Aug 072014
 
Healthcare workers in Africa carry out the dead body of an Ebola victim.

Healthcare workers in Africa carry out the dead body of an Ebola victim.

Just today the CDC issued a highest level alert over the current Ebola outbreak – this being only the third time it has issued a Level One warning in the last ten years (the other two being Hurricane Katrina in 2005 and Bird Flu in 2009).  The World Health Organization (WHO) declared it an international public health emergency on Friday.

The newspapers are full of articles about the latest Ebola outbreak in West Africa.  Apocalyptical stories in normally staid publications like The New Yorker tell of the current outbreak starting to assume ‘a medieval character’ (presumably as in the ‘Black Death‘ that killed off between 30% – 60% of everyone in Europe in a short seven-year period from 1346-1453) and describe West African hospitals full of Ebola patients and with

The floor was splashed with blood, vomitus, feces, and urine

The more sensational UK newspaper, The Daily Mail, talks of Ebola victims being dragged into the middle of streets in Liberia and left there to rot, and the locals perceiving the Ebola wards of the hospitals as being death traps.

CBS Atlanta quotes an unnamed ‘senior doctor for a leading medical organization in Liberia’ as saying that Ebola is spinning out of control in West Africa.

It is true that this outbreak is notable for being massively larger than any of the previous Ebola events, and furthermore, the current outbreak seems to be at an early stage of its cycle, with growing numbers of infected people every day (and growing numbers of deaths).  It is hard to know when this cycle will peak, and how severe its impacts will be.

A particular factor this time seems to be that Ebola is in some of the larger cities rather than just the smaller villages in Guinea, Liberia, Sierra Leone, and now Nigeria too.  The greater the population concentrations, the easier the spread of the disease.

Furthermore, and unlike earlier Ebola events, this time it is not only confined to nasty parts of the world that we’d never willingly travel to, and neither is it only confined to the people who live there.  Some of the infected people – and some of the dead people – have been/are Americans.  Even more alarming, not only are ‘ordinary people’ dying in West Africa, so too are some of the physicians and nurses in those countries – the people who you’d expect to be taking the greatest care to avoid infection.

Also very alarming for those of us who travel are stories coming out of Ebola infected passengers on planes (not all of which have been confirmed as true!).

On the other hand, comparing not yet 1000 deaths over a six month period, with the plague in the middle ages, is neither helpful nor accurate, and we need to keep in perspective that this Ebola outbreak, as awful as it is, is also significant for being slow developing and very limited in every respect.

One more point.  While many people die a nasty death, and there are no current cures, not everyone dies.  The mortality rate at present for this infection (and there are four different types of Ebola) is currently estimated at about 75%.

Nonsense in the Press

So, on the one hand, we have nonsense comparisons that do nothing except create inappropriate visceral fear.  On the other hand, we are also being reassured that ‘the authorities’ (you know, those warm fuzzy figures who are from the government and here to help us) are taking steps to protect us from an Ebola invasion, by carefully screening incoming passengers to ensure they are not infected (well, at least temporarily, at IAD and JFK, while delegates arrive for the African summit this week).

But that reassurance becomes actually quite the opposite when you consider that the screening involves nothing more than IR heat scans to possibly detect people running a temperature, and visually identifying people who are unwell as they pass through an arrival airport into the US.

Not only is that an imperfect screening process to start with, it totally fails to detect people who have been infected with the virus, but are still going through the up to three-week period of incubation between becoming infected and displaying any symptoms of the disease.  By the time those people fall ill, they’ll be who knows where in our heartland, or in the dense population crush of a big city, and by the time their illness has transitioned from seeming like nothing much more than a cough/cold/touch of the flu, might possibly more people have become infected?

There’s another issue as well.  If a person survives Ebola and returns to health, they could travel unimpeded, but they continue to carry the active virus for some time subsequently and could infect other people.  For example, live Ebola has been found in semen 61 days after the man experienced the onset of the illness.  It has also been detected in breast milk.

