Protecting America from Ebola


Some options for protecting America from arrival of Ebola,
moving from the least drastic to the most drastic action:

  1. No screening.
    Do nothing special,
    relying on screening of departing passengers in African airports
    and the public health system in the U.S.
    to treat such cases as may arrive.
    This was the approach of the Obama administration until Monday, October 6,
    when Obama announced that screenings of incoming passengers
    would begin at five airports in the near future.
  2. Screening for symptoms.
    Screen arriving passengers,
    but only for the external signs that suggest the person has Ebola.
    This is the approach of the Obama administration
    starting soon after Monday, 2014-10-06.
  3. Testing for the virus.
    Test all arriving travelers from the Ebola area for Ebola.
    Let them continue on their way while their tests are being evaluated,
    but have them provide contact information
    so they can be contacted if the tests show they have it.
    That would enable persons who test positive for the virus,
    but are not yet showing symptoms,
    to be isolated before they begin to potentially transmit the disease.
  4. Quarantine travelers until their status is confirmed.
    Quarantine all travelers from the Ebola area until the first of:
    a) a test for Ebola shows they definitely do not have it, or
    b) sufficient time passes (currently around 21 days)
    to show they do not have it.
    I have discussed this option in detail on a separate web pagee.
  5. Non-essential travel ban.
    Only allow incoming passengers from the Ebola area
    who are necessary for fighting the outbreak over there.
  6. Total travel ban.
    Ban all arrivals from the Ebola area.

Testing for Ebola

As of 2014-10-12, a CDC web page contained the following:

Diagnosing Ebola in an person who has been infected for only a few days is difficult, because the early symptoms, such as fever, are nonspecific to Ebola infection and are seen often in patients with more commonly occurring diseases, such as malaria and typhoid fever.

However, if a person has the early symptoms of Ebola and has had contact with the blood or body fluids of a person sick with Ebola, contact with objects that have been contaminated with the blood or body fluids of a person sick with Ebola, or contact with infected animals, they should be isolated and public health professionals notified.
Samples from the patient can then be collected and tested to confirm infection.

[My thought: Why not do this testing on
all persons arriving in America from the Ebola zone?]

Miscellaneous Articles

Ebola screening for some at Dulles detailed
By Lori Aratani
Washington Post 2014-10-15

C.D.C. Issues New Guidelines for Ebola Care
by Donald G. McNeil, Jr.
New York Times, 2014-10-21

[Oddly, this significant article,
which appeared on page A14 of the Washington and New York print editions,
does not seem to be at the nytimes.com web site
as of 2014-10-22 1830EDT]

Federal officials announced new guidelines on Monday evening for the protection of hospital workers caring for patients infected with Ebola -- guidelines that might have prevented the infection of two nurses had they been in place a month ago.

The new guidelines, from the Centers for Disease Control and Prevention, follow broad revisions announced just last week. The new recommendations provide considerably more detail, however, and have been reviewed by specialists at American hospitals that have successfully cared for Ebola patients.

The procedures are based on the very strict protocols used for years by Doctors Without Borders, Dr. Thomas R. Frieden, the C.D.C.'s executive director, said during an unusual late-evening telephone news conference. That organization also reviewed the new guidelines, he said.

They are voluntary, not required by law.

Among other changes, the guidelines say that no skin should be left uncovered; that street clothes and shoes should be replaced with waterproof fabric and boots; and that every step of putting on and taking off equipment must be done under the eyes of a supervisor whose job is to prevent mistakes.

The revamped guidelines, posted on the C.D.C. website, represent the agency's recognition that Ebola victims require precautions quite different from those for patients with airborne diseases like SARS, MERS, avian flu or tuberculosis.

Ebola patients have never been proven to infect others by coughing or sneezing, but they emit copious amounts of highly infectious vomit, blood and diarrhea, so it is crucial that not even a speck of it get into a medical worker's eyes, mouth, nose or cuts.

The most difficult and dangerous part of the process, experts agree, is removing safety gear when its surfaces are covered with infectious particles.

