Is the Ebola Quarantine Period of 21 Days Too Short? Dr. Oz Weighs In With New Research

"We have only sixty days to contain this epidemic or we face an unprecedented situation for which we have no plan" - World Health Organization

Dallas County Court Judge Clay Jenkins boldly asserted yesterday that the dozens released from quarantine in Dallas over the weekend posed "absolutely no risk" to the community. All of them had contact at some point with Thomas Eric Duncan, "Patient Zero", in the recent Ebola incident at Texas Health Presbyterian Hospital.

The problem is that this may not be accurate, given viruses change - in potency, as well as mortality rate and incubation period. This point was brought up two days ago by Fordham  Infectious Disease specialist Alexander van Tulleken, in a live interview with Dr. Mehmet Oz - on his Monday show. In his preface to the interview, Oz noted the "magic number being 21 days" for being safe,  but in the last week new research has emerged to controvert that. In other words, 21 days may not be a long enough period for those who've been exposed to the virus and they should be quarantined longer.

Dr. van Tulleken pointed out that we were "originally getting our ideas of what the incubation period should be from research done in the 1970s".  But recently a researcher, Dr. Charles Haas-  from Drexel University - has reviewed all the data from recent epidemics and found the actual incubation period is longer - with an average incubation period of 12 days (not 8 or 10) and the maximum being up to 30 days. So "if we want to catch everyone we need to probably extend it to thirty -one days" according to Dr. van Tulleken.

Thus, to have erred on the side of actual safety the Texas individuals should have been quarantined at least another ten days. The chance they may spread the disease to others while being infectious is admittedly small (about 12.5% of exposed persons are symptomatic after 21 days) but it is assuredly not "zero".  Thus, new cases could pop up in Big D and we shouldn't be surprised if that occurs and is traced to those released prematurely - based on this new research.

When asked about the WHO statement (top of post) van Tulleken observed that the response for stopping Ebola in West Africa is totally "inadequate" and he remains convinced this is the number one threat to global health at the moment - all the soothesayers babble to the contrary.

Oz then went on to give one of his trademark demonstrations to show why too many are not being serious enough (or humble enough) about Ebola.  He used a wall graphic depicting the spread of the virus in a body from 12 days after incubation -when symptoms begin- and also a 3D model of fluid expulsion and waste contamination. The first few days are when the virus just begins accompanied by a slight fever (e.g. 99.5- 100.4F) and muscle aches and pains. The problem with these symptoms is that most of us won't be able to tell the difference between what is happening and the flu. Thus, the Ebola virus is hiding in plain sight based on flu-like symptoms and causing too many to dismiss it as "just the flu" - meantime the virus is slowing down the body's immune response.

By day 6 or day 7 after the initial symptoms the virus is "exploding" in the organs: By a week out, blood pressure is dramatically dropping while there is highly infectious projectile vomiting, explosive bloody diarrhea and profuse bleeding from body cavities.

Oz observes that while a projectile bloody sneeze, for example, can travel far in the air (say from a passenger on a plane) that is not the primary fear, because it doesn't linger there. You'd have to have the sneeze droplets shot directly onto you.  It is thus "a weakling in the air".

The problems arise when the virus begins to overwhelm the immune system and the projectile vomit-diarrhea phase is underway.  Then, if the virus-laden fluids are ejected or expelled onto a surface - it can remain there "for up to three weeks" - according to Oz. In effect, it affects not only the nurses, doctors taking care of the patients, but also the janitor who has to clean the floors where the patient had problems. Even gloves may be inadequate because in pulling them off with even a couple drops of waste and getting it on the skin "could pose a major problem"

The huge issue then emerges as the VOLUME of this waste expelled and which then contaminates an area. Since each Ebola patient will generate 55 gallons of toxic waste PER DAY by the time of the immune system breakdown and fluid expulsion - that means any hospital purporting to treat Ebola patients must be prepared to deal with it. For example, if they take in two patients they will need to know how to eliminate up to 770 gallons of highly infectious waste each week. Where do they put it? They can't put it in regular trash. (For reference, one hundred and forty 55 gallon tanks of material were removed from Thomas Eric Duncan's apartment in Dallas, as noted yesterday morning on CBS News Early Show. This was incinerated at a facility in Galveston, Texas).

It must either be incinerated using specially designed medical incineration units, or it must be sterilized in an autoclave (which few hospitals have because they can't afford them). The medical waste incinerators are also rare - given many states have outlawed them on account of pollution. To make matters worse, neighboring states with specialized incinerators have refused to accept the waste from  other states.

As Sen. Barbara Boxer has aptly put it: "Storage, transportation and disposal of the waste will be a major problem".

