Conrad Theodore Seitz

CDC guidelines for health care workers in how to dress when treating an Ebola patient turn out to have been too lax, and were suddenly changed on Tuesday.  The new guidelines involve a hood to protect the neck area, two pairs of gloves, and rubber boots as well as a rubber apron.  In addition, dressing and undressing is to be individually watched by a supervisor, who ensures proper procedures are followed.  These precautions may be adequate for workers.

They do not, however, include spraying with bleach or chlorine during removal of protective gear, which is done by Doctors Without Borders in West Africa.  Respirators are also not recommended as they do not improve safety and cause claustrophobic reactions.

Additional information that has leaked into the New York Times: the Ebola patient who was admitted in Dallas after flying from Liberia had diarrhea on presentation on September 28.  This condition made transmission of the virus all the more likely, especially if the health workers did not have dedicated shoe protection, which apparently was the case initially.

Just how infectious is Ebola?  Apparently, only modestly so.  It is not contagious, that is, it is not transmitted through airborne means.  Body fluids and excreta are highly infectious, as is the skin of a deceased patient (noted in the preparation of corpses for burial, which involved extensive contact.)  The main fear of Ebola relates to its high mortality rate (50 to 70 percent) and its florid signs (vomiting and diarrhea, frequently bloody, and blood seeping from orifices) after an incubation period of a week to three weeks, rather than its being easily transmissible.

We will soon (in the next three weeks) find out just how easily Ebola can be transmitted, because of the third Dallas patient’s airplane flight with a low grade fever, the night before she became really ill.  Based on the information we have received about the poor infection-control procedures followed at the Dallas hospital where the first patient was treated, we can guess that the virus was transmitted through diarrhea contaminating the worker’s shoes.  Thus, the other airplane passengers are unlikely to become ill (we think.)

Today we feel less concern about Ebola virus infectiousness.  We could easily be wrong, and only time will tell.

On Tuesday, a second nurse who had treated the Liberian patient in Dallas developed symptoms and tested positive for Ebola virus.  Coincidentally, the day before symptoms began, she took a commercial flight from Ohio to Texas.  Now we have some really good tests for infectiousness.  Will anyone who was on that flight develop symptoms of Ebola?  We’ll know in three weeks.

The hospital described these two nurses as having “extensive contact” with the patient, although wearing protective gear, during the period of September 28-30, before the diagnosis of Ebola was confirmed but after the patient was admitted to the hospital.  “Extensive contact.”

The airline that the nurse flew the in the evening, before reporting symptoms in the morning, has removed the airplane she flew from service.   The pilots and staff from the plane have been put on paid leave, and all the passengers have been notified of possible exposure and advised to monitor their temperatures.   Apparently the nurse called the CDC before taking the flight and informed them that she had a low grade fever (99.5), but they allowed her to fly anyway.  The next morning she reported further symptoms and was admitted.

Another issue, or can of worms shall we say, is that not all patients with Ebola virus will report a fever.  The studies give a number of about 85 percent, which leaves fifteen percent without, perhaps, a fever.  This issue has not been clarified and will continue to haunt the people working with this virus.  If not all patients have fever, does just monitoring people’s temperatures work?

A nurse who cared for a priest dying of Ebola virus in Spain has been infected.  This occurred even before the infection of the nurse in Dallas, but didn’t get any news coverage here in the US.  The nurse was said to have changed the dying man’s diaper and cleaned his bed.

Spain’s response to the Ebola virus was entirely ad hoc, since there was no existing facility to receive the first patient who returned from Africa, a priest who died on August 12.  The infection control facilities had been mostly dismantled for cost reasons.   The second patient, also a priest, received the same improvisational treatment.  Cost-cutting left them unprepared.

On Tuesday, the World Health Organization stated that the mortality rate had risen to 70 percent from their previous estimate of 50 percent.  They also stated that the rate of new cases could reach 10,000 a week by December.  As of Tuesday, the total number of known cases was 8914, with 4447 known deaths.  An additional, unknown number of cases could have been missed or deliberately concealed.

A spokesman for WHO stated that they were particularly focused on isolating as many patients as possible– a goal of 70 percent within the next two months– to reduce the rate of spread.  Mortality rates have worsened as the disease has spread.  Bed space is not available for most active Ebola cases now and some have changed their advice to caring for patients at home with bleach and gloves.

With the majority of Ebola cases treated at home in the infection hot spots, the risks of further transmission are great.  There is especial reason for concern if Western nurses can catch Ebola despite having all the protective gear they need.  On the other hand, the practice of spraying workers with bleach after they contact a patient has been limited to Africa; that practice may be pressed into service here.

A total of five Ebola patients have been treated in the United States so far.  In a few weeks we will learn how rapidly the virus will spread.

The Centers for Disease Control has verified that a nurse who treated the index case of Ebola virus (the one who was turned away from the ER with a diagnosis of sinus infection) has fallen ill, possibly as a result of “violations of protocol” or inadvertent exposure to body fluids.  We hope that the nurse will be able to tell us that a significant exposure occurred; if there was no exposure that the nurse was aware of, that makes it all the more dangerous.

The range of potentially ugly outcomes has suddenly expanded beyond a “few million” Africans to two people in the United States (Dallas, Texas, to be precise, an ironic location.)  Surely, if Ebola hasn’t already spread more rapidly, it isn’t that infectious?  Or is it?

All the contactees of those two patients will need to be followed; twenty-one days is the maximum incubation time.  The number of cases that appear over the next few weeks will tell us a great deal about just how infectious the Ebola virus is.  Drum roll please…

About thirty miles from Devil’s Tower, as with the underexposed portrait.