Back to reassurance, again.  This article, from the noted refereed medical journal populist newspaper, the NY Post, and written by a medical professional attorney claims

Ebola is a lazy spreader. A cough, sneeze or sweat from an “active” case is harmless. Spreading the virus requires contact with large doses of bodily secretions such as blood or vomit.

and also reassures us

There’s no specific treatment for Ebola any more than there is for the common cold, but simple hydration with electrolytes and bed rest put the odds in your favor.

One of the above claims is true.  The other four we dispute (and, in case you don’t know this already, we are also neither medical professionals nor attorneys!).

The correct claim, as confirmed by the CDC in a conference call to medical professionals earlier this week, is that there is currently no recommended treatment for Ebola.

As for the odds being in your favor if you simply take it easy in bed and drink Gatorade, well, that’s a bet we’d rather not take.  It is hard to get accurate statistics on fatality rates because in the West African nations where the Ebola outbreaks have occurred, data capture and recording is at best incomplete and far from definitive.  We are aware of one outbreak in the Democratic Republic of the Congo with a 90% fatality rate in 2003, and most outbreaks have reported fatality rates in excess of 50%.

You could say these rates are skewed high because some people who were infected never entered the formal medical/care system and recovered on their own.  On the other hand, you could say these rates are skewed low because many families have chosen to obscure the deaths of relatives with Ebola due to shame and fear of being quarantined.  There are plenty of other adjustments you could selectively make to the statistics as well ( such as allowing for how not all cases first thought to be Ebola actually prove to be Ebola), but let’s just say that we urge the article writer not to infect himself and his family to prove his claim.

We also suggest he not expose himself to coughs, sneezes, and sweat to prove his claim that Ebola is a ‘lazy spreader’.  His lack of concern on that point is not matched by any health care authorities – in the field they are taking full ‘space suit’ type precautions any time there’s a hint of Ebola presence; in western hospitals they are not normally going to head coverings, unless they are carrying out aerosolizing procedures in the patient’s room which might cause contaminated liquids to be released into the air in droplet form.

Canada is more cautious.  Their guidelines would see Ebola cases and anything to do with Ebola – for example, blood testing – confined to the highest security Containment Level 4 facilities in Canada.  Health care workers are being told to wear double layers of protective clothing, plus eye protection and respirators.  The CDC in the US is slightly more relaxed, but only slightly so, and if you read between the lines of their treatment guidelines, and also receive their oral advice, they are clearly also treating this as very serious.

In their conference call earlier this week, the CDC said Ebola can be passed on through coughs, sneezes and sweat – through any and every form of bodily fluid.

The Canadian Public Health Agency says that as few as 1 – 10 aerosolized organisms are needed to create a viable infection in a new person.  Who do you believe – the attorney writing in the NY Post, who says you need to come in contact with large doses of blood or vomit?  Or the Canadian Public Health Agency, claiming that fewer than ten of these microscopic virus organisms are all that you need to ingest in order to have a high probability of contracting the disease?

Okay, enough of the rhetorical questions and the confusions.  Let’s try to establish some real world measures of what Ebola is and what we might expect in the future.

Well, perhaps let’s look at one more article, this one from Britain’s The Guardian, so as to put Ebola in perspective.  This article quite sensibly points out that every day, tens/hundreds/thousands more people die from many other causes, both natural and unnatural.  The ordinary common ‘flu kills thousands – maybe even hundreds of thousands – times more people each year than Ebola does.

Even the NY Post article gets one thing right – we’re probably all much more gravely and directly at risk of death through infection due to the failure of almost every remaining antibiotic and the massive growth of new super-bacteria that are resistant to all known antibiotics.  Where is the public alarm and clamor for massive investments in developing new antibiotics?

So why the alarm about Ebola, and why now rather than any of the previous outbreaks?

