There is very interesting news out of Pakistan today that the father of a child who has developed polio has been arrested because he refused to allow his son to be vaccinated:
After a polio case was detected here on Thursday, the Kohat administration arrested the father of the affected child because he had refused to get his child vaccinated against polio when vaccinators visited his home. Two health supervisors and a patwari have also been taken into custody for showing negligence in performing their duty.
Three-year-old Mohammad is the second victim of polio in Dhodha area of Kohat district this year.
Deputy Commissioner of Kohat Riaz Khan Mehsud told Dawn on telephone that he issued orders for arrest after an inquiry revealed that the father of the affected child, Mullah Mohammad Yousuf, had not allowed vaccinators to give polio drops to his son.
But Yousuf is not the only parent who has been arrested:
He said 56 people had so far been arrested this year for refusing to get their children vaccinated against polio.
Also on Thursday, two men were arrested in Kohat for not allowing vaccinators to give polio drops to their children. They were identified as Amir Khan and Hassan Khan.
Islamic extremist groups in Pakistan agitate against polio vaccines, spreading conspiracy theories that the vaccines are Western attempts to kill or dominate Muslims. They even attack health workers and in 2014, those attacks killed more people administering vaccines than the disease itself killed.
But of course, in a civilized country like the United States, there couldn’t be misguided attempts to prevent vaccination despite the solid scientific basis of the public health benefits of vaccines, could there? Sadly, the mass delusion that has led far too many parents to leave their children unvaccinated due to unfounded fears of autism is having the very predictable result of outbreaks of viral diseases previously under control. Here’s the latest on the current outbreak of measles that epidemiologists have traced to Disneyland. Unfortunately, we are learning that because of the reckless behavior of not vaccinating children, even those who have been vaccinated are now developing the disease because of the increased exposure from the outbreak: →']);" class="more-link">Continue reading
Back in late September, just a week before Ebola panic hit a peak in the US when a patient in Dallas was diagnosed with the disease, the CDC produced a remarkable study in which they modeled the expected number of Ebola cases both with and without intervention. That study received a huge amount of press coverage, primarily because the model predicted that without intervention by public health authorities, as many as 1.4 million people could be infected. By contrast, with a program of isolating infected patients and educating survivors on proper burial techniques, the model showed that the outbreak would be much less widespread. The modeling projected cases through yesterday’s date, January 20.
Less reported in the media at the time was the projected number of cases under the scenario of intervention. The model predicted an actual number of cases between 25,000 and 30,000 by this week and a reported number of cases of nearly 10,000. Here are the two projections placed alongside one another:
The latest data from WHO indicate just over 21,000 cases as of January 11. That is a remarkable achievement by the team that developed the model. The observed actual number of reported cases fell squarely within the range predicted by the model. With the influx of health professionals to the region to provide care for infected patients, it seems likely to me that the correction factor applied in the CDC model to correct from the reported number of cases to the actual number would be very different now, so that the reported number and actual number would be much closer to one another, making the prediction even more accurate.
Last time I posted on progress in stopping the spread of the virus, we saw that the rate of appearance of new cases was dropping rapidly in Liberia but was still accelerating in Sierra Leone. The good news is that the improved practices have finally been implemented sufficiently in Sierra Leone that the rate is now dropping there. Here are the plots of weekly new cases in the two countries from the latest WHO Situation Report:
Although the battle is not yet over, all indications are that the outbreak is well past the worst phase and should end soon. Considering how closely the CDC model predicted the eventual size of the outbreak with the control measures that were implemented, it seems safe to say that the world would have witnessed a truly horrific level of spread of the virus had improved safety measures not been implemented. As of the January 14 WHO Situation Report, a total of 825 health care workers have been infected, with 493 of them dying. Without their sacrifices, many more would have been lost.
