Protecting America from Ebola

2014-10-12:

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.

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Testing for Ebola

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

DIAGNOSIS:
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.

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

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Miscellaneous Articles

2014-10-15-WP-dulles-airport-outlines-ebola-screenings-for-those-coming-from-3-west-african-nations

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

2014-10-21-NYT-CDC-issues-new-guidelines

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.

2014-10-26-WP-Chertoff-the-case-for-suspending-us-visas-in-ebola-affected-countries

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.

[1]
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.

[2]
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.

[3]
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.

[4]
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.

[5]
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.

[6]
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.

[7]

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.

[8]
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.

[9]
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.

[10]
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.

Quarantining travelers from Ebola areas

2014-10-08

(A google search for the subject line.)

The purpose of this post is to suggest and request that
travelers to the United States,
arriving from parts of the world
where Ebola is running through the population in an unchecked manner,
i.e., where an Ebola epidemic is occurring,
be quarantined upon their arrival in the United States
until the first of two events happens:

1. They are tested for whether they are carrying the Ebola virus,
   and the test returns a negative (no Ebola virus) result.
2. Such time passes that,
   if they did have the Ebola virus when they entered the U.S.,
   that fact would become known because
   they were exhibiting external signs of the virus.
   I.e., the "incubation period" for the virus had passed.
   (Reports are that that "incubation period" is 21 days,
   but of course further research may change that duration.)

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Some practical questions and issues about such a quarantine:

• Question: Where would the quarantined travelers be held?
  Answer: Supposedly the U.S. military has more base structure
  than the size of its forces require.
  Indeed, reports are that DoD would like to have
  another round of base closings.
  In any case, given the priority this issue has,
  forces could be moved around so that
  some military base would be freed up
  to hold the quarantined travelers.
  Advantages of this approach include:
  most, if not all, military bases have a nearby airfield;
  the bases are separated from the surrounding civilian community;
  they were, in many cases,
  designed with some security features between them and their surroundings;
  they are currently available to the government without the need for
  time-consuming construction or purchase of new facilities.
• Less restrictive than an outright travel ban
• Requires effective tracking of airline passenger flight itineraries.
  To be most effective, it would be necessary to determine the original boarding location
  of a passenger arriving from, say, Brussels.
  Did the passenger change planes there (or at another layover point)?
  The airline industry would, hopefully, be willing to provide such information,
  if necessary, taking steps to produce the information.
• The Ellis Island precedent
  While this proposal might sound radical in 2014,
  in fact it is merely returning to our 1880s America precedents.
  Here is an excerpt from a 2014-10-09 NYT story:
  

  Historically, American health authorities have had
  elaborate systems to check immigrants’ health.
  On Ellis Island, for example,
  medical workers gave immigrants full medical examinations
  and even took cultures of bodily fluids,
  Professor Markel said.
  There were facilities nearby where the immigrants could be held
  while waiting for results.
  But those days were different:
  Many traveled for days or weeks to reach the United States,
  giving diseases ample time to surface.

  For more, see google at Ellis Island health screening
  

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Miscellaneous Articles

2014-10-24-Fox-Dr-Manny-Alvarez-cdc-must-control-ebola-quarantines-honor-system-not-working

CDC must control Ebola quarantines, honor system not working
By Dr. Manny Alvarez
Fox News, 2014-10-24

[1]

I think that
the approach that is being taken by the federal government—
the concept of
“It’s a matter of time before we see another case”—
reveals a poor strategy.

Yesterday, New York City had its first case of an Ebola-infected patient.
Identified as Dr. Craig Spencer,
he is an emergency room physician who everybody knew
had recently returned from West Africa,
where he was treating Ebola victims with the non-profit,
Doctors Without Borders.

[2]
Luckily enough, this health care professional, when he became flagrantly ill,
immediately called emergency services and thankfully was descriptive enough
to allow medics to come prepared for full isolation.

[3]
Now, here’s where it all breaks down for me:
I give him an A for effort,
but I give him a failing grade
for his full execution once he got back to the United States from West Africa.

[4]
He, of all people, should have known that a proper quarantine means
daily monitoring of temperatures, monitoring of any flu-like symptoms
and no contact with anybody else.
That’s what quarantine means.

[5]
And we have seen, over and over again,
not only from non-medical professionals,
but sadly by health care workers,
that this breach of protocol continues to happen.
This doctor went about the city of New York for several days
riding the subways, going to dinner and even bowling,
just to fall significantly ill only 12 hours after his latest outing.

[6]
So, what’s the bottom line here? Let me repeat:
If you’re not going to close the borders and put a travel ban or a visa ban in place,
t least create a very comprehensive quarantine protocol and monitor it—
because this honor system that has been in place,
just by telling people “monitor yourselves,”
is certainly not working.

[7]
I am not worried that hundreds of people are going to get infected
by this one doctor in New York.
That’s not what I’m saying.
But every time a case of Ebola pops up in any major city,
it creates chaos, anxiety and certainly an exuberant amount of costs that—
let’s face it—
we cannot continue to afford on a daily basis.

