Ebola in Perspective

I wrote an article in May of 2009 in response to the nearly hysterical swine flu warnings that were causing Americans to stop eating bacon with their bacon and eggs. In that article I made a tongue in cheek reference to the 1995 movie “Outbreak” and stated that if Ebola broke out here I would move to Africa and live with the monkeys. I now find myself in the unenviable position of having to explain why one or even several cases of Ebola does not constitute an outbreak and I will not proceed to rent a U-Haul for the trip to Africa.

Ebola is, of course, a serious disease and recent events demand a rational analysis. A man who traveled from Liberia to Dallas has become the first case of Ebola Hemorrhagic Fever diagnosed stateside. So far, all other domestic cases have been in US citizens diagnosed in Africa who were flown back to the US for treatment. No healthcare workers or patients in the US hospitals in which these patients have been treated have been infected with the virus. The two patients flown here in August, a doctor and a nurse infected in Liberia, were successfully treated at Emory University Hospital in Atlanta.

The CDC has stated on its Ebola web page that the risk of an Ebola outbreak in the United States is low. Public health officials and the White House have urged calm in a surprisingly sedate response that is decidedly antithetical to recommendations made regarding much less frightening maladies such as the bird flu and swine flu. So, given the historically apocalyptic predictions by the government regarding other diseases, why the rather tepid response to such a deadly disease? Most importantly, what should we do to reduce risk and at the same time avoid unnecessary and harmful overreaction?

In order to put Ebola in perspective, we must first understand what it is, and what it is not. Ebola is a virus, likely passed originally from bats to primates, including monkeys and humans. From the first identified outbreak in 1976 in the Congo, there have been several outbreaks with the current and thus far the worst outbreak of 2014 concentrated in Liberia, Sierra Leone and Guinea. The virus has an incubation period, the time from infection to illness, of between 2 and 21 days, though usually about ten days, and causes flu like illness progressing to vomiting, diarrhea and breathing problems with internal and external bleeding and multiple organ failure. Ebola is contracted by contact with the body fluids or tissue of infected animals or people. The virus is rapidly inactivated by exposure to air, so it is not easily transmitted by droplet infection at a distance. Therefore, it is not transmitted as easily as the flu. In Africa, the mortality rate is very high, around 70%, but this would be much lower in the US.

There is a world of difference between the heartbreaking conditions in which Ebola thrives in Africa and those in the US and other modern countries. Ebola thrives in dirty, crowded environments where there is open sewage, and uncontained waste. Hospitals in Western Africa are, for the most part primitive, lacking in supplies of masks, gloves and gowns necessary for the protection of family members and health care workers. Finally, and perhaps most importantly, clean water and soap for simple hand washing is often not available.

I outlined in a previous article many of the reasons I did not expect the swine flu to be as much of a problem as was predicted, and the fact that other doomsday disease predictions had been proven to be incorrect. I advised that the government had a vested interest in overstating the danger, and that we were in much more danger from panic than from the disasters the government wanted us to think they were preventing.  Ebola presents us with an intrinsically much more deadly disease than the others I discussed in previous articles, with a case fatality rate that far exceeds that of any flu. Yet, the White House urges calm and the CDC deems an outbreak unlikely. What do we make of this? Many of us are understandably concerned that we are being lied to. However, while I certainly feel the White House and CDC are capable of this, in light of what we know about the epidemiology of Ebola and the low risk of a true outbreak here, there would be little point in understating an already low risk.  For once, and likely accidentally, the White House and the CDC have got it right. Maybe they are just tired of making predictions that are always wrong. If we follow simple precautions we should be able to prevent any more than a few sporadic cases in the US.

