Thursday, October 30, 2014

If you can ride a bike - YoU CaN't SpREAd EbOLa!!!!

Since Ebola is only spread very late in the disease, like when you are sick and in the ICU, it goes without saying that Kaci Hickox is no risk to her community. But she looks to be in great shape, so any squirrel in the road better watch out!

Wednesday, October 29, 2014

Ebola - Some Hope for Control in West Africa

Ebola, as we all know, is out of control. As an example, every time I turn on the TV there is Dan or Mike or Dan staring back at me. Eventually, we will calm down in the US and begin to focus our attention on the critical outbreak in West Africa. My prediction is that this will happen sometime soon after November 4th (Election Tuesday). In the meantime, there is some possibly, maybe, hopefully good news out of West Africa in today's NYT. As of a few days ago, fewer than half of the 649 available treatment beds in Liberia were occupied. Of course this could be good or bad, but I'm holding out for good.

There was also some potentially good news in a report published in the Annals yesterday. Dan Yamin et al. analyzed a stochastic model of Ebola transmission populated with parameters from a 2000-2001 Uganda outbreak and the current outbreak in Montserrado County Liberia. The authors used the model to determine the number of secondary cases infected by survivors or non-survivors and also evaluated the effect of isolating/hospitalizing patients. I have included the key figures from the paper below. In Figure 1a, they estimate the Ro stratified by whether the index case was a survivor or non-survivor. For the whole cohort, the Ro was 1.73. However, the difference between non-survivors and survivors is striking. It appears that non-survivors infect four times as many people as survivors (2.36 vs 0.66). This may explain why the two Dallas nurses were infected after being exposed to a non-survivor while no secondary cases have yet occurred in other US hospitals, where everyone else (so far) survived.

Figure 1a
In Figure 1c, the authors provide an estimate of the average number of secondary cases per day of symptomatic disease. You can see that there is very little transmission in the community at day 1 and it remains very low for survivors but jumps up after day 2 for non-survivors. This implies that waiting for symptom development is a scientifically valid strategy for preventing community transmission of Ebola even in Africa. (We expect these numbers to be far lower in the US where our communities are less crowded and we are fortunate to have toilets, indoor plumbing and clean water.)

Figure 1c

Finally, in Figure 2 the authors evaluated at what time point non-survivors (very sick individuals) must be actively isolated to prevent community transmission. They estimate that if 75% of the non-surviving cases are detected and isolated by day 4 this results in a 74% chance of disease elimination and if 100% are detected and isolated by day 4 then there is a 94% chance of disease elimination. Currently, the authors report that the average time from disease onset to hospitalization in Liberia is 5 days, so there is some room for improvement. However, I suspect that the current expanded efforts could achieve 4 days. When I put the results of this Annals paper together with the NY Times report of empty beds, it suggests that there is available capacity to hospitalize and isolate patients within 4 days of symptom onset and it might even suggest that current efforts are already working. I'm certainly hoping this is the case.

Oh, and if isolating patients 4 days after symptom onset works in West Africa, it means WE DON'T NEED TO QUARANTINE ASYMPTOMATIC FOLKS IN THE US. So please stop it...and sorry for shouting.

Guest Post: Ebola and the Reversal of Transmission Dynamics

L. Silvia Munoz-Price, MD PhD
This is a guest post by Dr. Silvia Munoz-Price, Enterprise Epidemiologist at Froedtert & Medical College of Wisconsin Institute for Health and Society/Department of Medicine.

There is an interesting phenomenon occurring during this Ebola outbreak. The relationship between health care workers and personal protective equipment (PPE) has shifted. Let’s state a fact: up until now, most Infection Control providers have permanently struggled to ensure compliance with the use of gowns, gloves, and hand hygiene among healthcare workers. Even though all healthcare workers know these interventions (PPE and hand hygiene) are necessary to prevent transmission of pathogens among patients, healthcare workers persist being non-compliant with these measures. Why do we continue behaving this way? This is probably due to several factors, but one of the most relevant ones might be our inability to pinpoint whose non-compliance end up causing acquisition of hospital pathogens to individual patients. So, when patient X gets Clostridium difficile colitis on day 15 of hospital stay, who among the dozens of providers in contact with patient X caused this transmission? Nobody can tell. The result is a lack of accountability of medical teams.