She was referring to the two formidable aspects of the Ebola waste problem: 1) the highly contagious nature of the waste generated, and 2) the sheer volume of it.  Hardly any U.S. hospitals are prepared to cope with this no matter what they say, or the CDC says. They are, in fact, under-trained to the task and under-funded (no thanks to many state budget cuts) so have less than adequate resources.

Oz' other guest, Darriah Gillespie, M.D.,  pointed out that Emory "trained for years" before the first Ebola patients ever arrived. They made sure they already had state of the art isolation wards, the right sterilizing equipment and positive pressure suits and knew how to use them - especially in the arduous decontamination procedure. Only four special centers in the U.S. have such wherewithal, so let's not kid ourselves.

 This is why I totally agree with Mehmet Oz' recommendations for being proactive in view of the risks. These include:

- Four specialized hospitals and 11 beds is not enough if there is an Ebola outbreak of large magnitude so regional centers must be found - this means all funding taken away in earlier budget cuts must be reinstated.

- Training can't be done in a day or an hour. Weeks of training are needed - as Dr. Oz noted- merely to get "gowned up" for a regular hospital procedure. Ebola may require even more and can't be done "on the fly" (which likely happened in Dallas)

- As it is the focus of infections is to ensure only that doctors don't infect patients, not the reverse (more likely in the case of Ebola) so many more resources need to be provided which currently aren't there. "Providers should be protected with every resource possible" in the words of Darriah Gillespie.

- While no airport procedure will definitely,  100 percent stop an Ebola -infected person from coming to the U.S. and a total travel ban may not be practical (they can slip over into Mali, and obtain travel from there etc.)  we can still (Oz recommendation) limit the visas of those from the affected nations - especially Liberia - who want to come here to visit.

His reason is sound: Because these "put us at risk", while health care workers "have to be able to get in there."

This seems to me a balanced solution, midway between a total travel ban and simply allowing any and all non-essential travel from the hot zone. Given the obvious difficulty associated with hospital capacity to deal with a significant Ebola outbreak - including management and disposal of the infectious waste  - it is better to have a plan in place apart from simply checking people for fevers at selected airports.

Let me make it abundantly clear here, that I am not trying to spread "Ebola fear" or "Fear-bola" as some liberal websites have called it. I am not part of the whacky Right's memetic entourage, i.e. i using this in the mid-terms or against Obama. BUT... I do believe our officials aren't leveling with us or doing enough, and though the confirmed cases (3)  of the disease are so far rare- we need to be more proactive as Oz has said. If we want to quell the fear and panic then the gov't needs to be proactive and first show it's competent to deal with the crisis as it exists now - and that means adequately funding our gutted health care -medical system. Or let me put it this way, putting back in place the funding already cut. Until that happens, and our hospitals undergo specialized training to deal with this disease, fear and hysteria will reign. It is a natural outcome, flowing from the lack of political will to do anything substantive to show we can handle the worst IF it arrives!

See also:
http://www.smirkingchimp.com/thread/ted-rall/59328/the-governments-ebola-cover-up-never-let-you-see-them-sweat

and

http://www.denverpost.com/News/Local/ci_26755507/Ebola-is-one-of-many-lethal-infections-threatening-US-hospitals

Bringing Ebola Patients To The U.S.- Not A Very Good Idea!

Researcher working with Ebola using a BSL-4 positive pressure suit

"The road to hell is paved with good intentions"- John Ray, 1670

Murphy's Laws:

1)  "If anything can go wrong it will"

2)  "If there is a possibility of several things going wrong, the one that will cause the most damage will be the one to go wrong"

3) "If anything just cannot go wrong, it will anyway."

4) "If you perceive that there are four possible ways in which something can go wrong, and circumvent these, then a fifth way, unprepared for, will promptly develop"

5)  "If everything seems to be going well, you have obviously overlooked something."

6) "Mother nature is a bitch". (Addendum: "And not an obedient one at that")


At this stage, with one of the Samaritan Purse workers (Dr. Kent Brantly) infected with Ebola en route to the U.S. and Emory University Medical Center's Isolation Ward in Atlanta, one must wonder about the wisdom of the move - as well as that of the 2nd worker (Nancy Writebol), also being flown in via medevac in the subsequent flight.

In general, it is not a good practice to transfer patients infected with one of the most lethal viruses on the planet into a non-infected nation. This is different, materially and substantively, from keeping the virus in a Level 4 containment lab in one of the most secure places on Earth (ok, at least we thought so until cardboard boxes containing Variola (smallpox), Anthrax and a lethal Bird flu were discovered).  In the case of the latter, the actual contact with the virus can at least be controlled - and more importantly  - the risks of contamination don't extend to having to add many more protocols to confine the spread of the contaminated fluids spewed out of actual bodies. Workers need only control their contact with the actual isolated virus and not with the infectious diarrhea, vomit, sweat or blood spewed out.

