First person in US to catch Ebola: The Meaning of Ebola Patient Two (updated)

The first person ever to catch Ebola in the United States is now in isolation at Texas Health Presbyterian Hospital.

Don't panic, even if you live in Dallas. But also, don't fall into the hyperskeptical trap of assuming that because scientific authorities tell you everything is fine that concern is irrational. There are very rational reasons to be concerned. But you need to be smart about what to be concerned about.

A couple of weeks ago, as you know, a man came to Dallas with pre-symptomatic Ebola, and became symptomatic there. This was the first case of a person being diagnosed with Ebola in the US. The case was botched. The hospital sent home a man with pre-Ebola symptoms who had come from West Africa. He was later admitted after he got a bit sicker and tried a second time to get treatment. There were other ways in which the case was not handled too well, mainly from a public relations and messaging standpoint, but the CDC and the hospital involved seemed to be doing a good job and getting their acts together.

Now, the situation has developed in a rather disturbing way. A health worker that had been caring for Patient 0 has now been diagnosed with Ebola. This happened overnight. The patient was under self monitoring, had a mild fever, went to the hospital, was tested, and the reasonably reliable preliminary test indicated Ebola. A second much more reliable test is being done now but it is expected to be positive.

I just watched the news conference and from this I gathered the following important bits about the new patient.

  • The patient was in the low risk pool. Among Patient 0's contacts, there were higher risk and lower risk. Higher risk individuals were being isolated and/or monitored very closely, lower risk individuals were self monitoring. This patient was self monitoring.
  • The person cared for Patient 0 during his treatment prior to his death at Texas Presbyterian; there was no contact during the initial botched visit.
  • The new Ebola patient used protective procedures (gown, mask, gloves) in that care. The exact nature of the care beyond that is being kept secret at the moment owing to HIPAA rules. (But see below to see how absurd the HIPAA rules are in this case.)
  • The new patient seems to have lived with a second person who is now also in isolation.
  • Hazmat suit wearing teams arrived during the night at the apartment complex of the new patient, and decontaminated public areas such as the lobby of the apartment building, and the interior of the patient's car. It is thought that there is a pet inside the person's apartment, but teams, as of this writing have not entered the apartment. They plan to do that soon. Local police doorknocked everyone in the "immediate area" to explain to them that they should not panic, did a "reverse 911" call for the area, and are re-door knocking this morning. So, the identity of the patient will be known any moment now because you can't really do all that without that happening. (Which, frankly isn't too relevant. I'm not sure if HIPAA rules should protect health care workers in quite the same way as patients, though they may in fact do so.)

    So, what is the meaning of this all?

    First it means that when hundreds of administrators, police, government officials, hospital employees, health workers, etc. are tasked with the job in the US of making sure no one gets Ebola from a person who has Ebola, and also tasked with the care of that person, a) one person gets Ebola anyway, and b) the first patient dies.

    I very quickly add that this is a TINY SAMPLE SIZE OF N=1 and I'm being a bit cynical here. But it is still true that all these resources failed to prevent what every one feared, and what the authorities said would not likely happen.

    Second, note that this new patient did not get Ebola from Patient 0 prior to his first visit to the hospital, or after that first botched visit. Again, small sample size, but it points out something important. When we say that a human with Ebola can spread the disease only when they are symptomatic, that probably doesn't even count the initial fever period. Infectiousness is probably correlated to the severity of the symptoms. The family members or heath workers who deal with the bodily fluids randomly coming out of a person who is dying of Ebola, bed ridden and very sick, are at the highest risk, even those in the lower risk pool like this new patient. (This is why the HIPAA rules need to be set aside. We actually need to know what this person's role in the process was, what this person did exactly. That is important information that the public has a right to know. If this reveals the name of the worker by deduction, then so be it. The person's name has already been effectively revealed by deduction form the activities at the person's home.) But, importantly, once a person is really infectious, they are really, really, infectious. See my quick note below on spread of Ebola.

    Third, note that the medical authorities have said all along that following proper procedures minimizes risk. Note that even when following proper procedures one person was infected anyway. Note that at this morning's press conferences, the authorities have not changed their story. This is partly your fault, members of the public, because collectively you seem unable to understand that Ebola is both very dangerous and manageable. Your collective insistence that your fear being ramped up is somehow proof that Ebola has gone airborne is an example of that. If you collectively stop being unmitigated morons about this, then the authorities can stop being alarmingly Orwellian about it. Maybe.