As the last Friday before Christmas, late yesterday afternoon was the most obvious Friday news dump hour of the year, and the government didn’t disappoint. The Government Accountability Office released the results of a twenty-three month long study of the genetic analysis that was used to tie the material found in the anthrax attacks of 2001 to the laboratory of Bruce Ivins, whom the FBI concluded (pdf) was solely responsible for the attacks. The FBI’s conclusion is highly suspect for many reasons. On the science side, it is very unlikely that Ivins could have produced all of the attack material on his own and the detailed chemistry of the attack spores suggests that highly sophisticated materials and techniques unavailable to Ivins likely were used to prepare the attack material. Regarding that second point, note that even William Broad refers indirectly to the chemistry concerns in his New York Times article on the GAO report:
To the regret of independent scientists, the report made no mention of an issue beyond genetics: whether the spores displayed signs of advanced manufacturing. They have pointed to distinctive chemicals found in the dried anthrax spores that they say contradict F.B.I. claims that the germs were unsophisticated.
Evidence of special coatings, they say, suggests that Dr. Ivins had help in obtaining his germ weapons or was innocent.
The GAO study was undertaken, in part, because of questions raised by the National Academies study released in 2011 and with special prompting by Representative Rush Holt, from whose district the letters likely were mailed. The GAO study focused on obtaining a better understanding of the validity of the genetic analysis that was carried out and the statistics underlying the conclusions reached.
For a refresher, a helpful illustration from the GAO report shows the underlying biology of the genetic analysis that was carried out in the Amerithrax investigation. Here we see photos of a typical colony of the Ames strain of Bacilus anthracis on an agar plate and four variant colony types that occurred at low frequency when the attack material was spread out on agar so that colonies arose from single cells of the overall population of bacteria that were present in the attack material:
DNA sequence analysis was employed to identify the changes that led to these variant colony shapes. The FBI then commissioned private laboratories to develop DNA-based tests (relying on polymerase chain reaction, or PCR, methodology) that could be used to screen the large bank of isolates of the Ames strain that the FBI had accumulated through a subpoena submitted to all 20 laboratories known to have isolates of the Ames strain. Developing these assays represented a new frontier in forensic genetics and it did not prove possible to develop tests for all of the mutations identified in the original DNA sequencing. In the end, four tests were developed by the four different contractors.
The Amerithrax report stated that of the 947 samples included in the final analysis, only eight showed all four of the DNA changes the tests were designed to detect. Seven of those samples came from the laboratory where Ivins worked (U.S. Army Medical Research Institute of Infectious Diseases, or USAMRIID) and one came from Batelle Memorial Institute in Columbus, Ohio. The FBI noted that there was a record of material being transferred from USAMRIID to Battelle, accounting for the sample found there.
The GAO analysis finds a number of significant issues with the FBI’s work: →']);" class="more-link">Continue reading
Back in late September, the press had a field day with a mathematical model developed by CDC that estimated that if left unchecked, the Ebola outbreak in West Africa could wind up infecting over 1.4 million people. Almost missed in the hysteria over that high number was the fact that this same model predicted that even with key public health measures (patient isolation, monitoring of at-risk population who had contact with infected people and safe burial practices) falling short of 100% implementation, the outbreak could be brought under control around January of next year.
Word has been leaking out for a while now that the rate of new Ebola infections in Liberia is falling. Reports in the Washington Post on October 29 and November 3 told us as much. A chart in the WHO Situation Report for November 5 drives home just how dramatic the decline in new cases has become:
As can be seen in the chart, the rate of new infections for the two most recent weeks is less than one fourth the rate at the peak of the outbreak. Unfortunately, the news for Sierra Leone is not as good. While the rate of new infections may be leveling off, it is not yet falling appreciably:
Digging into the WHO report a bit further, we can find some evidence for how this dramatic drop in new cases has been brought about. We see that 52% of cases are now isolated. The WHO target for December 1 has been set at 70%, with a target of 100% by January 1. When it comes to management of dead bodies, though, the December 1 target has already been surpassed. WHO reports that 87% of the dead are being “managed in a safe and dignified manner” while the targets were set at 70% for December 1 and 100% for January 1. Also, although no benchmarks are reported, WHO states that 95% of registered contacts were reached daily (although in the text of the report, there are suggestions this number may be somewhat overstated).
It should come as no surprise that progress in implementing these basic measures has had a huge impact on bringing down the rate of new infections. It fits perfectly with the CDC mathematical model and it also addresses the known biology of Ebola infections. Patients are most infectious at or near death, so establishing safe burial practices is vitally important. Conversely, identifying infected individuals through daily monitoring of the at-risk population and then isolating infected individuals once symptoms begin means that far fewer people are exposed to people producing large amounts of virus.
