Calvert County Health Department

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Weekly Ebola Update November 3, 2014

With preparations for transporting and treating potential Ebola patients in Calvert well established and no major changes in West Africa over the past month, we hope that this will be the last regular, weekly update.

Leaders of Calvert’s 911 dispatchers, EMS, Sheriff’s Department, infectious disease physicians, Calvert Memorial Hospital ER and infection control, and Health Department met again this past week to discuss the latest revisions in CDC and Maryland guidelines for Ebola monitoring and treatment. Discussions have also taken place between the Health Department and the Calvert County school nurses and administrators. Our local agencies have made appropriate preparations and coordinated their services to best insure the both the health of anyone potentially infected with Ebola and the safety of those providing care.

We anticipate further refinements in treatment protocols. Accordingly, plans within county organizations and coordination of response across agencies will be updated to best serve our community.

The Calvert Health Department will continue to post updates on important changes in Ebola response as needed. Our staff takes to heart the importance of protecting the wellbeing of our citizens and educating everyone so they can play an active role in their own health. We are always happy to answer any questions you may have.

Larry Polsky, M.D., M.P.H.
Calvert County Health Officer

Ebola Update October 27, 2014

Note: This update is meant for people who are willing to give thoughtful consideration to ideas that they may not initially feel comfortable with. Some of the central issues dealing with Ebola involve unavoidable uncertainty and consideration of logical actions that run counter to our self-protective instincts. After being bombarded by television ads from some politicians that treat the public like morons, hopefully this will be a nice change.

There was mixed news on Ebola this past week. The big controversy at the moment is whether people traveling from affected African countries to the U.S. should be quarantined. That will be addressed in a moment.

We were very happy to see that the two nurses from Dallas have recovered from their infections. There was also hopeful news on the prevention front where two vaccines against Ebola will begin phase 1 testing. On the other end of the spectrum, cases of Ebola in West Africa continue to rise, especially in previously war-torn Liberia, and one case was reported for the first time in neighboring Mali. There have also been some cases in the Republic of Congo from a separate outbreak, but it looks like that is being quickly contained and will not present a threat to other countries.

Questions about quarantine have spurred heated debates in the medical and political worlds this week with the news that a New York physician who was treating Ebola patients in Guinea became ill from the virus six days after returning to the U.S. While self-monitoring for fevers and potential symptoms of Ebola disease, he rode on the NYC subway and entered public buildings, including his much-publicized night of bowling. In addition, a nurse in New Jersey was initially quarantined after caring for patients in Sierra Leone.

The medical experts at the CDC and in most states across the country, including Maryland, continue to say that quarantine of people potentially exposed to the virus who do not have fever or symptoms of infection is unnecessary. In the wake of the NY physician’s diagnosis, the states of New York, New Jersey, and Illinois announced a mandatory 21-day quarantine of everyone who has worked with Ebola patients. It is unclear at this time if medical experts or political officials in those three states made the decisions for blanket quarantines.

The scientific evidence accumulated from 38 years of research on Ebola has held true over the past several months. The only cases of Ebola transmitted in the U.S. were in healthcare workers exposed to body fluids of a very sick patient with correspondingly high levels of virus in his system. No one else has become ill, including the people who shared an apartment in Dallas with the man who died from Ebola or the people who had contact with the two nurses diagnosed more than a week after their exposures. No cases have been transmitted by a sneeze or cough. No cases have been transmitted by pet dogs.

To this point, the recommendations for monitoring those with potentially incubating Ebola infection have resulted in zero cases of infection in U.S. residents. So why is there a controversy about a need to quarantine? We can point to three factors. First, the monitoring and surveillance recommendations from the CDC have changed several times over the past month. Second, the two nurses in Texas were infected despite taking precautions recommended by the CDC at that time. Both of these factors have left doubt in the minds of many whether authorities are truly authorities.

The third reason for public concern is that experts say it is safe for potentially exposed people to stay in the community because, 1) there is no risk of transmission until someone develops symptoms and 2) even at that point, another person would need direct exposure to the infected person’s body fluids. However, once one of these potentially infected people is actually diagnosed with Ebola, the CDC then monitors people they had contact with. If potentially infected people really posed no threat to the public, why do these contacts need to be monitored?

The first two concerns mostly have to do with our innate, human fear of the unknown and our desire for someone to have all the right answers to protect us from our most vividly imagined dangers. For risks we have dealt with for years, such as car crashes (33,561 U.S. deaths in 2012) and influenza (most years 25,000-40,000 deaths), we continue on with our lives as if there is little or no danger. We even act in ways that increase our risk and the risks to others, such as using cell phones while driving or allowing sick employees to come to work and expose others.

When we’re confronted with a novel threat to our wellbeing, we act just as irrationally, but in the opposite direction. How many of us knew anything about Ebola three months ago? We have little means of understanding how much risk this truly poses to ourselves and our loved ones. News reports showing healthcare workers dressed as if they are taking on alien invaders in a science fiction movie (how often does that end well?) doesn’t help our sense of vulnerability.

