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

Mycobacterium chelonae outbreak

A cluster of infections due to Mycobacterium chelonae have been diagnosed in individuals who patronized the same upstate NY tattoo parlor. The outbreak was traced to a bottle of pre-mixed ink and the FDA is issuing a recall. 

For information on tattoos and mycobacteria infections see:

http://findarticles.com/p/articles/mi_hb4393/is_1_42/ai_n56785728/

and

http://www.ncbi.nlm.nih.gov/pubmed/19733936

Crack the case- Salmonella Heidelberg and chicken livers

Last week the news covered a story of chicken livers contaminated with Salmonella Heidelberg. They were labeled as “ready-to-eat” but the livers had been braised such that from the outside they looked cooked but the insides were coolly raw. The outbreak had been going on in New York and New Jersey for two months and we were approaching fifty cases without a solid lead when two public health students, working as interns in our office, cracked the case. Interviewing cases is not a glamorous task, in fact it is downright monotonous. We employ a 17-page shotgun questionnaire to the approximate 1000 annual cases of Salmonella that occur in NYC annually in order to elicit suspect food items. To accomplish this task we have a team of MPH students dial the cases and beg their indulgence as we plunge into the twenty-minute interview. The students make the calls one aisle over from my cubicle, so I overhear them as they repeat the same questions to every case. Questions like “have you any eaten any stuffed, frozen chicken products, such as chicken Kiev or chicken Cordon Bleu?” So when two students, classmates and friends, shared the uncommon mention of chicken liver we had a new lead. Chicken and eggs are of course standard questions but we don’t usually ask about individual chicken parts, such as hearts and livers. The next day a third person mentioned chopped liver. We dispatched a food inspector to the store to retrieve the chicken livers. At the city’s Public Health Lab they were able to grow the same Salmonella species (serotype Heidelberg) from the cooked chicken livers. A week later the molecular results came back, a perfect match to the strain causing the outbreak. The chicken livers were recalled and outbreak was stopped.  Two new disease detectives earned their badges.

For more information:

http://www.nyc.gov/html/doh/html/pr2011/pr028-11.shtml

http://www.foodsafetynews.com/2011/11/cdc-157-salmonella-chicken-liver-cases-in-ny-nj/

http://www.cdc.gov/salmonella/heidelberg-chickenlivers/111011/index.html