    Fourth, think about this. A huge effort is made to avert a possible Ebola outbreak. The effort fails in a couple of ways, but we get lucky, those failures don't cause too many problems other than, possibly, the death of the patient because care was not timely and proper drugs were not administered. But as far as the concern over an outbreak goes, the early screw ups did not cause one. So, proper and resource intensive procedures are in place and everything is going as well as it can be. Then somebody gets ebola anyway. This explains West Africa. Here, in the US, we have 200 people for every Ebola patient. In West Africa, you might have 1 person for every 100 (possible) patients out there. Those numbers are made up, but you get the point. In order to limit Ebola in West Africa we'd have to do what we can do here, and that proves to be of limited utility. Prior outbreaks were stopped because of the high ratio of health workers AND the disease burning out by killing almost everyone in some families or small villages so spread was stopped. So now we have a better sense of what is going on there. Imagine that every person in the US isn't just someone who heard about Ebola in some other city. Imagine, instead, that everybody in the US lives in an apartment building in which one or two other people in the building have Ebola. And there are no hospitals.

    So, collectively, that is all good news and bad news. One more piece of good news: We are near the end of the period during which someone who may have been infected might show up.

    On the spread of Ebola

    I've written about how Ebola is spread before and about the unlikelihood of it "becoming airborne" (see links below). But I keep hearing, again and again, that this or that vague observation someone has made proves that it has already gone airborne. Well, I've got a bit more to add to that discussion to help people put it in perspective. The truth is, pretty much every one who is saying it is already airborne or that it is likely to go airborne or that eventually it is inevitable that it will go airborne is an airhead. Sorry for the strong language, but at this point it is simply true that with so much information out there about this being utterly wrong is not acceptable.

    Consider Norovirus. It is roughly as infectious as Ebola. Two years ago, for example, we had an outbreak of it here in the Twin Cities. Someone at Huxley's daycare had it. Then Huxley, then everyone else at his daycare, and everyone in our family, and everybody. Had it been fatal, the entire region would be dead. It is not airborne, but it is a disease that there is a good chance all the people crowing about Ebola needing to be airborne have had, have seen in action. Next time you feel the need to insist that Ebola is airborne remember the last time everybody in your family, one by one, got the "stomach virus" (as it is often called). It wasn't airborne. You got it because germs form someones' poop or vomit got into your mouth. Perhaps you should not have been licking people's anuses or drinking their vomit with a straw during that time. Oh, you claim you did neither of these things? OK, fine, you weren't doing that. But you still got kooties that came from vomit or poop. The way bodily fluids get around, and the opportunities for contact, are much greater with Ebola. With the stomach flu, most of the time most people can make their own way to the bathroom to have diarrhea and vomiting. With Ebola, the sicker patients are lying in bed doing this in a closed room. Everything gets kooties on it. Maybe they were soiling themselves and puking for a few hours in a "taxi" waiting to get into a hospital. Touch touches stuff that touches stuff and bits of Ebola rich feces or Ebola laced vomitus are now on your hands.

    Even the flu is only barely spread airborne, but mainly through direct or indirect contact. Ebola is more infectious because it does better with indirect contact.

    UPDATE: Major Media is reporting, based on a Sunday AM show interview, that there was a "breach" in protocol in Dallas. But the doctor interviewed did not say that. He said, essentially, that there must have been a breach but they do not know what happened. This is important for media to get right, and it is the media's job to get these things right. If there was no breach in protocol, then the existing protocol allows for Ebola to cross the boundary. If there was in fact a breach, and we know what it was and can confirm it, that is a very different situation. To be clear: The fact that protocol was in place and used and Ebola got across does NOT mean that Ebola is being transmitted by air or in some other unknown way. It could mean that protocol was breached, but without specific evidence we don't know that to be true, and we don't know what went wrong. In between these two is the very high probability that standard protocol has a weakness or two that could be shored up. Personally, based on my own experience (not with Ebola) and based on some reports from the field, I would suggest this has to do with how gowns, masks, and esp. gloves are handled. You have to use the same kind of protocol to remove these things as when you are using these things. Perhaps care workers should be demasked, degloved, and degowned by a masked/gloved/gowned coworker who has just suited up in a space away from the patient. (I don't think that is done now.)