This topic reminds me of healthcare worker’s attire. We know that white coats are laundered on average every 14 days but scrubs are spontaneously laundered by providers every day. The former is in contact with patients and the latter is in contact with the provider’s skin. Why this difference in laundering frequency? Could it be that we care of our well being much more than what we care of our patients?

Many times I have discussed with hospital leadership about why there is such a difference in compliance with protocols between airplane pilots and healthcare workers. We thought this difference was probably due to the fact that if airplane pilots are not compliant…they die. In comparison, if healthcare workers are not compliant with hand hygiene or PPE usage…nothing happens to them.

Ebola has clarified this point for us. This tiny virus has successfully reversed the transmission dynamic in hospital settings. Now healthcare workers are not the only one spreading disease across the unit …now healthcare workers are actually getting sick if they are not compliant with infection control practice. What is the result? We are frantically re-learning how to cover every inch of our bodies before and after patient contact. That said, I understand that the mortality in West Africa has been very high, which is causing a generalized state of panic, but so far we are observing that patients treated early and adequately seem to do just fine. Compare this with C. difficile colitis among our immunocompromised patients which causes thousands of infections a year. I understand that C. difficile is not in CNN 24/7, and fails to have an exotic name, but it can certainly be as devastating and much harder to treat than Ebola in US healthcare settings. So, let’s reflect on our current state of generalized paranoia. Maybe patients with C. difficile, CRE, MRSA, VRE acquired in the hospital should run the same press campaigns 24/7 clamoring for better compliance with PPEs and hand hygiene among healthcare providers.

So, let’s think again about our behavioral drivers to comply with PPE and hand hygiene…maybe the answer to improved compliance with these interventions is to have a strain of C. difficile that would make healthcare providers sick.

Tuesday, October 28, 2014

We need better PPE

The bloggers have just published a viewpoint in JAMA on the need for better PPE in the era of Ebola. You can read it here.

Photo: John W. Poole, NPR

Monday, October 27, 2014

Bloggers in the News: Quarantine of Uninfected Health Care Workers

Earlier today MSNBC put Dan in the middle, Hollywood Squares style, and asked him very good questions about SHEA's recent press release that supports active monitoring but warns against mandatory quarantine of health care workers. After watching this, my hope is that future discussions are this informative. Great work Dan.


Sunday, October 26, 2014

Postmodern public health

An absurd situation has unfolded in New Jersey, where Kaci Hickox, a nurse who recently returned from Sierra Leone, is being quarantined. While she certainly could be incubating Ebola virus disease given her work with Ebola infected patients, she is asymptomatic, has had two negative Ebola tests, and currently poses no public health risk. To make matters worse, she was escorted to the hospital by a caravan of eight police cars and is being held in a tent (see photo) with no shower or flushable toilet. It is hard to believe that this is happening in the United States in 2014.

It seems that we have entered a new era of postmodern public health. No longer are decisions being made on evidence by experts who understand the epidemiology of infectious diseases, but by politicians who pander to the misinformed for political gain. It's reminiscent of the situation that existed for nearly a decade in South Africa where President Thabo Mbeki denied that HIV was the cause of AIDS, despite all evidence to the contrary.

David Gorski, in his blog Science Based Medicine, writes that from a post-modern viewpoint “scientific medicine is no more valid a construct to describe reality than that of the shaman who invokes incantations and prayers to heal, the homeopath who postulates “healing mechanisms” that blatantly contradict everything we know about multiple areas of science, or reiki practitioners who think they can redirect “life energy” for therapeutic effect. In the postmodernist realm all are equally valid, as there is no solid reason to make distinctions between these competing “narratives” and the “narrative” of scientific or evidence-based medicine."

