Ebola as a game-changer?

By Mary Odum

In crises, anxiety focuses attention. I continue to focus on the growing Ebola epidemic, which has no real restraints to keep it from becoming a global pandemic. Overpopulation, inequity, peak oil, and disturbed natural environment have converged with the problem of Ebola, to set up the conditions for a pandemic. If we add a slow response from complacent, frozen bureaucracies to this toxic mix, then we can expect a global pandemic to occur. We have met the enemy, and he is us.

Healthcare professionals need to speak up about healthcare inequity and US readiness for pandemics. And I have a particular interest in this topic, since I am potentially most exposed as a nurse to acquiring Ebola through patients shedding the virus in body fluids, and women are at high risk as typical care givers in the home and hospital. I have studied handwashing in hospital settings, with insight as to the gaps. So I will continue to perseverate here, and add my nursing voice to the choir of concerned healthcare professionals.

http://haicontroversies.blogspot.ca/2014/09/the-ebola-war.html
http://haicontroversies.blogspot.ca/2014/09/the-ebola-war.html

US foreign policy appears to be driven by arrogance, ignorance, or inertia, due to first world expectations of safety and frozen bureaucracies such as the military industrial complex bent on forever wars. Since TSA has implemented no policies to screen for fevers, Americans are displaying some arrogance in a belief that first world countries cannot be affected by pandemics. We screen assiduously for black swan terrorism events, but can’t seem to wrap our heads around a common plague. Yet we need health certificates for all dogs in the US when they travel–frozen bureaucracies lead to strange and sometimes contradictory policies.

Why do we choose to focus on Middle East terrorism, and ignore a burgeoning pandemic like Ebola? Perhaps a global pandemic will reset the priorities of our Security agencies and rewrite the meaning of terrorism. Our TSA obsession about shoes begins to look a little silly when one febrile Ebola victim on a plane to New York could rewrite the manual for the TSA, and change the face of healthcare in the US.

If the MSM does focus on Ebola, it is only an upbeat story about supposed cures, which experts say will not be available in enough time or enough measure to have much impact here. Or there’s an upbeat story about the saving of a single American healthcare worker (HCW), although there is no mention of how many resources went into that save, including vast amounts of disposable personal protective equipment (PPE), and a mainstream media focus on a single sick missionary’s status while ignoring the critical issues at the larger scale.

Epidemic to pandemic

First, a quick education on public health definitions. An epidemic is an incidence rate that exceeds the expected rate for an infectious disease. A pandemic is “an epidemic occurring worldwide, or over a very wide area crossing international boundaries and usually affecting many people” (Last, 2001, via Kelly). The pandemic phase 6 is “characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Indicates a global pandemic underway(World Health Organization [WHO], 2009).  We are in an Ebola epidemic phase 5 by WHO criteria, which suggests that the chance for pandemic is “high to certain.” There are currently about 5000 cases, and 2500 deaths in four countries in West Africa. Ebola 2014 may become a pandemic when outbreaks begin to occur in other regions or continents.

Wiki: Cumulative EBOV by country as of Sept. 10 on a log scale. Linear progression = exponential growth
Wiki: Cumulative EBOV by country as of Sept. 10 on a log scale. Exponential functions plot as straight lines on semi-log graphs

Case fatality rate (CFR) is the percentage of deaths within a population of cases. The touted 50-55%CFR for the current Zaire strain of Ebola may be underestimated, as suspected cases and mortality are both delayed and underreported. With patients lying at the doorstep of full field hospitals, CFRs are probably wildly inaccurate. A better estimate may come from  Médecins Sans Frontières (MSF) field camps, where a more controlled count of cases and mortality lead to an observed 70-80% CFR, which is more in line with the historical data for this strain.

