42 days is not long enough

Dr. Mosoka Fallah, the leader of the outbreak response who traced most of the cases through Monrovia and Liberia during the heat of the outbreak, said there was an overreliance in medical facilities on fever being an indicator of possible infection. “There should be a high level of suspicion because 90 percent of the patients lie,” said Fallah. In other words, Gbotoe should never have slipped through the cracks.

The boy's mother may have been an ebola survivor herself.

The 42 days number came, if I recall correctly, from a survey of patients who had been exposed, and represented the largest time known between exposure and showing symptoms. I think it should be revisited. And we know now of reservoirs of live virus in survivors lasting months after they are nominally cured, in semen and the fluid of the eye and who knows where else. If it got into those spots, it can get back out again. How long are antibodies good for? Can a milder infection produce "Typhoid Marys?"

"Ebola-free" is too strong a claim. Unfortunately.

Ebola and culture in Sierra Leone

National Geographic has an interesting article on how indigenous funeral rituals were adapted to deal with the outbreak. Good work.

Native ebola control

The conference call with Dr. Mosoka Fallah had a few enlightening notes. I've been deeply suspicious of the claim that ebola is declining in Liberia, but he said it was because local communities had finally gotten the picture, and were being proactive about control. They find a place to isolate the sick, bring food/water to the boundary, and let nobody in or out. Newcomers to a village have to stay in isolation (quarantine) for three weeks, since they are assumed to be infected.

In other words, the simple social tools work. Compare and contrast with Nurse Ebola and the federal refusal to use the same common sense. (Yes, I've heard the hyperbolic claims that quarantines would cripple provision of medical care to the afflicted areas. We can fast-track tests for medicals professionals on a new registry and reduce their quarantine time. Voila. In computer networking you put up a firewall and only punch holes for the protocols and systems you know you want to let through.)

Ebola vs excellent medical care

Mark Reiff sent me a couple of ebola-links, and the New England Journal of Medicine report was particularly interesting. The patient described isn’t exactly typical: he nearly died of a secondary infection as well, but he had top of the line medical care all along the way after he arrived in Hamburg. Among other things he got about 10 liters of plasma every day for a while (8-13) since he was losing 8 via diarrhea! There was no way he’d have survived without heroic treatment.

Grab a dictionary and have a look at the article.

One thing that was pretty startling is Figure 2, showing the levels of viral RNA detected in various body fluids. The blood levels decrease for a while and then drop like a stone—maybe the result of flushing by the plasma? The levels in urine track the projected decline in blood levels A report from the earlier outbreak in Congo found nothing in urine, but evidently their tests weren’t sensitive enough yet. Sweat levels drop too—and then rise with the onset of the secondary infection and then decline more slowly! At day 63 when the report was written the levels had dropped to undetectability. And of course we’ve heard the reports that viral RNA was found in semen 60 days after infection.

I take this to mean that the virus is holed up in some tissues: skin for one. And that someone can be infectious to touch for a while after they’ve recovered from the disease. The latter seems to conflict with earlier work, but the patient was atypical. Without the heroic treatment he wouldn’t have survived to touch people; maybe the typical survivor isn’t hit as hard. Or maybe not.

Still, something to keep in mind. (Texan99 seems to have been right about high performance medical treatment.)

Graves again

I wrote earlier that graves and markers seemed like a minor detail compared to the death itself, but: Graves matter.

In March, the second Wednesday of the month is National Decoration Day, a public holiday during which people flock to cemeteries to clear brush from the graves of relatives, and scrub and decorate headstones.

Cremations in the capital, and burials of Ebola victims in body bags outside Monrovia without relatives present, means there won't be a place to honor deceased relatives. Decoration days will come with many people not knowing where the remains of their loved ones are, or knowing they were cremated and that their ashes were not recovered.

Many will find it hard to accept that they will never see the graves of those lost to the disease.
.....
Nyenswah said many people are remaining home to die instead of reporting for treatment.