Sadly, those who remain exposed are the health care workers who are providing care to those who are infected. Despite shortages of equipment and supplies, WHO and other organizations are doing their best to overcome those shortages and to beef up training to reduce risk to these brave people on the front lines in the work to control the virus. As of this November 5 report, 546 health care workers have been infected, with 310 of them dying. Only four new infections were reported for the week ending November 2, so it is hoped that this rate is also dropping.
Had the alarmists who insisted that this was a new super-strain of Ebola capable of airborne transmission (or even a strain developed in a bioweapons laboratory), it is doubtful that these basic public health measures would have had such a dramatic impact on the rate of new infections. Perhaps those folks can go back to railing about chemtrails or the evils of vaccines, because basic boring science appears to be on the road to controlling the current outbreak before all of mankind succumbs.
In the meantime, we are at about two weeks into the three week incubation period both for anyone “exposed” by Craig Spencer or for Kaci Hickox (or anyone she “exposed”) to show symptoms. No reports of transmission so far, and the odds of any cases showing up are dropping very rapidly from the already very low levels where they started.
See the update below, as of about 2:45 pm, the Times has changed the wording of the erroneous paragraph without adding a note of the correction. Oops. I got off on the wrong paragraph when I checked back. See the comment from Tony Papert below.
For someone who has written on a range of technical issues for many years, the error committed last night by David Sanger could not be worse nor come at a worse time for the important events he is attempting to cover. In an article put up last night on the New York Times website and apparently carried on page A1 of today’s print edition, Sanger and the Times have garbled a key point at the heart of the negotiations between Iran and the P5+1 group of nations as they near the critical November 24 deadline for achieving a full agreement on the heels of last year’s interim agreement.
The article ostensibly was to announce a major breakthrough in the negotiations, although Gareth Porter had worked out the details of the progress last week. Here is what Porter deduced:
The key to the new approach is Iran’s willingness to send both its existing stockpile of low enriched uranium (LEU) as well as newly enriched uranium to Russia for conversion into fuel for power plants for an agreed period of years.
In the first official indication of the new turn in the negotiations, Iranian Foreign Ministry spokesperson Marzieh Afkham acknowledged in a briefing for the Iranian press Oct. 22 that new proposals combining a limit on centrifuges and the transfer of Iran’s LEU stockpile to Russia were under discussion in the nuclear negotiations.
The briefing was translated by BBC’s monitoring service but not reported in the Western press.
Undersecretary of State Wendy Sherman, who heads the U.S. delegation to the talks, has not referred publicly to the compromise approach, but she appeared to be hinting at it when she said on Oct. 25 that the two sides had “made impressive progress on issues that originally seemed intractable.”
As Porter goes on to explain, such an arrangement would allow Iran to maintain a large number of centrifuges continuing to enrich uranium, but because there would be no stockpile of low enriched uranium (LEU), the “breakout time” (time required to highly enrich enough uranium for a nuclear weapon) would remain at about a year. By having Russia convert the LEU to fuel rods for Iran’s nuclear power plant, that LEU would be removed from any easy pathway to a weapon. This would provide Iran the “win” of maintaining its present level of around 10,000 operational centrifuges but give the P5+1 its goal of a longer breakout time. The key here is that unlike a proposal in 2005 where Russia would take over enrichment for Iran, this new proposal would allow Iran to continue its enrichment program while shipping virtually all of of its LEU to Russia for conversion to fuel rods.
Sanger appears to start off on the right track with his article:
Iran has tentatively agreed to ship much of its huge stockpile of uranium to Russia if it reaches a broader nuclear deal with the West, according to officials and diplomats involved in the negotiations, potentially a major breakthrough in talks that have until now been deadlocked.
Under the proposed agreement, the Russians would convert the uranium into specialized fuel rods for the Bushehr nuclear power plant, Iran’s only commercial reactor. Once the uranium is converted into fuel rods, it is extremely difficult to use them to make a nuclear weapon. That could go a long way toward alleviating Western concerns about Iran’s stockpile, though the agreement would not cut off every pathway that Tehran could take to obtain a nuclear weapon.
