Archive for October 2014
l. Science has published two new EBOV articles on-line today. An article by Rasmussen, et. al. reports the presence of genetic markers in bred mice which make the mice susceptible to mouse adapted EBOV or make the mice resistant to mouse adapted EBOV. See: http://www.sciencemag.org/content/early/2014/10/29/science.1259595.full for this Research Report. Plandley, et. al. reports that case isolation, contact tracing, and sanitary funeral practices are the means to end the EBOV epidemic in Liberia. If we don’t do a better job on all three fronts, then 224 new EBOV cases will be identified daily in Liberia by December 1st. See: http://www.sciencemag.org/content/early/2014/10/29/science.1260612.full for this Research Report.
2. Nurse Hickox and Gov. LePage of Maine have not seen eye-to-eye on her state mandated quarantine. She took a bike ride today and shook hands with reporters. The Gov. promises he will enforce the law. But there is no court order on her quarantine. Her boyfriend acknowledged last week: ‘Gov. Christie took on the wrong redhead’. This whole business is distracting and draws attention from the need of the world to respond to West Africa. Yet, we do not have a Surgeon General and the Acting Surgeon General has nothing to say. I suspect he has been told to ‘stay out of this business’ by the Administration,
3. Time Magazine has an interview with DG Chan of WHO on-line this evening. Dr. Chan says that the EBOV epidemic spread ‘in a hidden manner’ from December to June. She says that she will reorganize WHO in her remaining term so that WHO can respond faster, more effectively, with less resources (fewer staff and U.N. money) than currently.
SHEA Spotlight this week has the following highlights:
l. Fecal transplants for recurrent C. difficile are excellent for these patients. Fresh transplants (require 4 d prep) and frozen transplants have similar cure rates of >90%. This cure rate occurs in patients with toxin and w/o toxin. The transplants change the GI microbiotome to resemble the donor microbiotome. Multiple transplants can be done.
2. Fecal transplants can be used in critically ill patients with C. difficile scheduled for colectomy. Cure rate is 88%. Vancomycin is given concurrently.
3. Contact precautions (gloves, gowns, masks) prevent MRSA spread in hospitals, but note that only 20% of MRSA is transmitted patient to patient in hospital. 80% of MRSA comes from the outside. See JAMA article.
4. Needle sticks may be prevented by sharp-protection needles, double gloving, and blunt sutures in surgery.
5. Only 1/3 hospital patients wash their hands after using the toilet. Remember 1/2 of hospital patients are on antibiotics at any given time. Not hard to see why antibiotic resistance has developed in hospitals.
6. EBOV waste should stay in the ‘hot area’; autoclaved or otherwise sterilized with DEDICATED autoclave or sterilizer; no shared autoclave or sterilizer.
See: https://col128.mail.live.com/?tid=cmOftTEDxg5BGSeQAiZMHTgA2&fid=flinbox for full stories on these highlights.
7. Becker’s reports that a gut Clostridium strain named C. scindens produces resistance to C. difficile. See: http://www.nature.com/nature/journal/vaop/ncurrent/full/nature13828.html#affil-auth in Nature.
l. Becker’s Infection Control and Clinical Quality today gives websites where hospitals/clinicians may take on-line courses on EBOV patient care given by hospitals/clinicians who have successfully treated EBOV patients in the U.S. The Univ. of Nebraska Medical Center has a course on Moodle and iTunesU. See: http://www.beckershospitalreview.com/quality/unmc-nebraska-medicine-offer-free-online-ebola-courses.html for details on this UNMC course. The CDC has turned to Johns Hopkins to produce an on-line course on how to use, put on, and take off Ebola PPEs. See: http://www.beckershospitalreview.com/quality/johns-hopkins-to-coordinate-ebola-personal-protective-equipment-workshop.html for details. Angelica linen service has issued guidelines to its customers on how it will handle transport of EBOV patient linens. Basically, the patients street clothes and hospital linens will be treated as Category A Infectious Substances. Category A means everything must be sterilized and/or autoclaved before transport will be considered. See: http://www.beckershospitalreview.com/quality/3-guidelines-for-handling-hospital-linens-used-by-ebola-patients.html for details. Finally, medicine is fully in the game; we now have doctors teaching doctors and nurses and techs and service workers.