There are some differences between the new guidelines, intended for American hospitals, and those of Doctors Without Borders, which tends Ebola patients in makeshift field hospitals in Africa, some of which are tents built on open ground.

For example, Dr. Frieden said, in Africa it is possible to disinfect workers with a sprayed chlorine solution as they stand in a gravel pit. But that would create slippery puddles in hospital corridors, so the guidelines now recommend bleach wipes.

Since the nurses at Texas Health Presbyterian Hospital were infected after treating a man who died of Ebola, there has been a great deal of finger-pointing.

Dr. Frieden had said some hospital staff members had not followed protocols. The nurses' union replied that the hospital had no protocols, had given no training, and had forced staff to work in gear that left skin exposed.

Hospital officials said they had followed C.D.C. protocols, but those turned out to be inadequate and outdated, designed to prevent routine infections and airborne diseases. For example, under them, workers could wear only one set of gloves, leave their heads and necks uncovered, and wear street clothes and shoes that could become soaked with lethal fluids.

Last week, the C.D.C. issued a preliminary one-page summary of changes it recommended; they included waterproof head-to-toe garments and supervised removal of gear. Agency officials said they would announce the details soon -- which they did Monday evening.

Over this past weekend, as hospitals waited, Dr. Anthony Fauci, the director of the National Institute for Allergy and Infectious Diseases, appeared on several TV news shows to discuss the administration's Ebola response, which included the appointment of an "Ebola czar."

Dr. Fauci has been on television hundreds of times since the 1980s, when he became the face of the government's response to the AIDS epidemic, and it appeared that the administration was tentatively using him as its top medical spokesman in Dr. Frieden's place.

Dr. Frieden has been heavily criticized in public and in Congress for saying that virtually any American hospital could handle an Ebola patient.

In fact, his answers to this question had been more nuanced, explaining that any hospital with a properly trained staff could treat patients without needing isolation rooms with negative pressure airlocks and other gear that make them resemble a space station more than a field hospital.

In answer to questions over the weekend from news anchors, Dr. Fauci said the C.D.C.'s old guidelines had been based on those issued by the World Health Organization and were meant for use "in the field, in the bush" rather than in a modern hospital.

In fact, W.H.O. guidelines are far more strict, although not quite as rigorous as those of Doctors Without Borders. The W.H.O. guidelines do mandate supervised gear removal, rubber aprons and boots, extra gloves and other steps.

In an interview on Monday, Dr. Fauci said that personal protective gear was not his specialty, and that he had been told by C.D.C. officials that their old guidelines were based on the W.H.O.'s.

Some critics claimed that his remark that W.H.O. guidelines were suitable "in the bush" implied that he felt African nurses needed less protection than American ones, because they were somehow expendable.

That was not remotely his intent, Dr. Fauci said. He said he meant that the desperate measures that advanced hospitals have tried on Ebola patients -- such as dialysis, intubation, arterial puncture and rectal drainage tubes -- can produce gushes of dangerous fluids while nurses are close and vulnerable.

Doctors Without Borders protocols do call for doing as few risky procedures as possible, including even drawing blood as seldom as is medically necessary.

The case for suspending U.S. visas in Ebola-affected countries
By Michael Chertoff
Washington Post Op-Ed, 2014-10-26

Michael Chertoff was secretary of homeland security from 2005 to 2009 and is co-founder and executive chairman of the Chertoff Group, a security and risk-management firm.

As alarm mounts over the spread of Ebola,
many are concerned that
screening travelers who arrive in the United States from West Africa
is not sufficiently protective
because it will not identify those who carry the virus
but are not yet symptomatic.
Yet over the past two weeks,
the Obama administration and supportive experts
saturated the media with the argument that
any comprehensive travel restrictions aimed at Ebola-infested regions
would be pointless and even counterproductive.

No doubt the experts who reject travel bans
understand disease and epidemiology.
But their arguments demonstrate less understanding of
how we manage risk in the context of border and travel security.
In fact,
restriction of U.S. travel visas
for residents of Liberia, Guinea and Sierra Leone —
the three countries in which Ebola is out of control —
could reduce the risk of significant disease import into the United States
without hampering efforts to assist those nations in combating the illness.

