I saw a dead corpse in a coffin lie in the close unburied – and a watch is constantly kept there, night and day, to keep the people in – the plague making us cruel as dogs to one another.

Samuel Pepys[1]

Well, for the moment the Ebola scare is in remission. The media have stopped treating it as front-page news, and mostly seem to have gone back to reporting on the Middle East. I guess that’s understandable – after all, nothing is more important than the Middle East and its endless wars – but it may be a mistake. Ebola continues to flourish in sub-equatorial Africa, and shows no sign of going away. This is the worst of a 38 year series of outbreaks and it is a dreadful disease. If you get it, it’s quite likely to kill you.

Back in June the Department of Health and Human Services [aka, HHS] reported morbidity from the current Ebola outbreak at 64%.[2] More recently, i.e. this month, HHS tells us that in this current epidemic there are

  • 1848 suspected and confirmed cases of Ebola;
  • 1176 confirmed cases; and
  • 1013 confirmed deaths.[3]

These figures, of course, are subject to constant upward revision. The main U.S. actor in the Ebola drama, the Center for Disease Control [CDC], is a unit within HHS.

How does that translate into percentages? My calculator says if you consider all cases, actual or suspected, as of this moment 55% of them have died. More could die in the coming weeks, of course, and some of the people in the “suspected” category may not have the disease. So when all is said and done, the actual death rate probably will be higher. If you consider only “confirmed cases” and “confirmed deaths,” the death rate right now comes out to be 86%. But that could rise as well.

All of this is very bad, but the story is incomplete. At the moment our efforts to contain the epidemic do not seem to be succeeding. And, according to people over in the World Health Organization (WHO), an organization within the UN[4], the current outbreak may be much worse than it appears. [5]

How do governments contain an epidemic like this? Since there’s no vaccine and no cure as of now, the authorities in Africa have resorted to quarantine. The idea is to keep the infected, or possibly infected away from the uninfected.[6] This, of course, is the same thing Samuel Pepys talked about back in the 17th Century.[7] It seems inhumane but the real problem with quarantine, at least today, is that it doesn’t always work. People escape[8], or break into quarantine zones. [9] And, of course, it’s most effective if the disease in question is transmitted from one person to another, and not in some other manner.

So how is Ebola transmitted to humans? Well, the bumper-sticker, or tweet version from our media seems to be that people get the Ebola virus by touching one another or through exchanging bodily fluids; so just avoid kissing or eating off the plates of people you don’t know and you’ll be fine. Well, that’s part of the story, but probably not all of it. To explain, I think it’s good to back up a bit and discuss the virus. I’ll do that by relying heavily on an Information Packet first distributed by the CDC back in 2009.[10]

Currently our scientists believe that there are 5 strains, or versions of Ebola. Apparently the virus comes from animals; four strains originate in an “animal host in Africa,” while the fifth, host unknown, was first detected in a species of monkey from the Philippines.[11] It appeared in a primate research facility in Reston, Virginia, and for that reason is named Ebola-Reston.

The fifth version is interesting, because apparently it was the only one to get loose in the U.S. It killed monkeys and infected some humans, but didn’t sicken the humans. I guess that’s the reason why CDC can report that, to date, that “No case of the disease in humans has ever been reported in the United States.”[12] Some humans were infected by Ebola-Reston, but none got sick [i.e., were diseased]. I wonder why?

The CDC view is that Ebola “can be” transmitted from one person to another by “direct contact with the blood and/or secretions of an infected person.”  Families who care for Ebola-stricken family members can be infected if they come in contact with blood and/or secretions, or are pricked by sharp objects, needles and the like that carry a residue of such fluids. The same is true also for health care professionals, who work in facilities where Ebola patients come for treatment. Back in 2009 CDC was of the opinion that medical professionals in Africa generally were infected because they failed to wear protective gear[13] or improperly handled needles, etc.[14]

I’ve read the Information Packet carefully, and the CDC has never said personal contact of some sort is the only method by which the Ebola is transmitted; that’s probably very wise of them. You see, the case of the Ebola-Reston infection points elsewhere. In that situation the virus occurred in a large number of monkeys, all occupying separate cages. That argues very strongly against the notion that the virus is spread only by contact. Instead, it may have traveled from monkey to monkey through the air.