[8]
I wish this doctor a speedy recovery,
and I would love to hear his side of the story once he gets out of the hospital.

Dr. Manny Alvarez serves as
Fox News Channel's Senior Managing Editor for Health News.

2014-10-26-nurse-in-newark-tests-negative-for-ebola

Tested Negative for Ebola, Nurse Criticizes Her Quarantine
By ANEMONA HARTOCOLLIS and EMMA G. FITZSIMMONS
New York Times, 2014-10-26

A nurse who was being quarantined at a New Jersey hospital after working with Ebola patients in Sierra Leone criticized her treatment on Saturday as an overreaction after an initial test found that she did not have the virus.

“I am scared about how health care workers will be treated at airports when they declare that they have been fighting Ebola in West Africa,” the nurse, Kaci Hickox, wrote in an essay on the website of The Dallas Morning News, in collaboration with a friend who works for the paper. “I am scared that, like me, they will arrive and see a frenzy of disorganization, fear, and most frightening, quarantine.”

She described being held in isolation for about seven hours at Newark Liberty International Airport on Friday, left alone for long stretches and given only a granola bar when she said she was hungry.

Ms. Hickox, 33, was placed in quarantine under a new policy announced on Friday by the governors of New York and New Jersey. All people entering the United States through Newark Liberty and Kennedy Airports will now be quarantined for 21 days if they had direct contact with Ebola patients in Guinea, Liberia or Sierra Leone, even if they show no symptoms of infection.

On Friday night, New Jersey health officials said the nurse had developed a fever after arriving, but on Saturday, they said her blood had tested negative for Ebola. Additional tests will be conducted.

Ms. Hickox disputed that she had had a fever. She wrote that at the airport, a forehead scanner showed her temperature to be 101, but that came after four hours during which she had not been allowed to leave.

“My cheeks were flushed, I was upset at being held with no explanation,” she wrote. “The female officer looked smug. ‘You have a fever now,’ she said.”

She was eventually escorted by eight police cars to University Hospital in Newark and taken to a tent outside the building. An oral thermometer showed her temperature to be 98, she wrote.

She added that the doctor felt her neck and rechecked the temperature. “ ‘There’s no way you have a fever,’ he said. ‘Your face is just flushed.’ ”

Her complaints served as a broadside against the new quarantine policy, which goes further than recommendations from the Centers for Disease Control and Prevention. The new policy has raised concerns among some health experts and doctors that it will discourage people from going to West Africa to try to contain Ebola at its source. The World Health Organization reported on Saturday that there were more than 10,000 suspected or confirmed cases in the three hardest-hit countries.

The C.D.C. calls for self-monitoring for travelers who have had contact with Ebola patients, but not for isolation, because a patient is not believed to be contagious until symptoms appear. But C.D.C. officials said that states had the right to go beyond their recommendations.

On Saturday, in a sign of growing concern about the virus, Gov. Pat Quinn of Illinois, the home of O’Hare International Airport in Chicago, began a quarantine program similar to the one in place in New York and New Jersey. Connecticut, which enacted a similar policy on Oct. 7, has quarantined nine people who have so far showed no symptoms.
Continue reading the main story

White House officials held a meeting on Saturday to discuss whether to revise nationwide policies regarding the return of health care workers from affected West African countries. An official said the administration may take further action, although it wanted to avoid anything that would hinder the ability to fight Ebola in West Africa.

On Friday, the day after a New York City doctor who had worked in Guinea through Doctors Without Borders tested positive for Ebola, the governors of New York and New Jersey described the quarantines as a necessary caution. Some of the details of where travelers would be quarantined, whether at their homes or elsewhere, were still being worked out Saturday.

Asked about the nurse’s essay while visiting Iowa, Gov. Chris Christie of New Jersey said, “My heart goes out to her because she’s someone who has been trying to help others and is obviously ill,” referring to earlier reports of a fever.

“I’m sorry if in any way she was inconvenienced but inconvenience that could occur from having folks that are symptomatic and ill out amongst the public is a much, much greater concern of mine,” he continued. “I hope she recovers quickly, and we’re going to do everything we can in New Jersey and in our public health system to make sure that she does.” In a telephone interview on Saturday night, Ms. Hickox’s father, Leon Hickox, said that his daughter “is not ill in any way.”

Doctors Without Borders said on Saturday that “there is a notable lack of clarity about the new guidelines,” and that it was concerned about the treatment of Ms. Hickox, who worked with the organization. It said she was in an unheated tent set up as an isolation ward next to a building at University Hospital. But a hospital spokeswoman, Stacie Newton, said the nurse was “in a building that’s part of the hospital.”

The New York City doctor, Craig Spencer, 33, remained in isolation at Bellevue Hospital Center in Manhattan on Saturday, with officials saying he had “entered the next and more serious phase of his illness, as anticipated with the appearance of gastrointestinal symptoms.” Mayor Bill de Blasio continued his reassurance tour on Saturday, sampling most of the menu at a meatball shop in Manhattan that Dr. Spencer had visited last week, as “a reminder about some core truths about Ebola.”