    More on Ebola:

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    UPDATE: The first health worker to have been affected with Ebola in Texas may not be moved to Maryland. From NBC: Nina Pham, one of the two nurses who contracted Ebola in Dallas, is expected to be moved to a National Institutes of Health isolation unit in Bethesda, Maryland, a federal official…
    Live blogging. Dr. Tom Frieden talking. Don't say "hand in glove!" What the are doing in Dallas: 1) Site manager on the site in Dallas every hour of the day, checking protective gear use. 2) Enhanced training, including by experienced nurses with Ebola experience. 3) Limit number of care staff so…
    First, let’s look at the situation in West Africa, because that is way more important than anything going on in the US right now. The WHO has said two things about this. First, if there is not a full intervention, there may be hundreds of thousands or even millions of cases of Ebola several months…
    According to popular literature (some fiction, some not) and movies, Ebola can cause havoc, infecting thousands of people, killing over half of them, and threatening an entire nation if it were to become airborne. Turns out that's not true. Ebola can do all those things without becoming airborne…

    My biggest concern is that ebola gets into the bat populations in North America and Europe. That may make it much more difficult to deal with in the short term.

    What would likely happen then is that vaccines for ebola would be developed and administered to bats, likely via GMOs. That would probably be pretty effective because bats have a low population growth, ~1 per year, and immunity would likely be long lasting.

    By daedalus2u (not verified) on 12 Oct 2014 #permalink

    It should be noted that rabies is endemic in Bat populations in the US already. Although it does take a bit to spread, clearly the risk of rabies is low enough that only those involved in animal health (vets animal services etc) get the vaccine.

    Remember, though, there are two kinds of bats and they are very different. Both Rabies (in the US) and Ebola (in Central/West Africa) is found in fruit bats. There are no fruit bats in the US or the New World. I am not certain that non-fruit bats have been tested for Ebola in Africa, but a lot of animals were and to my knowledge only fruit bats are regular hosts (and even there, it is spotty, found in many species, but the average sampled fruit bat may show no evidence or only evidence of prior infection, not active infections).

    Microchioptra and Megachioptra diversified a long time ago, probably the early Eocene. They are really different. Mega do not echolocate and are less nocturnal (though this is probably derived, but in antiquity). Ebola is a filovirus, suggesting that fruit bats originally acquired it from plants (in antiquity through a long history, likely). I don't think it is especially likely that the insectivorous (or blood drinking) microbats are carriers of ebola.

    But, after all, a lot of mammals can catch it. Dogs seem to have it but not get sick from it. The idea of Ebola taking up a new host is not at all outrageous. Probably it would be a mammal, and it would likely be gregarious (given the way ebola probably gets round in bats). So microbats are a possibility, as well as a wide range of rodents, I suppose.

    One also has to wonder how much training the workers had had with these procedures (or is that a stupid thought?)

    "Perhaps care workers should be demasked, degloved, and degowned by a masked/gloved/gowned coworker who has just suited up in a space away from the patient. (I don’t think that is done now.)"
    What level of concern would there be for these people's risk of exposure?

    If I'm not mistaken, the issue in West African bats and ebola is that the bats are a common form of bushmeat. Transmission comes from handling and eating the infected animals.

    Just guessing, but I think ebola would have to become widespread in humans before being transmitted to North American bats, and even then, Americans have very limited contact with bats.

    By Rob Honeycutt (not verified) on 12 Oct 2014 #permalink

    Bats are bushmeat but most outbreaks probably have involved primates or ground mammals. The a west African outbreak may not have been bushmeat at all.

    I am thinking a big threat now is terrorists deliberately spreading the virus using their own bodies. Ie if someone were to get themselves infected and travel to a populated area, deliberately mingling into crowded places. I hope the authorities have attention on that angle.

    That tactic goes back to the Middle Ages. And before that, too, I believe. (In the form of, e.g., livestock infected with anthrax being flung into walled towns to spread contagion.)

    I'm not aware that it's been done with human beings, although I wouldn't put it past some ethno-religious groups to do so...

    (Yes, yes, we're all now thinking about the castle scene in Monty Python and the Search for the Holy Grail...)

    By Brainstorms (not verified) on 12 Oct 2014 #permalink

    We're told that the chance of catching Ebola on a plane is very small. However I thought I heard that either the case in the US or in Spain was transmitted via a third surface, i.e. from the infected patient, to some surface, to the new patient, possibly from perspiration. If that is the case, then I would have thought the chance of catching Ebola is somewhat higher than we are being led to believe.

    Can anyone clarify this?


    Alistair, it is my opinion that if a person with advanced Ebola, exhibiting multiple symptoms, is a regular passenger on a commercial airline for several house, there is a very high probability of transmission.

    Thanks Greg, that aligns with my thoughts.

    So, to first approximation, our current estimate (with some margin of error!) of R0 in the US is now 1?

    Karsten, yes, a very small sample size, but yes. Or, greater than or equal to, I suppose.

