Thomas Eric Duncan
Here is a calender of the final days of Thomas Eric Duncan,
starting on September 15, 2014 and continuing into October,
with key dates in red:
September 15: Duncan hand carries Marthalene Williams in Monrovia, Liberia
September 16: Marthalene Williams dies of Ebola in Monrovia
September 19: Duncan leaves Liberia
September 20: Duncan arrives in the U.S., is "welcomed" with a cookout attended by 20 people
September 24: Duncan begins experiencing symptoms
September 25: Duncan enters Texas Health Presbyterian Hospital Dallas, complaining of fever, headache and abdominal pain, but not diarrhea or vomiting
September 26: Duncan released from hospital, without diagnosis of Ebola
September 28: Duncan begins vomiting and returns to hospital
September 30: Texas state health lab confirms that Duncan has Ebola
October 8: Duncan dies
October 10: Amber Joy Vinson, a Dallas nurse who cared for Duncan, flies to Cleveland, Ohio
October 11: Nina Pham, another Dallas nurse who cared for Duncan, tests positive for Ebola
October 13: Amber Vinson flies back to Dallas
October 15: Amber Vinson tests positive for Ebola
October 24: Nina Pham released from NIH, declared free from Ebola
November 7: Texas Health Department declares end of need for monitoring in Dallas
CDC vows: ‘We’re stopping it in its tracks’
By Mark Berman, J. Freedom du Lac, Elahe Izadi and Brady Dennis
Washington Post, 2014-09-30
Months after the deadliest Ebola outbreak in history began ravaging West African countries, a man who flew from Liberia to Dallas became the first case of Ebola to be diagnosed in the United States.
Health officials stressed that they are confident they can control this situation and keep the virus from spreading in the U.S.
"We're stopping it in its tracks in this country,"
Thomas Frieden, director of the Centers for Disease Control and Prevention,
declared during a news conference Tuesday afternoon.
The man who is infected, who was not identified, left Liberia on Sept. 19 and arrived in the U.S. the following day to visit family members.
Health officials are working to identify everyone who may have been exposed to this man.
Frieden said this covered just a "handful" of people,
a group that will be watched for three weeks
to see if any symptoms emerge.
...
Still, the fact that the disease has been confirmed on American soil immediately sparked fears in the U.S., turning a public health crisis from a faraway news story to something that makes people reach for Purell and facemasks. But experts said it was impossible to imagine that Ebola, which a CDC estimate projects could infect up to half a million people by January, would remain completely outside the country's borders.
“It was inevitable once the outbreak exploded,”
said Thomas Geisbert,
a professor at the University of Texas Medical Branch at Galveston,
who has researched the Ebola virus for decades.
“Unless you were going to shut down to shut down airports
and keep people from leaving [West Africa],
it’s hard to stop somebody from getting on a plane.”
[Right you are.
But there is another alternative:
making sure arrivals from the affected regions are Ebola-free
before they begin mingling with the general American population.
There are at least two ways of doing that:
1. Use (and if necessary, develop as a crash program) an effective, cost-effective test
for whether a person has the Ebola virus, even if they are not yet showing symptoms.
2. Until such a test becomes available,
simply quarantine arrivals from Africa for 21 days, until the incubation period is up.
Finally, if necessary American could survive quite well, I believe,
without new arrivals from the affected regions
other than those necessary for fighting the epidemic.]
But Geisbert quickly underscored how unlikely the virus is to spread in the United States. For starters, he said, officials placed the sick man in quarantine quickly in order to isolate him from potentially infecting others. In addition, health workers are already contacting and monitoring any other people he might have had contact with in recent days.
Two Dallas Fire-Rescue paramedics and one paramedic intern are being monitored for Ebola symptoms after transporting the patient to the hospital. The three EMS workers will remain at home for 21 days, Dallas Fire-Rescue Lt. Joel Lavender said Tuesday night. Their ambulance was decontaminated after they transported the patient, Lavender said.
“The system that was put in place worked the way it was supposed to work,” Geisbert said.
That doesn't guarantee that no one else will get infected, because the sick person could have transmitted the disease to someone else before being isolated. But that approach almost certainly ensures that the United States will quickly contain the disease.
The deadliest Ebola outbreak in history is centered in the West African countries of Liberia, Sierra Leone and Guinea, though there is a separate outbreak in Congo. Unlike in West Africa, where the affected countries have fragile or barely existent health care systems, where people are being turned away from treatment centers, where family members are caring directly with those sick and dying from Ebola, the U.S. is far more equipped to isolate anyone with the virus and provide the highest level of care.
For months, the CDC has been conducting briefings for hospitals and clinicians about the proper protocol for diagnosing patients suspected of having the virus, as well as the kinds of infection control measures to manage hospitalized patients known or suspected of having the disease. Many procedures involve the same types of infection control that major hospitals are already supposed to have in place.
Early recognition is a critical element of infection control. Symptoms include fever greater than 101.5 degrees Fahrenheit, severe headache, muscle pain, vomiting, diarrhea and contact within 21 days before onset of symptoms with the blood or other bodily fluids or human remains of someone known or suspected of having the disease or travel to an area where transmission is active.
The CDC also has scheduled more training for U.S. workers who either plan on volunteering in West Africa or want to be prepared in the event that cases surface at their own hospitals.
President Obama spoke with Frieden on Tuesday afternoon regarding the way the patient is being isolated and the efforts to scour the man's contacts to seek out any potential other cases, the White House said.
Frieden said during the news conference that the man who is infected did not develop symptoms until about four days after arriving in the country. This man sought medical treatment on Friday, two days after symptoms developed, but was evaluated and released. He was admitted to the hospital on Sunday before being placed into isolation. Frieden, who would not say if the man was a U.S. citizen, said the man is not believed to have been working as part of the response to the Ebola outbreak.
David Lakey, head of the Texas Department of Health Services, said the state's laboratory in Austin, Tex., received a blood sample from the patient on Tuesday morning and confirmed the presence of Ebola several hours later. This laboratory was certified to do Ebola testing last month.
Liberian Officials Identify Ebola Victim in Texas as Thomas Eric Duncan
By NORIMITSU ONISHI
New York Times, 2014-10-02
MONROVIA, Liberia —
A man who flew to Dallas and was later found to have the Ebola virus
was identified by senior Liberian government officials on Wednesday
as Thomas Eric Duncan,
a resident of Monrovia in his mid-40s.