“It cannot be contracted through casual contact. It is not an airborne disease,” he said.

In New Jersey, health officials did not say how long Ms. Hickox was to be kept at University Hospital. The nurse’s mother, Karen Hickox, said her daughter called her on Saturday morning crying. “She felt like you would treat a dog better than she’s been treated,” she said in an interview.

Kaci Hickox grew up in Texas and worked for the C.D.C. in Las Vegas until recently, when she moved to Fort Kent, Maine, her mother said. She has worked in several African countries with Doctors Without Borders.

In the essay, Ms. Hickox described her last night at an Ebola management center in Sierra Leone, when she gave crushed Tylenol and anti-seizure medicine to a dying 10-year-old girl as her body jolted in bed. “It was the hardest night of my life,” she wrote.

“We need more health care workers to help fight the epidemic in West Africa,” she wrote. “The U.S. must treat returning health care workers with dignity and humanity.”

The essay drew more than 1,000 comments on the Morning News’s website, including some criticism of Ms. Hickox. Many readers argued that the quarantine was necessary and that it should not be a major inconvenience for the nurse to spend 21 days in quarantine to ensure that the virus does not spread. Still, others argued that the quarantine was fair but that the authorities should have treated her better.

In a statement, the C.D.C., which was involved in Ms. Hickox’s case, described workers like her as “heroes” and said: “We must protect their health, safety, and well-being and treat them with respect when they return home while continuing to take action to protect Americans so Ebola does not spread here.”

If Ms. Hickox was asymptomatic, said Udi Ofer, executive director of the American Civil Liberties Union of New Jersey, he would have questions about the legality of her quarantine.

“Mandatory quarantine of people exhibiting no symptoms and when not medically necessary raises serious constitutional concerns about the state abusing its police powers,” Mr. Ofer said.

Nicolas P. Terry, director of the Hall Center for Law and Health at the McKinney School of Law at Indiana University, said Ms. Hickox could challenge her quarantine on the grounds that she was being held without cause. But he said if the order was directed only at travelers in countries affected by Ebola and did not say they had to be symptomatic, then her only choice would be to challenge the validity of the order itself.

“If she fits the definitions and the symptoms of the New Jersey emergency regulation, they can keep her,” Mr. Terry said.

Ms. Hickox’s mother said she had sent her daughter a text message asking if she thought she would be detained when she returned home: “She texted back: LOL that’s not going to happen.”

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[Note: An ABC News story on 2014-10-27 contains the following:

In a text message this morning [2014-10-27],
[Kaci Hickox] told ABC News Chief Health and Medical Editor Dr. Richard Besser,
"I'm so thankful for the immense attention and support I've received.
I just hope this nightmare of mine and the fight that I've undertaken
is not in vain!"

Hickox has tested negative for the virus twice
but was held in a quarantine tent at University Hospital in Newark anyway.
Her lawyer argued that her basic human rights were being violated.

End of excerpt from the ABC News story.

I wonder if I am the only one who thinks that
Ms. Hickox is way overreacting and overdramatizing what happened to her?
"A nightmare"? Really?]

2014-10-28-NYT-Editorial-ebola-policies-made-in-panic-cause-more-damage

The Dangers of Quarantines
Ebola Policies Made in Panic Cause More Damage
By THE EDITORIAL BOARD
New York Times Editorial, 2014-10-28

[1]
With good reason, Americans are deeply confused about the risks of Ebola. It is a frightening disease, made more so by dueling theories about how best to deal with people arriving from West Africa and by wildly different messages — based partly on erroneous information given out by New York City officials — about whether the doctor who returned to New York from treating patients in Guinea and came down with the disease was or was not a danger to others when he moved around the city.

[2]
To make matters worse, two ambitious governors — Chris Christie of New Jersey and Andrew Cuomo of New York — fed panic by imposing a new policy of mandatory quarantines for all health care workers returning from the Ebola-stricken countries of West Africa through John F. Kennedy and Newark Liberty international airports. There is absolutely no public health justification for mandatory quarantines.

[3]
It’s not surprising that they have started to adjust their earlier positions, which seemed politically motivated, as they have come under a barrage of criticism from public health experts for their dangerous overreaction. They now say they will allow health care workers to be confined to their own homes, where they will be checked twice a day by public health officials.

[4]
Lost in this grandstanding was one essential point. The danger to the public in New York in the case of Dr. Craig Spencer, who had worked in Guinea for Doctors Without Borders, was close to nonexistent. Health experts are virtually unanimous in declaring that people infected with the virus do not become contagious until after they develop a fever or other symptoms, such as diarrhea, vomiting, or severe headaches, at which time they need to be hospitalized and taken out of circulation.