"We understand that there are secret burials taking place in the communities," he said. "Let's stop that and report sick people and get them treated."
.....
A commentary on a website, Sierra Leone News Hunters, suggested that a memorial site be built to honor the dead who do not receive traditional burial rites, and to provide some comfort to their families.

It said: "The erection of a monument bearing the names of all Ebola victims would not take away the sad memories but it would at least pacify the broken heart somewhat."

Graves in Liberia

One of the things that makes ebola hard in Liberia is that the dead cannot be honored. Granted, that seems like a minor detail compared to the death and fear, but people have risked death themselves to honor their dead.

There isn’t a lot we can do about this: those dead of ebola cannot be touched, and would most safely be cremated--not exactly a customary way of honoring the dead. But I wonder if we can do something. If the burial teams have the names (and parents) of the dead, could someone carve the names into a stones to stand by a mass grave? Quite a few would be "woman known only to God."

I don’t know if anybody there could do it, and the lag time in getting something made elsewhere and then shipped there is large, so this probably wouldn’t be much use anyway, but if people knew their family members were being commemorated, it might be a little comfort.

UPDATE: Maybe it would help with the problem of bribing of burial teams.

Distributed doctoring

UPDATE: Prepositioning medicines won't work very well. They will deteriorate in the heat and humidity (want to bet the bottles won't be opened from time to time?). You would have to re-distribute regularly--possibly annually.

One of my favorite scenes in the movies is the engineers around the table in Apollo 13.

I wish I had a team of engineers and nurses.

Ebola is, of course, out of hand in Liberia/Guinea/Sierra Leone now. The centralized medical centers were overwhelmed and eviscerated. They are trying to open secondary centers. USAID is trying to bring in ebola management kits to distribute to the villages.(*) The kits aren’t quite complete enough but they have the right idea.

Treatment has to happen at the extremely local level: village or neighborhood. Without that presence people don’t buy into the system, and in any event there’s nowhere near enough beds even if you could transport everybody to the hospital without infecting another half dozen people on the way.

There are not enough doctors or nurses. There won’t be. All you have available is family members, with advice.

Cell phones are widely known and used, and though smart phones aren’t nearly as common as the candy-bar models this can help spread the word among the skeptical. But this is just the start.

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Here’s the challenge: given local resources (in the slum or in the village), how can we arrange for medical care while minimizing the risk of ebola infection to others?

A few features seem to be inevitable. Homes are crowded, so the patient needs to come out of the home and stay in a more isolated setting. One member of the family will be taking care of the patient—so the isolation area needs to have room for pairs. The caregiver has to assume that the patient has ebola, and so buckets of bleach water have to be available.

The patient probably doesn’t have ebola, so the kit is deficient. It should also have malaria suppressants and vermifuge and some anti-diarrhea tablets and some rehydration salts and maybe a few other things as well. The average caregiver will have no idea how to use these things. I’ll get back to that. (Tylenol might be more dangerous than it is worth unless the kit has only a little--that's a judgment call.)

The slums should have readier access to bleach, plastic bags, gasoline, cloth, and other useful items. The village will have more space to put an isolation building—the slums are horribly crowded—and better sewage disposal. Neither one has useful medical advice.

Engineers and Nurses:

Can one kludge procedures using cloth, plastic bags, and bleach that will let you clean a sick patient without exposing your own skin to ebola? How much bleach residue can someone with diarrhea stand, since you have to bleach the cup he drinks from? How can you use cloth and whatever to hold someone up enough to drink? What sorts of procedures can you use to wrap the dead (bearing in mind that whatever he was lying on is wet and contaminated) that won’t put you at excessive risk?

Can you make a decent mask with available cloth? How many do you need to have on hand if you have to keep soaking old ones in the bleach?

Can you make disposable bedding from leaves and branches (in season)?

What is bleach going to do to skin infections?

