From an expert observer upset with CDC’s betrayal of the public trust. We believe the US Government should nationalize the patents on Ebola, and radically over-haul CDC as well. The nationalization of the atomic bomb patents provides a precedent.
The U.S. Centers for Disease Control and Prevention (CDC) guidelines published for health care professionals attending to an Ebola, or suspected Ebola, patient, in a hospital or other healthcare setting, recommends a minimum of an N-95 mask during aerosol generating procedures [emphasis added] such as intubation.This recommendation may be dangerously inadequate and raises the specter of not only recklessly endangering health care workers, but also the public at large, undermining confidence in the health care system.
In the 24 hours since I wrote that opening paragraph, and submitted the first version of this article for publication, the Washington Post reported that a health care worker who attended to the Ebola patient in Dallas has since tested positive for Ebola. As further indictment of the dangerous insufficiency of the CDC guidelines, the article had this to say:
“The CDC did not consider person to be “high risk,” Varga said. The person treated Duncan, the Ebola patient, after his second visit to the ER, on Sept. 28. The health worker was “following full CDC precautions,” including wearing a gown, gloves, a mask and a protective face shield.”
Returning to the CDC mask guidance, an October 5, 2014 article on this topic notes that the specification for the N-95 mask is that it is designed to block 95 percent of particles 300 nanometers in width or larger. The Ebola virus, at 80 nanometers in width, is much smaller than that, barely one-fourth the size. As such, it could theoretically pass right through the mask, in either direction. So, not only may the CDC guidance be putting health care workers at risk, it may put those who the health care workers come in contact with, in a hospital or other healthcare setting, at risk. That’s you and me, folks.
The U.S. health care system is the country’s largest employer. The opening sentence of the U.S. Bureau of Labor Statistics 2009 report on health care in the U.S., declares that “Health care touches the lives of nearly everyone in the United States at some point.”
Undermining confidence in the health care system could have devastating impact, particularly in the face of a pandemic. According to the Washington Post report, the hospital in question has put its emergency room “on diversion”, which is to say they are not taking any new patients, but will continue to provide care to the existing patients. There may be an Orwellian interpretation to that “continuing care” – patients in the hospital may now be on a de facto quarantine – and perhaps they should be. Particularly since the chief clinical officer for the firm operating the hospital reportedly continues to declare that the hospital is safe for their workers, disregarding the simple fact that an infection has occurred. Orwellian once more.
Dr. David Nabarro, special envoy of the UN secretary general on Ebola, addressed the UN General Assembly on October 10, 2014 and stated that, in his 35 years experience as a public health doctor, he has been involved with many disease outbreaks and, indeed, some pandemics, but had “never encountered a challenge like this one in my professional life.”
Dr. Nabarro further declared that the number of cases is doubling every 3 to 4 weeks and that, unless control efforts succeed, the world may have to “live with Ebola virus, forever.” He stated that behavioral issues need to be addressed, one of which is that potential Ebola victims are frightened and turning to traditional healers (e.g., shamans, witch doctors) or families or friends, instead of a health care facility. While the UN special envoy would like the world to believe that this is simply a case of frightened victims acting irrationally, the reality might be much worse.
Reluctance to enter a health care facility in that region is understandable and would represent a dilemma of tragic proportions. Here’s why: health care workers, many highly skilled and adhering to CDC guidelines, represent 10 percent of all deaths in the current Ebola outbreak, which present yet another indictment that the CDC guidelines do not offer adequate protection against the Ebola virus. The infection of the health care workers in Madrid and now Dallas, both of whom were trained in infectious control procedures and employing personal protective equipment in accordance with CDC guidelines, is even further evidence that the fault may rest with the insufficiency of the guidance itself, not the worker, and not for the lack of the recommended equipment. Madrid and Dallas are not Monrovia and Freetown.
As National Public Radio reported in September 19, 2012 in the earlier outbreak of Ebola in the Democratic Republic of Congo, health care workers represented over one-third of all cases. The Guardian recently reported that, in the wake of the nurse’s assistant who became infected while attending to an Ebola patient in Spain, some medical staff are refusing to treat Ebola patients, some are resigning, nurses are being stigmatized, and potential replacement staff are refusing offers of employment, in a country with high unemployment.
Now that there is a confirmed case of Ebola in the U.S. that has passed from patient to health care worker, mirroring the earlier incident in Madrid, we should expect similar repercussions. As noted above, the afflicted Dallas hospital’s emergency room is diverting new patients to other facilities.
The early symptoms of Ebola are similar to malaria or even the common flu, which is far more prevalent than Ebola. Likewise, the mortality rate for malaria or the flu is very low compared to Ebola. Admitting yourself to an environment that is contaminated with Ebola, or exposing yourself to an Ebola-infected health care worker who is using an N-95 mask, with the odds being that you have malaria or the flu, could be the worst decision you ever make. Trading malaria or the flu for Ebola is a poor bargain. What’s desperately needed at this juncture is reassurance that the risk of doing so is minimal.
Indeed, there is an argument to be made that it might be advisable to avoid health care facilities and to keep some distance from health care workers in Liberia, Guinea, and Sierra Leone, until such time as genuinely effective controls are established. In light of the new development in Dallas, that recommendation may apply here in the U.S. as well.With an incubation period of 2 to 21 days, a health care worker may be infected and be in constant daily contact with patients for weeks on end. No amount of contact tracing could ever hope to put that genie back in the bottle.
The New York Times reported on October 11, 2014 that the official policy for potential Ebola victims in Sierra Leone is to now provide support to attending to the victim in a home setting, due to a shortage of health facilities – a case where a tragic shortage may prove to be a benefit in disguise.
The CDC needs to treat this problem more seriously. Certainly any protection, even a cloth handkerchief, is preferred to none, and the chronic shortage of medical supplies in developing countries cannot be disputed. But continuing reliance on measures that are dubious is dangerous. It does not seem excessive to recommend self-contained breathing apparatus when treating an Ebola patient, particularly in a health care setting while employing an aerosol generating procedures such as intubation.
Or is this yet another instance where political considerations override all else? We do have mid-term elections coming up and if you think there aren’t political operators making that calculation, you are being naive to the extreme. What role does political correctness play in this tragedy – are we so concerned about offending the world that we refuse to do what neighboring African nations have done – restrict travel to and from those nations? Why not ask the poor person who just got infected from Mr. Duncan how he/she feels about travel restrictions or how all infected health workers, and their families feel knowing that CDC guidance is dubious. Is bureaucratic ineptitude and arrogant disregard for the general populace an even greater epidemic that we need to concern ourselves with?