Mr. Duncan, the first person to develop symptoms outside Africa
during the current epidemic,
had direct contact with a woman stricken by Ebola on Sept. 15,
just four days before he left Liberia for the United States,
the woman’s parents and Mr. Duncan’s neighbors said.
In a pattern often seen here in Monrovia, the Liberian capital,
“He was holding her by the legs,
the pa was holding her arms and Sonny Boy was holding her back,”
said Arren Seyou, 31, who witnessed the scene
and occupies the room next to Mr. Duncan’s.
Sonny Boy, 21, also started getting sick about a week ago,
his family said,
around the same time that Mr. Duncan first started showing symptoms.
In a sign of how furiously the disease can spread, an ambulance had come to their house on Wednesday to pick up Sonny Boy. Another ambulance picked up a woman and her daughter from the same area, and a team of body collectors came to retrieve the body of yet another woman — all four appeared to have been infected in a chain reaction started by Marthalene Williams.
A few minutes after the ambulance left, the parents got a call telling them that Sonny Boy had died on the way to the hospital.
Mr. Duncan had lived in the neighborhood, called 72nd SKD Boulevard, for the past two years, living by himself in a small room that he rented from the Williams couple. He had told that them and his neighbors that his son lived in the United States, played baseball, and was trying to get him to come to America.
For the past year, Mr. Duncan had worked as a driver at Safeway Cargo, the Liberian customs clearance agent for FedEx, said Henry Brunson, the company’s manager. In a statement, FedEx said that Mr. Duncan was employed as a personal driver for the company’s general manager, not to work for FedEx’s global operations.
In an office with a large FedEx sign outside the building in downtown Monrovia, Mr. Brunson said that Mr. Duncan quit abruptly on Sept. 4, giving no reason. But Mr. Brunson said he knew that Mr. Duncan had family members in the United States as well.
“His sister came from the United States and he asked for a day off so that he could go meet her at the Mamba Point Hotel,” Mr. Brunson said, mentioning a hotel popular among foreigners. “He quit a few weeks after that.”
The way Mr. Duncan appears to have been infected with the Ebola virus is typical in Monrovia, where the epidemic is spreading rapidly and most people are dying at home because of a lack of ambulances and Ebola treatment centers. At home, they spread the virus to family and friends who are taking care of them.
Ms. Williams’s family said they had no choice but to take her back home after being turned away from John F. Kennedy Memorial Hospital, first at its maternity ward and then at its Ebola center. While she was sick at home, she appeared to have also infected a neighbor, Sarah Smith, whose corpse was picked up Wednesday.
Neighbors said that an ailing Ms. Williams used to visit Ms. Smith, who lived in a pink house next door. After Ms. Smith fell ill, a friend of hers living nearby started coming over to take care of her. That friend, Marie Wread, did chores for Ms. Smith, including washing her clothes.
On Wednesday, a visibly ill Ms. Wread was taken by ambulance to a hospital; her daughter, Mercy, 9, joined her in the ambulance, though she was not showing symptoms herself. Other neighbors, fearful of the growing contagion in their neighborhood, had insisted angrily that Mercy be taken away.
While Ms. Williams appears to have been the first patient in her area of the neighborhood, members of a local volunteer Ebola task force say they believe that the virus was brought in by an outsider. Ms. Williams rarely left home because of her pregnancy, they said. But a cousin who came to visit Ms. Williams later died of Ebola after apparently being infected by her mother, who is now in a Ebola treatment center, members of the task force said.
“That’s how Ebola came here,” said Mark Kpoto, 21, a task force member.
By MANNY FERNANDEZ and NORIMITSU ONISHI
New York Times, 2014-10-02
[This is a mash-up of the above article about what happened in Monrovia
with reporting by Manny Fernandez about the scene in Dallas.]
By Lindsey Bever
Washington Post, 2014-10-02
The Dallas hospital that failed to admit a man who later tested positive for Ebola said Thursday night that a nurse had noted his recent trip from Africa. But because of an electronic records “flaw,” his travel history wasn’t seen by the physician who released him. As a result, as many as 100 people may have come into contact with the Liberian man, who is the first person to be diagnosed with Ebola in the United States.
Thomas Eric Duncan was released from Texas Health Presbyterian Hospital Dallas on Sept. 26 after showing early symptoms of Ebola — fever, stomach pain and a sharp headache. Two days later, he was diagnosed with the disease and placed in isolation.
The handling of Duncan — from Liberia to the U.S. — has raised questions about the world’s general preparedness for coping with the epidemic beyond its epicenter in West Africa.
A more complete picture of Duncan’s recent travels was emerging Thursday night, though it’s still unclear exactly why he got on an airplane bound for the United States.
Back in Liberia, Duncan had been in direct contact with an Ebola-stricken neighbor, according to the Associated Press. He reportedly rushed to the 19-year-old woman’s aid when she began convulsing and rode with her in a taxi to a nearby hospital, where she later died. Everyone in the village assumed her illness was related to her pregnancy. But she turned out to have Ebola.
It’s not clear whether Duncan knew she had the virus when he decided to leave Liberia.
In an airport screening questionnaire, he said he had not come into contact with an Ebola patient. And before leaving the country, he had his temperature checked at the airport in Monrovia — and he did not have a fever.
...
[A] researcher with the Center for Immigration Studies in Washington said
Duncan shouldn’t have been issued a visitor’s visa in the first place.
“If you look at his circumstances,
it should have been really tough for him to qualify for a visa,”
Jessica Vaughn said, explaining that
Duncan was reportedly single, jobless, living away from his home country
and had a number of relatives in the U.S. —
all factors that often indicate
a person is unlikely to return home after their visa expires.
“He clearly appears unqualified.”
Duncan showed up at Texas Health Presbyterian Hospital Dallas the night of Sept. 25 with a temperature of 100.1 degrees, abdominal pain that had persisted for two days, decreased urination and a headache, according to the hospital. Though the symptoms can be early warning signs of Ebola, they are not specific to the disease and can be associated with other illnesses.
Duncan denied any nausea, vomiting or diarrhea — other symptoms consistent with the virus. He also told a nurse that he had not been around anyone who had been ill.
When hospital staff asked him whether he had traveled outside the United States in the past several weeks, he said he had been in Africa. A nurse entered that information into the hospital’s electronic medical record system but apparently did not take any further action.