But about halfway through the article, Sanger displays a shocking ignorance of the real points of recent negotiations and somehow comes to the conclusion that Russia would be taking over enrichment for Iran rather than converting LEU into fuel rods:
For Russia, the incentives for a deal are both financial and political. It would be paid handsomely for enriching Iran’s uranium, continuing the monopoly it has in providing the Iranians with a commercial reactor, and putting it in a good position to build the new nuclear power reactors that Iran has said it intends to construct in the future. And it also places President Vladimir V. Putin at the center of negotiations that may well determine the future of the Middle East, a position he is eager to occupy.
Somehow, Sanger and his New York Times editors and fact-checkers are stuck in 2005, suggesting that Iran would negotiate away its entire enrichment program. Such a drastic move would never be contemplated by Iran today and we are left to wonder whether this language found its way into the Times article through mere incompetence or more nefarious motives meant to disrupt any possible deal by providing false information to hardliners in Iran.
At the time of this writing (just before 9 am on November 4), the Times still has not added any correction or clarification to the article, despite the error being pointed out on Twitter just after 10:30 pm last night (be sure to read the ensuing Twitter conversation where Laura Rozen and Cheryl Rofer work out the nature of the error).
And now, around 2:45 in the afternoon, I see that the Times has changed the erroneous paragraph. So far, I don’t see a note that a correction has been made. Here is the edited paragraph:
Russia’s calculus is also complex. It stands to gain financially from the deal, but it also has an incentive to see the nuclear standoff between Iran and the rest of the world continue, because an embargo keeps Iranian oil off the market. With oil prices falling, a flood of exports from Iran could further depress prices.
Will they ever get around to adding a note? I’ll keep an eye out. Well dang, this is embarrassing. I went to the wrong paragraph when I looked back. The article is still unchanged. Thanks to Tony Papert in comments for catching my bone-headedness.
Yesterday evening, an Antares rocket built and operated by Orbital Sciences Corporation exploded shortly after liftoff. The rocket was intended to ferry supplies and equipment to the International Space Station. Orbital and Spacex have taken over some of the duties supplying the space station since the termination of NASA’s shuttle program.
In the early aftermath of the explosion, word came out that the crash site had to be secured because sensitive cryptographic equipment was on board:
The Cygnus mission was non-military, but the company’s Antares program manager, Mike Pinkston, said the craft included “some classified cryptographic equipment, so we do need to maintain the area around the debris in a secure manner”.
That initially struck me as odd. The International Space Station has a large number of cooperating countries, including Russia. It’s hard to imagine that the US would put sensitive equipment into the hands of cosmonauts right now, given the cool state of US-Russian relations. Of course, it would make sense for ISS communications to be encrypted in order to prevent meddling by hackers, but movement all the way to classified (and presumably military or NSA-level) encryption seems to be excessive.
This morning, we are seeing walk-back on the presence of classified equipment:
Shortly after the explosion, CNN quoted a launch director as saying that the spacecraft contained classified “crypto” equipment, but early Wednesday a NASA spokesman said by email that “We didn’t have any classified items on board.”
In trying to make sense of what could have been behind these strange statements, I ran across this interesting announcement of a new cryptographic technology that European scientists have proposed evaluating in an experiment on the space staion:
A team of European researchers have proposed a series of experiments that, if successful, could turn the International Space Station into a key relay for a quantum communications network.
The key basis of physics underlying quantum communications is entanglement. Entangled particles are connected in a way that pretty much defies common sense. If you change the spin of one of the particles, the spin of its entangled counterpart will change – even if they’re miles apart. And that change happens nearly instantaneously – at least four orders of magnitude faster than the speed of light, according to a recent experiment.
Another remarkable aspect of this technology that sounds almost too good to be true is its potential security. After noting that quantum networks are quite fragile, the Forbes article continues:
But why bother with these networks at all if they’re so fragile? The answer is pretty simple – because they’re almost perfectly secure. Here’s how it works. Let’s say that I want to send a message to New York City. My message is going to travel through normal channels, but it will be encrypted with a key. That key is transmitted via the entangled photons – so the changes I make to entangled particles on my end almost instantly show up in the particles in New York. We then compare the measurements of what I changed in my photons to those states in New York City.
