine. Since one can repeat numbers there are also ten options for the next three digits. That’s 10x10x10x10, or 10,000.  A computer program can run through every possible PIN number very quickly. Supposing a thief had a program that could submit the guessed PINs to your account. It wouldn’t take long before he or she was staring at your account balance.

Now consider the ever-changing world of nature. Instead of PIN numbers we are talking about the genetic code, large sequences of DNA or RNA. Each location is like the digit of a PIN number. Nature is like a huge supercomputer, changing the genetic code constantly. The change here is a mutation and instead of allowing access to your bank account the mutation of concern is one that improves the organism’s chance of survival or increases virulence. Millions and millions of mutations don’t, but by chance alone, sooner or later, a mutation is going to result in is a more virulent organism or one that can cross species. This is why there will always be new infectious diseases on the horizon. EV-D68 is a RNA virus. RNA viruses are more prone to mutation (influenza for example). But has EV-D68 somehow mutated to become a paralytic virus like its cousin polio? We don’t know yet. Right now the occurrence of paralysis is quite rare.

Meningococcal disease in young men of color, Brooklyn, New York

Meningococcal disease is a severe bacterial infection often called “spinal meningitis” or just “meningitis” by the media. Although it can spread from one person to another it is not as contagious as the popular press makes it out to be. Household members, sexual contacts and persons who share cigarettes or drugs are at the highest risk for catching the disease which is potentially deadly, claiming as much as 20% of victims. There is good news though, there are vaccines for meningococcal disease.

Meningococcal disease can be insidious. Often it looks like the flu at first, with fever, sore throat, chills, muscle pain and just feeling punky. A rash might develop which looks like small red dots that don’t go away when pressed with a finger (known as blanching). If meningitis develops these signs are much easier to recognize: headache, stiff neck, eye sensitivity to light, vomiting and a fogginess of mind. If you have any of these symptoms don’t delay. Especially if you have HIV. Contact your physician. This disease is readily treatable with simple antibiotics.

NYC has had two large outbreaks of meningococcal disease in the last decade. One in 2006 and another in 2011-2013. Both outbreaks were centered in Brooklyn, specifically the neighborhoods of Bedford-Stuyvesant, Crown Heights and Brownsville. The most recent outbreak affected men who have sex with men (MSM), many of whom were HIV-infected. The outbreak was thought to have been conquered in February 2013 but there have been 4 recent cases in HIV-infected MSM prompting new concerns and efforts to quell the disease. It is not yet known exactly how the disease is moving through the community but there is some evidence to suggest that multiple anonymous sex partners and sharing of drugs is involved.

The response to these outbreaks has been vaccine campaigns. One issue is that the vaccine’s effectiveness in HIV-infected is unknown and two of the recent 4 cases had been vaccinated with the recommended two doses. Still it is better to be vaccinated, as there may be some level of protection and prevention of the most serious outcome. Death.

Another issue is that there is a population of young men who are bisexual or not openly gay who have not gotten the message about vaccine. Many of the recent cases fall into this group. This is where the greater community can help. If you know someone who is at risk for meningococcal disease tell him or her about the vaccine. Urge them to protect themselves. Friends and family want them to stick around, so perhaps they’ll do it for you. One needn’t announce their sexual preferences to receive vaccine. Walgreens/Duane Reade and CVS pharmacies will give the vaccine no questions asked. Check to see that your local pharmacy has it in stock or where the nearest store with the vaccine is located. For those without insurance, you can visit one of the City’s free clinics. The Fort Greene location has Saturday hours. There will be a free vaccine event Sunday (September 7, 2014) at the 3^rd annual Bushwig event. Look for the van near the venue at 389 Melrose Street, Brooklyn.

Lastly, don’t allow fear to paralyze you into inaction.

Ebola won't be a pandemic

Between 2,000 and 5,000 travelers arrive monthly in the New York City metropolitan area from the West African Countries currently struggling to contain the Ebola Virus outbreak. It is highly unlikely though that an individual infected with the virus will arrive here without the medical community knowing about him or her.  Any passenger found to be sick on the flight would be reported to the CDC Quarantine Station by the flight crew and whisked into isolation with full infection control precautions in place. If the illness starts after arrival all emergency departments are prepared to isolate the sick traveler and determine the etiology of the febrile illness. Typhoid fever, cholera and malaria are infinitely more likely than Ebola.

Of the fifty or so people who have arrived in NYC from West Africa sick none have even had an illness worrisome for Ebola let alone the disease. This includes the well-known patient at Mt. Sinai. Should a patient with Ebola arrive in NYC there would still be little reason for the general public to be concerned. The primary transmission risk for Ebola is to health care workers who do not have adequate personal protective equipment and persons handling infected bodies during burial rites. The health care systems in the affected countries are both understaffed and under resourced, a problem not present in NYC (or anywhere in the US for that matter).  NYC has the ability to rapidly test suspect patients, something that isn’t easily done in West Africa. Additionally, Ebola, unlike say measles, isn’t contagious until after symptoms begin, so there is time to implement control measures. Ebola isn’t airborne so to be infected one needs to come in contact with body fluids. The risk of Ebola transmission is low during the beginning of the illness, therefore hospital infection control precautions can be put in place in time and reduce the risk to health care workers. Ebola just isn’t the type of disease to pose a risk to the general US population. It’s not the Andromeda strain.

New Book The Ratcatcher and the Mole is Coming Soon!

Book three in the Mackey Dunn series is the prequel to Mailaise and introduces Mackey as the protagonist. The story is told through the eyes of Will Benes, a CDC pubic health trainee assigned to the woeful River City Department of Health. Will is the literary nephew of Holden Caulfield, and is a few shavings short of a chip off the old block. In Mackey Dunn he finds a kindred spirit and the only person whose misfortunes seem worse than his own.