Epidemiologists and health policy experts are using words like “short, closing window of opportunity in terms of weeks,” and the need for a “massive global response,” for “a crisis unparalleled in modern times” (WHO) or even “it is too late to contain,” while  MSF says we’re “losing the fight” and countries are beginning to create field hospitals in football stadiums. There is some discussion that because cases are grossly underreported in the chaotic environment, the real numbers may be 2 to 3 times as many as reported already (Garrett, 2014). The WHO’s latest situation report uses new language in its categories, describing Guinea, Liberia and Sierra Leone as countries with “widespread and intense transmission” and Nigeria and Senegal as countries with “an initial case or cases, or with localized transmission.” WHO has added a third class of countries that neighbor countries with active transmission, with identification of preparedness assessment and surveillance abilities for those countries. One could argue that in this era of global travel, any country with direct flights could be considered neighbors. The US has called an emergency meeting of the UN Security Council, so maybe policy-makers have figured that out.

http://virologydownunder.blogspot.com/2014/08/ebola-virus-may-be-spread-by-droplets.html?spref=tw
http://virologydownunder.blogspot.com/2014/08/ebola-virus-may-be-spread-by-droplets.html?spref=tw

There are many pundits asking how we could have known that this would be the break-out disease. Ebola this time is different, since it is occurring during a time of extreme population overshoot and massive global poverty and inequity. It is also different because it is the first break-out of a truly novel disease during a time of common global air travel. The ECDC has recently defined high-risk exposure criterion for Ebola as “close face-to-face contact (e.g. within one metre) without proper personal PPE, including eye protection, with a probable or confirmed case who was coughing, vomiting, bleeding, or who had diarrhea.” That definition contradicts WHO claims that air travel is “low risk,” especially as the epidemic spreads. The difference between airborne and droplet precautions is a matter of distance, and there is no established science on what distance is safe. Some have proposed that a larger distance may be safer, of up to 9 meters, considering the lethality of the disease (more discussion in linked email). And if a HCW is working in a contaminated environment or going home to a crowded environment, hazmat suits may not do much good. There are many links in the chain of infection control, and with this disease, scrupulous attention to all details are necessary to prevent contagion. That level of control is very difficult in a complex, urban environment.

Other public transportation such as buses, trains, and taxis where people sit within three feet of each other are also high risk as this epidemic grows. Cleaning standards in public places would change, as would food preparation and serving standards. Tourism, education, places of work–all aspects of the economy would be impacted as worried citizens created self-imposed quarantines. Behaviors in all areas of one’s life would change, and adequate PPEs would become a new form of currency. An Ebola pandemic would be a game-changer–one very small virus could tip our modern, frozen bureaucracies upside-down, mandating a new set of rules.

Spread to other countries appears probable to certain, since there are many mechanisms and few barriers to international dissemination. We had better start preparing, as a country. What does that mean for the US and its healthcare system?

Weakest links in the chain of American readiness

WHO and MSF have calculated that isolation field clinics in West African countries demand 250 healthcare workers for every 80 patients, and that is what is required for a “low resource” environment, meaning bare minimum healthcare standards (perhaps not even intravenous therapy) which has still resulted in 1 in 10 HCW  in those countries with high transmission contracting Ebola. In the US, the healthcare standards are much higher, with biohazard isolation, hazmat suits, and intensive staffing. The team at Emory caring for the two imported missionary Ebola patients required 5 physicians, 21 nurses, and a supporting cast of hundreds.

In West Africa, beds, PPE, and healthcare providers appear to be the primary constraining factors in dealing with this disease appropriately. Of those three, PPE and nursing care are probably the larger constraints. Beds can be erected in field camps, but infection control-trained nurses or caregivers are another matter. And without PPE, caregivers in centralized locations only spread the disease. And as acuity of care rises in complex isolation patients, the ability to comply with handwashing and isolation standards declines. In a recent US study of handwashing, if a critical care staff washed their hands or used handrub as many times as they needed to comply 100% with hygiene policies, they would have to collectively wash their hands for about 230 minutes a day per patient. Which doesn’t leave much time for care.

