Ebola Perspective: Risks of spread to the US and elsewhere


It is true that this particular outbreak of Ebola has taken health officials somewhat by surprise. It is impossible to know, but I suspect that if you had asked a few ebola experts, a year ago, if there could be an epidemic that would spread across three or four countries, infect a couple thousand people, and last with no sign of letting up for a few months (that is the current situation, more or less), most would say no, probably not, though it is within the range of possibilities. Does the fact (assuming it is true) that this particular Ebola outbreak is unprecedented and kinda over the top even for an over the top disease like Ebola mean that there is something different about this Ebola or this outbreak? That is a question that may be on your mind.

Another concern is the possibility that since this outbreak involves populations with more mobility including via aircraft than previous outbreaks that the Hollywood Scary Fiction scenario could happen. Here's how that goes. Someone infected with Ebola, but not symptomatic, gets on a long plane flight, maybe with a few legs and layovers. They start to get sick on the first flight, and after changing planes twice and being very sick for the last leg, they get off the plane and collapse, are taken to a local hospital very far form the Ebola epidemic where no one is expecting Ebola, spend a little quality time in the waiting room, and are finally put in an in-patient unit in a room with two or three other people. Hundreds of people have been near this person. The patient threw up in the bathroom of each of the airplanes he was on, and later someone filled the sink in the same bathroom and used the water in the basin to wash his or her face. He drooled on his pillow while sleeping in his seat, and somehow the person next to him ended up with that pillow and slept on it for an hour. He threw up on some nurses and some orderlies had to clean up his diarrhea in the hospital a few times. And so on. By the end of all of this, a half dozen people are infected with Ebola, including a personal trainer, a grade school teacher, and four nurses. That's just the first scene in the movie, long before the character played by Morgan Freeman is on the scene, and when the character played by Morgan Freeman shows up, you know things are getting serious.

A variant of that concern is this: Two aid workers helping with the Ebola epidemic, Americans, catch Ebola and are very ill. It is decided to fly them back to the United States for treatment. This brings Ebola into the US, where it could spread to other people because, well, because Ebola! But is this a realistic concern or just a Hollywood studio's wet dream?

At this point in the epidemic we are seeing the usual bifurcation of reaction among the general public, sciency bloggers, and the press. On one had there is growing panic, people either being very scared, for real, or people or press outlets shopping fear on the market because it sells. On the other hand there is the stern corrective statement that all your fears are invalid, Ebola isn't going to get out of hand, isn't going to get to the US, there is nothing to worry about.

At the same time there is a parallel and equally bifurcated rhetoric about the bigger picture, about dealing with Ebola as a public health problem. On one hand you have people asking for a vaccine, or some sort of cure, to address this thus far orphaned disease, because they are worried about it. On the other hand you have people noting that Malaria kills millions a year, and most years, Ebola kills no one, and when there is an outbreak, it only kills dozens or hundreds, except this last time which is still only many hundreds dead and the very low three figures sickened.

Every one of the above mentioned concerns is valid and invalid at the same time, and every one of the reactions to the current Ebola crisis is both correct and incorrect at the same time. Let me explain.

What is the meaning of the bigness and badness of the Ebola 2014 outbreak?

There may be new things to learn about Ebola from this outbreak, but that won't be until after the dust has settled and scientists have had a chance to look more closely at the data, and the virus, and everything else. But there does not seem to be anything new or unusual about the disease, and I don't think there is any major difference in how the outbreak is being handled. But there are two differences from earlier outbreaks, one of which is certainly relevant to the large size of this event, the other perhaps important but as yet unclear.

  • Most, really all, prior outbreaks occurred in areas where the affected population was relatively thinly scattered on the landscape and the movement of people in and out of the area was minimal and slow. This outbreak is happening where there are much larger concentrations of population and a lot of movement of people. This has simply upped the chance of transmission in close quarters (higher density) and made for opportunities for spread to previously unaffected settlements.
  • There has been resistance to health workers coming into some villages. This story is spreading around as though it was a major thing, that large areas were becoming dangerous or difficult for health workers to enter or work in. We need to be cautious in drawing conclusions from the news. It is very easy for westerners to slip into blaming the natives for their own difficulties and contrasting native ignorance with Great White Smartness. There may well be areas where this is happening or important but until there is some actual unbiased carefully collected and evaluated information on this, please don't draw conclusions. If you hear about something that looks like a great story, there is a good chance that it is a great story. Emphasis on "story."
  • This particular Ebola outbreak is really like all the others, but jumbo size.