Those measurements then comprise an encryption key for our communications. So even if our communications are bugged, nobody can read them without knowing that encryption key. And here’s the important thing: if somebody were to try to eavesdrop on the quantum entanglement, they would alter the spin of the photons. So the measurements I make and the measurements made in New York would be out of sync – thus letting us know that we have an eavesdropper. It also prevents us from creating an encryption key, so we don’t send any communications. Theoretically, a quantum encrypted network is almost perfectly secure. (That said, they’re not perfect, and there are some exploits.)
The announcement from the European group that they wished to carry out the experiment based on what Einstein called “spooky action over a distance” came last April. Then, in June, it was announced that China had carried out a key demonstration of concept experiment back in 2010 but waited four years to publish the result.
With China announcing progress on the technology, one would think that the West would want to accelerate its work in the area, so it would not be at all surprising if equipment for the European experiment was among the items lost when the rocket exploded. Further, one would expect that Orbital would have been told that security for that equipment would be of the very highest level. In discussing the issue of sensitive equipment among the Antares wreckage, PCWorld this morning mentioned the incident of China perhaps examining the wreckage of the US stealth helicopter that was left behind after the mission to kill Osama bin Laden. It could well be that for this crash site, keeping the debris away from prying eyes from China is behind the call for security. Note also that the experiment quite likely would have been coordinated by the European Space Agency on behalf of the European scientists, so NASA’s claim that “We didn’t have any classified items on board” could be parsed as not applying to any classified items that ESA might have had on the rocket.
It’s really difficult to say which poor response to Ebola has done more damage to the public health system in the United States. First, we had the series of unforgivable errors at Texas Health Presbyterian Dallas that resulted in Thomas Duncan being sent home with Tylenol and antibiotics when he first presented with Ebola symptoms. This was followed up after he was admitted by Nina Pham and Amber Vinson coming down with the disease after they treated him. Now, we have Kaci Hickox, who treated Ebola patients in West Africa, confined to an unheated tent in a New Jersey hospital for 21 days even though she is asymptomatic and has tested negative for Ebola. Twice.
The hysteria over retracing the steps of Craig Spencer in New York City just before he developed his fever illustrates the way the US press has misled the public about when and where Ebola risk exists. Abundant evidence from this and previous Ebola outbreaks demonstrates clearly that there simply is no risk of transmission from asymptomatic patients and that transmission risk grows through the course of the infection.
We see that principle demonstrated very clearly in Duncan’s case history. See this terrific ABC timeline for relevant dates quoted below. Duncan arrived in Dallas September 20. No passengers on any of the flights he took have developed Ebola. The incubation period has elapsed, so we know that no transmission of the virus occurred during any of his flights. Duncan had symptoms on his first hospital visit on September 26 but was sent home. He was later admitted on September 28. No patients or personnel from the hospital became infected from his visit September 26. The incubation period has expired, so we know for certain that transmission did not occur for anyone near Duncan that day. Similarly, even though they were in the apartment with him for days after he developed symptoms, none of the residents of or visitors to the apartment where Duncan was staying in Dallas became infected. The incubation period for that exposure also has expired. From this timeline developed by the New York Times, it appears that Pham and Vinson treated Duncan on the day before he died, which would be at the time when the amount of virus being produced by his body was nearing its maximum.
The load of virus in a patient’s blood over the course of Ebola infection has been studied. In this CDC review, we have a graph showing the amount of virus over time: →']);" class="more-link">Continue reading
I had really hoped I wasn’t going to have to write this post. Yesterday, Marcy emailed me a link to a Washington’sBlog post that breathlessly asks us “Was Ebola Accidentally Released from a Bioweapons Lab In West Africa?” Sadly, that post relies on an interview with Francis Boyle, whom I admire greatly for his work as a legal scholar on bioweapons. My copy of his book is very well-thumbed. But Boyle and WashingtonsBlog are just wrong here, and it takes only seconds to prove them wrong.