[5]
Health care workers like Dr. Spencer know that it is in their interest to ensure that — if symptoms do arise — they get care quickly to improve their chances of survival and to reduce the risk of infecting their friends and families. Dr. Spencer reported his temperature promptly when it was a low-grade fever of a 100.3 degrees and was rushed to Bellevue Hospital Center for isolation and treatment while his fiancée and two friends were put into voluntary isolation.

[6]
Fortunately, for the public, there are clearer heads at the federal level than there are in the statehouses of New York and New Jersey. On Monday, strict new federal monitoring rules, announced by the Centers for Disease Control and Prevention last week, went into effect for travelers entering the United States from Guinea, Liberia and Sierra Leone. The rules are designed to avoid the confusion of state-by-state policies, give health workers and other travelers a clearer idea of what to expect and reassure the public that somebody is in charge. State and local health departments will contact travelers daily for 21 days after their departure from West Africa to check on their temperatures and other symptoms (21 days is the maximum period for symptoms to develop). If the returning health care workers fail to report as required, health officials will track them down using contact information they have provided upon entry.

[7]
The C.D.C. further refined this approach on Monday with additional guidelines recommending how people with direct exposure to Ebola patients or burials should be handled. A doctor at high risk of Ebola because he was exposed to a patient’s bodily fluids would be strongly advised — and, if necessary, even ordered by health authorities — to avoid traveling or congregating in public.

[8]
The problem with a mandatory quarantine, even if done at home, is that it can discourage heath care workers from volunteering to fight the virus at its source in West Africa. Doctors Without Borders, the nongovernmental organization that has led the battle there, typically sends its workers on arduous four- to six-week assignments. The risk of being quarantined for another 21 days upon return has already prompted some people to reduce their length of time in the field and may discourage others from volunteering in the first place.

[9]
An editorial published Monday in The New England Journal of Medicine cited estimates that tens of thousands of additional volunteers will be needed to control the epidemic and warned that a mandatory 21-day quarantine, for people who are not sick and may never become sick, would be “more destructive than beneficial.” Policies that will reduce the chances of recruiting additional volunteers — without actually protecting the public — will only make the Ebola crisis worse.

2014-10-29-NYT-Letter-Hospital-Chief-a-rational-quarantine-for-ebola

A Rational Quarantine
By STEVEN J. CORWIN, Chief Executive, NewYork-Presbyterian Hospital
New York Times Letter to the Editor, 2014-10-29

Re “The Dangers of Quarantines” (editorial, Oct. 28):

[1]
The arrival of Ebola in the United States has made two things abundantly clear: More needs to be done to fight the virus at the epidemic’s center in West Africa, and containing and treating the virus here on American soil are difficult and complex undertakings, particularly in a place like New York City.

[2]
I commend Gov. Andrew M. Cuomo and Mayor Bill de Blasio for their rapid and decisive actions over the past week to protect the health of New Yorkers while ensuring that returning heroes like Dr. Craig Spencer receive the best possible treatment. Governor Cuomo has instituted a rational quarantine policy that will help prevent the spread of the disease.

[3]
Because each Ebola patient requires enormous amounts of resources, scores of personnel, including nurses and physicians, and specialized equipment and protective gear, even small numbers of Ebola cases could hinder the delivery of other essential health services in New York City and State. The governor’s policy recognizes this. It will allow our region’s hospitals and medical professionals to focus their efforts on caring for people who become sick, while alleviating New Yorkers’ concerns about this frightening disease.

[4]
It is also entirely fitting that employers of medical professionals who have been on the front lines of the Ebola fight be required to provide them with full compensation during the 21-day waiting period. We at NewYork-Presbyterian Hospital are honored to recognize their enormous personal contributions in this small way.

STEVEN J. CORWIN
Chief Executive
NewYork-Presbyterian Hospital
New York, Oct. 28, 2014

Ebola in Africa

2014-11-20-NYT-ebola-response-in-liberia-is-hampered-by-infighting

Ebola Response in Liberia Is Hampered by Infighting
By DONALD G. McNEIL Jr.
New York Times, 2014-11-20 (Thursday)

The global response to the Ebola virus in Liberia is being hampered by poor coordination and serious disagreements between Liberian officials and the donors and health agencies fighting the epidemic, according to minutes of top-level meetings and interviews with participants.

Even now, three months after donors began pouring resources into Liberia, many confirmed cases still go unreported, countries refuse to change plans to erect field hospitals in the wrong places, families cannot find out whether their relatives in treatment are alive or dead, health workers sent to take temperatures sometimes lack thermometers, and bodies have been cremated because a larger cemetery was not yet open.

The detailed accounts of high-level meetings obtained by The New York Times, the most recent from Monday, lift the veil on the messy and contentious process of running the sprawling response to Liberia’s epidemic, one that now involves more than a hundred government agencies, charities and donors from around the world.

Despite these problems, with help from donors, Liberia, one of the three most afflicted West African countries, and the one with the highest death toll, has seen new cases drop to about 20 a day from about 100 a day two months ago. Experts attribute that to fearful Liberians touching one another less, more safe burials of bodies and distribution of protective gear to health care workers. But they also warn that cases are now holding steady and could explode again.