Returning to reality for a moment, we need to emphasize that mandatory quarantine of healthcare workers from West Africa will not make us safer. In fact, it is highly likely that fewer American healthcare workers will take on the difficult task of treating Ebola in Africa, despite the need for controlling the epidemic there. And without controlling the epidemic at its source, developing countries will continue to be ravaged, and there will continue to be sporadic imported cases in developed countries. Moreover, if one believes that returning healthcare workers should be quarantined, then logic would dictate that healthcare workers who care for Ebola patients in the US should also be quarantined. This will precipitate a crisis since it is highly likely that most healthcare workers would be unwilling to provide care in that situation. And the incredible expense of caring for the Ebola patient in the US would increase greatly.

Kudos to Dr. Anthony Fauci for speaking truth to power today, and to the Society for Healthcare Epidemiology of America for issuing an official statement opposing quarantine of returning healthcare workers.

In an interview several years ago, Stephen Colbert said, "It used to be, everyone was entitled to their own opinion, but not their own facts. But that's not the case anymore. Facts matter not at all. Perception is everything. It's certainty.” And because of that, a few politicians have been able to trump the brightest minds in medicine and public health.

Photo: Kaci Hickox, CNN.

SHEA Supports Evidence-Based Measures to Prevent Ebola Transmission, Opposes Mandatory Quarantine for Healthcare Personnel

FOR IMMEDIATE RELEASE: CONTACT: October 26, 2014 Kristy Weinshel, 703-684-1008

ARLINGTON, Va. (October 27) – The Society for Healthcare Epidemiology of America (SHEA) remains deeply concerned about the Ebola virus disease (EVD) outbreak. The recent news about Dr. Craig Spencer’s infection, along with the infections of the many other healthcare personnel (HCP) who have risked their lives to provide care during this tragic outbreak, illustrates how difficult it is to protect HCP serving patients with severe EVD.

SHEA supports the recent infection prevention guidance issued by the Centers for Disease Control and Prevention (CDC), and the commitment healthcare facilities across the country have made to train and prepare their teams for the care of patients with EVD.  SHEA continues to support the rigorous application of evidence-based measures to prevent EVD transmission. Based upon the strong evidence that Ebola is not transmitted by those who do not have symptoms of EVD, we do not support mandatory quarantine of individuals, including HCP, who have provided care for patients with EVD.  Our concern is about both the ramifications for HCP returning from West Africa and the potential application of this quarantine to all HCP caring for patients with EVD.  SHEA believes that mandatory quarantine will lead to fewer volunteers and increased difficulty in assembling care teams in West Africa and in other countries, including the United States, preparing to care for EVD patients.

SHEA and its membership of infection control and prevention experts support the active monitoring (twice daily, for fever and symptoms of EVD) of all HCP providing care for EVD patients, including returnees from Ebola outbreak areas in West Africa. Mandatory quarantine should only be implemented for those who do not adhere to such monitoring.

SHEA continues to work with the CDC and all relevant stakeholders to ensure the safety of HCP and to promote positive outcomes for those who contract Ebola. 


SHEA is a global professional society representing more than 2,000 physicians and other healthcare professionals with expertise and passion for healthcare epidemiology and infection prevention to improve patient care in all healthcare settings. SHEA's mission is to prevent and control healthcare-associated infections and advance the field of healthcare epidemiology. The society advances its mission through advocacy, science and research, expert guidelines and guidance on key issues, the exchange of knowledge, and high-quality education.  SHEA focuses resources on promoting antimicrobial stewardship, ensuring a safe healthcare environment, encouraging transparency in public reporting related to HAIs, focused efforts on prevention and more. 

Friday, October 24, 2014

Bowling Alone

The big news tonight is that the governators of New York and New Jersey decided to institute quarantine for everyone returning from West Africa after having contact with Ebola patients. This decision was driven by political considerations, including the costs (in time and money) expended due to the decision to do extensive contact tracing around Dr. Craig Spencer’s movements in New York City since 7 am on Tuesday, October 21.