Thursday night, the hospital said it released him because “separate physician and nursing workflows” kept physicians from seeing his travel history, which would have shown his recent presence in Liberia and possibly triggered extra scrutiny. The statement said that the “documentation of the travel history was located in the nursing workflow portion” of the electronic health records and “would not automatically appear in the physician’s standard workflow.”
So physicians never weighed in on his release.
Two days after he was sent home, witnesses said, he was seen vomiting on the ground outside an apartment complex as he was put into an ambulance.
“His whole family was screaming. He got outside and he was throwing up all over the place,” resident Mesud Osmanovic, 21, told Reuters on Wednesday.
By Associated Press
Washington Post, 2014-10-04
DALLAS — His week began thousands of miles away with a frantic bid to save a life.
It was Monday, Sept. 15, and Ebola, a terrifying disease, was ravaging West Africa, filling morgues and hospitals to capacity. In Monrovia, Liberia, the virus was about to claim one more person.
Marthalene Williams, seven months pregnant, had been diagnosed with low blood pressure when she was brought to a clinic, desperately ill.
Soon after coming home, she began convulsing. Thomas Eric Duncan, assisted by her family and others, lifted his neighbor into a taxi that rushed to a hospital maternity ward, where she was turned away. The 19-year-old woman returned to her house, where she died hours later.
That Friday, Sept. 19, Duncan arrived at Roberts International Airport in the capital of Monrovia.
He was about to embark on a three-leg journey, traveling from Africa, through Europe and into the United States. He would travel more than 8,000 miles before arriving at Dallas/Fort Worth International Airport in the early evening of Sept. 20.
His temperature, taken before he boarded the plane in Monrovia as part of precautionary government measures, had been below normal. But when he walked out into the steamy Texas night, he carried with him one of the deadliest diseases known to medicine.
Ten days later, he’d become the first person diagnosed in America with Ebola.
...
At the [Monrovia] airport, nurses wearing white lab coats, face masks and gloves take the temperatures of departing passengers. There are giant dispensers with chlorinated water and buckets for hand-washing.
When Duncan arrived Sept. 19, his temperature was taken and recorded on a passenger screening form. It was 97.3.
Citing the Ebola outbreak, the form notes: “We need your help to prevent the spread of this disease.”
...
He also was asked if he’d taken care of an Ebola patient or touched the body of anyone who’d died in an Ebola-stricken area in the last 21 days — the incubation period. He answered “no” to both questions as well.
It’s unclear if Duncan knew he may have been exposed to Ebola when he boarded his plane. While he had close contact days before with the pregnant woman, who neighbors now believe died from Ebola, she was never tested. It was initially suspected she had died of complications from her pregnancy.
This past week, however, Liberian authorities announced plans to prosecute Duncan when he returns, accusing him of lying on the questionnaire.
Once in Dallas, Duncan settled in at the Ivy apartment complex in the northeast part of the city, which is home to thousands of immigrants, many of them poor. This melting pot where dozens of languages are spoken is less than a five-minute drive from some of the toniest sections of Dallas.
Duncan was staying in a second-floor apartment with Louise Troh, her 13-year-old son, Duncan’s distant cousin and a family friend.
On Sept. 25, Duncan was feeling sick enough that he went to the emergency room at Texas Health Presbyterian Hospital. He was reported to have a fever, headache and abdominal pain, but no diarrhea or vomiting. The hospital said he told them he’d recently arrived from West Africa, but that he denied having been around anyone sick. He was released.
By Sunday morning, Duncan’s condition had worsened.
...
By MATTHEW L. WALD and JAD MOUAWAD
New York Times, 2014-10-02
As he was preparing to leave Liberia for Dallas two weeks ago, Thomas E. Duncan, the man confirmed to be the first Ebola case in the United States, was checked at the airport for signs of the disease. He was determined to have no fever and allowed to board his flight, American officials say.
Since the deadly Ebola virus began spreading rapidly through West Africa, the Centers for Disease Control and Prevention has been pushing the authorities in the worst-hit countries, including Liberia, Sierra Leone and Guinea, to implement just that type of screening for departing passengers.
In early August, the C.D.C. sent medical workers to the region to train local government officials and airport workers in Ebola screening, according to Dr. Nicole Cohen, an infectious disease specialist with the agency’s Division of Migration and Quarantine. As part of that process, the agency advises that airport workers ask travelers if they have been exposed to Ebola in the last 21 days, have had a fever, and have had any symptoms including severe headache, muscle ache, abdominal pain, unusual bruising or bleeding, vomiting and diarrhea. The screener is expected to use a hand-held non-contact temperature monitor, a few inches from the travelers’ forehead, to check for fever.
But the system has its limits, relying on the traveler to reveal whether he or she has been exposed. And it leaves it to local officials to conduct the screening as they see fit, Dr. Cohen said. It is unclear how consistently or effectively those screenings are conducted across West Africa, and Dr. Cohen said she did not know how many potential travelers had been caught by screeners — if any.
“Our expectation is that people who are sick or people who are exposed
should be getting the message
they shouldn’t be traveling.”
[How nice.
Just rely on the honor system to keep Ebola out of America.
I wonder if these potential Ebola carriers were traveling to, say, Israel
whether Dr. Cohen would have the same attitude.]
...
four have been quarantined
by Mark Berman
Washington Post, 2014-10-02
Public health officials in Texas said Thursday that as many as 100 people may have had contact with the Liberian man diagnosed with Ebola. Four of these people, at least some of whom are believed to be family members of the man, have been ordered to remain at home in an attempt to prevent the spread of the disease.
Still, authorities continued to stress that only Thomas Eric Duncan, who is the first person diagnosed with Ebola in the United States, had exhibited any Ebola symptoms.
...
extra cautions, hope and prayer
By Amy Ellis Nutt
Washington Post, 2014-10-02
DALLAS — Thomas Duncan shivered in the king-size bed, even though he was tucked under the covers and fully dressed — pants, socks and two shirts. It was Sunday morning, Sept. 28, and Duncan, from Liberia, had been in the United States visiting Louise Troh at her Dallas apartment for the past week. He felt weak and cold, he told Troh’s daughter, Youngor Jallah.
So Jallah took a quick trip to Wal-Mart and bought a $50 brown cotton blanket. When she returned, she draped it over Duncan’s shoulders and then gently lifted him by his back to try to get him to drink some hot tea. That’s when she looked into his eyes and knew in her heart that things were very bad.