...

Also, the support documents with the minutes indicate that there is no national plan for Ebola survivors — either for reuniting them with their families or for using them to do nursing tasks because they are thought to be immune.

...

In the minutes, Liberian officials regularly complain about the donors, and the donors argue back. On Nov. 12, James Dorbor Jallah, the task force’s deputy manager, said: “People will sit in D.C. or Geneva and want to direct what is happening here.”

The health minister, Dr. Walter T. Gwenigale, backed him up, complaining that “the U.N. and other agencies got their money before the ink was even dry,” while, he said, a group run by a Liberian pastor to teach rural people about Ebola “has not gotten one cent.”

On Sunday,
President Ellen Johnson Sirleaf replaced Dr. Gwenigale without explaining why,
but said he would remain an adviser.
Dr. Emmanuel T. Dolo, Ms. Johnson Sirleaf’s youth adviser,
complained that
the donors were “showing a level of disrespect”
by judging Liberian community groups
by “harsh standards” and “Western standards.”

...

Two days later, Shiyong Wang, the World Bank representative, confirmed that United Nations agencies had received nearly all their money and that the Liberian government had received only 7 percent of the $23 million allotted to it. But, he said, the government had not produced required documentation — not even, for example, names of dead health workers whose families awaited compensation. He criticized the government’s “overly complex and bureaucratic approval process,” including three signatures on each document.

Dr. Rosling said the three signatures were an anticorruption measure. Beneficiary lists are hard to produce, he said, when Liberians have children whose births are often not officially recorded. And it was “arrogant,” he said, for donors, for example, to assign contracts to operate field hospitals without Health Ministry permission.

The Nov. 12 meeting appeared to end on a bitter note, with Mr. Nyenswah telling every agency to document within 48 hours what people it had and what their jobs were. “If you don’t give us this list,” he concluded, “you are not allowed in this meeting.”

The meeting of Nov. 14 opens with Mr. Nyenswah reminding scientists not to do research without permission from a government ethics review board. On Nov. 17, Dr. Dolo complains that “There are a lot of people in this room who never contribute anything to this meeting.”

2014-12-16-theguardian-sierra-leone-scare-tactics-freetown-curb-ebola

Sierra Leone to use scare-tactics campaign in Freetown to curb Ebola
by Sarah Boseley in Freetown
The Guardian (UK), 2014-12-16

...

At the moment, swab tests show that 30% of bodies picked up by burial teams after calls from families are positive for Ebola. People are still nursing the sick rather than having them taken to holding centres for testing and then moved into treatment centres where half will probably die. It is in the last stages of the disease that victims are most infectious.

“We know it is out there. We have got to turn it around so that 2% to 3% of these bodies are actually positive,” said Brown.

The reluctance to make the call is rooted not only in family values but also cultural tradition around burials. In normal times, relatives would wash the bodies of those who die and dress them for the funeral. Many are still doing so – and calling the authorities afterwards, which means they have already exposed themselves to great risk.

“The behaviour change is not working,” said Brown. “We need to get to much more active surveillance, rather than passive surveillance.” Many thousands of people will be employed to visit communities and spread a tough new message in the course of the campaign, which will last for two to three weeks over the Christmas period. People now understand what Ebola is and what the risks are, but they are still in denial because they do not think it will happen to them, he said.

...

Questions about Ebola

Some questions about Ebola and America's readiness to handle what may be coming:

2014-11-02
Dr. Thomas Frieden, Director of the CDC, on 2014-09-30 famously said:

"I have no doubt that we will stop it in its tracks in the U.S.,
but I also have no doubt as this outbreak continues in Africa
we need to be on our guard."

To me, this begs some questions, especially
"How many cases of Ebola can the American health care system handle?"
Ebola requires such elaborate care,
to prevent transmission of the virus to the care-givers,
that it puts a special burden on those trying to treat its victims.
Indeed, four medical centers have been designated as biocontainment centers
to handle the virus, NIH, Emory, Nebraska, and Montana.
Their capability is quite limited, supposedly only 11 beds.
Beyond that, the capability to handle it no doubt varies.

That question concerns the American capability to handle the disease.

On the threat side, we need to war-game how bad the situation could be.
A while back I saw an estimate of something like 100 travelers per day
coming from the current Ebola zone of Liberia, Guinea, and Sierra Leone.
In late October U.S. governments put in place
screening procedures for those travelers,
aiming to give travelers who bring Ebola to the U.S. treatment
as soon as they begin to show symptoms.
Fine.
But what if a sizable number of those travelers DO show symptoms?
What if, say, 20 percent, or about 20 per day,
in fact have Ebola?
Twenty per day amounts to 140 per week.
Could the U.S. health care system really handle that number,
without risking that the virus be transmitted to some of those providing treatment?