    Could sick aid workers being brought to the US spread the disease here?


    You can stand in a room with a person infected with Ebola ten feet across the room from you, and stand there for hours, without a mask, and you will not, can not, get Ebola. It simply isn't transferred that way. Clean up Ebola vomit, Ebola diarrhea, physically move Ebola victims from bed to bed, give them a sponge bath, tend wounds or other injuries, insert and remove IV's, handle the bodies of recently deceased Ebola victims, and especially, give traditional treatment to those bodies which, as is done in many cultures, which may involve cleaning and even internal cleaning or handling of organs, etc. etc., and you've got a reasonable chance of getting Ebola. Even then, the number of health care workers who actually get Ebola is probably very small. Tragic and horrible when it happens, but a few out of thousands most directly exposed and at risk for months is a small number.

    The people who are being transported to the US are isolated, in negative pressure facilities, and are being handled with kid gloves. Well, latex gloves, actually. They can not infect anybody but their immediate caretakers, and those individuals are very well protected.

    There is a risk of a different sort, though. While these particular patients are being handled with great care, there are healthy helpers, medical workers or others, who have been working with Ebola patients and seem to have not contracted the disease, who are occasionally wandering off to their respective homes and, I'm pretty sure, not being quarantined. I am not sure if all the people involved in helping in West Africa are being tested or properly watched. They may be, but there is some evidence that this is not the case. I'd like to learn more about that, and I hope we don't learn anything the hard way.

    One US based doctor has returned to the United States and decided to quarantine himself. Alan Jamison will keep himself separate from society for 21 days since his last potential exposure to Ebola.

    If he is doing this on his own, there is the implication that doctors or others who were working with Ebola victims are being allowed two wander off and commune with the rest of us with the prospect that they are infected and eventually could spread the disease. However, I'm not sure that this is true. I don't know that Dr. Jamison was not tested, I don't know how much exposure he had and I don't know what the procedure is for managing this potential problem. This is one guy who may be making hay where there is no grass. Worst case scenario, though, is that a health worker gets sick, the beginnings of Ebola like symptoms emerge, and the health worker gets treated. Nobody who has been working with Ebola patient is going to get a head ache, feel like throwing up, and say to themselves, "Hmm. I wonder if I've got allergies or something?"

    We should be worried about people wandering off, leaving the sites of the outbreak, generally. That's clearly how this has spread to begin with. This applies to health workers and regular people. It applies to journalists in the field. We should not assume, but we can reasonably hope, that people are doing the right thing. But even when they don't, remember, this is not measles, which is highly contagious.

    (Also, in case you didn't know, Ebola is of course already in the United States. See this.)

    Can the scary hollywood scenario happen?

    Yes, of course it can. There is nothing in that scenario, taken on its own, that can't happen. Bodily fluids get around. People are confined on aircraft, share a bathroom, and occasionally eat each other's cookies by mistake. I don't think there is any scientifically valid way to suggest that people who are symptomatic with Ebola are anything but a nightmare on a regular airplane flight, hanging around in airports, sharing cabs, et. When I hear international health experts saying that the chance of Ebola transmission on an airplane is pretty much non existent, I want to ask them: Ok, so, you'll be entering and leaving the sick rooms of Ebola patients, maybe taking your kids along because it's Follow Your Parents to Work Day, and maybe even have your kid sit next to the patient in bed and read them a story, without any protective gear at all. Right? No, absurd.

    However, the crazy scenario I gave you above, with the vomit and the pillow and the bathroom, requires a lot of things to go wrong in sequence, which is pretty unlikely. Also, the worst case scenario is that a few people end up with Ebola. It would be very hard for that to spread in the US. We're too good on our health care, even when it seems we are not. On the other hand, if an air route with a symptomatic Ebola patient is sending people to any of many other places, with high population density, little education or information about things like Ebola (or even a belief that it is not a disease you get from other people) and no monitoring, I'd worry that smaller outbreaks could show up in other countries or other cities, in West Africa, elsewhere in Africa, or beyond. You can say that chances are it won't happen. But it did happen. Ebola is in multiple countries spreading from multiple sites in West Africa.

    I'm pretty sure the people who deal with Ebola, though, try to not take chances. Rhetoric to the contrary is to avoid panic. Avoiding panic is good, and in fact, panic is unnecessary. Ebola is not that contagious. But somewhere between being concerned and avoiding panic by making it sound like Ebola refuses to pass from person to person on air planes, there is clearly something lost in translation.

    Who cares about Ebola, it is not Malaria!