We unrealistically want someone in authority to completely eliminate the risk. So any indication that those in the role of protector may not have all the answers to completely insure our safety unsettles us tremendously. Think back to the first weeks and months post-9/11 and our collective anxiety about public safety in the wake of a new type of violence. Our rational side knows that almost every complex situation has some degree of uncertainty, so the expectation that every possible contingency related to this Ebola outbreak can be anticipated is unrealistic. But given that this is a novel threat, the potential negative consequences envisioned by our instinctual selves are magnified, even to the point that those imagined consequences defy well-established facts.

This is not meant to suggest that we shouldn’t hold those responsible for making critical decisions to a very high standard. It’s more the acceptance that even the best solutions often require imperfect compromises to maximize social good and minimize harm.

Competing factors on quarantine include:
- Violating people’s basic liberties versus minimizing risks of a potentially fatal infection spreading to the public. We have a long history of protecting individual liberty under the U.S. constitution. We have an even longer history of quarantining individuals for suspected infections such as yellow fever that goes back to the colonial era. How much risk does an individual need to present to the public health to justify denying her/him the basic right of liberty? Currently, the medical experts at the CDC and in most states have determined that decades of evidence indicates the risk of transmitting the Ebola virus to the general public are extremely small until a person is very ill. As long as the potentially infected individual is capable of carrying out the necessary steps required for self-monitoring, depriving one of his/her liberty hard to justify.

This also ties into the third reason for public concern mentioned above. The risk of allowing potentially infected people to live outside of quarantine is not zero, but in the early stage of illness, all evidence shows that it is extremely small. It would require direct contact with body fluid and even if this were to occur, the levels of virus present in early stages of disease have shown limited potential to transmit infection. The virus has spread in West Africa because care for the very ill and handling of the bodies of the deceased frequently involves contact with highly infectious body fluids in ways that are unlikely to happen in the U.S.

Because of the shortage of medical care in the affected African countries, most people with Ebola receive all of their care at home where there is no personal protective equipment and often, basic sanitary measures such as running water and proper waste disposal are lacking. In the U.S., the chance of transmission is extremely low, but since the risk is not zero, people who could have been exposed to an infected person’s body fluids after he/she began to show symptoms, need to be monitored as a precaution. As noted above, it is natural to feel uneasy about basing this policy on a limited amount of observational evidence, but 38 years of study gives a very good, if not perfect, foundation for recommendations.

- Short-term risk of infections versus long-term risk of infections. Subjecting everyone involved in patient care to a 3 week separation from their families following a month or more in Africa potentially discourages healthcare workers from volunteering their services where they are critically needed. The only way to eliminate the risk to the American public is to eliminate the disease in Africa. The entire country of Liberia has fewer doctors than we have in Calvert County. Without international help, new cases of Ebola will continue and the risk of importation to the U.S. will remain. Although allowing returning healthcare workers to have contact with the public while they are still potentially incubating the virus could carry some small risk, this needs to be balanced against the risk of a prolonged outbreak in Africa due to a decrease in U.S. medical aid.

These comments are meant to give some background and perspective to the ongoing debate of quarantine and not to serve as the last word. Continued experience may lead to further changes in public health recommendations. As mentioned in a previous post, adapting theories and positions to best protect the health of the public as new evidence becomes available is the proper response of science to our complex world. We welcome your comments.

Ebola October 20, 2014

Newscasts and social media continue to churn with stories and posts about Ebola. As head of the Calvert County Health Department, I want to address two topics that have been on many people’s minds. The first is the current risk of Ebola infection to Americans. The second is the capability of the CDC and the healthcare system to prevent and treat infections.

The risk of infection for people living in the U.S. remains close to zero. Despite the hypothetical scenarios of widespread disease mentioned on television and on the internet, no one other than the two healthcare workers who were exposed to the body fluids of a very ill patient has become infected. That includes the people who shared a Dallas apartment with the person who later died from Ebola. It is possible that an occasional person with early infection may enter the country, but large-scale outbreaks are extremely unlikely.

As medical science has learned since the discovery of Ebola in 1976, there has been no transmission of the virus by airborne route or by casual contact. However, medical science did not predict that nurses wearing recommended protective equipment would get infected. This unforeseen event demonstrates the frustration and challenge of a developing science, more than the failure of experts.

Researchers at the CDC based their initial recommendations for protective equipment on the best information available from 38 years of clinical experience in Africa. Until September, this was the only evidence available. But care for a very sick patient in Texas involved procedures that had never taken place in Guinea or the Republic of Congo. As a result, the recommendations based on the best available evidence proved insufficient to fully protect hospital workers in the U.S.

The practice of medicine is an extraordinarily complicated task. Both the infectious organisms that we deal with and the defenses of the human body are almost infinite in their variations. Understanding all of these variations and designing strategies to keep people healthy will continue to challenge some of the greatest scientific minds for generations to come.

