Monday, October 13, 2014

Speculation about future infection control and social distancing mounts after new Dallas case, and breakdown of "voluntary isolation" in New Jersey; insurance companies stew on this

Today, I enjoyed a leisurely and tasty breakfast in the cafeteria at the Virginia Hospital Center in Arlington – even some bacon and eggs, not so healthful, unless you believe in Atkins – and I overheard what sounded like an informal job interval.  I heard a candidate being told, “they always have to care for patients”.

No, there are no reported Ebola cases there as of this writing, but hospital employees have to be wondering everywhere if it will show up next.

Of course, there is a lot of talk about proper care protocol today, training of personnel, and whether all hospitals should treat Ebola patients.  But any emergency room could have to handle a potential Ebola patient without warning.
The Dallas Morning News has a story on how the decontamination efforts can affect a neighborhood around where a diagnosed Ebola patient lives, here.  Many people in Dallas got “reverse 911” calls and knocks on the door. 
In New Jersey, a whole cohort of people were placed in formal quarantine because one person broke the rules of voluntary cooperation.   According to the New York Daily News, the “guilty party” was NBC’s Dr. Nancy Snyderman, link here. This group had minimal contact with NBC cameraman Ashoka Mukpo.
And Natalie DiBlasio writes in USA Today (I read the print story during breakfast) about business insurance in relation to Ebola, especially travel insurance, link here(Yes, travel insurers won’t pay for “fear”.) So far the travel issue is only about travel to certain West African countries.  But “what if”, say, a passenger from Brussels who sat next to a passenger from Liberia somehow touches something and develops it.  Will this turn into a concern about all international travel?  This can get out of hand quickly.
As for the mutation risk, Ebola is more likely to develop the ability to transmit infection before symptoms appear, than become airborne (because viruses that affect blood vessel linings don’t usually invade respiratory tract cells).  A more relevant question is how to control the next SARS outbreak or avian Influenza  SARS has a mortality rate of close to 10% -- but perhaps of only the worst cases. 
Again, we wonder how social distancing strategies could play out.  Will bars and discos have to ban “dirty dancing” some day?   The fact is, with most common viruses, adults build immunity over lifetimes, and probably benefit from some “dirty” contact.  It is the few that can be so deadly that provide the “exception that swallows the rule”.  HIV was the least contagious of all, but also the most universally deadly at first.  In the 1980s, we saw the baths closed as a result (starting in San Francisco).  Ebola is much more contagious, but still not spread through the air, but “intimate contact” with a person (including heterosexual) is risky – but, unlike HIV, the person has to show symptoms – which can be mild, and this fact may not always be the case in the future.   Airborne respiratory viruses are the most contagious of all, and can install great fear – but the fact is that the real death rate from them is probably much lower than reported, because most respiratory virus infections of any kind produce relatively mild symptoms, usually unreported, in most healthy adults – who gradually build beneficial antibodies and “herd immunity” from incidental contacts (including those in bars). 
In nature, the best defense against infectious disease is gradual exposure, allowing immunity to develop.  We don’t have time with something like Ebola, or perhaps bird flu or the next SARS.  We need to be much more aggressive with developing and deploying vaccines and prophylactic antiviral treatments.  By the way, we should start smallpox vaccinations again, too.   And don’t forget Meningitis (especially Type B) but that is bacterial.  

Update: Oct. 14 

Dr. Sanjay Gupta has explained the difference between "infectiousness" and "transmissibility".

The New York Times article explains the enormous viral load on the individual, which tends to increase for at least a week after symptoms appear. Unlike many viral diseases, this tends to get worse after several days of mild symptoms.  

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