It is true that Ebola is a truly nasty virus.  It causes a very nasty sort of death, with patients sometimes bleeding out of every orifice in an undignified and painful death.  There are no cures, and as of their Tuesday morning conference call, the CDC said there are no recommended treatment procedures for patients with Ebola.  The visceral and visual impact of an Ebola death is much greater than many other types of disease/death.

Let’s now look at some of the facts and some of the possible implications of Ebola and this current infection.

How Do You Get an Ebola Infection

The answer to this question is being offered up by some people as good news.  We see it, rather, as closer to bad news.

Ebola is passed from person to person via the bodily fluids of the infected person.  Anything liquid, from tears to urine, from spit to blood, from sweat to semen, and anything/everything else you can think of, will contain the Ebola virus.

Apparently, during the period of incubation between when a person is infected and starts to exhibit symptoms, they are most likely not passing on Ebola in their fluids.  That’s a major blessing.  On the other hand, if a person beats Ebola and survives their infection, they continue passing on active deadly Ebola in their fluids for some weeks subsequently.  As mentioned above, Ebola has been tested as present in semen 61 days after the onset of the illness, and the CDC is recommending caution for up to three months.

So, on the face of it, as long as you don’t get wet from some type of liquid from an infected person, you’re safe.  Right?

Wrong!

First, there is a possible risk of what is termed aerosolized liquid infections.  When a person coughs, that is a disease’s attempt at perpetuating its life by spreading itself in tiny droplets of bodily fluid that are shot out as part of the coughing process.  These tiny droplets are termed an aerosol, and they can hang in the air for an extended time, and can travel appreciable distances.  It is thought that Ebola may possibly be transmitted this way, but you’d need to be close to the person for some time to have your chance of infection become material.

For example, if you’re on one side of the road, and an Ebola-infected person on the other side of the road coughed, your chance of contracting the disease is close to nil.  But on the other hand, if you’re in a closed space – a room of uncertain size – and a person on one side of the room coughed, then depending on the room volume, the airflow patterns, and how long you were in the room yourself, your chance of contracting Ebola from that cough starts to climb up the scale and may reach a point of significance.

The Canadian Public Health Agency is circumspect in their commentary, saying

airborne spread among humans is strongly suspected, although it has not yet been conclusively demonstrated

On the other hand, the World Health Organisation says (in an April note)

Airborne transmission has not been documented during previous EVD outbreaks

So airborne transmission of infection is very much an unknown at this stage, although you need to also realize that saying ‘has not been documented’ is not the same as saying ‘is impossible’.

Now, what about airplanes?  They are of course a very relevant type of closed space for many of us.  The good news is that modern planes have fairly well planned airflow paths designed to move air in and out of the cabin fairly quickly, rather than having a worst case scenario of air traveling all the way from one end of the cabin to the other before being removed.  But studies have shown there is a danger radius of several seats around a coughing person (don’t ask how many ‘several’ is – it also depends on how much coughing the person is doing, how long the flight is, how the air flow is being regulated, etc, but it is probably more than two and less than ten).  If you’re in an aisle seat, there’s also the chance of copping a ‘full load’ if the person goes up/down the aisle, coughing as they go.

So there may possibly be some risk if you’re traveling on a flight with an infected person who is also demonstrating Ebola symptoms.

But, wait.  There’s more.  It isn’t just the passengers you are flying with who you have to worry about.

What is the dirtiest thing you’ll touch when flying somewhere?  It isn’t what you might think – nothing to do with the bathroom.  According to this article, the biggest disease spreader are the bins into which you place objects when going through security.  If an infected person, some time before you, touched or coughed on the bin you’re now loading/unloading your stuff into, you might get an infection before you even leave your departing airport!

Now, when you get into your seat and obediently buckle your seat belt – ooops.  Another of the dirtiest places on the plane – the seat belt buckle.

Then, the real kicker.  You pull down the tray table, and place some food items on it prior to eating them.  Oh no!  That’s another of the dirtiest things on the plane.  And you just put some food on it – and even if you didn’t, you touched it with the hands that you are now touching your food with.