    Brainstorms, would those be the "ethno-religious groups" who aren't equipped to just bomb or starve the ethno-religious groups they don't like? Yes, it's theoretically possible that A Terrist would infect himself, come here, and perhaps make a few people sick who might make a few more people sick. (When you're shedding huge amounts of virus, it's because you are experiencing constant vomiting and diarrhea, and as Greg points out above, this doesn't make it easy for you to walk around town rubbing your hands on things.) This pales in comparison to the hundreds of people who are being infected every single day by accident - though some of the racist right seem to think that this too is a plot against them.

    I wonder what is the estimate of R0 of the CDC. If 0.1, with some reasonable uncertainty, this first data point ought to cause a significant upward shift in their posterior. It might not shift a prior of 0.5 very much, but then if their prior is 0.5, surely they can't be *that* confident that it couldn't be above 1. I for one, am not reassured by the logic of their communications. I want them to tell me the mean and standard deviation of their current posterior distribution for R0 in the U.S. Surely they've thought about this, no?

    Jane, viruses aren't racist, they're more like opportunists. So any opportunistic group that wants to create mayhem could, theoretically, send infected-but-not-yet-symptomatic individuals abroad to mingle with groups they have it out for. They would not be vomiting, et al -- yet. And wouldn't need to go around town rubbing their hands on things. Which is exactly why this is so worrisome. They will eventually end up in the ERs (spreading as they are assisted in getting there) and that's all they require. Nature (human & viral) will do the rest -- as both have already combined & done in West Africa. Which is exactly why this is so worrisome.

    By Brainstorms (not verified) on 13 Oct 2014 #permalink

    @bob #8

    ... And all I'm thinking now is "we're all fucked."

    Tim, we could just close the borders to save ourselves. Only, then Big Business would be screwed. So, since Big Business always gets its interests put first, they'll pull political strings to keep the borders open. THEN we'll all be f'd.

    (Ironically, then Big Business will be f'd, too. But "it must be this way", since Big Business' intellect inevitably follows its morals.)

    Feel free to substitute AGW into the above and find that it computes the same...

    By Brainstorms (not verified) on 13 Oct 2014 #permalink

    I'm thinking more of little business, which is what would be hurt most when the communities that sit astride the border from each of these African countries and the US is cut in two.

    Yes, but I can't see any way to deal with this other than to partition/quarantine and deprive the virus of new hosts. It's too easily spread, and there are many cultural norms that only help to spread it. (E.g., the W African custom of handling the deceased seems tailor-made for Ebola propagation.)

    Of course, all that assumes that a vaccine either can't/won't be produced, or that it will be "held hostage" to make its developers rich. Time is of the essence when you're dealing with exponential growth...

    By Brainstorms (not verified) on 13 Oct 2014 #permalink

    It hasn't hurt the black markets moving 'ill-advised' things, Greg Laden #20. -- They don't seem to always follow protocal. Or respect their own reputations when fake and deadly 'K2' happens to accidentally get on their shit, weed-killed, compressed-half-biodiesel glop of what passes for 'weed' when *they* turn off the domestic pipes.

    'Insipid {... fill insomething here... my thoughts have turned to glop} L-glopamine(™)...

    Brainstorms, if you're not actively sick, you're not likely to be shedding so much virus that just strolling by and breathing on people will give it to them. If you are sick, as soon as you go to the bathroom you'll have virus on your hands, which you can spread by touch, but you will soon be feeling too lousy to do much of that. Experts have said that Ebola is not a "rational" bioweapon - as if there is such a thing - for this reason.

    There are thousands of currently infected, soon to be sick innocent citizens in these three countries, and very few "terrorists" indeed. The former group poses a much greater risk for significant spread out of the region, because even the tiny fraction of them who will innocently travel while incubating the virus outnumber any plausible number of - so far completely imaginary - disease terrorists. If we wall them off and try to pretend they aren't there, by the end of the year there will be hundreds of thousands, and the risk of unintentional spread will go through the roof.

    Meanwhile, to shut down unintentional community transmission outside that region quickly, it's essential that anyone who might possibly be infected has access to care and does not have good reason to fear seeking it. If the local level of paranoid discourse is so high that a traveling foreigner or returned citizen from an "ethno-religious group" targeted for scapegoating thinks that going to a hospital might get him treated as a "suspected ebola terrorist" and thrown in a locked room with substandard if any care and no phone, he might rationally decide to stay home a couple more days and see if whatever is making him sick gets better. And you don't want that.