“I’ve been seeing Ebola on TV, how it starts, with muscle pain, red eyes. When I see his eye, it is all red, and I think maybe this time it is Ebola virus and I should be careful,” Jallah, 35, said in an interview with The Washington Post at her nearby apartment, where she and her family have been quarantined.
She took his temperature — 102 degrees.
“I’m going to call an ambulance,” she said.
Duncan tried to resist. He had been to the hospital once already, several days earlier, and all they had done was send him home with antibiotics. Jallah didn’t listen to him. She dialed 911.
“My daddy is going to the bathroom constantly,” she told the operator, referring to Duncan, whom she considers her stepfather.
Fifteen minutes later, two paramedics knocked on the door. Jallah greeted the two men but told them that they couldn’t enter until they put on gloves and facemasks.
“He just come from Liberia,” she explained. “For safety, don’t touch anything. Viruses.”
She didn’t use the word Ebola, she said, because she didn’t know whether it was the lethal virus. All she knew was that Duncan was very ill and that Liberia was being devastated by the hemorrhagic fever. The paramedics asked Duncan to walk to the ambulance, which he did, but they would not let Jallah give him the blanket.
By Editorial Board
Washington Post Editorial, 2014-10-04
[Well, yeah.
Who could disagree with that?
But mistakes are inevitable.
We all know, or should know,
that both hospitals and doctors have a history of making errors.
They're human, after all.
To say "Missteps ... can't be repeated"
seems hardly different from King Canute's command to the tides.
The only ways to prevent Ebola from spreading in America
are either a flat travel ban or, my favorite proposal,
quarantining arrivals from the affected regions
until their Ebola incubation period is up.]
[1]
IN THE MIDDLE of a disease outbreak, panic and fear can themselves be a destructive force. When the Ebola virus first broke out in West Africa, governments dropped the ball and were unable to contain the dread, leading people to take action — such as evading quarantine — that spread the infections. A core requirement of managing a crisis like this is that public health officials and political leaders maintain the public’s confidence.
[No mention of the body-washing funeral practices of many in West Africa.
Too touchy a topic to mention?]
[2]
This premise applies just as well to the United States as it does to Africa, and in recent days, a significant misstep in Dallas has shaken that confidence.
[3]
A man from Liberia, Thomas Duncan,
had contact with a pregnant woman there who was infected,
although he may not have known that when he carried her to a hospital.
[If Duncan knew that
Williams had been "turned away from a hospital
for lack of space in its Ebola treatment ward",
how could he not have known Williams had Ebola?]
She later died.
He did not show symptoms immediately, and went to the airport, where he signed a screening form saying he had not had contact with anyone with Ebola, and flew to the United States. Once in Dallas, Mr. Duncan began to feel ill and went to the emergency room at Texas Health Presbyterian Hospital. While there, he came in contact with other people who were healthy. He was released by the hospital, which concluded he had only a low-grade fever from a viral infection. The hospital apparently did not connect the dots of his illness and his recent travel from Liberia, one of the nations most seriously hit by the recent outbreak. Mr. Duncan then returned to the hospital when his symptoms worsened and officials confirmed he was infected with the Ebola virus.
[4]
The misstep was the failure in the Dallas emergency room to realize that he was a potential Ebola victim, allowing him, at least theoretically, to come in contact with others present and after he was released. The virus does not transmit through the air, only through bodily fluids, and is not contagious if the person is not symptomatic, as was the case while Mr. Duncan was flying to the United States. But on his first visit to the emergency room, he was showing symptoms and should have been immediately isolated and tested. The key to fighting Ebola — for which there are no readily-available vaccines or therapeutics — is identifying those infected, isolating them and tracing those they have been in contact with. This kind of vigilance was not on display in the hospital emergency room.
[5]
Screening airline passengers is certainly useful, but it is not foolproof, since Ebola doesn’t always show symptoms right away. This is unlike influenza, which is more readily detectable. A screening form did not stop Mr. Duncan from boarding a plane to the United States.
[So quarantine possible Ebola carriers for the Ebola incubation period,
after which positive knowledge about whether they had/have Ebola
will be available.]
[6]
Ebola presents a frightening challenge from nature, but it can be stopped. The United States enjoys one of the most advanced and robust health-care systems in the world, capable of isolating Ebola patients when they arrive and halting transmission. But it is going to require zero tolerance for oversights like that which appears to have occurred in Dallas. Other U.S. hospitals — including those in the Washington area evaluating possible Ebola cases — must take a lesson.
By JEFFREY WEISS
Dallas News, 2014-11-07 (Friday)
Official Dallas heaved a public sigh of relief Friday, marking the last day when anybody local would be screened for Ebola symptoms.
...
For North Texas, however, the spotlight was finally off. All total,
177 people had been monitored for the disease
after possibly coming into contact with one of three Dallas patients.
None contracted Ebola.
The Texas health department signaled the all-clear
with a tweet early Friday evening:
“It’s official.
This evening’s final monitoring check is done.
No symptoms.
We are happy to close this Ebola chapter with Dallas tonight.”
...
starting on September 15, 2014 and continuing into October,
with key dates in red:
| S | M | T | W | T | F | S |
|---|---|---|---|---|---|---|
| 15 | 16 | 17 | 18 | 19 | 20 | |
| 21 | 22 | 23 | 24 | 25 | 26 | 27 |
| 28 | 29 | 30 | 1 | 2 | 3 | 4 |
| 5 | 6 | 7 | 8 | 10 | 11 | |
| 13 | 15 | |||||
| 24 | ||||||
| 7 |
September 16: Marthalene Williams dies of Ebola in Monrovia
September 19: Duncan leaves Liberia
September 20: Duncan arrives in the U.S., is "welcomed" with a cookout attended by 20 people
September 24: Duncan begins experiencing symptoms
September 25: Duncan enters Texas Health Presbyterian Hospital Dallas, complaining of fever, headache and abdominal pain, but not diarrhea or vomiting
September 26: Duncan released from hospital, without diagnosis of Ebola
September 28: Duncan begins vomiting and returns to hospital
September 30: Texas state health lab confirms that Duncan has Ebola
October 8: Duncan dies
October 10: Amber Joy Vinson, a Dallas nurse who cared for Duncan, flies to Cleveland, Ohio
October 11: Nina Pham, another Dallas nurse who cared for Duncan, tests positive for Ebola
October 13: Amber Vinson flies back to Dallas
October 15: Amber Vinson tests positive for Ebola
October 24: Nina Pham released from NIH, declared free from Ebola
November 7: Texas Health Department declares end of need for monitoring in Dallas
Miscellaneous articles about Thomas Eric Duncan:
2014-09-30-WP-cdc-confirms-first-case-of-ebola-in-the-u-s
As Ebola confirmed in U.S.,CDC vows: ‘We’re stopping it in its tracks’
By Mark Berman, J. Freedom du Lac, Elahe Izadi and Brady Dennis
Washington Post, 2014-09-30
Months after the deadliest Ebola outbreak in history began ravaging West African countries, a man who flew from Liberia to Dallas became the first case of Ebola to be diagnosed in the United States.