CDC admits that, under certain circumstances Ebola may move into the air as an “aerosol,” and travel. “[A]ll Ebola virus species have displayed the ability to be spread through airborne particles (aerosols) under research conditions, this type of spread has not been documented among humans in a real-world setting, such as a hospital or household.”[15] So while it’s not scientifically proved, it is possible that such things can happen outside the laboratory and in the real world.

Why is this important if we haven’t seen any cases of airborne Ebola? Well, look at it this way. To date most Ebola outbreaks have occurred in the rural areas of Africa. Being rural, these places have less people and more space per person, so even if there’s “something in the air” at a given place and time, this doesn’t necessarily mean that others will breathe it. There’s the wind, the sun and so forth to disperse the aerosols. But suppose now that we concentrate the people in metropolitan areas, send them to work in large buildings with closed environments, transport them in really closed environments (say aircraft, trains or the like), and recycle their air. What happens then?

It looks as though CDC takes this issue seriously, at least if someone intends to transport an Ebola patient. They prefer that airlines, etc. put all such patients in a completely sealed medical unit, thereby effectively insulating them from everybody else.[16] The unit should, among other things, provide HEPA filtration to “remove aerosols generated during [any] procedures” in it.[17] Health care workers, who actually treat Ebola patients or at least are around them, are told to wear lots of protective gear, including N 95 face masks[18]. These masks are also effective against aerosols, at least of the water-based variety.[19] So why tell the public that Ebola aerosols are not a problem while, at the same time, recommending measures against them?

And what about food? Do we have to worry about Ebola popping up in the food chain at any point? Maybe yes. Some animals caught, killed and eaten in the African bush may be infected and, more importantly, some governments are concerned that Philippine pork ought to be screened for the contagion.[20] If you recall, the Philippines provided the monkeys that carried Ebola-Reston to the U.S.

None of this presents a happy picture, but the situation is not hopeless, either. We have a lot of smart people working on Ebola and surely they’ll find a vaccine or a cure someday. But who knows how long that will take, and how many may die in outbreaks before it happens?

It’s quite likely Ebola will visit us some day, and if it does we really need to know more about how it will operate in an urban environment.  Right now the media position [and possibly the CDC’s] seems to be, don’t worry, be happy, Ebola won’t travel far. Frankly, I don’t think we really know that, and denial is not an option when dealing with a vicious disease. Note to Congress: More research is needed, right away! As the saying goes, “Don’t die of ignorance!”[21]

 

 

[1] See Oxford Dictionary of Quotations (6th Edition, 2004) (henceforth, ODQ at __) at Samuel Pepys, p. 591 – 592, n. 9 on 502.  Pepys was a famous English diarist of the 17th century, and the plague he mentioned was no metaphor. He was talking about the bubonic plague that hit England in 1665. If you want to know more about Pepys, check out Wikipedia at http://en.wikipedia.org/wiki/Samuel_Pepys

[2] See CDC, Morbidity and Mortality Weekly Report, Ebola Viral Disease Outbreak (June 27, 2014) at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6325a4.htm

[3] For the latest data, see CDC, 2014 Ebola Outbreak in West Africa (August 14, 2014) at http://www.cdc.gov/vhf/ebola/outbreaks/guinea/index.html  The data in this last site is current as of August 9, 2014) See  also CDC, Emergency Preparedness and Response, HAN 365: CDC Ebola Update #1, at http://emergency.cdc.gov/han/han00365.asp

[4] See World Health Organization, website at http://www.who.int/en/

[5] See U.S News: Health, Health Day Staff, Scope of Ebola Outbreak May Be Greater Than Statistics Show: WHO    (August 15, 2014) at  http://health.usnews.com/health-news/articles/2014/08/15/scope-of-ebola-outbreak-may-be-greater-than-statistics-show-who