    To me this is one of the most insidious problems we have and it doesn't just apply to Ebola vs. Malaria. Let me give you an example from an entirely different area.

    How much money have spent on the science of subatomic physics, say, just in the US. And, what are the benefits? More importantly, what were the benefits that were specified at the outset of various research projects, and which of those have been realized?

    The answer to that second question is probably zero, zero. No benefits were specified, and thus, any gained don't count. You are probably thinking, "No, wait, what about the knowledge, and all that stuff!?? That was surely specified in the grant proposals!" No doubt, but simply advancing knowledge is not a benefit. How do I know that? Malaria! Those physicists may have advanced our knowledge, and as a side effect invented the DVD and stuff, but nobody cured Malaria. Therefore it doesn't count.

    Sounds like an incredibly stupid argument, doesn't it?

    Now, side step over to Ebola. Is creating, say, a vaccine to address Ebola worth it? No! Why? Because Malaria! Malaria is way bigger, kills more people, is a truly serious public health problem, Ebola is rare. So if you've got some research money don't spend it on Ebola, spend it on Malaria.

    That would be the smart thing to do!

    This is also an incredibly stupid argument, for a few reasons. The only reason you can compare Ebola and Malaria is because they are both diseases. They aren't even the same kind of disease, they don't have the same geographical spread (though it is overlapping). But they are diseases, so when we consider spending resources on research in one, it is natural to compare to the others. But they are also two different things. If I had a million dollars in the bank of my Malaria Vaccine Research Institute and gathered all the scientists together and said, "OK, folks, until we've spent this one million dollars, I want you all working on Ebola instead of Malaria, K?" they would look at me funny for a while and then call my wife to take me home. Ebola is a virus, Malaria is a cellular organism. They are very different things. The expertise and lab equipment would not be in my Institute. I might as well tell my scientists to spend a million dollars working on the next generation of high definition TV. That would be cool! And, suggesting that we compare the costs and benefits of that project to working on Malaria or Ebola would be dumb.

    One of the benefits of working on a vaccine for ANY virus is advancing knowledge of vaccines for viral disease generally, and we have a lot of work to do on vaccines for viral diseases. Perhaps work on Ebola would have some great side benefits. Indeed, money spent on a vaccine for Ebola would very likely produce ... wait for it ... a vaccine! Money spent working on a vaccine for Malaria has thus far failed to produce squat.

    A vaccine for Ebola is probably relatively easy to develop. Ebola is not a human disease. It comes from an animal reservoir. Ebola, if hit with a vaccine in human populations, can't evolve resistance to that vaccine (or other treatment). Humans have little or no history of immune response to Ebola, and a very long (in essence, multi million year long) history of immune response to Malaria and its cousins. Developing an Ebola vaccine would be like putting up a childproof gate in your house, where the 2 year old is Ebola and the childproof gate is the Vaccine. Developing a vaccine for Malaria is like trying to stop a squadron of Navy Seals from penetrating a drive-in theater at a date and time of their choosing.

    This is why literally billions of dollars has been spent ... billions, seriously ... on developing a Malaria vaccine and there isn't one. I would venture to say that if we looked at the part of the money spent on Malaria research in general (including vaccines) that covered just couriers and postage over the years, we'd have enough to fund a full on Ebola vaccine development program. Maybe not. Maybe you'd have to add in a few percent of the money spent on conferences (which are very important, I'm not saying they are not) by Malaria scientists. There is probably more money being spent right now on retirement payments to retired scientists who spent most of their time working on Malaria than needed to build an Ebola Research Center that could get a vaccine out there in a few years. Seriously. Please don't compare Malaria to Ebola and use that to suggest that we should ignore Ebola. The crumbs that fall off the pieces of Malaria cake at the Malaria birthday party would be enough to handle Ebola. (Bonfire of the Vanities Reference.)

    But still, why should we bother with Ebola?

    Why bother with any disease? Why not figure out which one disease causes the most mortality or morbidity, and disallow any research on anything else? Then, when that is solved, move on to the next one. There are several reasons to not do this. First, it might not be possible to solve the big bad disease quickly, or ever, so the entire research program would spin its wheels forever. Second, the second and third and way down to the tenth or twentieth diseases are all real disease people really get and that really cause suffering. While the argument that spending excessively on a rare disease is a poor choice, spending a modest amount on a very addressable problem that is also small is exactly what we should be doing. Third, you can and should think of some of this as pure research. Pure research is where scientists seek out the answers to questions in a special category of question: Questions that scientists ask. No other criteria need apply. Scientist tend to ask questions that are at the edge of knowledge, or perhaps that are hanging around this or that water hole of ignorance. Scientists ask the questions they ask because they have two characteristics: There is something unknown, and there is something about that unknown thing that is knowable. With research. Usually.