Health officials stressed that they are confident they can control this situation and keep the virus from spreading in the U.S.
"We're stopping it in its tracks in this country,"
Thomas Frieden, director of the Centers for Disease Control and Prevention,
declared during a news conference Tuesday afternoon.
The man who is infected, who was not identified, left Liberia on Sept. 19 and arrived in the U.S. the following day to visit family members.
Health officials are working to identify everyone who may have been exposed to this man.
Frieden said this covered just a "handful" of people,
a group that will be watched for three weeks
to see if any symptoms emerge.
...
Still, the fact that the disease has been confirmed on American soil immediately sparked fears in the U.S., turning a public health crisis from a faraway news story to something that makes people reach for Purell and facemasks. But experts said it was impossible to imagine that Ebola, which a CDC estimate projects could infect up to half a million people by January, would remain completely outside the country's borders.
“It was inevitable once the outbreak exploded,”
said Thomas Geisbert,
a professor at the University of Texas Medical Branch at Galveston,
who has researched the Ebola virus for decades.
“Unless you were going to shut down to shut down airports
and keep people from leaving [West Africa],
it’s hard to stop somebody from getting on a plane.”
[Right you are.
But there is another alternative:
making sure arrivals from the affected regions are Ebola-free
before they begin mingling with the general American population.
There are at least two ways of doing that:
1. Use (and if necessary, develop as a crash program) an effective, cost-effective test
for whether a person has the Ebola virus, even if they are not yet showing symptoms.
2. Until such a test becomes available,
simply quarantine arrivals from Africa for 21 days, until the incubation period is up.
Finally, if necessary American could survive quite well, I believe,
without new arrivals from the affected regions
other than those necessary for fighting the epidemic.]
But Geisbert quickly underscored how unlikely the virus is to spread in the United States. For starters, he said, officials placed the sick man in quarantine quickly in order to isolate him from potentially infecting others. In addition, health workers are already contacting and monitoring any other people he might have had contact with in recent days.
Two Dallas Fire-Rescue paramedics and one paramedic intern are being monitored for Ebola symptoms after transporting the patient to the hospital. The three EMS workers will remain at home for 21 days, Dallas Fire-Rescue Lt. Joel Lavender said Tuesday night. Their ambulance was decontaminated after they transported the patient, Lavender said.
“The system that was put in place worked the way it was supposed to work,” Geisbert said.
That doesn't guarantee that no one else will get infected, because the sick person could have transmitted the disease to someone else before being isolated. But that approach almost certainly ensures that the United States will quickly contain the disease.
The deadliest Ebola outbreak in history is centered in the West African countries of Liberia, Sierra Leone and Guinea, though there is a separate outbreak in Congo. Unlike in West Africa, where the affected countries have fragile or barely existent health care systems, where people are being turned away from treatment centers, where family members are caring directly with those sick and dying from Ebola, the U.S. is far more equipped to isolate anyone with the virus and provide the highest level of care.
For months, the CDC has been conducting briefings for hospitals and clinicians about the proper protocol for diagnosing patients suspected of having the virus, as well as the kinds of infection control measures to manage hospitalized patients known or suspected of having the disease. Many procedures involve the same types of infection control that major hospitals are already supposed to have in place.
Early recognition is a critical element of infection control. Symptoms include fever greater than 101.5 degrees Fahrenheit, severe headache, muscle pain, vomiting, diarrhea and contact within 21 days before onset of symptoms with the blood or other bodily fluids or human remains of someone known or suspected of having the disease or travel to an area where transmission is active.
The CDC also has scheduled more training for U.S. workers who either plan on volunteering in West Africa or want to be prepared in the event that cases surface at their own hospitals.
President Obama spoke with Frieden on Tuesday afternoon regarding the way the patient is being isolated and the efforts to scour the man's contacts to seek out any potential other cases, the White House said.
Frieden said during the news conference that the man who is infected did not develop symptoms until about four days after arriving in the country. This man sought medical treatment on Friday, two days after symptoms developed, but was evaluated and released. He was admitted to the hospital on Sunday before being placed into isolation. Frieden, who would not say if the man was a U.S. citizen, said the man is not believed to have been working as part of the response to the Ebola outbreak.
David Lakey, head of the Texas Department of Health Services, said the state's laboratory in Austin, Tex., received a blood sample from the patient on Tuesday morning and confirmed the presence of Ebola several hours later. This laboratory was certified to do Ebola testing last month.
2014-10-02-NYT-ebola-victim-texas-thomas-eric-duncan
U.S. Patient Aided Pregnant Liberian, Then Took IllLiberian Officials Identify Ebola Victim in Texas as Thomas Eric Duncan
By NORIMITSU ONISHI
New York Times, 2014-10-02
MONROVIA, Liberia —
A man who flew to Dallas and was later found to have the Ebola virus
was identified by senior Liberian government officials on Wednesday
as Thomas Eric Duncan,
a resident of Monrovia in his mid-40s.
Mr. Duncan, the first person to develop symptoms outside Africa
during the current epidemic,
had direct contact with a woman stricken by Ebola on Sept. 15,
just four days before he left Liberia for the United States,
the woman’s parents and Mr. Duncan’s neighbors said.
In a pattern often seen here in Monrovia, the Liberian capital,
the family of the woman, Marthalene Williams, 19,
took her by taxi to a hospital with Mr. Duncan’s help on Sept. 15
after failing to get an ambulance,
said her parents, Emmanuel and Amie Williams.
She was convulsing and seven months pregnant, they said.
Turned away from a hospital
for lack of space in its Ebola treatment ward,
the family said it took Ms. Williams back home in the evening,
and that she died hours later, around 3 a.m.