We should institute a reasonable quarantine of persons likely to have been exposed who are returning to the US, such as healthcare workers or others who have cared for Ebola patients. The quarantine of large populations is cruel and of debatable efficacy, but the isolation of those who have a high likelihood of exposure makes sense. Screening at the point of departure from Africa is being done. Voluntary restriction of apparently healthy but exposed persons to their homes for the duration of the incubation period would reduce the risk of contagion is an option. Since an infected person cannot spread the disease until they have signs or symptoms, simple monitoring for 21 days after the last known exposure, with isolation at the onset of any sign of infection, should be sufficient in most cases.

We should increase aid to the countries involved in the outbreak, and this is happening. This is both a moral and a practical imperative. The current epidemic in Africa can only be brought under control by education to alter behavior, improved sanitation and better medical care. While we must do what we can to reduce the likelihood of an outbreak here, we cannot ignore the suffering of those affected by this terrible disease over there.

We live in a modern country with excellent sanitation, thankfully making it unlikely that those of us not in healthcare will come into contact with the body fluids or waste of strangers. Those of us in healthcare have protective equipment and are unlikely to contract the disease from an infected patient. Americans have access to excellent medical care, and we should be cognizant of the fact that the first two patients treated here for Ebola have recovered. While there is a serious outbreak in three countries in West Africa, other nearby countries have had few cases, and many bordering countries have had none. For perspective, about 7,000 people in Africa have died of Ebola over the past year, while over 500,000 died of Malaria. An estimated average 30,000 Americans die per year of the flu.

According to the CDC, an outbreak occurs when there are multiple cases of a disease in a community or institution over a short period of time. An epidemic is a widespread, much larger version of an outbreak. I do not think we will have an outbreak or an epidemic here. My son lives in Dallas, where the Ebola patient is being treated, and I have advised no precautions. As I previously wrote, if you develop symptoms such as severe cough, shortness of breath, fever, chills, nausea or vomiting, see a doctor. Take precautions to prevent the spread of illness to others. Most importantly, wash your hands. But live your life fully, not fearfully. You are in much more danger from panic than from Ebola.

Frank S. Rosenbloom, MD is president of the Oregon chapter of  Docs4PatientCare

I wrote an article in May of 2009 in response to the nearly hysterical swine flu warnings that were causing Americans to stop eating bacon with their bacon and eggs. In that article I made a tongue in cheek reference to the 1995 movie “Outbreak” and stated that if Ebola broke out here I would move to Africa and live with the monkeys. I now find myself in the unenviable position of having to explain why one or even several cases of Ebola does not constitute an outbreak and I will not proceed to rent a U-Haul for the trip to Africa.

Ebola is, of course, a serious disease and recent events demand a rational analysis. A man who traveled from Liberia to Dallas has become the first case of Ebola Hemorrhagic Fever diagnosed stateside. So far, all other domestic cases have been in US citizens diagnosed in Africa who were flown back to the US for treatment. No healthcare workers or patients in the US hospitals in which these patients have been treated have been infected with the virus. The two patients flown here in August, a doctor and a nurse infected in Liberia, were successfully treated at Emory University Hospital in Atlanta.

The CDC has stated on its Ebola web page that the risk of an Ebola outbreak in the United States is low. Public health officials and the White House have urged calm in a surprisingly sedate response that is decidedly antithetical to recommendations made regarding much less frightening maladies such as the bird flu and swine flu. So, given the historically apocalyptic predictions by the government regarding other diseases, why the rather tepid response to such a deadly disease? Most importantly, what should we do to reduce risk and at the same time avoid unnecessary and harmful overreaction?

In order to put Ebola in perspective, we must first understand what it is, and what it is not. Ebola is a virus, likely passed originally from bats to primates, including monkeys and humans. From the first identified outbreak in 1976 in the Congo, there have been several outbreaks with the current and thus far the worst outbreak of 2014 concentrated in Liberia, Sierra Leone and Guinea. The virus has an incubation period, the time from infection to illness, of between 2 and 21 days, though usually about ten days, and causes flu like illness progressing to vomiting, diarrhea and breathing problems with internal and external bleeding and multiple organ failure. Ebola is contracted by contact with the body fluids or tissue of infected animals or people. The virus is rapidly inactivated by exposure to air, so it is not easily transmitted by droplet infection at a distance. Therefore, it is not transmitted as easily as the flu. In Africa, the mortality rate is very high, around 70%, but this would be much lower in the US.