    Now go back to Ebola again. Doesn't somebody want to know about Ebola? Of course they do. Ebola is one of a family of viruses, the Filovirus family, that includes some pretty benign viruses and a handful of nasty ones (Ebola isn't the only one). In the past there was a lot of research interest in the filovirus family for use as a biological weapon. Imagine making an Ebola like virus that spread though the air! You could really kick ass, militaristically speaking, with such a weapons. But, fortunately, we as a species have recently decided to not view biological weapons as legitimate. Research on biological weapons continued, of course, long after they were outlawed because we assumed we needed to "understand them" (make them and test them on rats) in case the other guys were making them, so we could deal with them. But I'm pretty sure most of that research has gone by the wayside as well. I would not be surprised, and I'm not much of a conspiracy theorist so I don't want to emphasize this too much, if a lot of the work to make an Ebola vaccine was in a file drawer somewhere.

    Also, there is the simple stark reality of Ebola. If you are a typical American you may not care about Ebola because it is in a different country and won't get here and there are other problems. But say you are like my neighbor here in Coon Rapids, Minnesota, Decontee. Decontee is Liberian. She is part of a large Liberian community here in the Twin Cities. Many Liberians are American Citizens with strong ties to Liberia. There is constant travel back and forth. I asked a Liberian guy I know where he gets his sombe (a wonderful traditional West and Central African dish) and he said "From my grandmother." "Does she grow it?" "Yes. In Liberia. I get it when I go there." The point is, there is a lot of back and forth. To be an American who is Liberian is to be a member of a community of people who is currently, at this very moment, threatened with Ebola. People in your community, in your family, can get Ebola. Decontee's husband and her sister in law both got Ebola and died of it last week. Ebola is a problem that affects communities that are Diaspora that include our very neighbors and friends. It should not be an orphan disease.

    So wait, there was way too much nuance and possibly contradiction here, what am I supposed to think?

    I don't want to tell you what to think.

    But in this case I'll make a suggestion.

    Do not be worried about the health workers being brought back to the US. Indeed, at this point, openly worrying about this can do little more than make you look a bit dumb and a bit insensitive.

    Yes, worry about the possibility of Ebola getting "out" to pretty much anywhere, elsewhere in Africa, to the US, etc., because it can. But don't worry too much. The chances are low. Forget about this "Oh, Ebola is not transmitted between people on airplanes" magical thinking. Of course it is. But Ebola is always hard to transmit, even on airplanes. In other words, be realistic.

    Forget about this comparison between Ebola and Malaria. When the Malaria people turn up a vaccine after spending billions of dollars of research money we can make a comparison. At the moment, Ebola is probably a vaccine-ready disease, and Malaria is not. You are comparing apples and oranges. No, worse than that. They're both fruit. You are trying to compare, in a cost benefit analysis, the efficacy of spending money on a new car vs. working out whether or not it is worth clipping coupons when you go to the grocery store. Why are you doing that?

    But, if you are a member of a community like the various African communities in the US, then you do indeed have more of a concern. Not so much that travelers will bring Ebola to your doorstep, though that is a tiny bit more likely for you than for some others, maybe. But because your community is being directly affected because your community lives in two worlds, and one of those worlds is being invaded by a monster.


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    My confusion is this (mistrust):
    I saw the coverage of the medical progessional that have just entered or will be coming back to the US while they were treating patients infected by Ebola. They were gloved and wearing masks as infectious disease professionals were yrsined to do. If this is obvious the standard for safety precautions and we are told that Ebola is NOT AIRBORNE then how is it that these Doctors were infected?

    Seems that the truth has not been told?

    By Vanessa McClintock (not verified) on 03 Aug 2014 #permalink

    That is a good question. There are two parts to the answer.

    First, "airborne" means aerosol. Aerosols from bodily fluid, usually from the mouth and nose (like when you sneeze or cough) develop aerosols of tiny liquid drops. A virus has to be able to survive in that environment for more than a short time to be considered airborne. Not only is Ebola not capable of that, but efforts to make it capable probably did not lead to much (though that is uncertain).

    Having said that, a wad of snot or puke or poop can still come flying across the room at you. You don't want to get that in your eye or mouth. So you wear protection.