Nothing that has happened during this tragic Ebola epidemic has called into question this simple fact: Ebola is not transmitted in the absence of symptoms. Nor is it transmitted to casual or household contacts during early infection. Consider Mr. Duncan, sent home from the hospital with fever, spending the early days of his Ebola illness with almost 20 close contacts (mostly family members), until he was finally taken back to the hospital after vomiting “wildly” in an apartment complex parking lot. Let’s count the community and family transmission events: ……..ZERO. 

Careful monitoring of symptoms and signs (fever) is sufficient for early detection of symptomatic Ebola infection and prevention of community transmission. Movement restrictions, including strict home quarantine, provide no additional benefit. The adverse consequences of misguided quarantine of caregivers are clear, however: fewer providers willing to assist in the outbreak area, and fewer providers willing to volunteer to join Ebola care teams in US hospitals, complicating preparedness efforts. If Ebola providers returning from West Africa are quarantined, how can we not also quarantine US healthcare workers who provide care for Ebola patients? How will such providers commute to work, if they depend upon public transportation? Conversely, how will we convince anyone to participate in care, if they cannot return home to family for the duration of caregiving (+ 21 days)?

Don’t take it from me, though. Listen instead to an infectious diseases doc who’s been fighting the outbreak in Sierra Leone:
Dan Kelly, 33, an infectious disease doctor and a founder of Wellbody Alliance, a nonprofit organization working in Sierra Leone, criticized the governors’ response as knee-jerk. 
“I think we are just digging the grave deeper,” he said in a telephone interview from Freetown, the capital. “Come on, that’s exactly the move to push people away from going to Sierra Leone and other affected areas. It’s going to escalate the epidemic and not help solve the crisis."
He added: “If we’re going to get in front of it, we need health care workers from abroad. They cannot feel shunned or discriminated against.”

Thursday, October 23, 2014


The news tonight about Dr. Craig Spencer, an MSF volunteer who recently returned from caring for Ebola patients in Guinea, is sobering for several reasons. There are many details to come, but I thought I’d post a few quick initial thoughts (or reminders) about how this tragic development should, or shouldn’t, change the way we think about the Ebola virus outbreak:

This outbreak is occurring in West Africa. Not in the US. West Africa. The level of hysteria in the US is directly proportional to the number of Ebola patients on US soil, but we should never forget, even for a minute, that the outbreak continues to rage in Liberia, Sierra Leone, and Guinea (where Dr. Spencer acquired the infection). This widely cited Lancet modeling study suggests that 2-8 Ebola infected individuals will board planes monthly during their incubation period. Thus the best way to combat Ebola in the US is to mobilize resources for West Africa.

In the US, those at risk for Ebola are healthcare workers who have cared for Ebola patients (whether here or in West Africa). Not mall-goers, bowlers, subway riders, or those who might have been in an airport terminal on the same day as an asymptomatic Ebola patient. The greatest transmission risk is borne by those who provide direct care for Ebola patients during severe illness, when viral shedding is very high. 

There may be no way to reduce Ebola transmission risk to zero in healthcare settings, given the current state of Personal Protective Equipment technology. Dr. Spencer reported no breaches in the MSF protocols, which are widely recognized as the most stringent (and effective) in use. Healthcare workers have always accepted some risk in provision of healthcare, and Ebola reminds us that the risks can be grave, and that healthcare workers willing to bear these risks are heroic.

This case may make it far more difficult to assemble care teams for suspected or confirmed Ebola patients. Not just because we have yet to determine how Nina Pham, Amber Vinson, Craig Spencer, and several other caregivers were infected, but because this case could result in more stringent protocols regarding self-monitoring and movement restriction (quarantine) for those willing to care for Ebola patients. Healthcare workers who learn they may be required to restrict their movement during the entire time they care for patients (and 21 days thereafter) may be less likely to step forward. 

All eyes now will be on Bellevue. If Dr. Spencer receives all of his care at Bellevue rather than being transferred to one of our four federally-funded and designated biocontainment facilities, the hypothesis that any well-prepared hospital can safely care for an Ebola patient will again be tested.

Photo credits: Facebook; Bryan Smith