There is a world of difference between the heartbreaking conditions in which Ebola thrives in Africa and those in the US and other modern countries. Ebola thrives in dirty, crowded environments where there is open sewage, and uncontained waste. Hospitals in Western Africa are, for the most part primitive, lacking in supplies of masks, gloves and gowns necessary for the protection of family members and health care workers. Finally, and perhaps most importantly, clean water and soap for simple hand washing is often not available.

I outlined in a previous article many of the reasons I did not expect the swine flu to be as much of a problem as was predicted, and the fact that other doomsday disease predictions had been proven to be incorrect. I advised that the government had a vested interest in overstating the danger, and that we were in much more danger from panic than from the disasters the government wanted us to think they were preventing.  Ebola presents us with an intrinsically much more deadly disease than the others I discussed in previous articles, with a case fatality rate that far exceeds that of any flu. Yet, the White House urges calm and the CDC deems an outbreak unlikely. What do we make of this? Many of us are understandably concerned that we are being lied to. However, while I certainly feel the White House and CDC are capable of this, in light of what we know about the epidemiology of Ebola and the low risk of a true outbreak here, there would be little point in understating an already low risk.  For once, and likely accidentally, the White House and the CDC have got it right. Maybe they are just tired of making predictions that are always wrong. If we follow simple precautions we should be able to prevent any more than a few sporadic cases in the US.

We should institute a reasonable quarantine of persons likely to have been exposed who are returning to the US, such as healthcare workers or others who have cared for Ebola patients. The quarantine of large populations is cruel and of debatable efficacy, but the isolation of those who have a high likelihood of exposure makes sense. Screening at the point of departure from Africa is being done. Voluntary restriction of apparently healthy but exposed persons to their homes for the duration of the incubation period would reduce the risk of contagion is an option. Since an infected person cannot spread the disease until they have signs or symptoms, simple monitoring for 21 days after the last known exposure, with isolation at the onset of any sign of infection, should be sufficient in most cases.

We should increase aid to the countries involved in the outbreak, and this is happening. This is both a moral and a practical imperative. The current epidemic in Africa can only be brought under control by education to alter behavior, improved sanitation and better medical care. While we must do what we can to reduce the likelihood of an outbreak here, we cannot ignore the suffering of those affected by this terrible disease over there.

We live in a modern country with excellent sanitation, thankfully making it unlikely that those of us not in healthcare will come into contact with the body fluids or waste of strangers. Those of us in healthcare have protective equipment and are unlikely to contract the disease from an infected patient. Americans have access to excellent medical care, and we should be cognizant of the fact that the first two patients treated here for Ebola have recovered. While there is a serious outbreak in three countries in West Africa, other nearby countries have had few cases, and many bordering countries have had none. For perspective, about 7,000 people in Africa have died of Ebola over the past year, while over 500,000 died of Malaria. An estimated average 30,000 Americans die per year of the flu.

According to the CDC, an outbreak occurs when there are multiple cases of a disease in a community or institution over a short period of time. An epidemic is a widespread, much larger version of an outbreak. I do not think we will have an outbreak or an epidemic here. My son lives in Dallas, where the Ebola patient is being treated, and I have advised no precautions. As I previously wrote, if you develop symptoms such as severe cough, shortness of breath, fever, chills, nausea or vomiting, see a doctor. Take precautions to prevent the spread of illness to others. Most importantly, wash your hands. But live your life fully, not fearfully. You are in much more danger from panic than from Ebola.

Frank S. Rosenbloom, MD is president of the Oregon chapter of  Docs4PatientCare