    Those of you suggesting a bio-terrorism approach lack imagination. Guinea pig terrorists (or prisoners) would be infected by the virus from the fluids of an infected corpse that was smuggled out of west Africa. The infection would be allowed to proceed until copious infectious fluids were gathered. The fluids would be sent to terrorists in locations around the world who would spread them on surfaces in public places, while contracting the disease themselves. Then as long as possible they would infect as many individuals as possible. In other words, you don't need to be infected yet to start spreading the cheer.

    Jane, Dan-- You needn't make this complicated: If someone infected goes to another country while they're asymptomatic, then gets sick later, then even if incapacitated, someone (multiple Good Samaritans?) will "help" by seeing to it that such "people in need" end up in an ER or medical office.

    While that's occurring, everyone involved will be in contact with bodily fluids, touching surfaces, and causing what Jane refers to as "unintentional community transmission".

    With 3 weeks from exposure to symptoms, that means a lot of chances for incidental exposure that goes unaware + travel before symptoms appear, leading to the culturally-expected assistance ... that all leads to exponential growth of exposure.

    This would be different, if, say, an exposed person turns purple and oozes slime within minutes of being infected/infectious. Only then would repugnance lead to consciously avoiding contact.

    We don't have that. We have "Oh you're sick, you need to see a doctor.. Let me help you..." Cultural norms and social pressures of "Polite Society" lead us to do things that lead to bodily contact and that's all it takes...

    By Brainstorms (not verified) on 13 Oct 2014 #permalink

    Brainstorm... Greg can probably verify whether this is correct, but I think there's a big difference in cultural aspects in west Africa and here that would likely prevent similar rapid spread of the disease.

    On of the big problems in Africa has been that most of this has occurred in small villages where people have a limited capacity to comprehend what is actually happening. I've watched a Frontline piece and a NOVA special about this outbreak (and if I'm getting things right) it sounds like a lot of people have been infected there due to the tradition of washing the bodies of their dead. That, and the fact that, rather than having the option to go to a hospital, ebola victims are often cared for in their homes. It's only when medical workers get word of an outbreak in a village that the go their to try to locate them. By then you have entire extended families who've been in close contact with a symptomatic victim.

    Then, on top of everything else, you have these foreigners who show up in the village, speaking strange languages (English), putting on space suits, then carrying their loved ones off, and then returning them a week later when they've died. Just tragic and awful for everyone involved over there.

    It's definitely a big concern over here, but I kind of doubt we would see anything similar as what's been seen there. (I hope I'm right.)

    By Rob Honeycutt (not verified) on 13 Oct 2014 #permalink

    You all lack imagination. While everyone is looking for Ebola is not the time to spread Ebola. Marburg. Spread that around, and the confusion will be immense and the fear will be ten fold. Throw in a little Lassa for good measure.

    Rob, I hope you're right, too. OTOH, history of brain-dead Americans reacting to something they're scared of and don't understand; patients being sent home incorrectly; hysteria over the airborne tope; nurses getting infected after supposedly following procedures; etc. And I hope you're right, too.

    By Brainstorms (not verified) on 13 Oct 2014 #permalink

    Greg, you're just too damn intelligent not to have been on their radar the entire time...

    By Brainstorms (not verified) on 13 Oct 2014 #permalink

    Truly a radical, and probably a subversive... But at least you're protected.

    By Brainstorms (not verified) on 13 Oct 2014 #permalink

    Actually the authorities (and others in the know) being alarmingly Orwellian about it brought this outbreak on my radar in the first place.
    Without having seen any sign of imminent panic, getting constantly told not to panic, that makes me nervous. You know, like when someone tells you not to call the police, you should call the police.

    You guys tell us a lot about what didn't and probably won't go go wrong (mostly obsolete 2 weeks later).
    What you aren't quite as verbose about is what went wrong in the first place, why the virus has pushed the fast-forward button in Africa real hard. It didn't start as much last year, did it?
    Has anything changed there, say reproduction rate or infectiousness or is this just a random freak ocurrence?

    First, there is no "you guys." I have personally written about what is different about this ebola outbreak. Look at the side bar (topics) and you'll find an entry for Ebola, you can see all my posts.

    This Ebola strain is not spreading differently than earlier strains in terms of how it goes from person to perosn. But this is the first outbreak that wasn't in a thinly populated region separate from other villages or towns by a good distance. This is an urban outbreak in a place with almost no health care. SO not exactly a freak occurrence, but different in that very important respect.

    What is a matter of concern here is the fact that there are many very large cities around the world with high numbers of very poor families with practically no access to health services. If, for example, Ebola spread to the slums of Mexico City, there is a high likelihood that a "West Africa" scenario would play out there as well.