    The second answer, related, is simply this: The CDC and WHO etc. have levels of standards, higher protection levels for certain kinds of disease, and it is a LINEAR pattern. There are four or five (depending on how you count them) biosafety, and that number of procedures, with the procedure for each level being pretty much the same no matter what. Ebola is a high level (level 4, the highest) so it gets all the level 4 treatment, and all the level four treatment is the same. By keeping the levels the same a) less goes wrong and b) if anything they are overdoing it, which is good.

    Valid question, though!

    Ebola is a high level (level 4, the highest) so it gets all the level 4 treatment, and all the level four treatment is the same. By keeping the levels the same a) less goes wrong and b) if anything they are overdoing it, which is good.

    In other words, well practiced routines?

    Am I wrong in being amazed that the doctor (apologies for not remembering his name) who was transported to Atlanta walked from the ambulance to the building? Does that mean he is reasonably into recovery or does it mean he is not at a "bad" part of his illness? (Or can't it be determined without being involved?)

    I have to admit that I am a surprised that there has not been a boat-load of abuse (from the usual suspects) heaped on President Obama for allowing this to happen. The only foolishness I've seen was a couple of tweets from the donald.

    The fact that he walked is being taken as a good sign that he is improving. I'm annoyed by some people on twitter who are mad at him for being able to walk.

    One thing I did see (again, on twitter) was a complaint that President Obama's executive order to address people coming in the country with respiratory symptoms supposedly exempts "illegals." It does not, that is something people made up. Well, one annoying person made up.

    And yes, I think well practiced routines is the thing. Also CDC and similar organizations make extreme assumptions to be safe. On one hand there is no sign that Ebola has mutated to become airborne. On the the other hand, you don't want to be the CDC and let airborne Ebola get around because you made a safe but not extreme assumption. Better to assume that it could become airborne when dealing with things like keeping it in labs, dealing with patients at American facilities, etc.

    I'm hoping you could give some pointers on what are some of the best ways to stay "safe" while flying? I have 3 small children whom will be flying home with me (flying from Tokyo to San Fran to Arizona) beginning of September. I'm really concerned about being on a plane right now or in the near future. Any suggestions?

    At this point dont' worry at all. People likely to be sick are being watched for very closely .More likely, yo traveling with three children are going to give other people colds that time of year!

    Otherwise, lots of washing of hands is the ticket.

    Thank you for the input!!!

    Another reason for excessive care re: the masks, suits, etc.: It's a lot harder to touch something contaminated by someone's bodily fluids and then wipe your nose, rub your eyes, pick at your teeth, chew a nail, etc. (things we do without consciously thinking about) when you have a mask over your face...

    By Brainstorms (not verified) on 04 Aug 2014 #permalink

    Africa are closing borders to stop the spreading but we are shipping them here. How smart is that? ...

    You seem to have missed two things:
    a) Only two infected people are being brought here, and
    b) They are not simply wandering, in street clothes, from the point of infection to downtown Atlanta (or have you not seen or read of the protections taken during their transfer and treatment?)

    Clearly though, two things are now going on.
    a) Like the aptly named poster at 9, some people are, for whatever foolish reason, not thrilled with this:

    b) The "make up any crap at all to claim that President Obama is doing his best to needlessly endanger us" right-wing is beginning to show up:

    No matter how foolish the lie there are some who will be lapping it up.

    At this point there have been several reports of Ebola in other countries. Two are valid, the rest have been shown to be not valid. Hong Kong, the US, somewhere in South America, and the Philippines are examples. The Philippines to give an example has a valid concern, there is a lot of back and forth between the affected areas and the Philippines (as is true with the US as well), but nothing has panned out though there has been some sensationalizing.

    The only valid cases I know of are Nigeria which may or may not have a local outbreak (probably not but it is unclear) and the two patients brought to the US, who are simply not a risk at all.

    The truth of the situation is that it is out now. And there is no telling how many people are carriers - we only know about the ones that we know about. Chaos theory always holds true. Or is that too general?

    That might be kind of general... but anyway, it is true that we only know about the ones we know about!

    The leading authority of Ebola, who was a doctor, even well suited caught the disease and died. So don't tell me you know everything about it. It's a virus.

    By Luke Thomas (not verified) on 06 Aug 2014 #permalink

    2 death, 8 positive confirmation in Nigeria and 1 death in Saudi. Ebola is jumping the continent. How about vaccine?.

    Lagos is a densely populated city, Most Nigerian health facilities can barely cope with malaria outbreak. We urgently need specialist assistance. I hope am not an alarmist.