You know, the people putting out information
always give reassuring words, saying "the rise is low" or "very low".
But that depends, it seems to me, on the number of arriving Ebola carriers
being a number the U.S. can manage.
How do they know that the number will be that low?
I think it is really necessary to bound the risk,
by limiting incoming travelers.

Ebola transmission rate and exponential growth

2014-10-19:


Link to White House video of President Obama's 2014-10-18 Weekly Address
Embed of White House video of President Obama's 2014-10-18 Weekly Address:


Text of the address:
Remarks of President Barack Obama
Weekly Address
The White House
October 18, 2014

President Obama:

...

We have to remember the basic facts.

First, what we're seeing now
is not an "outbreak" or an "epidemic" of Ebola in America.
We're a nation of more than 300 million people.
To date, we've seen three cases of Ebola diagnosed here-
the man who contracted the disease in Liberia, came here and sadly died;
the two courageous nurses who were infected while they were treating him.
Our thoughts and our prayers are with them,
and we're doing everything we can to give them the best care possible.
Now, even one infection is too many.
At the same time, we have to keep this in perspective.
As our public health experts point out,
every year thousands of Americans die from the flu.

---

Back to remarks by the author of this blog:

I have zero training in anything related to health care,
but I know a little math.
President Obama,
along with many commentators who have been making the same points
Obama just made,
absolutely misleads Americans on what the significant issue is.
It is not how many Americans currently have Ebola;
it is what the transmission rate is
(and, of course, the mortality rate for those who contract Ebola).

Let me illustrate with two alternative estimates for the transmission rate.
In each case, we will assume that after a person contracts Ebola,
he has 20 days in which he may pass it on to others.
(This seems reasonably realistic:
Thomas Eric Duncan, for example, evidently contracted Ebola on September 15,
died on October 8 (23 days later),
and evidently passed the disease on to
at least two of the nurses who cared for him in Dallas,
Nina Pham and Amber Vinson.)
We will consider alternative scenarios for different transmission rates
(how many other people each Ebola patient passes his disease on to).

In the first scenario,
assume the transmission rate is 1:
each Ebola patient, after the 20 days are up. has one successor patient.
That means one more patient every 20 days.
Over a year, there would be about 18 total patients (365/20).
Nothing I would worry about much, in a nation of over 300 million.

In the second scenario,
assume the transmission rate is 2:
each Ebola patient, during his 20 days of contagiousness, passes it on to two people.
(As Duncan did to his two Dallas nurses.)
So after one generation of transmission (20 days), there are two patients.
After two generations (40 days), 2x2 = 4.
After three generations (60 days), 2x4 = 8.
After n generations (20xn), 2ⁿ Ebola victims.
The useful number to keep in mind here is 2¹⁰ = 1024, or roughly 1,000.
Thus after ten generations (200 days), there would be at least 1000 patients;
after twenty generations (400 days), over one million victims;
after thirty generations (600 days), over one billion victims.

In the general case, the transmission rate is R
(the above two scenarios were the cases R = 1 and R = 2).
So after n generations, there would be Rⁿ victims.
If R is between 1 and 2,
you get results intermediate between the above two scenarios.
If R is less than 1 (exponential decay), the disease eventually dies out
(the lower R is, the sooner it does so).
If R is greater than 2, things are even worse.

So what I am saying is:
What is critical is now how many people currently have Ebola,
but what is the rate at which people pass it on.
Where did Obama acknowledge that point?
I don't see where he did.

In my opinion,
the nation should not be concerned with treating the unfortunate people who have contracted Ebola,
but in ensuring that those people do not pass their disease on to others.
The emphasis should be on containment, not treatment.
If treatment can be done with zero risk of passing the disease on, fine, do it.
But if the typical American hospital (i.e., not the NIH, not Emory, not Nebraska)
is no better at preventing transmission than Texas Health Presbyterian Dallas was
(and according to the New York Times they were well-regarded in Dallas),
we really need to be very, very careful about how cases are managed
and the disease controlled.

Ebola in America

2014-10-16-NYT-lax-us-guidelines-on-ebola-led-to-poor-hospital-training

Lax U.S. Guidelines on Ebola Led to Poor Hospital Training, Experts Say
By DONALD G. McNEIL Jr.
New York Times, 2014-10-16

Many American hospitals have improperly trained their staffs to deal with Ebola patients because they were following federal guidelines that were too lax, infection control experts said on Wednesday.

Federal health officials effectively acknowledged the problems with their procedures for protecting health care workers by abruptly changing them. At 8 p.m. Tuesday, the Centers for Disease Control and Prevention issued stricter guidelines for American hospitals with Ebola patients.

They are now closer to the procedures of Doctors Without Borders, which has decades of experience in fighting Ebola in Africa. In issuing the new guidelines, the C.D.C. acknowledged that its experts had learned by working alongside that medical charity.

The agency’s new voluntary guidelines include full-body suits covering the head and neck, supervision of the risky process of taking off protective gear, and the use of hand disinfectant as each item is removed.