    Greg, What differentiates the Reston ebolavirus from Zaire ebolavirus? How was Reston able to become airborne (or communicable by that exposure pathway) and Zaire cannot? I read your blog on why ebola [Zaire] will not become airborne, and accept your assertions. Also, why is Zaire able to infect humans and Reston cannot? Cellular receptors?

    Reston is not Ebola, and it is from Asia (prob. Philippines). It is incorrect to day that Reston is Ebola that has gone airborne. It is a different (but related) virus from a different part of the world that seems to be doing something different. Seems to not bother humans. We don't know much about it, even what its wild host is. Reston may be able to infect humans; there is a case of that, one as far as I know. But I think it may not make humans sick usually. The positive case was a man in the Philippines, he tested positive but did not get sick . Might have caught it from a pig.

    Yes, urban outbreak, that much is obvious from the news.
    But why urban outbreak? That's what my question boils down to. Didn't it start quite seperate and did nothing uncommon for many months or are those two seperate outbreaks.

    @28. Greg Laden : Would a test for ebola also pick up marburg?

    Also, while thinking gee thanks, about giving 'em possible ideas, I do wonder whether the Islamic ritual bathing practices* - among other things - would be a preventative factor -and I think they'd realise how likely a tactic like that would be to be backfire on them? Maybe?

    * Apparently as I understand it, not a Muslim so don't really know) Muslims have to ritually wash their hands and faces before each prayer (5x daily if devout) and I think also on entering a mosque yeah? Communal facilities there make the implications for ebola infective folks rather obvious don't they? Also aren't Muslim burial practices similar to West African ones and thus also would risk infection spreading too so they probably wouldn't use this method.

    Final thought :I know some Mullahs /Ayatollahs / islmaic leaders have put a Fatwah on nuclear weapons (read somewhere a few times) so wonder if they've done the same for bioweapons like this speculative one? Of course there's also apparently fatwahs (bans) on suicide too and that hasn't stopped the homicide-suicide bombing practices so , yeah, who knows? (Not me - hence asking!)

    By Astrostevo (not verified) on 13 Oct 2014 #permalink

    Greg, I found a paper saying that R0 for Norovirus is 2.62:…

    If your comparison is viable, then yes there is cause for considerable worry, given the rapidity of spread of Norovirus.

    I recall seeing R0 = 1.38 for Ebola from more than one credible source, possibly including in this blog. I'm inclined to think that 1.38 may be low, and the actual number would be a little above 2 in the US and a little above 4 in Africa, but that's my "intuition" speaking, _not_ a science-based estimate. (I came up with those numbers before I found the paper on Norovirus for comparison.)

    (For those who don't know this: R0 = the number of new patients that can be expected to catch a disease from any given patient. For example Alice has a bug that has an R0 of 1.5: we can expect one more person to catch it from her, and a 50/50 chance of a second person catching it from her. Bill has a bug with an R0 of 2: we can expect two more people to catch it from him. Etc.)

    Re. Ebola terrorism: (Bob and others):

    I've been making noise about the risk of Ebola suicide terrorism for well over ten years, including in a couple of places that had/have good to excellent channels to the TLAs (three-letter agencies). I've also seen indications that they have been thinking along similar lines independently. So I would say it's highly likely that the scenarios are convergent: anyone who thinks about this comes to similar conclusions. I'm confident that the TLAs are on alert for this, including looking out for suicide terrorists, smuggled animals, bedding, clothing, bodily fluids, etc. And I'm also confident that the methods available, are up to the task.

    Seriously: with all the bad press about the TLAs, what you don't hear about are their successes, but there are many. For example TSA catches over 100 firearms a month that would otherwise have gotten onto airplanes. If you assume that 99.9% are innocent mistakes (e.g. someone left their legal firearm in a travel bag after a car trip), that's still two potentially fatal hijacks per year prevented. And yet all you see in the media & the blogs are complaints about having to take our shoes off.

    To characterize the Ebola terrorism risk in terms of "rational actors" is a mistake: rational actors are by definition death-averse and this-world-oriented. Contrast to "irrational actors" who are death-seeking and other-world-oriented, for example motivated by martyrdom ideologies. (These are not limited to Islam: there are segments of Dominionist Christianity in the US that promote martyrdom.) It is precisely the "irrational actors" that we have to worry about. And as the activities of ISIL have shown, their capacity for evil deeds is limited only by the available opportunities.

    The fact that other viruses e.g. Marburg, may also be used by bioterrorists, only increases the total risk. However, again, I am confident that the TLAs are aware & alert about all of this.

