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Old 10-26-2014, 11:12 PM   #441
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Possibly bearing on the issue of screening/detection (from the LA Times):

Quote:
Yet the largest study of the current outbreak found that in nearly 13% of "confirmed and probable" cases in Liberia, Sierra Leone, Guinea and elsewhere, those infected did not have fevers
.
The study, sponsored by the World Health Organization and published online late last month by the New England Journal of Medicine, analyzed data on 3,343 confirmed and 667 probable cases of Ebola

. . .

For doctors and nurses fighting the epidemic in West Africa, the risk of encountering Ebola in the absence of fever is more than academic.
Dr. Nick Zwinkels, a Dutch physician, last month closed a hospital he had been running with a colleague in central Sierra Leone after five nursing aides contracted Ebola — possibly from unprotected contact with three patients who were not promptly diagnosed with the virus.
Four of the nursing aides died, as did all three of the patients belatedly found to have Ebola.
Interviewed by email, Zwinkels said that hospital staff members took the temperature of one of the doomed patients four times a day for three consecutive days, and the patient never showed a fever. The readings were taken by a digital thermometer placed in the armpit, he said.
Based on what his staff observed, Zwinkels wrote, "it seems that only measuring the temperature as a form of triage is insufficient."
It is very clear, based on info learned in this Ebola outbreak as well as previous ones, that about 12-15% of those with Ebola have no fever and yet can be infecting others.
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Old 10-26-2014, 11:31 PM   #442
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+1
I think it more than inconvenience for those brave health care work, I think it potentially cost the lives of some Africans.

Imagine you are Doctor volunteering for Doctors without borders, or US public health care professional asked to go to West Africa. During the 9-12 months you'll be overseas, you know you have to come back to or may need to comeback a couple of times to the US, an elder parent, wedding, critical business meeting. The 3 week quarantine, three times extends your tour of duty by 9 weeks. Best case the NIH,CDC, Doctors with Borders, has to find somebody to fill in for the extra 3 weeks you are gone. Which wouldn't be so bad except for no such person exists. The worse case is that you decide that as much as you'd love to help out family comes first and stay home.

Yes this puts Americans at some tiny elevated risk, I still contend its far less than risk than having a 1 million ebola cases in Africa.
It should be noted that Doctors without borders pays the folks during the any quarantine.
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Old 10-26-2014, 11:53 PM   #443
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The worse case is that you decide that as much as you'd love to help out family comes first and stay home.
I'd say this is far from the worst case. Maybe the worst case is that you do go to Africa, spend time getting splashed with all manner of fluids from very sick people, go home without bothering with a quarantine and then expose a lot of other people to Ebola back in your home town.

We'll probably develop a test that allows surefire detection of the disease in tested individuals before they develop symptoms or become contagious. We don't have such a test now, and it seems prudent and reasonable to ask those who have been at increased risk of getting this communicable and fatal disease to wait before re-entering healthy populations. Heck, if I were in their booties I would want to go through quarantine to make absolutely sure I was clear before getting near my family.

Should this quarantine apply to anyone who has been treating Ebola patients? Maybe not. If the treatment is happening in a US or other hospital that has adequate protective equipment and adequate training and supervision to assure the procedures are known and followed, then we should consider the actual risk before making health care workers stay away from others. But we have zero assurance that these tiny clinics in W. Africa are operated in this fashion, and the number of health care workers who get Ebola in them is adequate testimony to that.
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Old 10-27-2014, 12:16 AM   #444
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It should be noted that Doctors without borders pays the folks during the any quarantine.
Starting pay for doctors in Doctors without Border is <$1800/month and average is in the low $2,000. About what most would earn in 2 or 3 days in their real jobs.
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Old 10-27-2014, 07:53 AM   #445
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Starting pay for doctors in Doctors without Border is <$1800/month and average is in the low $2,000. About what most would earn in 2 or 3 days in their real jobs.
I'm fine with having our tax dollars support returning health care workers in a manner that rewards them for their service, rather than making it a burden, while they are in some form of quarantine. Take care of them and their families in style, make quarantine as comfortable as we reasonably can, compensate them for lost wages, and/or give them other non-contact work to do.

Like samclem said, infecting others in the US would be a bad thing, not just from a US-centric view, but it would create a real backlash against health care workers, and probably cause more problems than requiring a quarantine.

