Saturday, August 2, 2014

Two Ebola Sufferers Coming to Georgia

This is the extent of protection from Ebola that is practiced in many places in Africa at the moment.

              The two surviving medical staff members who are currently afflicted with fulminant Ebola Hemorrhagic Disease deserve the best care we can provide to them.   Both of them risked their own lives to help others who were afflicted.  Dr. Kent Brantly is thirty three years old, a young husband, a physician and a father of small children.  Mrs. Writebol is an accomplished missionary who was working the front lines of the war with Ebola as an hygienist when she was stricken.

                     Today, all the most respectable newspapers are filled with "how Ebola won't spread in the US as it does in Africa."   Let's examine this assertion for a moment.   It is true that much of the continent and countries of Africa are in their absolute infancy in terms of public health and hygiene.  In many nations in Africa, raw sewage flows from residences to the street and townsfolk share whatever organisms, whether hemorrhagic fevers or anything else. The water supply is often tainted with a variety of organisms. You can track heavy rains and sewage leakage to deaths the following week to disease.   Vinyl or latex gloves are in very short supply in most places there. Disposable syringes are uncommon, and some syringes are resanitized before reuse, something that has not occurred here in more than fifty years (and even then, our objective would be sterilization and not sanitization.).  Laundry facilities are limited. The all important handling of dead bodies is shoddy at best.

               In places where loss of life is so common, and life is understood to be short, sexual encounters may occur more readily than in places where we feel we can wait and create relationships in which to frame them.  For this reason, HIV has spread in Africa, like wildfire.  Therefore it is not incorrect to compare the hygiene in many nations in Africa with that of the hygiene of London during the time of the Black Plague.
                 What I do take exception to is the notion that the US could not become a place where Ebola could become an epidemic.  When I was sixteen, working in a nursing home and going to high school as I pondered either becoming a physician or a nurse, I was cleaning the diarrhea stool of patients who ultimately turned out to have Creutzfeldt-Jacob Disease, without latex or vinyl gloves.  Remember that "universal precautions" for all body fluids came into vogue in the US and the world during my nursing career.

  The US did not know everything about the containment of disease then, when it exposed me, and it does not know everything about the potential avenues for spread of Ebola Hemorrhagic Fever now.

                   If patients with Ebola and carriers of Ebola remained bedridden and calm, then we might have an opportunity to better contain this illness.  The fact is that some of the characteristics of a hemorrhagic fever make it tough to contain.

                  A patient with a hemorrhagic fever initially has a sore throat, headaches and muscle aches.  During this time, they likely complete their working tasks and spread the illness to others. They may also continue to have sex and transmit the disorder to another/others.    They are ambulatory.
  Then, they begin vomiting and diarrhea.   Anyone including family members who must attend to these body fluids are at risk for developing the illness.  As the disease progresses, they become decidedly non-ambulatory.  They often become incontinent of diarrhea.   Then the hemorrhagic phase begins where they develop skin lesions which leak serous fluid and blood.  Anywhere they are given an injection may continue to leak serous fluid continuously.  They may also become delerious and potentially combative which may also make body fluids and therefore the contagion difficult to contain.    All of these body fluids, their laundry, or items which have come in contact with these body fluids can transmit Ebola Hemorrhagic Fever to others. Their tears, sputum, and nasal drainage also carries the virus.  There is presently a 50-90% mortality rate for these patients.  There is no effective treatment other than intravenous fluid and electrolyte support, medication for pain and high fever, etc.    (There are experimental treatments being administered to Dr. Brantly and to Mrs. Writebol, but these were not sufficiently advanced enough, even to be tried on the expert Ebola physician who died last week.)  There is no effective vaccine for this disease.    We know that there have been 25 or so incidence of Ebola in various African nations since 1976.  The very high mortality rate has remained consistent, and isolation and quarantine of entire villages has been effective in limiting spread.  We are told, however, that "it is not easy to catch."

                 When I was first  a student nurse, and then later as a new graduate, we were told that "as long as we practiced good technique that we would likely never catch any of communicable diseases our patients in hospital isolation rooms had."      We did shuttle pregnant nurses to other assignments pretty quickly though.  Of course, since my career began, HIV-AIDS was discovered,  Ebola virus only slightly preceded my career, Lyme Disease was described,  and  MRSA of different types developed and was discovered.   Drug resistant tuberculosis has evolved and refined itself.     During my career, I have known a number of physicians and nurses who seroconverted to being HIV positive following a needlestick in the course of their work.   I have known nurses or physicians who developed Hepatitis A through G  (yes, there are that many versions of communicable hepatitis now) in the course of caring for patients, some from needlesticks and some from simply caring for these patients.   I recall a pediatric nurse who died from exposure to a child with a childhood disease.  During a code in an ICU in 1989, while I was pregnant,  I was stuck with an arterial blood gas needle, by a physician.  I spent the next few years having HIV tests.  I fortunately never seroconverted.
          Did all of these health care workers who caught something in the course of their work practice bad technique ?    Certainly not.    The fact is that if each of us worked two or three hour shifts with three patients maximum,  then we could do absolutely everything exactly as taught and with our full attention.  However, nurses in acute care settings  now work routinely  12-14 hour shifts and some physicians work even longer, especially during a patient's acute illness. Patient loads have never been higher and the patients are often a great deal sicker on entry to the hospital than they were in the past.  

            It is therefore my own opinion that gambling with the lives of people in North America with a hemorrhagic fever with a probably 90% mortality rate by bringing two patients to an urban center is unwise.
I say this with the full knowledge of the type of isolation rooms these patients will enter.  A completely independent ventilation system will exist in these rooms, and a specially trained and inserviced nursing and housekeeping staff will be assigned to these patients.   The CDC in Atlanta will oversee this process and will have input with the care and containment of both of these patients.

           I would like to have seen these patients be sent to a more isolated facility in another region of the US or perhaps to an island where the US could set up top isolation hospital facilities and rotate top physicians through them.    Do the people of the United States deserve any less, or has the CDC fallen to the slackers as well as other branches of our federal government ?

           Secondly, we live in a time in which terrorism is rampant throughout the world.  Who is to say that a disgruntled extremist Muslim, for example, won't find a way to steal the contaminated articles thrown out in specially marked trash bags on their way to incineration?   Who says they won't be used to spread Ebola through particularly densely populated areas of the US ?

            In a future post I will discuss the limited options we have as citizens to protect ourselves from this disease, should it escape from the containment created for it in Georgia.

My prior post  on this subject:

Please see my post that follows this one on the topic of Basic Preparedness Should Ebola Escape Containment in the US:


Linda said...

Earlier today, I was going to ask you what actions/precautions you would take if Ebola is found to have escaped the confines of the Atlanta isolation unit. I never thought of equipping an island. Good idea. It could have been ready by the name Dr. Brantly arrived. Yes, the US can do these things quickly if we desire.

Someone said antivirals could help. But, if they do, should they be taken before exposure. No, I am not going to stock up.

JaneofVirginia said...

As late as the 1940s, the US moved patients with communicable diseases such as tuberculosis, leprosy, etc. to geographically isolated locations, which sometimes included fully medically outfitted coastal islands. Then, public health officials got the idea that we could conquer anything, and such facilities fell into disrepair or were razed completely.
I will be making a post such as you have mentioned soon.