2. Dr. Flanigan’s blog reports that Dr. Tim is finishing up his two months in Liberia and will eventually return to Brown University. But first he flies to Rome to bring Caritas up-to-date on his experience and what Catholic hospitals and HCW could do better in Liberia. He plans to self-isolate and monitor himself in a location in or out of Rome before returning to the U.S.
3. WHO reports on its website today that EBOV survivors have post-EBOV symptoms/signs in 50% of cases. These sx and signs include: muscle aches, HA, fatigue, and visual symptoms. The visual symptoms are most worrisome because we do not know if there is corneal injury or optic nerve injury or other injury.
4. NY Times reports that Dr. Bruce Aylward of WHO says that EBOV may be slowing in Liberia because fewer cases are coming to treatment centers and more beds are unoccupied. But Liberia may be seeing these changes because more EBOV patients are avoiding treatment centers and hospitals due to fear or stigma attached to their families. We need to stay the course.
5. NEJM published on-line today an article by Schleffen, et. al. entitled: ‘Clinical Illness and Outcomes in Patients With Ebola in Sierra Leone’. This report is a summary of the clinical course of 106 patients treated at Kenema Hospital in Sierra Leone during 18 days in late May/June of 2014. Several of the authors are also authors of Gire, et. al. article in Science last August which showed the sequence of EBOV in Sierra Leone for the same patients during the same time period. Frequent sx and signs include: fever, HA, weakness, dizziness, and diarrhea. These sx and signs occur in >50% of cases. Patients >45 y,o. die at twice the rate of patients <21 y.o. Initiation of treatment after 6 days of sx and signs, chest pain, CNS sx and signs, diarrhea, older patients are all poor prognostic signs. See: http://www.nejm.org/doi/full/10.1056/NEJMoa1411680?query=featured_ebola for the complete NEJM report.
6. NPR reports that initiation of treatment during the first 6 days of EBOV symptoms is key in saving EBOV patients. Otherwise the viremia overwhelms the body and massive fluid losses and electrolyte imbalances cannot be corrected. West Africa needs IV fluids, labs for electrolyte management on site, anti-nausea and anti-diarrheal medicines. See: http://www.npr.org/blogs/goatsandsoda/2014/10/29/358350420/why-the-ebola-evacuees-survived-and-what-we-learned-from-them for this story.
7. Secretary of Defense Hagel has ordered a 21 day quarantine for all military personnel in West Africa before return to the U.S. Hagel said this was a ‘safety valve’; that these troopers were not volunteers; that trooper families wanted the quarantine for their spouses, sons, daughters, etc.; that most of the troopers were young men and women and not trained in infection control,
l. NY Times reports that the new CDC Guidelines for Ebola Monitoring at: http://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html#table-monitoring-movement differ from NY/NJ guidelines which differ from U.S. Army guidelines. So no wonder political parties and candidates are ‘stirring the pot’ with elections this coming Tuesday. While this debate in the media takes place, Dr. Jim Kim, President of the World Bank, reports that 5000 HCW are needed in Liberia, Sierra Leone, and Guinea, and they are not forthcoming. The African Union countries have promised 2000 workers, but none delivered to date. Caseloads and deaths continue to mount and supplies are low in these three West African countries.
2. Figure 2 of this week’s CDC Morbidity and Mortality Weekly Report (October 28) shows one reason the West Africa caseload is exponentially expanding: the highest concentration of cases are in Freetown, Sierra Leone, and Monrovia, Liberia. Both are large urban cities with crowded conditions. The concentration of cases fans out from these large cities along major roadways when you match concentration maps to Google terrain maps. See: http://www.cdc.gov/mmwr/pdf/wk/mm63e1028.pdf with Figure 2.