There is no prepackaged set of rules that will successfully navigate all the potential problems that we may face from Ebola in the near future. The most we can expect from even the best minds at the CDC and other expert organizations is a continual reexamination of evidence and refinement of recommendations. Until we learn enough, our methods of dealing with the problem will be very good, but they will not be perfect. What we can expect, is that intelligent, dedicated professionals will incrementally improve the way we prevent and treat Ebola infections. Methods that work well in Africa may not be adequate in the U.S., and strategies appropriate for developed countries may not be practical in a country like Liberia where the median income is $410 per year.

On a personal level, hearing about the infections of the two nurses in Dallas was sad and initially frightening for the safety of the other hospital workers who had provided care for Mr. Duncan. But as a physician who, despite taking precautions in my 20+ years of patient care, has been stuck by needles and splashed by blood and almost every other type of body fluid, I know that this is part of the sacrifice all clinicians make when we enter into patient care. As a scientific community, we have learned from these unexpected and very unfortunate infections and have already developed better protocols to keep others safer in the future.

This Ebola outbreak in West Africa also reminds us of the value of funding basic medical research. As long as a health problem mostly affects poor regions of the world, private pharmaceutical companies will not invest research dollars into vaccines or medications. Without government-funded research, outbreaks will continue and there will be risk of spread to the U.S. Over the past decade, CDC funding has been decreased by 23% when adjusted for inflation.

So what does this mean for the residents of Calvert over the upcoming weeks and months? Although we don’t understand everything about the virus, we already have a very good base of knowledge. The Health Department continues to actively work with the staff at Calvert Memorial Hospital, local medical offices, and the EMS leadership to screen for potential infections. If a patient is identified with a possible Ebola infection, the Health Department will immediately (24 hours a day/ 365 days a year) implement the latest expert protocols in concert with local clinicians to provide the best care possible to the patient and to keep healthcare workers and the community safe.

Local healthcare workers have been practicing proper safety techniques with appropriate protective equipment. Protocols for disposal of medical waste and lab specimen transport are in place. We expect that if someone in Calvert should ever become infected with Ebola, a specially trained unit of clinicians would provide initial care at Calvert Memorial Hospital until patient transport can be arranged to a hospital such as the NIH. This transfer would almost certainly occur in less than 24 hours.

Please be assured that although the chance of an Ebola infection in Calvert County is extremely low, the Health Department takes its responsibility to prepare for the possibility very seriously. I feel fortunate to work with a group of professionals who share this sense of responsibility to our community.

Larry Polsky, M.D., M.P.H.
Calvert County Health Officer

 

Ebola October 16, 2014

Ebola has received a lot of attention during the past month. The two recent cases in Texas have raised questions and concerns for many Americans. Despite the situation in Dallas, the risk of infection for almost everyone in the U.S. remains close to zero. With that in mind, there is always a very small chance that someone in Calvert could become infected. For that reason, the Health Department and Calvert Memorial Hospital have teamed up with our local EMS (emergency medical services) to develop a coordinated system of surveillance and response to any potential cases of Ebola.

Although Ebola seems like a new disease to most people, it was identified by medical researchers close to 40 years ago in Zaire, near the Ebola River. Since that time, there have been close to 20 outbreaks in central and western Africa. All of these outbreaks were successfully stopped with tried and true public health measures. These experiences have led to a tremendous understanding of how the virus spreads and how it can be contained.

Calvert Memorial Hospital and the Health Department are in daily contact with Maryland infectious disease specialists and CDC experts on Ebola. We have plans in place to protect the health of the community if anyone is suspected of carrying the virus. Protocols have also been developed to protect workers who may need to come in contact with any being treated for the disease.

Community members seeking care at the hospital or a local provider’s office can expect to be asked about recent overseas travel history, particularly to affected countries in West Africa. Callers requesting 911 medical assistance can expect the same telephone screening from our EMS providers. The key to preventing the spread of the virus is rapid identification and isolation of potential cases.

Please keep in mind that a person can only be infected with Ebola virus if they have direct contact with the bodily fluids of someone who has the virus and has symptoms such as fever or diarrhea. It is also important to remember that the only current source of the virus is in western Africa. So anyone with fever and diarrhea who has not been to Africa or in contact with someone else who has been to Africa in the previous 3 weeks (the longest amount of time it would take to get sick), does not have Ebola. They likely have an illness such as the flu or food poisoning.

Because symptoms of Ebola and the influenza are impossible to distinguish over the first few days of illness, we strongly encourage everyone to get a flu shot to avoid unnecessary fear and confusion. We also remind everyone, that there has been one death from Ebola in the U.S. In a typical year, there are over 35,000 deaths and 250,000 hospitalizations from the flu.

The Calvert County Health Department will update its website, Facebook page, and Twitter account as more information becomes available. Additional resources can be found on the CDC website http://www.cdc.gov/vhf/ebola/