How much cloth is one person with the runs going to need?

If the patient is bed-ridden, what can one use for a bedpan?

If the patient is not bedridden, how can one kludge a latrine in the slum? Since the waste is potentially deadly (even without ebola), this isn’t a trivial problem.

Other ideas and questions--straw men and otherwise.

Beef up those medical kits. I’m assuming the information pamphlets are cartoons, since most people can’t read. The medicines need to be brightly and distinctly colored so they can tell them apart easily. Probably everybody has worms, so dosing everybody in the village on general principles is probably harmless and might increase overall health.

Create medical teams that just answer cell phone questions. You need a lot of them, because there will be a lot of questions and a lot of languages. Their job is not to provide care but to explain how to use the souped-up medical kits. They in turn will not be doctors or nurses; they’ll be working mostly from scripts. If they get stumped they call for advice from medical central (which might not even be in the country). Not all villages will have a cell phone to call with. Can't solve that problem here.

The circulating education teams have to demonstrate all the details of all the procedures. This means that it will take a long time to finish a circuit. Folding cloth to make a support or an impermeable mitten is something that needs to be practiced a little. So long as one person gets it, the team has to rely on that person to train the others as needed since they can't stay for too long. Cartoons are all very well, but there’s no substitute for trying procedures out yourself (even cartoons aren't as clear as their creators dream). The teams will have to resupply the medicines from time to time. Some villages can only be reached by a few day’s walk. Some slums are dangerous.

I'd thought that for somebody in a village with ebola a trench filled with leaf bedding would be useful, but since there won't be a diagnosis (probably ever) I don't know if this would be suitable. For a one-off treatment site it might be OK for easing cleanup.

If a man dies you need to bury or burn his contaminated clothing and bedding. This will be a bit of a sacrifice, and in the rainy season (like right now) difficult. How long can you soak a filthy shirt in bleach before it is safe enough for someone else to inherit?

If the people intensely dislike the smell of chlorine bleach on the departed one, maybe perfume would help mask the smell, and also mask the fact that the person hasn’t been bathed as thoroughly as custom demands.

Sometimes liquid latex is available from rubber trees—can that be used to make cloth less permeable?

In the slums, the city is going to have to clear some areas out to make room for isolation buildings and latrines. This will make people angry. If you compensate those whose houses were razed, the neighbors will be angry that they didn't get a share. Money allocated for compensation will leak away before it gets to the people. You just have to deal with the anger somehow.

This will need lots of volunteers with working knowledge of tribal languages. You can probably find some in churches.

The isolation buildings don’t have to be any fancier than anything else in the area—in fact it is probably a bad idea to have them be too good since there will be squatters in the slums. The shelters have to keep the rain off, fresh air in (insofar as there is any), and the patients out of the draft and separated from each other. Latrines outside, places for paraphernalia where the caregiver can keep an eye on them so they don’t get stolen (the slums are slums). There need to be a lot of these shelters, since a caregiver will likely have other obligations to other family members and can’t spend 24/7 at the isolation building—so these can’t be far from home.

What kind of landscape is needed for siting an isolation building?

Try to recruit burial team members from the slums. You may have to pay by the body or they might not show up.

Water is a problem--too big to solve on a useful timescale for stopping ebola.

UPDATE 27-Sep: See this story about makeshift protective gear.

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(*)