Mr. Duncan, who was a family friend
and also a tenant in a house owned by the Williams family,
rode in the taxi in the front passenger seat
while Ms. Williams, her father and her brother, Sonny Boy,
shared the back seat, her parents said.
Mr. Duncan then helped carry Ms. Williams,
who was no longer able to walk,
back to the family home that evening, neighbors said.
“He was holding her by the legs,
the pa was holding her arms and Sonny Boy was holding her back,”
said Arren Seyou, 31, who witnessed the scene
and occupies the room next to Mr. Duncan’s.
Sonny Boy, 21, also started getting sick about a week ago,
his family said,
around the same time that Mr. Duncan first started showing symptoms.
In a sign of how furiously the disease can spread, an ambulance had come to their house on Wednesday to pick up Sonny Boy. Another ambulance picked up a woman and her daughter from the same area, and a team of body collectors came to retrieve the body of yet another woman — all four appeared to have been infected in a chain reaction started by Marthalene Williams.
A few minutes after the ambulance left, the parents got a call telling them that Sonny Boy had died on the way to the hospital.
Mr. Duncan had lived in the neighborhood, called 72nd SKD Boulevard, for the past two years, living by himself in a small room that he rented from the Williams couple. He had told that them and his neighbors that his son lived in the United States, played baseball, and was trying to get him to come to America.
For the past year, Mr. Duncan had worked as a driver at Safeway Cargo, the Liberian customs clearance agent for FedEx, said Henry Brunson, the company’s manager. In a statement, FedEx said that Mr. Duncan was employed as a personal driver for the company’s general manager, not to work for FedEx’s global operations.
In an office with a large FedEx sign outside the building in downtown Monrovia, Mr. Brunson said that Mr. Duncan quit abruptly on Sept. 4, giving no reason. But Mr. Brunson said he knew that Mr. Duncan had family members in the United States as well.
“His sister came from the United States and he asked for a day off so that he could go meet her at the Mamba Point Hotel,” Mr. Brunson said, mentioning a hotel popular among foreigners. “He quit a few weeks after that.”
The way Mr. Duncan appears to have been infected with the Ebola virus is typical in Monrovia, where the epidemic is spreading rapidly and most people are dying at home because of a lack of ambulances and Ebola treatment centers. At home, they spread the virus to family and friends who are taking care of them.
Ms. Williams’s family said they had no choice but to take her back home after being turned away from John F. Kennedy Memorial Hospital, first at its maternity ward and then at its Ebola center. While she was sick at home, she appeared to have also infected a neighbor, Sarah Smith, whose corpse was picked up Wednesday.
Neighbors said that an ailing Ms. Williams used to visit Ms. Smith, who lived in a pink house next door. After Ms. Smith fell ill, a friend of hers living nearby started coming over to take care of her. That friend, Marie Wread, did chores for Ms. Smith, including washing her clothes.
On Wednesday, a visibly ill Ms. Wread was taken by ambulance to a hospital; her daughter, Mercy, 9, joined her in the ambulance, though she was not showing symptoms herself. Other neighbors, fearful of the growing contagion in their neighborhood, had insisted angrily that Mercy be taken away.
While Ms. Williams appears to have been the first patient in her area of the neighborhood, members of a local volunteer Ebola task force say they believe that the virus was brought in by an outsider. Ms. Williams rarely left home because of her pregnancy, they said. But a cousin who came to visit Ms. Williams later died of Ebola after apparently being infected by her mother, who is now in a Ebola treatment center, members of the task force said.
“That’s how Ebola came here,” said Mark Kpoto, 21, a task force member.
2014-10-02-NYT-after-ebola-case-in-dallas-health-officials-seek-those-who-had-contact-with-patient
U.S. Patient Aided Ebola Victim in LiberiaBy MANNY FERNANDEZ and NORIMITSU ONISHI
New York Times, 2014-10-02
[This is a mash-up of the above article about what happened in Monrovia
with reporting by Manny Fernandez about the scene in Dallas.]
2014-10-02-WP-dallas-hospital-blames-flaw-in-electronic-record-keeping-system-for-release-of-ebola-patient
Dallas hospital blames ‘flaw’ in ‘workflow’ for release of Ebola patient as a more complete picture of his travels emergesBy Lindsey Bever
Washington Post, 2014-10-02
The Dallas hospital that failed to admit a man who later tested positive for Ebola said Thursday night that a nurse had noted his recent trip from Africa. But because of an electronic records “flaw,” his travel history wasn’t seen by the physician who released him. As a result, as many as 100 people may have come into contact with the Liberian man, who is the first person to be diagnosed with Ebola in the United States.
Thomas Eric Duncan was released from Texas Health Presbyterian Hospital Dallas on Sept. 26 after showing early symptoms of Ebola — fever, stomach pain and a sharp headache. Two days later, he was diagnosed with the disease and placed in isolation.
The handling of Duncan — from Liberia to the U.S. — has raised questions about the world’s general preparedness for coping with the epidemic beyond its epicenter in West Africa.
A more complete picture of Duncan’s recent travels was emerging Thursday night, though it’s still unclear exactly why he got on an airplane bound for the United States.
Back in Liberia, Duncan had been in direct contact with an Ebola-stricken neighbor, according to the Associated Press. He reportedly rushed to the 19-year-old woman’s aid when she began convulsing and rode with her in a taxi to a nearby hospital, where she later died. Everyone in the village assumed her illness was related to her pregnancy. But she turned out to have Ebola.
It’s not clear whether Duncan knew she had the virus when he decided to leave Liberia.
In an airport screening questionnaire, he said he had not come into contact with an Ebola patient. And before leaving the country, he had his temperature checked at the airport in Monrovia — and he did not have a fever.
...
[A] researcher with the Center for Immigration Studies in Washington said
Duncan shouldn’t have been issued a visitor’s visa in the first place.
“If you look at his circumstances,
it should have been really tough for him to qualify for a visa,”
Jessica Vaughn said, explaining that
Duncan was reportedly single, jobless, living away from his home country
and had a number of relatives in the U.S. —
all factors that often indicate
a person is unlikely to return home after their visa expires.
“He clearly appears unqualified.”
Duncan showed up at Texas Health Presbyterian Hospital Dallas the night of Sept. 25 with a temperature of 100.1 degrees, abdominal pain that had persisted for two days, decreased urination and a headache, according to the hospital. Though the symptoms can be early warning signs of Ebola, they are not specific to the disease and can be associated with other illnesses.
