Ebola

spillover

I first read about Ebola from the 1995 bestseller The Hot Zone by Richard Preston, which recounted how monkeys in a government lab in Reston, Virginia suddenly started dying from what turned out to be the only strain of Ebola that doesn’t affect humans. A great read and thriller that I highly recommend.

Over the years I have followed the periodic outbreaks of the Ebola virus that all were fairly quickly extinguished. I also read another great book called The Coming Plague: Newly Emerging Diseases in a World Out of Balance by Laurie Garrett about emerging infectious diseases, which I also highly recommend.

There are few who are not aware of this current outbreak of Ebola, which continues to escalate and for the first time reached this county with a patient found in Texas, although most believe this additional cases that may reach us, will be fairly easily contained because of the health care structure here, higher sanitary standards and the cooler climate. Let us hope so.

Let me try now, based on what I have read to describe how the Ebola outbreak happened and why it has been so bad, as well as make some predictions for the future.

Ebola may have lived in the jungle for millions of years. Although its natural reservoir has not been found, most believe it likely lives in bats. A bat with Ebola eats some fruit, which it drops while flying. A chimpanzee picks up the fruit and eats it, getting some of the bat’s saliva in its mouth, and then the chimp gets sick and dies. Perhaps in more recent days, a hunter comes along and eats meat from the freshly deceased chimp. The hunter gets sick and dies alone in the jungle, or returns to his isolated village where half the tribe will die because they believe they have angered the spirits. Life goes on.

Fast forward to the modern world. The jungle has been deforested, roads have been built. The dead monkey is now brought into the village, where it is eaten by several people, who infect other members of their families. Hand washing is not a norm in their culture. One of them, who does not yet know he is sick, takes the road to the next village, where he becomes ill and spreads the disease to others. Soon Ebola is in the city, and the fear is it is next on an airplane and landing in New York City or an airport near you.

Typically, in past cases as soon as there has been an outbreak, health workers have quarantined the sick and traced all of their contacts. This time the system broke down. There weren’t enough workers and in some cases the workers who all arrived in yellow suits spooked the villagers who thought that perhaps the workers were the ones spreading the disease. People hid in the jungle or hid their symptoms. Some visited a bush doctor who declared she could heal the sick. There was lots of hands on attempts at healing. She died along with most she had contact with. In one area armed men attacked a quaranteen center believing the doctors were evil. Other health workers were macheted to death by those who blamed them for the outbreak. Infected patients fled.

Ebola is spread by body fluids — saliva, blood, vomit, feces, urine, perspiration and by prolonged touching of the dead body. In Africa, when someone dies there is a lot of touching and cleaning of the body. Also, in Africa, the hot humid climate contributes to perspiration and makes cleanliness difficult. There is a lack of medical supplies and beds for sick patients. They die because Ebola cripples their immune systems, the vomiting and diarrhea lead to dehydration. They are ravished by infections, their organs fail. Bodies are not disposed of properly. The virus spreads again.

The Americans who have gotten the disease and survived likely survived not because of the “miracle drug” they received, but because they got first rate medical care, hydration, electrolyte replacement, and antibiotics in a timely fashion. Fluid replacement is critical to survival.

Many fear the the worst case scenario is if this strain of Ebola mutates (Ebola as an RNA virus is subject to constant mutation) into an airborne contagion. There reportedly was a study that showed the virus was passed by pigs to monkeys through a respiratory droplets, but I have also read that they don’t know that the disease might not have been spread in another manner, passed by unclean conditions in feces from one stall to the next.

I am currently reading a third recommended book called Spillover: Animal Infections and the Next Human Pandemic by David Quammen. Ebola is a zoonotic disease, meaning a disease that has jumped from animals to humans — like SARS, avian flu, rabies, Lyme Disease and Hanta Fever. According to Quamman, these zoonotic diseases are becoming more and more prevalent as we humans disrupt the natural world and allow these diseases the opportunity to catch a ride on humans. He cites a great example of the opportunity for a disease to jump to humans. Cities and villages disrupt the forest, bats now live in closer contact with humans. A farmer builds a giant pig stockade under a mango tree that is home to many bats. A sick bat eats a mango that drops to the pig pen. The pigs eat the saliva infected fruit. The pigs live in close quarters with each other and then are shipped all over Asia, again stored in tight dirty quarters. Feces is spread from one pen to the next. A rule of epidemics is population density increases the threat of the spread. Walla!