Sean G. Kaufman, who oversaw infection control at Emory University Hospital while it treated Dr. Kent Brantly and Nancy Writebol, the first two American Ebola patients, called the earlier C.D.C. guidelines “absolutely irresponsible and dead wrong.”

Speaking by phone from Liberia, where he was training workers for Samaritan’s Purse, the medical charity that Dr. Brantly and Ms. Writebol worked for, Mr. Kaufman said he had warned the agency as recently as a week ago that its guidelines were lax.

“They kind of blew me off,” he said. “I’m happy to see they’re changing them, but it’s late.”

Melissa Brower, a C.D.C. spokeswoman, said the agency was “taking a hard look at our recommendations and may be making changes.”

Dr. Thomas R. Frieden, the director of the C.D.C., expressed regret about his agency’s initial response to the first Ebola case in Dallas.

“In retrospect, with 20/20 hindsight,” he said a few hours before his agency tightened its guidelines, “we could have sent a more robust hospital infection control team and been more hands-on with the hospital from Day 1.”

Some major hospitals, aware of the inadequacy of the older C.D.C. guidelines, have followed more stringent standards in training their staff. But many — including Texas Health Presbyterian Hospital in Dallas, where two nurses were infected by a dying patient — have not.

The Doctors Without Borders guidelines are even stricter than the new C.D.C. directives in that they require full coverage of the torso, head and legs with fabrics that blood or vomit cannot soak through, along with rubber aprons, goggles or face shields, sealed wrists and rubber boots. Doctors and nurses wear two sets of gloves, including long outer ones that strap or are taped to the gown; janitors wear three sets.

As they undress in choreographed steps, Doctors Without Borders workers wash their hands with chlorine solution eight times and are sprayed with a chlorine mist. Most important, all personnel disrobe only under the eyes of a supervisor whose job is to prevent even a single misstep.

Risky procedures like blood sampling are kept to a minimum.

“I’ve seen the C.D.C. poster,” said a Doctors Without Borders representative who spoke on the condition of anonymity because she did not want to be named criticizing the agency, and who was referring to C.D.C. guidelines before they were changed on Tuesday. “It doesn’t say anywhere that it’s for Ebola. I was surprised that it was only one set of gloves, and the rest bare hands. It seems to be for general cases of infectious disease.”

National Nurses United, the country’s largest union and professional association of nurses, with 185,000 members, criticized the C.D.C. on Wednesday for taking so long. Worse, the union said, many hospitals ignored even the lax guidelines because they were voluntary.

For example, the union said, nurses at the Texas hospital complained that the protective gear the hospital issued left their necks exposed — and they were told to wrap their necks with medical tape.

“They were learning infection control on the fly,” said DeAnn McEwen, chief of infection control for the union. “That’s no substitute for planning.”

Nurses United called for federal and state laws making C.D.C. guidelines mandatory.

While Dr. Frieden has been criticized for arguing that almost any American hospital can handle Ebola patients and critics have demanded that all Ebola patients go to special isolation units, that debate is somewhat misguided, experts said.

The isolation units — which have filtered air, double doors and negative pressure — were built to prevent the spread of airborne diseases like SARS and tuberculosis.

The greater Ebola danger is large amounts of blood, vomit or diarrhea splashing caregivers. That is prevented by training, proper protective gear, rigorous cleaning and close supervision, specialists said.

Ebola victims resemble cholera victims in some ways.

In Bangladesh, which trains doctors all over the world in cholera treatment, hospitals do not place cholera patients on padded mattresses with bedpans. They usually lie on rubber sheets stretched across bed frames with holes cut so diarrhea can run out into buckets.

Doctors Without Borders personnel place buckets or chamber pots under patients. Its protocols require cleaning pools of fluid not by mopping, but by spraying them with chlorine and then throwing large absorbent cloths over them. Like doctors, janitors work in pairs, watching over each other.

All infected materials are immediately burned, sometimes in a field right behind the hospital. Reusable rubber items like aprons and boots are cleaned with detergent and bleach. One important Doctors Without Borders step — chlorine sprays — could be dangerous inside hospitals because it would make corridors slippery.

A step considered vital — which the new C.D.C. guidelines now include — is having a sharp-eyed “site supervisor” constantly watching for errors.

“The buddy system works for getting dressed, but not for getting undressed,” said Dr. William Fisher II, a critical care specialist from the University of North Carolina who worked in a Doctors Without Borders center in Guinea this summer and said he was now designing training for the C.D.C.
Continue reading the main story Continue reading the main story
Continue reading the main story

Doctors go into wards feeling fresh, he explained. But they emerge an hour later exhausted, sweating and sometimes shaking from a close call, like one he had when a patient grabbed his mask.

In the exit area, he said, “there was someone in charge whose sole focus was helping you get undressed safely.”

“You stood in front of them and did nothing until they said so,” he said. “They didn’t care if it was your first time or your 800th time. I was exhausted and emotionally drained. I looked forward to it.”

Initial Doctors Without Borders training takes two to five days, followed by three to six weeks of supervised work.