Shortly after getting the email and reading the blog post, I sent out tweets to this summary and this original scientific report which describe work on DNA analysis of Ebola isolated from multiple patients during the current outbreak. That work conclusively shows that the virus in the current outbreak is intimately related to isolates from previous outbreaks with changes only on the order of the naturally occurring mutation rate known for the virus. Further, these random mutations are spread evenly throughout the short run of the virus’s genes and there are clearly no new bits spliced in by a laboratory. Since I wasn’t seeing a lot of traction from the Washington’sBlog post, I was going to let it just sit there.
I should have alerted last night when I heard my wife chuckling over the line “It is difficult to describe working with a horse infected with Ebola”, but I merely laughed along with her and didn’t ask where she read it.
This morning, while perusing the Washington Post, I saw that Joby Warrick has returned to his beat as the new Judy Miller. Along with the line about the Ebola-infected horse, Warrick’s return to beating the drums over bioweapons fear boasts a headline that could have been penned by WashingtonsBlog: “Ebola crisis rekindles concerns about secret research in Russian military labs“.
Warrick opens with a re-telling of a tragic accident in 1996 in a Soviet lab where a technician accidentally infected herself with Ebola. He uses that to fan flames around Soviet work in that era:
The fatal lab accident and a similar one in 2004 offer a rare glimpse into a 35-year history of Soviet and Russian interest in the Ebola virus. The research began amid intense secrecy with an ambitious effort to assess Ebola’s potential as a biological weapon, and it later included attempts to manipulate the virus’s genetic coding, U.S. officials and researchers say. Those efforts ultimately failed as Soviet scientists stumbled against natural barriers that make Ebola poorly suited for biowarfare.
The bioweapons program officially ended in 1991, but Ebola research continued in Defense Ministry laboratories, where it remains largely invisible despite years of appeals by U.S. officials to allow greater transparency. Now, at a time when the world is grappling with an unprecedented Ebola crisis, the wall of secrecy surrounding the labs looms still larger, arms-control experts say, feeding conspiracy theories and raising suspicions.
Enhancing the threat is the facilities’ collection of deadly germs, which presumably includes the strains Soviet scientists tried to manipulate to make them hardier, deadlier and more difficult to detect, said Smithson, now a senior fellow with the James Martin Center for Nonproliferation Studies, a research institute based in Monterey, Calif.
“We have ample accounts from defectors that these are not just strains from nature, but strains that have been deliberately enhanced,” she said.
Only when we get three paragraphs from the end of the article do we get the most important bit of information to be gleaned from the Soviet work on Ebola:
Ultimately, the effort to concoct a more dangerous form of Ebola appears to have failed. Mutated strains died quickly, and Soviet researchers eventually reached a conclusion shared by many U.S. biodefense experts today: Ebola is a poor candidate for either biological warfare or terrorism, compared with viruses such as smallpox, which is highly infectious, or the hardy, easily dispersible bacteria that causes anthrax.
Note also that, in order to make Ebola more scary, Warrick completely fails to mention the escape of weaponized anthrax from a Soviet facility in 1979, infecting 94 and killing 64, dwarfing the toll from the two Ebola accidents.
And lest we calm down about Ebola and the other bioweapons the Soviets worked on, Warrick leaves us this charming tidbit to end the article: →']);" class="more-link">Continue reading
I’m either a lone voice in the wilderness or just another angry old man shouting at clouds on this, but, to me, the issue of personnel flow inside a facility treating a patient for Ebola is critical. Texas Health Presbyterian Dallas got that issue terribly wrong in the case of Thomas Duncan, and now, although they provide very good guidance on the issue of personal protective equipment and its use, new guidelines just released by CDC sadly fall short of correcting the problem I have highlighted.
The issue is simple and can even be explained on a semantic level. If a patient is being treated in an isolation ward, that isolation should apply not only to the patient but also to the staff caring for the patient. As I explained previously, National Nurses United complained that health care workers at Texas Health Presbyterian Dallas treated Duncan and then continued “taking care of other patients”.
Allowing care providers to go back to treating the general patient population after caring for an isolated patient is in direct contradiction to one of the basic recommendations by WHO in a document (pdf) providing guidance for treatment of hemorrhagic fever (HF, includes Ebola):
Exclusively assign clinical and non-clinical personnel to HF patient care areas.
By exclusively assigning personnel to care of the isolated patient, then the isolation is more complete.