SIEGEL: That kind of gear and information is in kits that will soon be distributed by the U.S. government in Liberia. But as NPR's Nurith Aizenman reports, the home health care kits come with mixed messages.
NURITH AIZENMAN: Here's what's in these kits...
NANCY LINDBORG: It's a bucket that contains a sprayer, which is used for disinfectant, rolls of bags for capturing any infected garments or items, gloves, a gown, a mask, soap, chlorine.
AIZENMAN: Nancy Lindborg is a top official at USAID. She says the agency's plan is to distribute the kits to 400,000 households across Liberia. The first 50,000 kits are arriving next week. And here's the question - can these kits help slow this outbreak?
Kits like this have been distributed in previous Ebola outbreaks, but never on this scale. Dr. Daniel Bausch is an infectious disease expert with Tulane University and the U.S. Navy. He's advising the U.S. government on the current Ebola outbreak, though he's not working directly on the home kits.
DANIEL BAUSCH: In previous outbreaks, the question was is it better to try to take care of people at home with these sorts of kits or should we really focus on getting people into an Ebola treatment units? But that's not an option now.
AIZENMAN: There are very few treatment centers in Liberia. So people are taking care of their family members at home. They don't have a choice. President Obama is promising to build 17 new treatment centers with a total of 1,700 beds. But that's going to take time.
BAUSCH: Until we can do that, I think that we have to be honest. And we have to offer people what protections and what care we can even though it's far from ideal.
AIZENMAN: But USAID says that the kits are not meant to be used to provide treatment. For instance, they don't contain Tylenol for fevers or rehydration salts to help replace fluids lost through vomiting and diarrhea. Officials say the most important item in the kit is an information pamphlet telling people how to protect themselves. Dr. Bausch says that while using items in the kits like gloves or surgical gowns won't completely protect the family members and friends of someone with Ebola, every little bit helps.
BAUSCH: If we can cut down - rather than having five infected people from a sick person in a home, if we can cut down to three, obviously that's a good thing.

Liberian govt vs ebola

They've established isolation centers and have retrieval squads working. This isn't pretty: the WSJ calls it "A Grim Picture", but it is a good start. What's needed is more of this, not less, and ways of doing it without government sponsorship.

THIS is the grim picture: isolation broken, patients brought out, and soiled blankets stolen. In the community preliminary estimates (reported last week, so probably based on 3-week-old info) claimed 1.8 new infections for each existing one.

Ebola without hope

People are taking the old traditional approach to epidemics: head for the hills and leave the sick to die. As long as this is true--"The villagers who abandoned Fatu and Barnie have meanwhile themselves been shunned by neighbouring towns also in fear of the spread of the virus, Wile said."--it will probably work. If they get to take refuge in other towns, it will backfire.

That doesn't make it any less heartbreaking to read about. Protocols and supplies to help family take care of their own might have meant that the sick didn't have to die alone, but there wasn't enough time once the scope of the problem was known.

If I were a villager without resources, would I be willing to stay and tend the sick knowing I'd probably die too? Christians used to.

Ebola and the researchers

Tales new and old from the research front:

• There remains some residual reaction to the virus after 12 years, suggesting survivors might have something like antibodies
• Are there forms of the virus that offer partial immunity (like cowpox vs smallpox?)
• Can animal tests be used for faster approval for human tests? (2009)
• Animal tests of something similar (2012)
.
• One group claimed that ebola works so fast the immune system can’t always react in time (2003). I'm not sure that's quite the whole story.
• I get the sense this report was released a little early. It sounds like they weren't quite finished studying the protein, but since it is in the news...

I have a feeling we're going to discover more in a few months about immunity: do people who have recovered get the disease again?

Ebola continues

The lead doctor at JFK hospital in Liberia died of it, and a Liberian flew to Lagos and died of it there. Two Samaritan's Purse missionaries have caught it. In Liberia they're taking some actions:

All borders of Liberia will be closed with the exception of major entry points including the Roberts International Airport, James Spriggs Payne Airport, Foya Crossing, Bo Waterside Crossing, Ganta Crossing. At these entry points, preventive and testing centers will be established, and stringent preventive measures to be announced will be scrupulously adhered to;

A new travel policy by the Liberia Airport Authority covering inspection and testing of all outgoing and incoming passengers will be strictly observed;

Restrictions on public gatherings such as solidarity marches, demonstrations, promotional advertisement are to be restricted;

Hotels, restaurants, entertainment centers and video clubs are to play five-minute film on Ebola awareness and prevention;

Government vehicles will be commandeered, as appropriate, to provide needed logistics support to the health delivery system;

Without those kinds of border assurances I'd bet that within a week or two EU or US airports would stop admitting Liberians/Sierra Leoneans/etc from anywhere. Even with border checks, they'll probably stop soon anyway, or only allow in after a week's observation. The Xray machine at the Roberts airport didn't work and the baggage search wasn't particularly efficient; will medical checks be any better?