“On average, each patient was contacted directly 159 [95% confidence intervals (CI) 144-178] times and contacted indirectly 191 (95% CI 174-210) times/day. Observed post-contact hand hygiene rates were 43% for direct contacts and 12% for indirect contacts. Staff contacting more than one patient during routine care, who carry the highest risk of transmitting infection between patients, made, on average, 22 direct and 107 indirect contacts without adequate hand hygiene/patient/day. One hundred percent hand hygiene compliance by all healthcare workers would require about 230 min/patient/day (100 min for direct and 130 min for indirect contacts)” (McArdle, Lee, Gibb, & Walsh, 2006).

SCA-HandwashingInfographicSCA-1024x663This study didn’t count the violations based on not washing your hands or using alcohol handrub before you enter the room, just after exiting. So if one really adhered to US healthcare infection control standards, the fail rate for handwashing would be much higher, since most staff are going from room to room and only wash on exiting a patient room. Four hours at the sink is the needed cumulative total time per patient per day for all the caregivers going into that room. And the study above is not describing isolation patients, or patients with excessive vomiting and diarrhea and deadly body fluids, as happens in Ebola. In Ebola care, the highest viral loads are in diarrhea, blood, and corpses, as the virus requires body fluids to survive. Thus, arguably, the most dangerous jobs in this epidemic are nursing care and post-mortem care. Nurses in the current healthcare system are already under-staffed and overworked. The further this epidemic spreads, the less ability we will have to stop or contain it, because the work becomes more chaotic and dangerous, isolation standards collapse as patient acuity rises, healthcare workers become sick, and resource supply lines fail. Add in the need for careful and extensive isolation garb with complex gowning and de-gowning for each patient (over and above already time-consuming isolation procedures), and standards start to slide, making staff very vulnerable. In a previous handwashing study of mine, housekeepers had the worst compliance, with a handwashing compliance average of about 10%, followed by physicians with 15-20% handwashing rates. What does that mean for infection control in hospitals during pandemics?

Samaritan’s Purse just called for extra-hospital care of Ebola patients either in stand alone isolation units or at home, and it seems clear to me that this is a better model in a pandemic. Setting up a local healthcare communication system of community preparedness, with a system for safe, humane quarantine, food delivery, proper disposal and incineration of medical waste, stocking of isolation and contamination gear in communities, and education of non-HCW volunteers are things that need to happen now to prepare for a pandemic.

Should we send aid?

The United States has finally chosen to send some token military help, to set up a single field camp for the care of foreign (non-African) healthcare workers who acquire Ebola. Cuba, which has a much more sustainable and low-resource-based system, is sending 165 physicians and nurses. If this turns into a global pandemic, do we have the HCP and isolation gear to spare? Our US healthcare system is very high-resource, with 2.42 physicians per thousand population, while Sierra Leone has 0.02/1000.  Similarly the US has 9.8 nurses per thousand population, while Sierra Leone has 0.2 nurses/1000.

http://geocurrents.info/wp-content/uploads/2013/04/physician_density_nurse_density.jpg
via World Economic Forum data

There is some discussion that HCW from first world healthcare systems are simply not equipped to work in low resource environments–that is a given. American aid organizations with hospital ships appear leery to send their ships into the Hot Zone because of the risk of contamination.  In a pandemic situation, our high-tech healthcare system could be become a hindrance instead of a help, as our expectations and standards would quickly devolve from over-burdened hospital care to home care with PPE to, eventually, home care without PPE as chaos ensued and supplies and resources, which are all disposable, were used up (but perhaps not disposed of, at least not properly).

And all of this depends on oil, of course. I am afraid to do the math on what high-resource healthcare Ebola isolation would need in terms of a steady stream of isolation disposables. In a pandemic situation, we would probably not be able to keep up. Full biohazard gear for protection would devolve into standard PPE, which would then devolve into a mask and gloves, good handwashing, and some prayer. Home care might end up as it now is in West Africa, with no gloves available unless you bought them on the black market. Viruses are Nature’s equalizer. One country can use disposable, high-tech isolation gear, while another country struggles to provide clean water for basic handwashing. Viruses act as economic equalizers to reorganize the global landscape into units appropriate to available resources. 