    Re. animal vectors:

    Let us not forget common rodents: mice and rats. There are two risks here: One, mice or rats in housing occupied by patients. Two, mice or rats getting into contaminated wastes, either at patients' homes (e.g. apartment dumpsters) or at hospitals.

    Of these scenarios, to my mind, the "apartment dumpster" route is the most dangerous, followed by single-family residential refuse bins. It's essential to practice proper sanitation here, by making sure that refuse bins are covered with tight-fitting lids, and that lids on dumpsters be checked (and repaired if needed) and used properly as well.

    Very often, apartment dumpsters are left wide open all the time, because the lids are noisy and heavy (and frankly because people have forgotten that flies and rodents are serious public health hazards in general). That has to stop, and dumpsters need to be fitted with new strong plastic lids, or small hatches in the metal lids, that are easy for people to open and close.

    Someone needs to do some testing ASAP to ascertain a) whether mice or rats can acquire the virus, b) whether it can sicken or kill them, and c) whether they can transmit it via their urine, saliva, droppings, etc. I would assume (a) has already been done and the answer is Yes, since rodent models would likely have been needed in Ebola research to date. But I'm not aware of any findings on (b) and (c): does anyone here know of anything?

    Astrostevo: I don't know, it might. That would have to be determined. They are both filovirus.

    G(40), my intention was not to say that the R0 value of Ebola and Norovirus was the same. Actually, my experience is that Norvirus has an effective infection rate of "everybody, you can't avoid it!!!!' which is pretty close to 3 in an American suburban setting with daycare. It is probably much more infectious that Ebola, so Ebola is really really infections and Norovirus is don't even ask, you've got it infectious.

    Greg, thanks; and I figured you meant something like that, but the question was the axis of comparison. If it's not virulence, it's infectiousness, which translates to R0, so I went and dug it up.

    And yes, Noro also scares the hell out of me, having had either it or food poisoning a couple of times, decades ago, and never wanting to repeat that experience as long as I live.

    If everyone who went to the hospital for Noro was given a sympathetic but clear talk about hand-washing and food sanitation, they'd come back from the hospital "reborn" with true zeal and fervor, and run around seeking to "convert" all their family members & friends who are still "living in sin" by way of ignorance of how bad it is and how easily prevented. That's one kind of preaching we can all live with;-)

    G: I know. All we need now is a virus that loves it when you wash your hands!

    Dan: I keep thinking of Rio. Actually wasn't Ebola the virus spread in a Tom Clancy novel using the misters at the Australian olympics?

    I'm not going to assume that other concentrated poor areas are just like West Africa in the critical ways that matter. But I don't think we actually know what the key factors are. Certainly, dense, poor, lousy health care system, a certain mix of beliefs about disease, etc. must matter.

    It might be true that diaspora are less likely to develop between poor and poor regions than poor and rich regions. There are probably not too many communities spit between Monrovia and Rio, for example. If this was an East African phenomenon I'd worry a LOT about South Asia.

    I think lack of health care services and lack of access to clean water are going to be the critical break points for Ebola, not cultural practices. I think the whole cultural practices shibboleth is quite simply a form of denial to avoid looking Ebola square in the eyes.

    The cultural practices problem does emerge as such, I agree. But on the ground, in its actual form (what happens, with all its variations and actual manifestations) it is a real thing that has to be addressed. For example, in the first few outbreaks, the outbreaks were exacerbated by local burial practices. That had to be addressed, and was addressed. But what emerged from that is the myth that all Africans use burial practices that enhance Ebola spread, and/or that all Africans can't change practices to reduce Ebola spread. Neither of those is true. Burial practices (by which I mean the whole mortuary ritual) vary a lot across the continent and even within communities, and often people are willing to understand the problems and change.

    If a nurse in full protective garb contracts the disease, then the unfortunate family members caring as best they can for Ebola-struck loved ones prior to diagnosis have only luck and God's protection. Seriously, do we even know how the Texan nurse contracted it?

    Just think about this, if an R0 of 3 for norovirus translates to "everybody gets it": I've recently seen an R0 of 18 for measles. No, there wasn't a decimal point dropped there. Eighteen means everybody and all their invisible friends get it, which is why earlier generations considered a vaccine so desirable. A couple of the vaccinated-against Western diseases that had more significant death rates, including diphtheria, had an R0 of 4 or 5. Of course, living space, sanitation and nutritional quality were all poorer at the time giving rise to those estimates. Food for thought, though.

    G writes: "To characterize the Ebola terrorism risk in terms of “rational actors” is a mistake: rational actors are by definition death-averse and this-world-oriented. Contrast to “irrational actors” who are death-seeking and other-world-oriented, for example motivated by martyrdom ideologies."