With regard to Ebola, he makes an interesting observation. He says Ebola is not very contagious but extremely infectious. By this he means, you can sit in a crowded room with someone with Ebola and perhaps no one else in the room will become infected, but should you give the Ebola patient an Iv, and accidentally prick your finger, you could be dead in seven days without proper care.

Generally Ebola is not contagious until it turns symptomatic. The fear again is someone who is not symptomatic gets on a plane, and becomes symptomatic shortly after landing. (One of the American doctors had been scheduled to return home a few days before he became sick, but was delayed so he was still in Africa when he became symptomatic). When someone fits this scenario, what if they believe their symptoms are not due to Ebola, but perhaps a common cold or the flu? What if in fear, they deny their symptoms instead of seeking immediate help. We need to be ready.

What are the symptoms of Ebola? The key early symptoms are fever, sore throat, and body aches, followed shortly after by abdominal pain, vomiting and diarrhea. GI and mucosal bleeding comes later. Some people develop a rash. Patients will go into shock before death, and become listless. Oddly, hiccups can be a telltale sign.

For EMS providers, according to the latest CDC advisory, we should be on the alert for patients who are both symptomatic and who have risk factors such as recent travel in an area ravaged by Ebola.

As I mentioned because it is an RNA virus, it mutates easily. Perhaps it may mutate into a less lethal disease, which while good on one hand, would mean it would then have a greater chance of spreading and staying alive in humans, while causing great although not as lethal suffering.

One of the books I read said we need to not view Ebola as invading our world, but as humans living in Ebola and other microbe’s world. We are both prey and a vehicle for Ebola’s survival. If it kills us too efficiently without finding a way to spread to others, it will not survive in humans.

Two things I predict in the near future, we will see more Ebola cases in the US. With luck, these people will be quarantined(the government has this power), and their contacts checked, and excellent care given them, and the spread will be minimal. Nigeria has reportedly done a great job at halting the spread of the disease in their country through such measures. Liberia and West Africa lack the infrastructure to do this, thus the disease continues to rise there, and will until sufficient resources gain traction. I also predit shortly after out first case of Ebola in Texas, we will experience an even greater number of Ebola scares or false alarms that will test us.

What will you do when the dispatch comes for the man vomiting blood recently arrived from West Africa? What will your partner and the first responders do? How will the hospital staff react? How will your friends and family react to you when you tell them about the call? Will they even let you in the door? Or maybe out of fear for your family, you won’t want to possibly risk infecting them. Where will you go? (It is good to keep in mind if you are exposed, you have time to go home have a nice family dinner, and then back your suitcase before you are at risk of infecting your family.)

Chilling times.

I don’t think Ebola will be the end of the world for us here. The fact that for the most part the disease doesn’t spread until it is symptomatic (although it stays in the semen of men who have recovered from Ebola and can be passed sexually for up to six weeks) heightened awareness, cooler temperatures, different habits, hand washing, and a strong public health structure should protect us.

I said at the beginning I would make a prediction for the future. Here it is. At some point in the future, a super deadly disease will come out of the jungle and wreak havoc worldwide. Imagine an Ebola like illness that spreads through the respiratory route but stays hidden in the body while still being contagious. HIV came out of the jungle, caught a ride on a dirt road to the city or came downriver on a canoe, and then jumped a plane to the modern world, and 30 million have died with another 30 million infected. The coming plague that Laurie Garrett writes about in her book and the others have talked about may be among us one day. I don’t think Ebola is it. From what I have read, what experts fear the most is a pandemic flu that spread across the world in a matter of days.

All we can do is plan and prepare.

Here is the latest CDC guidance:

EMS patient assessment criteria for isolation/hospital notification are likely to be:

1. Fever, headache, joint and muscle aches, weakness, fatigue, diarrhea, vomiting, stomach pain and lack of appetite, and in some cases bleeding.

AND

2. Travel to West Africa (Guinea, Liberia, Sierra Leone, Senegal, Nigeria or other countries where Ebola transmission has been reported by W HO) within 21 days (3 weeks) of symptom onset.

If both criteria are met, then the patient should be isolated and STANDARD, CONTACT, and DROPLET precautions followed during further assessment, treatment, and transport.

IMMEDIATELY Report Suspected Ebola Case(s) to Receiving Facility.

Source-CDC

Check out these links for more CDC Ebola Advisory Information:

Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States

CDC EMS Checklist
Stay safe.

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