Duncan denied any nausea, vomiting or diarrhea — other symptoms consistent with the virus. He also told a nurse that he had not been around anyone who had been ill.
When hospital staff asked him whether he had traveled outside the United States in the past several weeks, he said he had been in Africa. A nurse entered that information into the hospital’s electronic medical record system but apparently did not take any further action.
Thursday night, the hospital said it released him because “separate physician and nursing workflows” kept physicians from seeing his travel history, which would have shown his recent presence in Liberia and possibly triggered extra scrutiny. The statement said that the “documentation of the travel history was located in the nursing workflow portion” of the electronic health records and “would not automatically appear in the physician’s standard workflow.”
So physicians never weighed in on his release.
Two days after he was sent home, witnesses said, he was seen vomiting on the ground outside an apartment complex as he was put into an ambulance.
“His whole family was screaming. He got outside and he was throwing up all over the place,” resident Mesud Osmanovic, 21, told Reuters on Wednesday.
2014-10-04-WP-across-3-continents-ebola-makes-it-way-to-america
Across 3 continents, Ebola makes its way to USBy Associated Press
Washington Post, 2014-10-04
DALLAS — His week began thousands of miles away with a frantic bid to save a life.
It was Monday, Sept. 15, and Ebola, a terrifying disease, was ravaging West Africa, filling morgues and hospitals to capacity. In Monrovia, Liberia, the virus was about to claim one more person.
Marthalene Williams, seven months pregnant, had been diagnosed with low blood pressure when she was brought to a clinic, desperately ill.
Soon after coming home, she began convulsing. Thomas Eric Duncan, assisted by her family and others, lifted his neighbor into a taxi that rushed to a hospital maternity ward, where she was turned away. The 19-year-old woman returned to her house, where she died hours later.
That Friday, Sept. 19, Duncan arrived at Roberts International Airport in the capital of Monrovia.
He was about to embark on a three-leg journey, traveling from Africa, through Europe and into the United States. He would travel more than 8,000 miles before arriving at Dallas/Fort Worth International Airport in the early evening of Sept. 20.
His temperature, taken before he boarded the plane in Monrovia as part of precautionary government measures, had been below normal. But when he walked out into the steamy Texas night, he carried with him one of the deadliest diseases known to medicine.
Ten days later, he’d become the first person diagnosed in America with Ebola.
...
At the [Monrovia] airport, nurses wearing white lab coats, face masks and gloves take the temperatures of departing passengers. There are giant dispensers with chlorinated water and buckets for hand-washing.
When Duncan arrived Sept. 19, his temperature was taken and recorded on a passenger screening form. It was 97.3.
Citing the Ebola outbreak, the form notes: “We need your help to prevent the spread of this disease.”
...
He also was asked if he’d taken care of an Ebola patient or touched the body of anyone who’d died in an Ebola-stricken area in the last 21 days — the incubation period. He answered “no” to both questions as well.
It’s unclear if Duncan knew he may have been exposed to Ebola when he boarded his plane. While he had close contact days before with the pregnant woman, who neighbors now believe died from Ebola, she was never tested. It was initially suspected she had died of complications from her pregnancy.
This past week, however, Liberian authorities announced plans to prosecute Duncan when he returns, accusing him of lying on the questionnaire.
Once in Dallas, Duncan settled in at the Ivy apartment complex in the northeast part of the city, which is home to thousands of immigrants, many of them poor. This melting pot where dozens of languages are spoken is less than a five-minute drive from some of the toniest sections of Dallas.
Duncan was staying in a second-floor apartment with Louise Troh, her 13-year-old son, Duncan’s distant cousin and a family friend.
On Sept. 25, Duncan was feeling sick enough that he went to the emergency room at Texas Health Presbyterian Hospital. He was reported to have a fever, headache and abdominal pain, but no diarrhea or vomiting. The hospital said he told them he’d recently arrived from West Africa, but that he denied having been around anyone sick. He was released.
By Sunday morning, Duncan’s condition had worsened.
...
2014-10-02-NYT-man-in-us-with-ebola-had-been-screened-to-fly-but-system-is-spotty
Man in U.S. With Ebola Had Been Screened to Fly, but System Is SpottyBy MATTHEW L. WALD and JAD MOUAWAD
New York Times, 2014-10-02
As he was preparing to leave Liberia for Dallas two weeks ago, Thomas E. Duncan, the man confirmed to be the first Ebola case in the United States, was checked at the airport for signs of the disease. He was determined to have no fever and allowed to board his flight, American officials say.
Since the deadly Ebola virus began spreading rapidly through West Africa, the Centers for Disease Control and Prevention has been pushing the authorities in the worst-hit countries, including Liberia, Sierra Leone and Guinea, to implement just that type of screening for departing passengers.
In early August, the C.D.C. sent medical workers to the region to train local government officials and airport workers in Ebola screening, according to Dr. Nicole Cohen, an infectious disease specialist with the agency’s Division of Migration and Quarantine. As part of that process, the agency advises that airport workers ask travelers if they have been exposed to Ebola in the last 21 days, have had a fever, and have had any symptoms including severe headache, muscle ache, abdominal pain, unusual bruising or bleeding, vomiting and diarrhea. The screener is expected to use a hand-held non-contact temperature monitor, a few inches from the travelers’ forehead, to check for fever.
But the system has its limits, relying on the traveler to reveal whether he or she has been exposed. And it leaves it to local officials to conduct the screening as they see fit, Dr. Cohen said. It is unclear how consistently or effectively those screenings are conducted across West Africa, and Dr. Cohen said she did not know how many potential travelers had been caught by screeners — if any.
“Our expectation is that people who are sick or people who are exposed
should be getting the message
they shouldn’t be traveling.”
[How nice.
Just rely on the honor system to keep Ebola out of America.
I wonder if these potential Ebola carriers were traveling to, say, Israel
whether Dr. Cohen would have the same attitude.]
...
2014-10-02-WP-officials-say-as-many-as-100-had-contact-with-ebola-patient-four-have-been-quarantined
Officials say as many as 100 had contact with Ebola patient;four have been quarantined
by Mark Berman
Washington Post, 2014-10-02
Public health officials in Texas said Thursday that as many as 100 people may have had contact with the Liberian man diagnosed with Ebola. Four of these people, at least some of whom are believed to be family members of the man, have been ordered to remain at home in an attempt to prevent the spread of the disease.