http://cdn1.vox-cdn.com/assets/4850726/health_spending_per_capita_jpg.jpg
http://cdn1.vox-cdn.com/assets/4850726/health_spending_per_capita_jpg.jpg

So how does a pandemic impact a high-resource economy and healthcare system differently than a low-resource system? I’m not sure, but I’m not sure it makes a difference. As control of this epidemic weakens, cases will expand. Expanded cases will lead to even weaker control. If you want an idea of how quickly any healthcare system can become overwhelmed in an exponentially growing pandemic, go back and watch the movie, Contagion, which was a pretty accurate representation of what might happen to us if we fail to contain this epidemic.

vsWestAfricanIsolation

  • tom

    This thing has had my attention for at least a few days now anyway. I don’t see much news, and in the beginning I assumed it would not spread far as in the past. But I guess the problem is crowded urban areas. I would think Nigeria is the biggest problem, given its international population of oil people, etc. Makes you not want to travel anywhere, being in crowded airports or trains. Will be watching. Thanks for this post.

  • Impoverished, crowded, urban areas . . . . Viruses as nature’s great equalizers, and we have almost no defenses. Make a habit of washing your hands every time you come in the house, and you probably already leave your shoes at the door :-} This will rearrange the airline industry . . . .

  • TimW

    It’s very scary to see what is going on over there. Frontline did an amazing job of putting a face to the ebola crisis and one of the most heartbreaking things was hearing a little girl cry out as she was being brought into a field hospital.
    Health care is one of those high transformity processes so it is not surprising to see it constrained on the global scale as energy reserves start to dwindle. Though I think the main issue, that unifies this crisis to global war on terror, is inequity.

    • Crises like this make it hard to examine the issues, as the inequity is so blatant, and the crisis exposes the flaws in our system, which are great. I think our vaunted US healthcare system could be a big failure in a situation like this. We sold our community hospitals to corporations in the 1990s, and we’ve been sucking the life out of them ever since. There is no redundancy or organizational slack in our healthcare system, and our public health system is a skeleton. We have too much of the wrong kind of healthcare . . . . it could be converted so easily into a more equitable and sustainable system, but the corporations would have to let go.

      http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61613-5/fulltext

  • hwf

    I’ve posted your article on facebook, Mary, describing it as the best single description of the problems with the current pandemic. I wonder, however, if the risk from Ebola itself may not be as great as you imply, at least for “first-world” countries. Although Ebola can be spread by almost any direct contact, including droplets, it does not appear all that contagious except presumably for those who must care for those who are vomiting or have diarrhea from the disease. To that extent, first-world sewers, running water, and intact governments and police forces provide some protection as long as they last. The economic problems may prove decisive, however, as the pandemic effects third-world countries that are important parts of the global economy: OECD countries are much more vulnerable to supply-chain interruption and cascading shocks once international trade is substantially affected, as it will be. David Korowicz may be discuss many aspects of the fragility of our systems, how we’re not only subject to perhaps inevitable decline but also right now to catastrophic shocks and immediate collapse: http://www.feasta.org/2012/06/17/trade-off-financial-system-supply-chain-cross-contagion-a-study-in-global-systemic-collapse/.

    Obviously, our government, and we as individuals, need to plan immediately to put some redundancy into the system in case it’s needed for survival. Perhaps then everyone will learn something, maybe even before it all collapses, maybe even if it doesn’t.

    • Thanks, HWF, your question is the big question here for public health in first world countries. In trying to pull together the big picture and not narrow my focus too much to details, I danced around this most important issue a bit, especially since it’s complicated, and there is no hard science on this. Thanks for letting me clarify my thoughts, because you are asking the real question that we need to answer here. First read this long, heartbreaking account of a physician in Lagos who appears to have contracted Ebola through indirect contact by touching a victim’s IV bag. I’ve excerpted the critical statement below:

