Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas - Died

[hawkeye]

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

Does anyone know if this guy went from the ambulance into isolation, or went through intake in the ED first? Wondering how far the contact tracing is going to have to go.

They would have logs/tracing. Hopefully straight to Isolation. But if he had gone straight to isolation does that mean the ambulance was immediately pulled and the personnel didn't go home to their families that night but rather went straight into quarantine? Doubtful - it sounds like at least a day has transpired before action was taken.

 

[sharon sanders]

Re: Discussion - 1st ebola case in US (not deliberate health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (not deliberate health care worker transfer) Dallas, Texas

Please also see the news thread on this topic here.

 

[MHSC]

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

Isn't it most likely that it was his second visit to the ER that was via ambulance, not the first time? If so then once the hospital personnel suspected ebola the EMT's and their rig would have been dealt with asap and the unit taken out of commission while they waited for test results.

It was taken out of service upon diagnoses so two days after he rode in it and two days for the personnel & patients to be exposed.

 

[MHSC]

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

They would have logs/tracing. Hopefully straight to Isolation. But if he had gone straight to isolation does that mean the ambulance was immediately pulled and the personnel didn't go home to their families that night but rather went straight into quarantine? Doubtful - it sounds like at least a day has transpired before action was taken.

What I have heard suggests that the personnel & unit were not isolated until the patient was confirmed.

 

[hawkeye]

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

What I have heard suggests that the personnel & unit were not isolated until the patient was confirmed.

The hospital issued a press release on their web site on the 29th. It should have been pulled as soon they suspected it. Are ambulances disinfected between runs - just as a normal operating procedure?

 

[MHSC]

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

The hospital issued a press release on their web site on the 29th. It should have been pulled as soon they suspected it. Are ambulances disinfected between runs - just as a normal operating procedure?

In theory the stretcher & equipment are disinfected after each patient and the unit at the end of the day. The reality is it can go days because there isn't enough time between patients or enough motivation after a long hard day. Keep in mind some of these people work 24 hr shifts. Fatigue plays a huge role in mistakes whether the wrong med is given or if ppe is forgotten. If the inside of the unit looks clean after running 24 hrs or 12 hrs straight often it's called good enough or given a cursory wipe down but far from the thoroughness needed for this.

 

[hawkeye]

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

Re: US - Texas: Patient tests positive for Ebola in Dallas - travel history to Liberia

In theory the stretcher & equipment are disinfected after each patient and the unit at the end of the day. The reality is it can go days because there isn't enough time between patients or enough motivation after a long hard day. Keep in mind some of these people work 24 hr shifts. Fatigue plays a huge role in mistakes whether the wrong med is given or if ppe is forgotten. If the inside of the unit looks clean after running 24 hrs or 12 hrs straight often it's called good enough or given a cursory wipe down but far from the thoroughness needed for this.

At least it is apart of the protocol. Hopefully this serves as a wake up call and compels those who might let it go until tomorrow to do it as often as possible.

 

[JJackson]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

The flight left Liberia on the 19th and all passengers were being temperature checked by that time. Elevated temperature is one of the most reliable of the symptom set. Therefore the patient is very unlikely to have been symptomatic until after they reached the US. If the CDC, WHO et al are correct and patients are not contagious prior to symptom onset (and there are no documented cases to challenge this to date) all contacts prior to about the 22nd should not be a problem.
Early symptoms are so vague it is going to be very difficult to stop the first round of infections from an index case but once that patient is diagnosed it is relatively straightforward to stop the next round of infections assuming, and that is a big assumption, you do not miss any of patient zero's contacts.

While 'health tourism' is a potential danger - as argued by FOXP3 - there are aspects of this cases that do not fit. If the patient knew he was exposed then when he sought treatment on the 24th, and was about to be sent home, he would have said 'I have just returned from Liberia do you think it could possibly be Ebola?' at which point he would have immediately been isolated and the CDC contacted and he would have got the treatment he came for.

 

[MHSC]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Hawkeye

Here is your answer, 3:32 today they quarantined them.

The city of Dallas also activated its Emergency Operations Center and is on Level 2: High Readiness after the person was confirmed to have the virus at 3:32 p.m. Tuesday, according to a release. The Dallas Fire-Rescue EMS crew that transported the patient Sunday as well as the ambulance were quarantined, Mayor Mike Rawlings said. None are showing symptoms.

http://thescoopblog.dallasnews.com/...t-hospital-continuing-normal-operations.html/

 

[hawkeye]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

The flight left Liberia on the 19th and all passengers were being temperature checked by that time. Elevated temperature is one of the most reliable of the symptom set. Therefore the patient is very unlikely to have been symptomatic until after they reached the US. If the CDC, WHO et al are correct and patients are not contagious prior to symptom onset (and there are no documented cases to challenge this to date) all contacts prior to about the 22nd should not be a problem.
Early symptoms are so vague it is going to be very difficult to stop the first round of infections from an index case but once that patient is diagnosed it is relatively straightforward to stop the next round of infections assuming, and that is a big assumption, you do not miss any of patient zero's contacts.

While 'health tourism' is a potential danger - as argued by FOXP3 - there are aspects of this cases that do not fit. If the patient knew he was exposed then when he sought treatment on the 24th, and was about to be sent home, he would have said 'I have just returned from Liberia do you think it could possibly be Ebola?' at which point he would have immediately been isolated and the CDC contacted and he would have got the treatment he came for.

The point about indexes first round infections is very key. We are on day 6 going into day 7. Any initial contacts would most likely be symptomatic.