A very important issue to understand is therefore to know how long the Ebola virus remains active and a threat, when on an exposed surface, even after the liquid it was in has dried out?  The Canadian site says that it can survive, even without water, for ‘a number of days’, and adds that infectivity at room temperature is found to be stable.  We don’t know, because their source reference material is not linked and easily found on the internet, as to how many days ‘a number of days’ is.  One is a number, so too is a million!  But even if the ‘number’ is a relatively small number, that enormously magnifies the potential for transferred infection.

So, if you’re on a flight (or anywhere else), you not only need to be aware/concerned about the people around you, but you also need to wonder about who was also in your seat on the previous flight, using your bin at security, opening the overhead locker above your seat, and so on.  And the person on the flight before the previous flight, and possibly for several other flights, too.

The Wall St Journal published an excellent article about issues to do with catching infections of most sorts on planes back in 2011.  If you can’t access it, search for ‘Where Germs Lurk on Planes’ on Google and click the link from there and it will open.

The article points out that there are significantly elevated risks of catching some sort of infection on a plane (as many as one in five get a cold), and this risk is not so much as a result of the (re)circulated air (more people get an infection with the air off than with the air on) as it is from other transmission vectors such as dirty tray tables, etc – and also from all the other infection points in the airports you travel through too.

Our point is that practicing good hygiene on a plane is something to do as a matter of course, on all your flights, and the demonstrable risk of getting some sort of infection on a flight makes the potential risk of Ebola credible (assuming an Ebola-infected and afflicted individual recently flew in your same seat, etc).

How Serious is this Ebola Outbreak?

No-one really knows how serious this outbreak may grow to become.  It is already much larger than any previous outbreak, and it seems that it is still in a growth phase, with more newly reported cases and deaths every day.

It is true that Ebola has not spread like wildfire in past outbreaks, and one could even say that its present rate of growth in West Africa is slow rather than fast.  The present epidemic was first declared in March, and at the time of writing on 7 August, there are only 1070 confirmed cases of Ebola reported, plus another 641 unconfirmed suspected cases.  Of the total confirmed and suspected cases, 932 people have died (note that many of the people currently in the count of cases are still going through their period of sickness and some of these will die, making the mortality rate appreciably higher than 932/1711).

The good news is that currently there are no confirmed cases of Ebola ‘in the wild’ outside of West Africa.  As long as that continues, we can all semi-relax.

On the other hand, why did the CDC issue a Level One alert today for such a limited outbreak of a disease, so far away?  In the US, more than 200,000 people are hospitalized each year for ‘ordinary’ seasonal flu; in a good year 3,000 people die and in a bad year, as many as 50,000.  Currently no Americans have contracted Ebola in the US, so why is it being given so much prominence?

We’re not sure how much of the CDC decision is a response to media-induced anxiety, and how much is a reflection of the distant but real potential for Ebola to spiral out of control and deciding that it is better to prepare for a disaster than to be taken by surprise by it.

One of the problems with Ebola is that treating people with the disease is a resource-intensive process, and it would only take a very small percentage of our population coming down with Ebola to overload our hospitals.  There are, in total, 930,000 beds in US hospitals, and of course, many of these are occupied on an ongoing basis with non-deferrable emergency care of all kinds.  So even if something like one-quarter of one percent of the population were all infected at the same time, our hospital system would be overloaded.  Plus, even if the hospital beds were available, how soon before all the necessary supplies were exhausted?  (This is more likely to be a problem than you might think.  As an aside, my own recent ankle injury used up 2000 ft of four-inch gauze, along with all manner of other supplies, during the course of its care.)

Understanding what might happen is extremely speculative at this time, and the last few credible semi-panics about things such as SARS, Bird Flu and Swine Flu all proved to be much less impactful than was feared.  However, you might find it interesting to read about the impacts of the 1918 Spanish Flu on our country, and what that might mean to us if it reoccurred now – we discussed that, some years ago, here.