      “The following day however, his condition worsened. He barely ate any of his meals. His liver function test result showed his liver enzymes were markedly elevated. We then took samples for HIV and hepatitis screening. At about 5.00pm, he requested to see a doctor. I was the doctor on call that night so I went in to see him. He was lying in bed with his intravenous (I.V.) fluid bag removed from its metal stand and placed beside him. He complained that he had stooled about five times that evening and that he wanted to use the bathroom again. I picked up the I.V. bag from his bed and hung it back on the stand. I told him I would inform a nurse to come and disconnect the I.V. so he could conveniently go to the bathroom. I walked out of his room and went straight to the nurses’ station where I told the nurse on duty to disconnect his I.V. I then informed my Consultant, Dr. Ameyo Adadevoh about the patient’s condition and she asked that he be placed on some medications.”

      http://www.bellanaija.com/2014/09/15/must-read-through-the-valley-of-the-shadow-of-death-dr-ada-igonoh-survived-ebola-this-is-her-story/

      This is one of those indirect contacts with fomites (inanimate objects that can harbor viruses and bacteria) described in the handwashing study in the post. This is where HCW cheat a bit, and skip gloves or handwashing, because indirect contacts are so ubiquitous and endless in a complex healthcare setting. Such a simple act–she picked up the IV bag and hung it back on the stand–but she didn’t wash her hands afterward. Ebola is a very messy disease, with viral load scattered everywhere–in this case probably invisible fecal material on what looked like a very clean IV bag, from the patient carrying the IV bag to and from the bathroom, or even fecal material in the bed linens. I don’t know why the MSM is so het up about airborne transmission–droplet and contact transmission is more than enough to create a global pandemic in this disease, since Ebola spreads blood and body fluids far and wide in its dissemination, and the research shows that EBOV lasts on fomites if it is in body fluids, for quite a while (thus the workers with bleach backpacks sanitizing everything). It is the indirect contacts that will make first world countries vulnerable, with exposures through bathroom fomites, airplane seats, and, well, just use your imagination.

      So your statement that “it does not appear all that contagious” is the critical issue here that has got the experts confused. You said it: “except presumably for those who must care for those who are vomiting or have diarrhea from the disease.” EBOV doesn’t need airborne transmission when it has droplets, vomit, and diarrhea spreading everywhere, onto everything.

      Then read the post below (and linked email) which describes the reason for the widely varied methods of HCW protection as we try to understand the chain of infection. Anyone who cares for patients with this disease process is vulnerable. A hospital setting with stellar infection control processes is preferred, but I don’t think those exist outside of Biohazard 4 facilities. Most hospital handwashing studies yield an average compliance of less than 50%, even on a good day. Once the epidemic gets out of control in home settings where infection control is much looser, we’ve got a pandemic on our hands, unless we quarantine assiduously. And we don’t have the public health surveillance system for 300 million people, much less 7 billion. Absolutely first world running water and sewers are a big help, but you can’t get the populace to wash their hands (unless they’re scared to death). The spread of this pandemic will result from hospitals with inadequate infection control and urban settings where EBOV spreads through home care of patients in denial or not hospitalized because we will quickly run out of room. And Korowicz is right, an overly complex system can fall apart faster when exposed to novel shocks because it is all connected and critically reliant on the other operational parts.

      “From: Bjorg Marit Andersen [edited]

      Infection control concerning EVD is not working, especially when more than 240 [now 300] healthcare personnel have been infected, and more than 120 workers have died. Guidelines used to control SARS in 2003 should be used, not “contact and droplet protection of 1-2 meters,” as is still recommended by WHO.

      Personal protective equipment (PPE) for contact and airborne infections should be used because of

      a) respiratory symptoms,

      b) a big distance — up to 9 meters — for droplets when coughing and sneezing (Bourouiba et al. J Fluid Mechanics 2014;745:537-563.),

      c) re-aerosolization from the environment, bed clothes etc.,

      d) long survival of the virus outside the body, and

      e) high lethality.

      Healthcare workers (HCW) and helpers should be protected with PPE as they were during the SARS epidemic. The SARS epidemic was an infection control success by the healthcare system of some countries in Asia in 2003. But WHO should not repeat the same failure as was done during the early phase of the SARS-epidemic by using “contact and droplet isolation.” Separate hospitals for EVD should be built, like in China (1000 beds in 8 days for SARS), and only patients with laboratory documented EVD should be cohorted. Suspected cases should be isolated separately.