The nurses’ group, which is unfamiliar with those protocols, sent a letter to the White House on Wednesday demanding the adoption of the standards used by the University of Nebraska Medical Center with some enhancements.

That hospital is a designated isolation center, and its guidelines resemble those of Doctors Without Borders in some ways. A recent update to them called for head and neck hoods and the wiping of rubber clogs with bleach. The nurses’ union also demanded hazardous materials suits and powered air-purifying respirators.

Those can be cumbersome and claustrophobic, and the Nebraska guidelines treat them as recommended, not as standard.

2014-10-17-NYT-obama-may-name-ebola-czar-after-amber-joy-vinson-flight-causes-concern

Obama May Name ‘Czar’ to Oversee Ebola Response
By JACK HEALY, SABRINA TAVERNISE and ABBY GOODNOUGH
New York Times, 2014-10-17

...

A federal official said that the Centers for Disease Control and Prevention had broadened its search for contacts of Amber Joy Vinson, the second nurse infected with Ebola at Texas Health Presbyterian Hospital here, after interviewing family members who gave a different version of events from Ms. Vinson’s. The nurse had said she had a slight fever before boarding a flight from Cleveland to Dallas on Monday. But family members said she had appeared remote and unwell during her trip to Ohio over the weekend.

The C.D.C. said it was now tracking down passengers on Frontier Airlines Flight 1142 from Dallas to Cleveland, which Ms. Vinson took last Friday. It had already been tracing passengers on her Monday flight.

Ms. Vinson’s case raised flags for investigators because the day after she arrived home in Dallas, she reported substantial symptoms. Health experts say those would be unlikely to develop in just one day.
...

Mr. Obama spoke Thursday night
after meeting with several top aides working on the Ebola issue.
The president praised their work
but said they were also responsible for other tasks,
including national security matters and other health care concerns.

“It may be appropriate for me to appoint an additional person,
not because they haven’t been doing an outstanding job,
really working hard on this issue,
but they are also responsible for a whole bunch of other stuff,”
Mr. Obama told reporters.

He added that appointing an Ebola chief would make sense
“just to make sure that we are crossing all the t’s
and dotting all the i’s going forward.”

[Obama seems really, really clueless here.
The point of having a czar is to have one person responsible for the effort,
who has no other responsibilities other than this one.
The next step is to give that person authority commensurate with their responsibility.
Will Obama give them that authority?
We shall see.]

...

Another line of questioning dealt with why Ms. Vinson had been allowed to fly even after she called the C.D.C. from the Cleveland airport on Monday and told officials she had a slight fever. It was not known then that she had contracted the virus.

“Were you part of those conversations?” Representative Tim Murphy, Republican of Pennsylvania, asked Dr. Frieden.

“No, I was not,” Dr. Frieden responded.

The hearing thrust the Ebola virus and the government’s halting management of it into the realm of politics in the midst of a national election season.

“Errors in judgment have been made,” Mr. Murphy said. “We have been told, ‘Virtually any hospital in the country that can do isolation can do isolation for Ebola.’ The events in Dallas have proven otherwise.”

2014-10-17-NYT-controls-poor-at-hospital-nurse-says

Controls Poor in Dallas, Nurse Says
By KEVIN SACK
New York Times, 2014-10-17

DALLAS — A nurse who observed and participated in the care of Ebola patients at Texas Health Presbyterian Hospital spoke out publicly on Thursday about what she characterized as inadequate training and infection control there.

The nurse, Briana Aguirre, 30, who has worked at the hospital for three years,
...

2014-10-17-NYT-Fineberg

Ebola in America: The Crisis Widens
New York Times Letters to the Editor, 2014-10-17

To the Editor:

I have been teaching health care classes professionally for nearly 30 years.
In that time, it has become clear that
many health care administrators are more concerned about
saving time and money
than they are about saving and protecting lives.
Especially for low-paying, low-level jobs,
administrators sometimes look the other way,
even when it should be obvious that
applicants lack the medical aptitude to perform their job safely.
And with more and more recent immigrants entering the field,
there are many people who simply do not understand
what physicians, co-workers and patients are saying.

Containing Ebola means setting and enforcing strict protocols.
Just one weak link in the chain is a recipe for disaster.
So administrators need to be vigilant in
their hiring, training and supervision of health care workers,
to ensure that patients — as well as the community at large — are safe.

JOHN FINEBERG
St. Paul, Oct. 16, 2014

The writer is an emergency medical technician.

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:

Thomas Eric Duncan's final days in September and October 2014

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 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

---

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 Ill
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,

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 Liberia
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.]

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 emerges
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.

2014-10-04-WP-across-3-continents-ebola-makes-it-way-to-america

Across 3 continents, Ebola makes its way to US
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.

...

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 Spotty
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.]

...

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 repeated
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.

2014-11-07-DallasNews-a-relieved-dallas-marks-final-day-of-ebola-monitoring

A relieved Dallas marks its final day of Ebola monitoring
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.”

...