[6] See The World Post, Paye-Layleh, Liberia, Sierra Leone Race To Enforce Ebola Quarantine (08/07/2014)  at  http://www.huffingtonpost.com/2014/08/07/ebola-quarantine_n_5657861.html

[7] But with a modern twist. Countries are also beginning to limit air travel, so that they can avoid importing (or exporting) Ebola to one another. See, e.g., CNN Money, Petroff, Airlines cancel flights over Ebola fears (August 6, 2014) at http://money.cnn.com/2014/08/06/news/companies/airlines-ebola-africa/index.html

[8] See Salon.com, Gray, A woman with deadly Ebola virus escapes quarantine, now loose in a city of 1 million  (Jul. 25, 2014) at http://www.salon.com/2014/07/25/a_woman_with_deadly_ebola_virus_escaped_quarantine_now_loose_in_a_city_of_1_million/

[9] See The World Post, Ebola Clinic Is Looted In Liberian Capital’s Largest Slum (August 17, 2014), at     http://www.huffingtonpost.com/2014/08/17/liberia-ebola-clinic_n_5685635.html

[10] See HHS, CDC, National Center for Emerging Zoonotic Infectious Diseases, Ebola Hemorrhagic Fever Information Packet (2009). The document is available as a pdf download from HHS. You can find it at http://www.cdc.gov/vhf/ebola/pdf/fact-sheet.pdf . (Henceforth we’ll cite it as Information Packet at __.) There are, of course, later versions.

[11] See Information Packet at p. 1 of 12: “The exact origin, locations, and natural habitat (known as the “natural reservoir”) of Ebola virus remain unknown. However, on the basis of available evidence and the nature of similar viruses, researchers believe that the virus is zoonotic (animal-borne) with four of the five subtypes occurring in an animal host native to Africa. A similar host, most likely in the Philippines, is probably associated with the Ebola-Reston subtype, which was isolated from infected cynomolgous monkeys that were imported to the United States and Italy from the Philippines. The virus is not known to be native to other continents, such as North America.

[12] See Information Packet at p. 1 of 12: “No case of the disease in humans has ever been reported in the United States. Ebola-Reston virus caused severe illness and death in monkeys imported to research facilities in the United States and Italy from the Philippines; during these outbreaks, several research workers became infected with the virus, but did not become ill.”

[13] See Information Packet at p. 1 of 12

[14] Actually, it looks like other objects, in addition to needles, might transmit diseases. See Information Packet at p. 8 of 12: “Examples of vehicles that can transmit diseases include cooking or eating utensils, bedding or clothing, toys, surgical or medical instruments (like catheters) or dressings. Water, food, drinks (like milk) and biological products like blood, serum, plasma, tissues or organs can also be vehicles”

[15] See Information Packet at p. 2 of 12.

[16] See CDC, Guidance on Air Medical Transport for Patients with Ebola Virus Disease (current, date unknown) at http://www.cdc.gov/vhf/ebola/hcp/guidance-air-medical-transport-patients.html Hereafter, this will be cited as Air Transport Guidance at __.

[17] See Air Transport Guidance at C, Infection Control.

[18] See CDC Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals (current, no date), at   http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

[19] See, e.g., DoMyOwnPestControl, at http://www.domyownpestcontrol.com/n95-valved-respirator-mask-p-1408.html?utm_source=nextag&utm_medium=cpc&utm_content=Moldex&utm_term=Safety+Equipment&utm_campaign=1408&zmam=70093104&zmas=1&zmac=8&zmap=1408 for an example of specifications for such a mask. Limited research, I’ll admit, but I think it’s basically correct.

[20] See, e.g., Food Safety News, Richardson, Deadly African Ebola Virus Linked to Bushmeat  (September 17, 2012) at   http://www.foodsafetynews.com/2012/09/deadly-african-ebola-virus-linked-to-bushmeat/  ; Pig Progress, Ter-Beek, Ebola: Philippine pork exports may be banned (March 2, 2010), at      http://www.pigprogress.net/Home/General/2010/3/Ebola-Philippine-pork-exports-may-be-banned-PP003990W/

[21] See ODQ at Official advice, p. 572, n. 6.

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