      HCW and helpers should be trained and especially observed concerning [putting] PPE on and taking [it] off. The observers should also use PPE. During the SARS epidemic, HCW were re-contaminated by not knowing how to take off PPE.

      Exposed people and patients with other diseases should be treated in professional triages to reduce the population’s fear of being EVD-infected during contact with healthcare. Exposed people should be taken care of by professional helpers.

      There is a need for a lot of resources, especially concerning infection control work.

      — Bjorg Marit Andersen, MD, PhD Professor in Hygiene and Infection Control Speciality: Medical Microbiology”

      http://crofsblogs.typepad.com/h5n1/2014/09/promed-mail-on-ebola-infection-control-is-not-working.html

      • hwf

        It’s important to distinguish between the limits of communicability and the likelihood of it. Yes, for 100% security, protection against droplets and fomites may be necessary. And yes, our hospitals have limited infection control. (That’s why, e.g., we still have endemic MERSA.) Nevertheless, there’s a huge range of actual communication rates among infectious agents. That previous Ebola epidemics have been controlled even in a desperately poor African countries suggests that the disease is usually not very communicable. Of course, it’s communicability may have changed, or may change. (It appears that the case fatality rate has declined significantly, which in itself may make it more communicable, but also underlines that the virus may be changing.)

        It still seems that our big risk is not from direct spread but from global trade shut-down if and when it spreads to other developing countries with weak governments, presumably first Nigeria but also the Middle East, Pakistan, and ultimately the rest of South Asia. If international trade grinds to a halt, only countries with very strong governments that can furnish basic necessities without imports (Cuba and maybe China) may survive. Without any spread of the pandemic to them, the OECD countries could still experience severe economic contraction and even general systems collapse.

        • You make very valid points, Will, about communicability. Another possible factor is that the transition zone historically was very small villages at the end of the line whose residents rarely travelled very far, mostly on foot. I felt compelled to post the first time on this topic when I saw that it had made it to urban settings–a whole different creature, with different behavior, IMO, especially as overpopulation reaches its limits and cities become more chaotic and inequitable. And that first post was about what it would do to already shaky economies and global trade, yes.

          In first world countries we have a less healthy population generally, as there has been less genetic selection and much rescue by advanced healthcare, and extension of lives, and medical immunosuppression. And then there’s the higher background radiation–why is Japan now suffering from Dengue? And how does overpopulation impact mutation rates–we had one-fourth as many people in 1918, for instance?

          • will

            One can hardly say anything with a great degree of assurance, can one? Let us hope and act so that as a society we recognize our vulnerability in a new way, a way that leads us finally to address it realistically, and that indeed it’s not too late.

          • Just a comment about dengue fever in Japan (where I live)… it moved around quickly in Tokyo because of high population density, popular public parks, and unfamiliarity…. radiation levels in Tokyo are not a concern on the post-Fukushima timescale. Dengue has been booming in Southeast Asia in recent years, and in Manila for example, where there is chronic seasonal flooding in the wet season, and poor sanitation in the slums. Manila is just a short flight from Tokyo and Osaka, and there are many flights every day between Japan and that city. I worry about the Philippines receiving a returning flood of their hardworking expats from Ebola affected regions.

          • Thanks, Peter. It will be interesting to see what types of migration occur in the next decade as people look for a better situation in general.

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  • tom

    I just read that a person without symptoms is not contagious. Unfortunately, it sounds like the symptoms are pretty common ones, fever, headaches, muscle pain, etc., could be alot of things, ebola would not be the first suspect I think. So until it becomes very severe, I’d think a number of people could be infected from that person. I also just read that the two healthcare workers that came to the US have been released. Wow, it’s a death warrant in Africa, but apparently very survivable with intensive US treatment. There’s the money again.