During my time as U.S. homeland security secretary,
we planned extensively for the possibility of a global pandemic —
specifically, mutated avian influenza.
If that virus had achieved efficient human-to-human transmission,
it would have rapidly globalized,
and closing borders would have had little lasting impact.
Simply put, it is difficult to shut out the entire world.

But Ebola is not a highly efficient contagion.
For months, the vast majority of cases have been concentrated in
Liberia, Guinea and Sierra Leone.
There, the disease is still uncontrolled
due to inadequate medical infrastructure
and family-oriented medical and burial customs.
As demonstrated by the tragic case of Thomas Eric Duncan,
the Liberian man who died of Ebola in Dallas,
there is a real risk that people who
come into contact with a contagious individual in these countries
could bring the disease to the United States.

Unlike in a global pandemic,
it is possible to reduce the risk of Ebola importation
by suspending all but essential travel to the United States
from just those three nations.
The government simply has to suspend travel visas
for citizens and residents of those nations.

Contrary to administration warnings, this does not mean
impeding the travel of essential medical personnel to the region
to help stamp out the epidemic at its source.
Trained medical and other aid experts should be supported in going to West Africa,
but as the lesson of New York doctor Craig Spencer makes clear,
they need to be more closely monitored in country and upon their return.
In particular, they should be restricted in returning to medical or other work
involving close physical contact with others in the United States
until they are cleared of any risk of infection.


Equally misguided is the contention by Thomas Frieden,
head of the Centers for Disease Control and Prevention,
that a visa suspension would drive affected travelers underground,
leading them to sneak into the United States
unscreened and unmonitored.
Whether a Liberian flies to Europe
or drives across Africa to an airport in an unaffected country,
he or she would still have to present a Liberian passport
to board a plane to the United States.
At that point, a visa suspension would result in a denial of boarding.

Nor is it realistic to fear that
our hypothetical traveler would sneak across our land borders.
First, we can and should
coordinate a visa suspension with Canada and Mexico.
Second, smugglers are unlikely to welcome migrants
who may be physically unfit to make an arduous trip
while posing a threat to the safety of the smugglers themselves.

To be sure, it is possible to conjure scenarios in which
foreign citizens denied visas forge passports from other nations.
But in the wake of the 9/11 attacks,
we and other countries substantially upgraded anti-counterfeiting protections
that can be easily adapted to detect those who seek to evade travel restrictions.

Of course, the visa suspension I suggest would not guarantee that
no Ebola sufferer would enter the United States.
But health officials, of all people,
should not argue that protective measures are unwarranted
unless they are 100 percent effective.
Public health professionals continually urge us to eat right,
get checkups and engage in other preventive behavior to reduce illness rates,
even if those rates cannot be driven to zero.
Travel restrictions
that reduce the number of Thomas Duncans traveling to the United States
are the kind of prudent risk management
that health experts applaud in other contexts.

I don’t doubt the sincerity of health officials who assure us that
we will not likely see a major Ebola outbreak in the United States.
[A key word there is "likely".
There are numerous plausible scenarios under which
just that is possible.
Specifically, what if a large number of Ebola-infected travelers enter the U.S.
before they begin showing sysmptoms?
I.e., dozens or scores of Thomas Duncans?
I can see nothing that has been done, as of 2014-11-01, to rule out that possibility.
Further, consider the argument that
people infected with Ebola but not yet showing symptoms
cannot transmit the virus.
Even if that is totally true,
what about the possibility that
the first symptom exhibited
is vomiting Ebola-carrying vomit over their companions,
or over a public carriage?]

But after the mishandling of the few cases we have had —
including allowing an infected nurse to travel by air —
we are close to a crisis of confidence.
A few more bungles and we will see significant numbers of people
canceling trips, closing schools and staying home from work.
The essence of effective public crisis management is
bold and aggressive action demonstrating that leaders are in control of events,
not reacting in a halting and belated fashion.
Targeted visa suspension is one of several steps urgently needed.

Labels: , , ,