 

[hawkeye]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Hawkeye

Here is your answer, 3:32 today they quarantined them.

The city of Dallas also activated its Emergency Operations Center and is on Level 2: High Readiness after the person was confirmed to have the virus at 3:32 p.m. Tuesday, according to a release. The Dallas Fire-Rescue EMS crew that transported the patient Sunday as well as the ambulance were quarantined, Mayor Mike Rawlings said. None are showing symptoms.

http://thescoopblog.dallasnews.com/...t-hospital-continuing-normal-operations.html/

Great find! Glad they are not showing symptoms!

 

[sharon sanders]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Agreed. MHSC - I made a copy of your post to the news thread.

 

[hawkeye]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

From MHSC's link, the following comes from Dr. Edward Goodman, hospital epidemiologist at the Texas Health Presbyterian Hospital

Head-to-toe coverage for doctors treating the patient is not required, Goodman said. Doctors will be wearing two waterproof gowns, gloves, surgical masks, eye protection and shoe protection.

It does not require a highly specialized unit to care for someone with Ebola, Goodman said. But in the event that a negative pressure unit is required, the hospital has that capability.

 

[Sharky]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Quoted from the news thread:

What We Know About the Texas Ebola Patient
By Maggie Fox

How did he get infected?
...
CDC and Texas health officials are not giving details about the patient. But he would have to have been in close contact with someone who was sick with or died from Ebola in Liberia. Ebola spreads in bodily fluids such as blood, vomit or diarrhea. And those fluids have to get inside your body through the mouth, eyes or nose, or in a cut or via a needle stick. The virus doesn’t spread in the air and it cannot persist on surfaces like flu viruses can.
...
http://www.nbcnews.com/storyline/ebola-virus-outbreak/what-we-know-about-texas-ebola-patient-n215451

I've been following the outbreak in West Africa since the very early days, and I've come to believe that the above statement about the mode of transmission is unlikely to be correct. There have been quite a few stories of infection of "unknown origin," among other things.

There was also a virologist in Nigeria who explicitly said he thought transmission was possible via droplets and surfaces.

My understanding is that there are only a half-dozen or so facilities in the US that are capable of correctly testing for airborne or more complex modes of transmission, and that this has not in fact been done for the Liberian strain (apparently closely related to Ebola Zaire, but not identical).

Does anyone else here have similar concerns?

 

[MHSC]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Quoted from the news thread:



Does anyone else here have similar concerns?

Yes,

At one time there was a graphic that discussed droplet transmission within a meter of the patient. You can find it here now in this blog is written by a highly respected Queensland virologist. There is a lot on the site if you want to learn.

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



We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks.

http://www.cidrap.umn.edu/news-pers...ers-need-optimal-respiratory-protection-ebola

 

[curiosity]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

The recommendations for protective equipment by the CDC are standard and droplet precautions- which is what the Texas hospital describes as protection for their staff.

An airborne virus is very different than one that can be carried on droplets through aerosolization - like suctioning, forceful vomiting, coughing, etc ...

-------------

I think there is a reasonable possibility, based on the information related to this patient's interaction with healthcare prior to recognition, that secondary cases in the patient's family and the unprotected healthcare providers will occur.

I also find it interesting that the US - of all the places in the world - just happens to receive the first case exported from the African continent.

 

[Sharky]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

An airborne virus is very different than one that can be carried on droplets through aerosolization - like suctioning, forceful vomiting, coughing, etc ...

True. But a virus that can be carried on droplets is also much different from one that is only spread through "direct contact" between infected bodily fluids and mucus membranes or open sores, which is what the CDC and others appear to be saying to the public.

Yes, it's harder to spread than influenza -- but it's easier than AIDS.

It sounds to me an awful lot like crowd management, not disease management.

On a related subject, does anyone know if Ebola transmission via mosquitoes or other insect vectors has been investigated? I realize they aren't a long-term repository, but I'm wondering about short-term transmission. As I understand it, West Africa is starting to enter malaria season, which means mosquitoes.

 

[Graupel]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks.

http://www.cidrap.umn.edu​

Sorry, but there should be a clear disclaimer here: CIDRAP has as a "Leading Underwriter" 3M, which is a primary manufacturer of the respirators under discussion. Moreover, a 3M employee is acknowledged as a consultant on the report.

This doesn't necessarily change the underlying epidemiological evidence-base, but it should be clear and transparent.

 

[Pirante]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Based on the patients statement of initial symptoms on the 24th, we are at +6 today and should probably start seeing the first secondaries soon.

And two to five days from now, if any of the initial ER contacts were infected.

Such a mess.

Although at least this gives me some confidence that he was probably not symptomatic on the flight. That being over 10 days ago, there should have been more sick people showing up.

Although, the fact that it was only 10 days ago makes me feel like the patient was probably infected at least a couple of days before their flight, maybe as many as 5.

 

[sharon sanders]

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

Re: Discussion - 1st ebola case in US (excluding health care worker transfer) Dallas, Texas

I think we can observe the ebola situation in West Africa and the cases transferred into the US and come to a couple of conclusions:

1) If ebola was as transmissible through air as flu, it would have spread throughout the world as a flu wave does. We have not seen that. There would be 10s of thousands dead in several global regions by now after 6+ months.

2) Apparently whatever the health care workers at Emory University Hospital wore for PPE provided enough protection that no one became sick.

It appears the current CDC ebola PPE recommendations are adequate for the current circulating strain of ebola.