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Old 10-27-2014, 08:08 AM   #446
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It does not mean there will be no Ebola death in the U.S. in the future. I am very disappointed when the two nurses got infected and the government was saying that every hospital in the U.S. was well prepared. They just lost my trust.
Blindly trusting our government has not been the wisest thing to do for at least the last few decades. I'm not sure it was ever very smart. Fortunately, we can still believe in Santa and the Easter Bunny.
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Old 10-27-2014, 08:12 AM   #447
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Starting pay for doctors in Doctors without Border is <$1800/month and average is in the low $2,000. About what most would earn in 2 or 3 days in their real jobs.
That would be part of the cost of the doctors or nurses going to aid Ebola patients in Africa. They all take a financial hit by going as do anyone that volunteers.
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Old 10-27-2014, 08:36 AM   #448
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It is very clear, based on info learned in this Ebola outbreak as well as previous ones, that about 12-15% of those with Ebola have no fever and yet can be infecting others.
Although this is what the LA Time article implies, I don't believe this is a reasonable conclusion based on the original article in the New England Journal of Medicine. However one can read it and decide for themeselves: PDF link


In particular

(1) The study is not trying to see if fever is a reliable indicator of infection. Rather it is collecting observational data and running various regressions/models to understand the course of behavior. Observational data does not typically have very high accuracy and high accuracy is not necessary to get useful information out of their regressions.

(2) The data includes suspected and probably cases. There will be some people without the disease in their data

(3) The presence of fever is not measured accurately at all. From the article "in practice, health care workers at the district level often do not have a medical thermometer and simply ask whether the person’s body temperature is more elevated than usual."

(4) The case reports that are used are pretty long. There are bound to be errors in writing them up especially as the people filling them out are probably extremely overworked and tired. You can see the form here: PDF Link (it's at the end)

(5) The NEJM article does not state or conclude that someone without a fever can be infectious.

I read/skimmed the article pretty quickly (so I might have missed something) but those are my thoughts.
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Old 10-27-2014, 08:46 AM   #449
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Although this is what the LA Time article implies, I don't believe this is a reasonable conclusion based on the original article in the New England Journal of Medicine. However one can read it and decide for themeselves: PDF link
Okay, but the LA times article also cited virtually the same figure (about 15%) based on studies done during previous Ebola outbreaks. And then they cited anecdotal evidence and the direct clinical observations from doctors who had run hospitals there. I think this is about as close to "truth" as we're going to get under the present circumstances -- unless we take steps to assure Ebola gets well established in the US so we can study it with greater precision.
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Old 10-27-2014, 09:36 AM   #450
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Well it does look like the anti-quarantine folks won, although it remains to be seen what their prize may end up being.

I do wonder what are the legal rights of someone local who gets a Ebola infection from one of these returning healthcare workers? Do they have a right to sue or is it just tough luck?
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Old 10-27-2014, 09:49 AM   #451
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Things That Have Killed Americans Since First US Ebola Patient - Business Insider

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Old 10-27-2014, 10:05 AM   #452
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A silly chart because we have not had a outbreak of Ebola in the USA yet.

The whole point of excess caution is so you don't have to revise that chart later.

There is a reason billions will be spent recalling faulty airbags when only four people are known to have died possibly due to their failure. Sometimes you exercise caution before people die.
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Old 10-27-2014, 10:16 AM   #453
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There is a reason billions will be spent recalling faulty airbags when only four people are known to have died possibly due to their failure. Sometimes you exercise caution before people die.
People are willing to believe the safety experts regarding air bags, but ignore the medical experts and epidemiologists regarding Ebola. I don't understand that disconnect?
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Old 10-27-2014, 10:37 AM   #454
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People are willing to believe the safety experts regarding air bags, but ignore the medical experts and epidemiologists regarding Ebola. I don't understand that disconnect?
I think I understand it, and it's apples and oranges, IMHO.

If the subset of experts in the anti-quarantine camp are wrong, the consequences could be exponentially horrific (if, by some chance, the virus "gets loose", thousands? millions?, who knows? will die).

If the anti-recall experts are wrong, it might mean we collect another couple of years worth of data and maybe a handful of people die, at most.

So the possible consequences of being conservative in the two cases are as different as night and day.
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Old 10-27-2014, 10:45 AM   #455
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People are willing to believe the safety experts regarding air bags, but ignore the medical experts and epidemiologists regarding Ebola. I don't understand that disconnect?
Physics, electronics, and vehicle accident rates= "hard" science. Experimental method = easily applied
Ebola, biological processes, societal responses to infection = "soft" science.

"Hard" science is more easily tested, more quantifiable, and more easily understood. Experimental method often requires retrospective analysis, time, and trying to control for variables that invariably reduce the faith we can have in the results.

It's clear that the situation is entirely different.
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Old 10-27-2014, 11:11 AM   #456
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I think I understand it, and it's apples and oranges, IMHO.

If the subset of experts in the anti-quarantine camp are wrong, the consequences could be exponentially horrific (if, by some chance, the virus "gets loose", thousands? millions?, who knows? will die).