    • Yes, and unfortunately it mimics malaria–there are a lot of people flying on planes with fevers from Africa who have malaria. So most commonly, suspected cases were ruled out as the immigrant was found to have malaria instead–a diagnostic truism, look for horses (malaria) instead of zebras (Ebola). But as this epidemic grows, Ebola zebras will become horses. Thus the WHO is scrambling, above, to provide guidance to ports of entry. I don’t think we can count on countries of departure in West Africa to do thorough screening, and we certainly can’t rely on self-reports on customs declarations, as India tried to do, since someone fleeing to a better situation will deny any previous contacts. Yes, Ebola is more survivable with good care, or at least thorough oral replacement fluids with proper electrolyte balances.

    • will

      I think it’s important to emphasize again that available treatments are nonspecific and may have little effect on survival. Quarantine is all important and the ONLY way to control the pandemic. Fortunately, the disease doesn’t (yet) seem very contagious, even though it may occasionally spread without much contact. Unfortunately, the world often can’t stop an epidemic that isn’t very contagious. Witness the devastation that AIDS has caused.

      • Javier

        If AIDS start killing fast as Ebola… then you will zero contacts without condoms 🙂 on this world you need to be punished by sure to behave yourself.

  • http://reliefweb.int/sites/reliefweb.int/files/resources/WHO_EVD_Guidance_PoE_14.1_eng.pdf

    WHO just published recommendations for international points of entry (airports). TSA as physicians, to assess, diagnose, and clean up, too. Do you think TSA is up to this? We’re going to need a lot more PPE.

    • will

      No, the TSA isn’t up to it now, but it may become so. Unfortunately, though, we may be pursuing impossible ends and end up failing to do the possible. It could be a classic case of the perfect being the enemy of the good. With Ebola, there’s a big difference between having 100% prevention and control, which is what we’d like, and enough control to prevent an epidemic. Of course, we don’t know enough about either of those, but especially IF contagion is generally as unlikely as it has been, we probably have enough control now to prevent an epidemic. What may derail us is either panic at home, or more likely, a rapid decline as our economy shuts down in our ability to respond as we have been able to do for other public health problems.

  • Here’s the bottom line. The way Ebola could/would/will spread internationally is when patients are cared for in communities without quarantine. Controlled, scrupulous isolation care in hospitals works, until it doesn’t. The disease is not that contagious, but it is very infectious. Any care-giving without isolation gear rapidly becomes a death sentence and mode of rapid spread because of the infectivity and messiness of the disease. Control of this disease works until patients either avoid hospitals or can’t get into hospitals because they’re full, or the hospitals become centers for transmission because they’re overloaded or have shoddy infection control. Many hospitals have shoddy infection control and not enough caregivers on a good day, much less a bad day. Americans are more vulnerable than we perceive, and caregivers can be our protection, until they become the mode of transmission. It’s about the numbers that overwhelm the system, and in the case of US healthcare, there is little resilience or slack in a high-transformity, capitalist system bent on profit.

    http://oig.hhs.gov/oei/reports/oei-06-13-00260.pdf

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  • kushalkumar

    In order to bring Ebola under control, this writer is suggesting a very simple and easy remedy which may be tried by combining with any right type of related medical or healing treatment for effective wellness of a patient. Green or yellow or a mix of both ,colored dress for the patient could be useful. Similarly, bed -sheets and pillows ought to be of said color. The doctors/nurses/and other staff engaged in treating or looking after the Ebola infected patients may usefully also wear similar dress to so that they do not attract infection from patients. A question may obviously arise of making distinction of identity between patients and those looking after them. A clear separating distinguishing color between patient and doctor/nurse/staff may be chosen, as convenient, from out of (1) Green (2) Yellow (3) Mix of two so that there is no confusion of identity,

    Note :- I thought I may take this opportunity to bring to knowledge of readers my partly related distinguished and useful article published recently at http://www.alternativetomeds.com/blog/2014/11/tackling-mental-illness-with-alternative-remedies.

  • tukangtahu upload

    Ebola Myths & Facts For Dummies-For Dummies (2015).pdf – 1.3 MB
    http://www.anafile.com/c38rq9xoy6xf.html