The bottom line is that the worst case scenario is beyond imagination.  The best case scenario is that Ebola never leaves West Africa.  The most likely outcome?  We can’t even guess.

There’s one interesting measure of how serious the present situation is.  The CDC’s Tuesday conference call discussion of Ebola, with physicians and other health care professionals invited to participate, saw some people unable to log into the call, requiring up to 15 minutes of dialing to get past the busy signals.  It is thought the CDC initially set up the conference call with a greater than usual number of incoming lines, and then needed to add more lines, realtime, as the call was progressing so as to allow the greatly larger than normal number of people to listen in.  When it closed there were still 95 pending questions from participants unanswered (due to running out of time).

Clearly the medical community in the US is treating this very seriously.

Is There a Cure for Ebola?  A Vaccine?

The short answer is ‘no’ and ‘no’.  All that healthcare providers can do is provide palliative care – helping to make sufferers comfortable, keeping them hydrated, and hope for the best.

There are some experimental drugs under development, but they are a long way being ready for full release, and even if/when that happens, the time it would take to make vast quantities of these drugs to combat a major global epidemic would cause it to be a case of ‘too little, too late’.

Work is also underway on developing Ebola vaccines, but in the cruel calculus that the drug companies work to, there’s not a lot of profit to be made in developing a vaccine that would primarily be sold (ie almost given away) to people in some of the poorest countries in Africa.  It is better – for them – to work on a new improved anti-anxiety drug or ‘social medicine’.

Where Does Ebola Come From?  Will it Keep Re-occurring?

Ebola was first identified in the Democratic Congo Republic in 1976.

It is believed to be present in some West African animal species – possibly monkeys and probably bats, and so while human outbreaks come and go, the potential for new outbreaks remains and will likely continue to remain for the foreseeable future, due to the presence of the virus in these wild animal populations.

There are four different types of Ebola virus, and one closely related (Marburg).

What Should You Do

Until such time as Ebola appears ‘in the wild’ in the US, there’s nothing specific you need to do.

But, having said that, we’d suggest you use this as a ‘wake up call’ and as a gentle encouragement to become more vigilant about hygiene matters in general.  No, we’re not talking about hygiene in the sense of changing your socks and showering more often, but in the sense of washing your hands and avoiding ‘dirty’ things.

Carry hand sanitizer gel with you, and make a habit of washing your hands or using the gel any time you’re about to handle food.  Be more aware of what are termed ‘fomites‘ – surfaces on which infections can be passed from one person to another.

The next time you press an elevator button, wonder who else has been pressing it (or coughing on it) earlier in the day.  The next time you hold onto a support railing on a bus or subway, think who else has been doing the same.  You hold on to the moving handrail on an escalator, the same as thousands of other people each day.  The next door handle you reach for.  The keys on a credit card charging PIN pad.  And so on and so on.

After appreciating the potential for all manner of germs to be passed on via such fomites, make a point of washing your hands more often.

It might also be interesting to do a thought experiment, discussed in the next paragraph.

A Useful Thought Experiment

Ask yourself what if Ebola (or any other infectious disease) was to break out.  How could you adjust your work and personal lifestyle to reduce your contacts with other people?

If you work in a role directly serving customers, then you probably have little chance of adjusting your work duties.  But if you work in an office, shuffling papers (or, more likely these days, their electronic equivalent), how much of that work could you do remotely, from home?

What other requirements do you have – what other unavoidable needs are there to be in public and therefore at risk?

For many of us, the main unavoidable need is to buy food.  Even that can sometimes be minimized if your city offers an internet grocery delivery service.  If you choose to buy food in person, we’d suggest you go very early in the morning to do so.  Yes, very late at night is also an option, but we prefer early in the morning just to put some more hours between us and when the main swell of people visiting the supermarket, during the daytime, has occurred.

You might also want to alter your food buying habits – we’d go easy on fruit or anything else that is not likely to be thoroughly heated prior to eating, and we’d also consider everything we bought as a possible fomite, with infection on its hard surfaces.