If the anti-recall experts are wrong, it might mean we collect another couple of years worth of data and maybe a handful of people die, at most.

So the possible consequences of being conservative in the two cases are as different as night and day.
I understand a large part of the problem in West Africa is the way bodies are prepared for burial. The family must wash the body, which at that point is a great way to get the disease. This is like folks in the US handled death 150 years ago (see the number of family plots etc.).
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Old 10-27-2014, 07:39 PM   #457
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Physics, electronics, and vehicle accident rates= "hard" science. Experimental method = easily applied
Ebola, biological processes, societal responses to infection = "soft" science.

"Hard" science is more easily tested, more quantifiable, and more easily understood. Experimental method often requires retrospective analysis, time, and trying to control for variables that invariably reduce the faith we can have in the results.

It's clear that the situation is entirely different.
The point I'm making does not involve nuanced differences of the subject matter, but the cafeteria style approach as to which 'experts' people believe. The disconnect I'm seeing is that the same overarching scientific establishment (scientific industrial complex?) that created our modern civilization - vaccines, penicillin, computers, space exploration, heart transplants - is only believed when people 'feel' like they agree with the scientific determination. It turns out Ebola is one of those scientific determinations that people just 'feel' is wrong, for whatever reason, without any actual proof for their skepticism. That's the disconnect I see.
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Old 10-27-2014, 10:37 PM   #458
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I wonder why someone returning from a high risk situation (treating ebola patients) is not simply automatically blood tested for the virus upon his return, rather than having him self-monitor and/or voluntarily quarantine for 21 days to see if symptoms develop?

The virus, like all viruses, has an incubation period. During that time, the virus is undetectable by any means, and the person is not contagious at all. The problem here is that we don 't have precise information about the minimum incubation period and if there is any contagiousness possible prior to onset of symptoms.

For example we know that with chicken pox, a susceptible person will start the rash 10-21 days after exposure, no more and no less. We also know that a person is contagious up to two days prior to onset of the rash, and it is spread by respiratory droplet-you can't get it at a significant distance, unlike measles, which is truly airborne. So a person exposed to chicken pox should be quarantined from immunocompromised people for 8-21 days. There is a defined period of contagiousness after the rash starts as well. 5-14 days, usually 8 or less.

With ebola, much less is known. I ran across a study from the last outbreak which makes me wonder how much our CDC folks know or bother to search. The paper suggested to reduce the risk to <1% one should use a maximum incubation of 25 days, not 21 days. And the authors failed to commit to a minimum incubation period--which is too bad.

That doctor in NYC was very foolish, going bowling and taking the subway.

Here is the article, though it's a difficult read:

http://www.ncbi.nlm.nih.gov/pmc/arti...4/#!po=78.3582



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Old 10-28-2014, 05:48 AM   #459
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The virus, like all viruses, has an incubation period. During that time, the virus is undetectable by any means, and the person is not contagious at all. The problem here is that we don 't have precise information about the minimum incubation period and if there is any contagiousness possible prior to onset of symptoms.

For example we know that with chicken pox, a susceptible person will start the rash 10-21 days after exposure, no more and no less. We also know that a person is contagious up to two days prior to onset of the rash, and it is spread by respiratory droplet-you can't get it at a significant distance, unlike measles, which is truly airborne. So a person exposed to chicken pox should be quarantined from immunocompromised people for 8-21 days. There is a defined period of contagiousness after the rash starts as well. 5-14 days, usually 8 or less.

With ebola, much less is known. I ran across a study from the last outbreak which makes me wonder how much our CDC folks know or bother to search. The paper suggested to reduce the risk to <1% one should use a maximum incubation of 25 days, not 21 days. And the authors failed to commit to a minimum incubation period--which is too bad.

That doctor in NYC was very foolish, going bowling and taking the subway.

Here is the article, though it's a difficult read:

Incubation Period of Ebola Hemorrhagic Virus Subtype Zaire



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Thanks, I suspected it was something like that. Here is an article about a nurse in Connecticut who seems to have done things the right way.

Tolland Nurse Just Back From Treating Patients With Ebola In W. Africa - Hartford Courant
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Old 10-28-2014, 05:54 AM   #460
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Thanks, I suspected it was something like that. Here is an article about a nurse in Connecticut who seems to have done things the right way.

Tolland Nurse Just Back From Treating Patients With Ebola In W. Africa - Hartford Courant
Your link just takes me to a home page for the newspaper. I'm assuming this is the nurse that fought NJ's quarantine. It will be interesting what happens should this nurse develop symptoms later.

I'm sure there have been many dozens of heathcare workers that came back from West Africa without issues. Unfortunately, we've just seen one that didn't.
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