A Caregivers Disease

Yet again, Ebola has infected a caregiver: a nurse who gave extensive care to Thomas Duncan in Dallas. She wore full protective gear and is not aware of any breach of anti-infection protocol. [NYT 10/13/14] This is worrisome, but consistent with the pattern we have previously noted: How Contagious is Ebola?

Update 10/15/14: Another nurse has been diagnosed. This is tragic, and unnecessary, but completely predictable given the criminally shambolic conditions under which Duncan was treated. [AP / Mashable 10/15/14]  Obviously, America has to do a lot better. But there’s every reason to think that we will rise to the occasion. What cannot continue is for Ebola patients — especially in the last stage of the illness — to be treated casually or on an ad hoc basis. Ebola will bite you if you don’t respect it! But MSF knows how to handle Ebola patients with minimal risk to caregivers. CDC simply needs to take the lessons of Africa and Spain and Dallas to heart. The solution is simple:

  1. All healthcare providers must be trained to identify and isolate potential Ebola patients, with minimal risk to themselves and others, and
  2. Confirmed Ebola patients must be treated by fully-trained professionals, with top-notch equipment, in well-designed facilities, following clear and prudent protocols.  At the moment there are plenty of beds in the four bio-containment hospitals but at least one hospital should gear up in each major city to be able to safely treat Ebola patients. Full bio-containment isn’t necessary for Ebola.

Some facts about Ebola are becoming clear:

  • Those at greatest risk are caregivers — either healthcare providers or those who care for a seriously ill patient in the home. Intense focus and attention to detail are needed to protect a caregiver, especially when a patient is in the last stage of the illness.
    • The African protocol developed by Médecins Sans Frontières / Doctors Without Borders (“MSF”) has been extraordinarily successful, although some members of their staff have nevertheless been infected.
    • The protocols used in Spain and in the U.S., as implemented so far, have not given caregivers complete protection.
  • Patients are most infectious in the last stage of the disease. There is no evidence of transmission before a person becomes symptomatic, and even after symptoms begin patients seem to be remarkably non-contagious until the final stage. The main focus should be on where patients are, and who has contact with them, in the final stage of the illness.
  • Corpses are also highly infectious. African customs of washing and touching corpses present a second important channel of infection, that needs to be discouraged. Developed countries should not encounter this issue, however, so long as suitable precautions are taken.

These lead to a few specific conclusions:

  • In the developed world the main risk presented by Ebola is to healthcare providers. There are plenty of beds, and nobody is going to try to care for an extremely ill patient in their home. CDC needs to refine its anti-infection protocol and to provide better training and support to hospitals and staff who treat Ebola patients, and similar steps need to be taken in other developed countries. There’s every reason to think that this will happen, and indeed is already happening. Ebola will teach us, as I’m sure it taught MSF in the early outbreaks, what we need to do to stop it. I still see no reason — apart from possible mutation — why the developed world should have any problem snuffing out little Ebola outbreaks as they inevitably occur.  (I’m still quite concerned about the ability of other poor countries, with crowded slums, to do the same.)

    • Healthcare providers need to be monitored for 21 days after their last contact with an Ebola patient. Duh!
  • West African healthcare providers also need to be better protected, ideally with identical gear and an identical protocol to those in the developed world.
  • In West Africa the key to stopping Ebola is isolation beds for patients in the last stage of illness. The best feasible standard of care should be provided for humanitarian reasons, but from the perspective of stopping the epidemic the critical element is isolation. The only way to bring the Effective Reproduction Number down below one is to break the cycle of transmission to home caregivers, by isolating patients and caring for them under the anti-infection protocol. Again, this issue has been identified and is being dealt with. The big question is whether beds can be provided fast enough to get ahead of the epidemic.
  • West African funeral practices also need to be addressed, and of course corpses must continue to be buried or cremated, which may prove problematic if the numbers of deaths mount as currently predicted. [NYT 10/14/14]
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1 comment
  1. Tprof said:

    The way Ebola affects Health Care workers is troubling. 1 patient approximately knocks off ~20 health workers, either through actual infection or via quarantine requirement for 3 weeks. Not sure whether a quarantined doctor can see as many patients as a non-quarantined doctor. At this rate, how many concurrent Ebola patients in theory could paralyze most hospitals in Dallas? My guess is around 30-50. Boston should have a much higher capacity, but smaller cities in the US may suffer a lot.

    Like

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