The new CDC guidelines, released on Monday, offer updated recommendations on the types of personal protective equipment (PPE) to be used and how it is to be used. The guidelines also stress the importance of training on effective PPE use prior to beginning treatment of an Ebola patient. Unfortunately, though, the guidelines still leave open the possibility of health care workers moving between the isolation area and the general patient population.
In the preparations before treatment of an Ebola patient commences, the guidelines state:
Identify critical patient care functions and essential healthcare workers for care of Ebola patients, for collection of laboratory specimens, and for management of the environment and waste ahead of time.
And then once treatment begins, we have this:
Identify and isolate the Ebola patient in a single patient room with a closed door and a private bathroom as soon as possible.
Limit the number of healthcare workers who come into contact with the Ebola patient (e.g., avoid short shifts), and restrict non-essential personnel and visitors from the patient care area.
So the facility is advised to identify the “essential” workers who will provide care to an Ebola patient and to limit the number of personnel coming into contact with the patient. And even though the patient is to be in an isolated room, the guidelines still fall short of the WHO measure of calling for the Ebola treatment staff to be exclusively assigned. Precautions for safely removing the PPE are described, but once removed, the workers presumably are free to go back to mixing with the general patient population. Hospitals are cautioned against allowing large numbers of care providers into the room and to avoid “short shifts”, but there still is no recommendation for workers to be exclusively assigned to the isolation area.
The first thing that comes to mind in this regard is to question whether the CDC recommendations fall short of the WHO call for exclusive assignment in order to allow US hospitals avoid the perceived expense of dedicating a handful of personnel to treatment of a single patient. Is the ever-constant push to reduce personnel costs responsible for this difference between CDC and WHO guidelines? In the US healthcare system, it appears once again that MBA’s can carry more weight than MD’s on critical issues.
The incompetence of Texas Health Presbyterian Hospital Dallas is staggering. In following today’s rapidly developing story of a second nurse at the hospital now testing positive for Ebola, this passage in the New York Times stands out, where the content of a statement released by National Nurses United is being discussed (emphasis added):
The statement asserted that when Mr. Duncan arrived by ambulance with Ebola symptoms at the hospital’s emergency room on Sept. 28, he “was left for several hours, not in isolation, in an area where other patients were present.” At some point, it said, a nurse supervisor demanded that Mr. Duncan be moved to an isolation unit “but faced resistance from other hospital authorities.”
The nurses who first interacted with Mr. Duncan wore ordinary gowns, three pairs of gloves with no taping around the wrists, and surgical masks with the option of a shield, the statement said.
“The gowns they were given still exposed their necks, the part closest to their face and mouth,” the nurses said. “They also left exposed the majority of their heads and their scrubs from the knees down. Initially they were not even given surgical bootees nor were they advised the number of pairs of gloves to wear.”
The statement said hospital officials allowed nurses who interacted with Mr. Duncan at a time when he was vomiting and had diarrhea to continue their normal duties, “taking care of other patients even though they had not had the proper personal protective equipment while providing care for Mr. Duncan that was later recommended by the C.D.C.”
From the context of both the New York Times article and the nurses’ statement, it seems most likely that this movement of nurses from treating Duncan to treating other patients took place during the period after Duncan was admitted to the hospital and before the positive test result for Ebola was known. However, from the nurses’ statement showing that at least some of the personnel on duty realized Duncan almost certainly had Ebola, proper isolation technique should have been initiated immediately.
And that movement of nurses from a patient who should have been in isolation back into the general patient population is a huge, and obvious, error. Consider this publication (pdf) put out in August by the World Health Organization, summarizing precautions to be taken in care of Ebola patients. The very first page of actual content, even before the section labeled “Introduction”, is a page with the heading “Key messages for infection prevention and control to be applied in health-care settings”. The page lists nine bullet points about dealing with ” hemorrhagic fever (HF) cases” (hemorrhagic fever diseases include Ebola). Here is the third entry on that list:
Exclusively assign clinical and non-clinical personnel to HF patient care areas.
There really is no point in saying a patient is isolated if staff are freely moving back and forth between the isolation area and the general patient population. I’m wondering how long it will be until there is a whole new management team at Texas Health Resources, the parent firm for the hospital.