Containing The Ebola Epidemic – Or Not

Standard public health measures for dealing with infectious disease epidemics have long been known. The mainstays are quarantine and contact tracing. These are obviously easier and more effective when there are very few cases. Apparently, neither hospitals nor individuals have adhered to CDC guidelines. Texas Health Presbyterian Dallas discharged the index Ebola patient despite his travel history.

Allegedly, the patient was not entirely honest on an airport questionnaire, and his family members violated quarantine, as did members of an NBC filming crew after their cameraman was diagnosed. Furthermore, CDC guidelines have been inconsistent and lax. The CDC is now saying contacts may not use public transportation during the monitoring period of twenty-one days. But people with contacts in West Africa may still enter the United States as long as they don’t have a fever and they provide contact information. They receive a tear sheet with instructions they can show to staff at a hospital if they develop symptoms. CDC is currently expecting all hospitals to be prepared.

But it is still presuming that a level-4 pathogen can be safely treated with level-2 or level-3 precautions. Even in Africa, workers with Doctors Without Borders check to be sure that protective gear leaves not a square millimeter of skin exposed. And workers are doused with strong disinfectant before removing the gear. The CDC simply provides pictures of how to remove gear without touching the outside. One mistake, and you might die. A BSL-4 facility protects against airborne pathogens. Masks are not adequate; attendants need powered air-purifying respirators (PAPRs).

How many nurses will we sacrifice to the CDC’s dogma? They are heavily exposed to aerosols when patients have projectile vomiting and explosive diarrhea, or when they flush the toilet. (At Emory, they disinfected the water before flushing, apparently out of concern for the sewage system – never mind the nurses). What about decontaminating the room? Hospitals’ current housekeeping procedures don’t protect patients against MRSA (methicillin-resistant Staphylococcus aureus) or Clostridium difficile infections. In a BSL-4 facility, everything that leaves the room must be sterilized or incinerated on-site. Most hospitals send their linen to an off-site laundry, and on-site incinerators are forbidden by EPA regulations.

How many times is waste handled? What is done to protect workers or to disinfect trucks? And what about decontaminating the environment? Vomit from the index patient in Dallas remained on the ground for days until it was treated with a high-pressure spray by workers clad in T-shirt and jeans. How many people or animals walked through it – or licked it up?

If we are not to harbor Ebola for decades, we must not infect a reservoir species. A survey in Gabon found that more than 30 percent of dogs had antibodies to Ebola virus in the 2001–2002 outbreak.

While dog-to-human transmission has not been shown, a future spillover by a mutant strain is possible. This is why the Spanish nurse’s dog was killed, and why merely quarantining the dog for a time is not enough. Note that the quarantine procedure for persons exposed in a laboratory accident in a BSL-4 facility is far different than that used for workers exposed to the index patient in Dallas. David Quammen recounts how a woman in full protective gear stuck herself while injecting Ebola-infected mice with antibodies. She went immediately into a medical facility called the “Slammer,” a chamber entered only through an airlock.

If the patient proves to be infected, the suite becomes an active BSL-4 zone, in which doctors and nursing staff must wear the full “space suits” and shower thoroughly on the way in and out, leaving their scrub clothing behind in a bag to be autoclaved (steam sterilized). She had to stay in the Slammer for twenty-one days, having blood tests every day. Fortunately, she did not get Ebola. If she had gotten Ebola and died of it, she would have had an autopsy and then the body would have come out of the autoclave (steam sterilizer) chute. Such treatment is not feasible for the dozens of people who had unprotected contact with a sick patient.