Hence, there is much greater probability of things going wrong when stringent added protocols are incorporated -  to protect against Ebola-laden fluids - and there is, literally, no margin for error.  Murphy's Laws, which many take only in a facetious or non-serious vein, are actually apropos here. They really do provide a mental caution against adopting hubris or projecting human arrogance, especially the ever present human failing embodied in the misplaced belief that all their systems are "perfect" and "nothing can go wrong."  ("We have it all under control." - perhaps the sorriest words ever written or said.)

Actually, many things can. The transport to Emory itself means a 20 mile trip along a highway to get to the Emory center. Though a police escort is to be provided, the possibility of some kind of accident still exists. But we can concede this is relatively low.

Move now to the Emory Isolation ward itself which will keep each patient separate from the rest of the hospital and with an air-filtered space to boot. Two specially trained nurses will tend to each patient and 4 infectious disease specialist doctors. However, there is no indication whatsoever that any of these Emory people have had previous experience in handling Ebola patients. That implies they will not be as careful as say, a 'Doctors without Borders' specialist in Sierra Leone, who knows every single pitfall and goes the extra mile to avoid human error.

Again, these specialists won't be working with the virus per se but rather treating two symptomatic patients expelling contaminated body products. We can expect as the two patients are attended to, they will still be in the phase of vomiting, diarrhea as well as hemorrhagic release from multiple orifices, so that the slightest drop of any fluid on a pressure suit or even its duct tape will be an alert or alarm point. How will the nurses, doctors deal with it? How intensely will they clean themselves after being in contact with the patients? How sure are they that there are no minute holes in their suits? How will any contaminated clothing, bedding be handled? Even if the doctors themselves work on the patients from outside using robotic type devices, someone will have to go in, collect the fouled bedding, clothing and dispose of it.

It is in the handling and disposal of those contaminants that the real risk inheres and Murphys' laws come to the fore.  While it is true Ebola is "not contagious like the flu" (so far as we know) it is still quite capable of penetrating medical barriers erected against it, as Dr. Brantly found out. Hence, one must exercise constant and meticulous care if error is to be avoided. It only takes one misstep!

This is especially important given we live in a country which already sees something like 98,000 deaths by medical accident or  hospital infection each year. In the case of the latter, most of those deaths  - say from c. diff. or MRSA - could have been easily prevented if proper disinfectant techniques had been observed. But they weren't.

 Many people forget that, especially those who demand we show "compassion" to the two aid workers. (Forgetting that the needs of the few or the one do not exceed the needs of the many.) Well, we do, but also suggest that reasonable compassion can't mean putting many thousands or millions at possible risk, or compassion at any price.

Maybe the Emory specialists and CDC honchos are correct that there's nothing at all to worry about and nothing will go wrong. But having seen a number of Murphy's laws in action in other settings I am not so sure. I definitely lack the hubris or overt self -assurance detected in the words I've beheld uttered by one of the Emory docs who will be treating the patients. ("We know what we have to do and we're confident!")

We've been given all the reasons this move is a great idea, including that the patients can now receive the best of care (of which I have no doubt) and also the protocols are in place to ensure maximum safety (of which I am unsure). We also have been told the protocols in Africa are too difficult to follow because of the lack of supplies, etc. However, I dispute that given the disease has been in the spotlight and studied since 1976, and some of the best specialists have been there to treat and tend to the disease in its actual environs. They have also flown in all the equipment they might need, to specific locations. Yes, the Emory site does afford some extra advantages (more easily controlled temperature environment, more backups) but again, are the risks worth it?

Only time will tell, and if one of Murphy's laws is violated and an outbreak of Ebola occurs in Atlanta, we have to hope it is expeditiously contained and doesn't spread. Bill Maher, as on Real Time last night, may mock "morons" for expressing their fears about the situation and its potential unraveling - but alas, those fears aren't warrantless, they're quite real.  Alas, the real morons will be those who proclaim- in the aftermath of other possible cases in the area weeks later:   "We never knew it could happen!  We thought we'd done everything humanly possible to prevent it!"  

Read each of Murphy's laws again, then think about them. Carefully! Especially the last, recognizing that already in Africa , Ebola is manifesting 'Mother Nature's' fury at its most extreme and is spinning out of control - exceeding all medical efforts to contain it. Then ask if it is truly a good idea, irrespective of any "humanitarian" aspirations, to have brought it to our shores. 

Will our good intentions possibly have visited "hell" upon us? We will see.