Still, authorities continued to stress that only Thomas Eric Duncan, who is the first person diagnosed with Ebola in the United States, had exhibited any Ebola symptoms.
...
2014-10-02-WP-Nutt-report-on-Duncan-and-family-in-Dallas
For quarantined relatives in U.S. Ebola case,extra cautions, hope and prayer
By Amy Ellis Nutt
Washington Post, 2014-10-02
DALLAS — Thomas Duncan shivered in the king-size bed, even though he was tucked under the covers and fully dressed — pants, socks and two shirts. It was Sunday morning, Sept. 28, and Duncan, from Liberia, had been in the United States visiting Louise Troh at her Dallas apartment for the past week. He felt weak and cold, he told Troh’s daughter, Youngor Jallah.
So Jallah took a quick trip to Wal-Mart and bought a $50 brown cotton blanket. When she returned, she draped it over Duncan’s shoulders and then gently lifted him by his back to try to get him to drink some hot tea. That’s when she looked into his eyes and knew in her heart that things were very bad.
“I’ve been seeing Ebola on TV, how it starts, with muscle pain, red eyes. When I see his eye, it is all red, and I think maybe this time it is Ebola virus and I should be careful,” Jallah, 35, said in an interview with The Washington Post at her nearby apartment, where she and her family have been quarantined.
She took his temperature — 102 degrees.
“I’m going to call an ambulance,” she said.
Duncan tried to resist. He had been to the hospital once already, several days earlier, and all they had done was send him home with antibiotics. Jallah didn’t listen to him. She dialed 911.
“My daddy is going to the bathroom constantly,” she told the operator, referring to Duncan, whom she considers her stepfather.
Fifteen minutes later, two paramedics knocked on the door. Jallah greeted the two men but told them that they couldn’t enter until they put on gloves and facemasks.
“He just come from Liberia,” she explained. “For safety, don’t touch anything. Viruses.”
She didn’t use the word Ebola, she said, because she didn’t know whether it was the lethal virus. All she knew was that Duncan was very ill and that Liberia was being devastated by the hemorrhagic fever. The paramedics asked Duncan to walk to the ambulance, which he did, but they would not let Jallah give him the blanket.
2014-10-04-WP-Editorial-missteps-in-handling-the-ebola-virus-in-the-us-cant-be-repeated
Missteps in handling the Ebola virus in the U.S. can’t be repeatedBy Editorial Board
Washington Post Editorial, 2014-10-04
[Well, yeah.
Who could disagree with that?
But mistakes are inevitable.
We all know, or should know,
that both hospitals and doctors have a history of making errors.
They're human, after all.
To say "Missteps ... can't be repeated"
seems hardly different from King Canute's command to the tides.
The only ways to prevent Ebola from spreading in America
are either a flat travel ban or, my favorite proposal,
quarantining arrivals from the affected regions
until their Ebola incubation period is up.]
[1]
IN THE MIDDLE of a disease outbreak, panic and fear can themselves be a destructive force. When the Ebola virus first broke out in West Africa, governments dropped the ball and were unable to contain the dread, leading people to take action — such as evading quarantine — that spread the infections. A core requirement of managing a crisis like this is that public health officials and political leaders maintain the public’s confidence.
[No mention of the body-washing funeral practices of many in West Africa.
Too touchy a topic to mention?]
[2]
This premise applies just as well to the United States as it does to Africa, and in recent days, a significant misstep in Dallas has shaken that confidence.
[3]
A man from Liberia, Thomas Duncan,
had contact with a pregnant woman there who was infected,
although he may not have known that when he carried her to a hospital.
[If Duncan knew that
Williams had been "turned away from a hospital
for lack of space in its Ebola treatment ward",
how could he not have known Williams had Ebola?]
She later died.
He did not show symptoms immediately, and went to the airport, where he signed a screening form saying he had not had contact with anyone with Ebola, and flew to the United States. Once in Dallas, Mr. Duncan began to feel ill and went to the emergency room at Texas Health Presbyterian Hospital. While there, he came in contact with other people who were healthy. He was released by the hospital, which concluded he had only a low-grade fever from a viral infection. The hospital apparently did not connect the dots of his illness and his recent travel from Liberia, one of the nations most seriously hit by the recent outbreak. Mr. Duncan then returned to the hospital when his symptoms worsened and officials confirmed he was infected with the Ebola virus.
[4]
The misstep was the failure in the Dallas emergency room to realize that he was a potential Ebola victim, allowing him, at least theoretically, to come in contact with others present and after he was released. The virus does not transmit through the air, only through bodily fluids, and is not contagious if the person is not symptomatic, as was the case while Mr. Duncan was flying to the United States. But on his first visit to the emergency room, he was showing symptoms and should have been immediately isolated and tested. The key to fighting Ebola — for which there are no readily-available vaccines or therapeutics — is identifying those infected, isolating them and tracing those they have been in contact with. This kind of vigilance was not on display in the hospital emergency room.
[5]
Screening airline passengers is certainly useful, but it is not foolproof, since Ebola doesn’t always show symptoms right away. This is unlike influenza, which is more readily detectable. A screening form did not stop Mr. Duncan from boarding a plane to the United States.
[So quarantine possible Ebola carriers for the Ebola incubation period,
after which positive knowledge about whether they had/have Ebola
will be available.]
[6]
Ebola presents a frightening challenge from nature, but it can be stopped. The United States enjoys one of the most advanced and robust health-care systems in the world, capable of isolating Ebola patients when they arrive and halting transmission. But it is going to require zero tolerance for oversights like that which appears to have occurred in Dallas. Other U.S. hospitals — including those in the Washington area evaluating possible Ebola cases — must take a lesson.
2014-11-07-DallasNews-a-relieved-dallas-marks-final-day-of-ebola-monitoring
A relieved Dallas marks its final day of Ebola monitoringBy JEFFREY WEISS
Dallas News, 2014-11-07 (Friday)
Official Dallas heaved a public sigh of relief Friday, marking the last day when anybody local would be screened for Ebola symptoms.
...
For North Texas, however, the spotlight was finally off. All total,
177 people had been monitored for the disease
after possibly coming into contact with one of three Dallas patients.
None contracted Ebola.
The Texas health department signaled the all-clear
with a tweet early Friday evening:
“It’s official.
This evening’s final monitoring check is done.
No symptoms.
We are happy to close this Ebola chapter with Dallas tonight.”
...
Labels: Ebola
posted by KHarbaugh at 02:16
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