Sierra Leone's Sheik Umar Khan treated over 100 ebola patients before contracting the disease himself. That suggests a 1% failure rate of the systems they have in place: bleed-through, airborne spittle, a stray fly that got past the screens, needle sticks, sloppy laundry--something. The safety suits are horribly hot: you last 40 minutes or so in the tropics, and I assume getting them off and on is tricky. (BTW, if you look at the pictures of the isolation units you see open concrete block, but you don't see the screen over the holes. They're not crazy, it's a camera lighting problem. And even with the "window" blocks, it gets hot and stuffy indoors.)

I'd put trying to understand how the system failed as one of the top medical priorities; something the US/EU should throw effort into ASAP for their own self-interest. That 1% doesn't seem high, but with hundreds of patient contacts the probabilities start to look ugly--and you lose your doctors and nurses. Top priority is border control testing, of course, and third would be trying to get tribal-custom friendly protocols for caring for the sick and dead back in the villages.

That last idea is scary. Just suppose that they worked up some cheap and easy protocols like my WAGs about making an isolation hut of mats, some sort of easily draining "bed" of rags and leaves, soaking all rags (and the deceased's body later) in bleach, and setting fire to the isolation hut afterwards and burying the ashes. Some such protocols might help reduce the transmission rate, and if they were custom-friendly and in the native languages and if you had teams go out to explain how to do it and distribute bleach...

Now your team visits a village where it turns out somebody has ebola right now. You have to demonstrate the procedures that you know aren't nearly as effective as the hospital's. They're better than what the villagers will do otherwise, but will they believe you if you refuse to do them yourself? That's going to take some courage.

UPDATE: It looks like Canada is not taking this seriously.

One of those headlines I can't quite believe

"Liberia: JFK Nurses Abandon JFK ER Ward Over Suspected Ebola Death"

And you shouldn't either, once you read the story, which refers to the ER staff, but doesn't actually go into any detail about how many left or where they went. It does say that a "case management" team went to handle matters. I suspect that most of the staff have a better idea of what the risks are than your average reporter. Quite probably some left in haste, but I'd guess that most didn't. I admit that panic can be contagious, but I'd still bet most people stayed around, though maybe not in the ER. ("We should sanitize the place." "Great idea! You go first.")

Back in the villages they have been hiding people with Ebola. There's a long tradition of kidnapping people to use body parts in magic. It didn't happen often--there was much more fear of it than actual instances--but it happened often enough to keep the fear alive. So if people in scary garments take your cousin away and you never see her again--what do you suspect, and what do you warn people about? It doesn't matter if the people telling you about the risks are important people--a Senator was caught trying to cement his power with some human sacrifice magic a few decades back.

So nobody really knows how many are sick.

Ebola

This is getting closer to home. I don't recall spending any time at the ELWA hospital, but we've been by it.

Kits are being distributed, and instructions, but it is hard to get information or reliable bleach supplies upcountry were people don't speak very good English. I wonder if they've got some plans for quick and dirty isolation units in villages far from hospitals. Maybe the village can throw together some kind of shelter made of mats that they can burn when the patient is done, with triple layers of fabric to tie it together (burned or bleached later?). If the local folks get a clear understanding of the nature of the risks they can probably work up some mostly effective kludges. Not hospital quality or reliability, but orders of magnitude better than nothing...

Ebola is horrible and frightening, but malaria and dysentery kill more, and probably will still be the big killers even if ebola spreads.