We’d buy large quantities of food infrequently so as to keep our contacts with the outside world to a minimum.  And also – a really scary thought – but if infection levels did start to rise, this would start to cause gaps in the supply chains for many things.  You know that any time there is a threatened snow storm, or even just an ordinary long weekend, the supermarkets fill with crowds of people and quickly empty of food.  An epidemic could create disruptions of unknown severity to what is a fragile supply system with lots of dependencies and very little ‘fault tolerance’ or redundancy built into it.  So we’d ramp up our at-home supply of food, just in case.

Our article on minimizing your risks of infection has other ideas and strategies.

One more thing we’d do.  We’d cut back on any non-essential air travel, so as to keep away from all the crowds of other people in airports and on planes.

Working through this thought experiment, it might be a good idea to make some preliminary preparations, particularly in terms of adjusting your work duties to allow for much of your work to be done from home.  This would be good not only for you, but also for the continued operation of the business if it became difficult or imprudent to have everyone rubbing shoulders with everyone else at the same time.

Ebola, the Airlines, and the Travel Industry

Many airlines (most recently, British Airways and Emirates) have curtailed or cancelled their flights into the affected regions of West Africa.  That probably has very little impact on their operations or profitability currently, but what if – like with the SARS scare – people start to reduce their flying, due to concerns about Ebola exposure?

We can only guess about this, but it would seem to be part of the unbreakable cycle of bad luck for the airline industry – almost without exception, every time the airlines claw their way back to healthy profit, as is the case at present, something disruptive occurs and they dip back into terrible losses once again.

Of course, if people aren’t flying as much, they’re not renting as many cars, staying in as many hotels, and neither are they eating as many meals out.  If people are avoiding crowds, they’re also avoiding Disneyland and other amusement parks and tourist attractions.  The entire travel industry would suffer.

It remains to be seen what impact the current Ebola scare might have on the global travel industry.  But there is definitely a palpable possibility that it could mess things up.

Summary

Ebola is a deadly virus-based disease that kills more than half of all people infected.  There is currently neither any cure nor a vaccine to prevent infection, although both are under development.

At present, it is impossible to predict how this (and future) Ebola outbreaks will unfold.  Just because it is currently growing (and at only a slow/moderate rate) does not lead to an inevitable continued and massively more rapid growth.  On the other hand, just because it has never traveled out of West Africa before does not guarantee it won’t get loose in North America or Europe this time.

In a sense, each extra Ebola patient is a bit like having another chance at winning a macabre lottery.  The more patients, the more tickets in the lottery, and the more chances of ‘winning’ – but in this case, the prize is a major international outbreak.

Just like, with real-life lotteries, we buy many tickets but seldom/never win the jackpot, the thousands of ‘tickets’ in the form of Ebola infected people over the last almost 40 years have yet to ‘win the jackpot’ (of the disease spreading outside of Africa).  But, with each passing year and each extra infected person, the chance grows, because of the continued spread of easy fast international travel.  The up to three-week gap between when a person gets infected with Ebola and starts to then show the symptoms would allow such an international disease carrier a lot of time to get to just about anywhere in the world.  Not to be melodramatic, but in the worst case scenario, nowhere would be safe.

For now, there is nothing any of us need to do other than to do a prudent re-appraisal of our personal hygiene practices.  But if Ebola does end up in the general population of the US, things could drastically change.

Meantime, please remember that there are many more diseases and more pressing challenges in our immediate lives than Ebola.  For example, apparently even rabbit fever!

The CDC have ongoing updates on the Ebola situation, with pages of material prominently linked from their homepage.

  2 Responses to “Will Ebola Destroy the World? Or Just its Airlines? Or Neither?”

  1. Thank you for this thoughtful piece. Published more widely, it might stem the oncoming tide of fear, ignorance and xenophobia.

  2. […] wrote about Ebola last week, with our essential conclusion being that while it is a very nasty disease, the present scare […]

Leave a Reply