    This falls into the trap of caricaturing Others' actions which we don't like as being due to their evil, irrational beliefs. Studies of terrorists (by dictionary or American definitions) make it clear that most are motivated primarily by political goals. People are probably more willing to give their lives for a cause if they believe in an afterlife, but this does not mean that the purported cause is not actually meaningful. That pretense allows us to ignore the real injustices that often provoke intergroup violence.

    Meanwhile, I strongly disagree either that the behavior of outgroup members is much less rationally motivated than that of good Westerners - all humans have a mixture of rational and irrational motivations - or that to be rational is "by definition" to be "death-averse". (On the contrary, to be rational, I must recognize that my own short life is of finite value; therefore I should be willing to risk or sacrifice it for something I consider of greater value, such as my child or my people. The needs of the many outweigh the needs of the few, etc.)

    But anyway, when I spoke of a rational bioweapon, I didn't mean "one that a Vulcan would consider it desirable to use", to continue the Star Trek theme. I meant "one that a typical, emotionally motivated human who had already decided to develop or use a bioweapon would think was a good candidate." Both U.S. and Russian researchers who had no qualms about working on potential ways of killing off "enemies" with epidemic disease looked at filoviruses and decided that yes, they are very nasty diseases, but no, they do not make "good" bioweapons. This is not to say that no scuzbag will ever set out to infect another person with one on purpose; the U.S. had a small group of [white] scuzbags some years back who contaminated local salad bars with a diarrhea-inducing bug, causing a few illnesses. But if you're trying to bring about the apocalypse, it's a really stoopid way to go about it.

    " if an R0 of 3 for norovirus translates to “everybody gets it”: I’ve recently seen an R0 of 18 for measles."

    Exactly. Everybody gets NORO, and for the measles, everybody gets that too, plus the people down the hall in another room. Here, "everybody" is everybody in your household, of course.

    "Of course, living space, sanitation and nutritional quality were all poorer at the time giving rise to those estimates. " Right, R0 is context dependent.

    "This falls into the trap of caricaturing Others’ actions which we don’t like as being due to their evil, irrational beliefs. " Yes, always a very bad mistake to make!

    With respect, Reston ebolavirus is an ebolavirus, as confirmed by the CDC. Hence my curiosity and questions yesterday.

    From CDC:
    "Tissues from pigs that had died from Porcine Reproductive and Respiratory Syndrome were sent from the Philippines to the USDA Plum Island laboratory for diagnostic analysis. Several viruses known to infect pigs (e.g. circovirus and arterivirus) were detected in some of the tissues. Using new molecular detection assays, Ebola-Reston virus RNA was detected unexpectedly in some of the samples. Ebola-Reston virus has not been shown to infect or cause disease in swine previously.

    Although infection with Ebola-Reston virus can cause a hemorrhagic fever with high fatality in non-human primates, the Reston subtype of Ebola virus has not yet been proven pathogenic to humans with antibody evidence of Ebola-Reston infection; however, infection with other Ebola virus species, such as Ebola-Zaire and Ebola-Sudan, usually causes a severe hemorrhagic fever that is often fatal in humans.

    In October 2008, the Centers for Disease Control and Prevention (CDC) confirmed that swine from two farms in the Philippines were infected with a filovirus, which was confirmed to be the Reston species of Ebola virus."

    Yes, it is called that. It is an Asian virus with an apparently different ecology, host, and infection potential that has little to do with the African Ebola virus but that we know little about. I don't happen to think it is correct to call it a subtype of Ebola. Is rather call it Reston for the very reason we are having this conversation (generally). Reston is not informative of Ebola's potential.

    Makes me angry that they bring such a disease here to the u.s. A HUGE part of me knows they have a cure but it's not in the budget to save us and everyone else in the world. Population control. We are screwed. There are things they're not telling us. God help us all. If you pray... pray about this. The end is near if they're precdicting 10000 a week. You do the math.

    By katrina dorsey (not verified) on 14 Oct 2014 #permalink

    katrina, they may be slow in telling us stuff but I'm pretty sure there are no things they are not telling us.


    Very scary. On September 17 CIDRAP - the Center for Infectious Disease Research and Policy at the University of Minnesota "strongly" urged the CDC to adopt new standards for PPE (personal protective equipment) for healthcare workers treating Ebola patients. They urge the CDC to change the protocol and have healthcare workers use powered air-purifying respirators (PAPR) rather than the masks currently specified.…

    By Dan Owen (not verified) on 15 Oct 2014 #permalink

    In reply to by Karsten (not verified)