3. NEJM has published on-line an editorial by its editors stating their opinion that mandatory quarantines of EBOV HCW does not do any good. See: http://www.nejm.org/doi/full/10.1056/NEJMe1413139?query=featured_ebola for the editorial. Yet the editorial adds to the confusion about exactly when infected Ebola patients become contagious. Dr. Fauci has stated that RT-PCR tests may be positive up to 20 hours before symptoms. Dr. Drazen in his editiorial states that fevers in Ebola patients may develop 2-3 days before RT-PCR becomes positive. There is agreement that the larger the viral load, i.e., the more symptomatic the EBOV patient, the greater the risk for contact infection. I believe the U.S. Army has made the best decision re: isolation and monitoring: the Army does it for everyone involved in affected countries for 21 days. For civilians one half the isolation could be done in country in unaffected region, and the other half of the isolation (one week and pre and post weekends) in the U.S. That type of isolation shouldn’t dissuade committed volunteers to West Africa.
4. Ms. Vinson, the second nurse infected by contact with Mr. Duncan, was discharged from hospital today without any EBOV in her blood.
There is one bit of good news today: Dr. Karen DeSalvo, who has experience in federal government and epidemiology, has been transferred to Secretary Burwell’s office to help the Secretary manage EBOV in the U.S. So medicine/science is now a part of The White House mission to end EBOV in the U.S.
1. WHO reported this morning that keeping GSK vaccine frozen once deliveries have been made to West Africa will be a big problem because the vaccine must be stored at -80 degrees Celsius.
2. Dr. Tim Flanigan’s blog from Liberia shows a photograph of nurses in maternal medicine in full protective garb. See: http://www.timothypflaniganmd.com/2014/10/27/members-of-the-maternity-team-during-training-wearing-advanced-ppe/. Note there is still the possibility of skin contamination between the googles and the face mask which may move while talking to the patient. Disposable hoods should be worn so no facial skin is ever exposed. Facial skin is too close to the lips which are the entrance to the mouth for droplets.
3. Time Magazine reports that the troopers in Liberia for scouting out locales for treatment centers and were planning to return to the U.S. have been isolated and monitored in Vincenza, Italy, by Italian authorities. Major General Darryl Williams, their commander, is among the isolated. He has turned his duties over to the 101st Airborne. Now the shoe is on the other foot. I wonder what Ambassador to the U.N. Samantha Power plans to do after her West African visit.
4. Dr. Sabeti has produced a video on EBOV for the World Economic Forum. This video explains the complicated figures in the Gire, et. al. article in Science on the genome of the EBOV virus in Sierra Leone. The video also shows that West Africa has very capable scientists. Yet scientists are few in number in West Africa so the death of a single scientist is a tragedy to his/her family but also to West Africa. See the 26 minute video at: http://forumblog.org/people/pardis-sabeti
5. Becker’s Hospital Review contains a timeline for the travels of Dr. Spencer in NYC before he was hospitalized at Bellevue Hospital with EBOV. See: http://www.beckershospitalreview.com/quality/physician-tests-positive-for-ebola-in-new-york-city-5-things-to-know.html for details.
6. White House press officer says that CDC will have some guidelines for isolation/monitoring of HCW who have contact with EBOV patients shortly. Maybe a compromise with the governors can be reached so that this business is taken out of the political realm and returned to the medical community.
Today’s update is posted early because my laptop needs to go to the shop this evening for an overhaul. I hope for its return tomorrow afternoon.
Be safe wherever you are,
1. NY Times reports that Nurse Hickox who is quarantined in a tent adjacent to a New Jersey hospital has texted conditions of her quarantine: paper gowns, no heat, no TV, portable toilet, and no fever. ACLU may take her case against New Jersey.
2. NY Times reports that President Obama’s staff is in contact with Gov. Cuomo and Gov. Christy about their state quarantines. Dr. Fauci does not believe the quarantines are necessary; that HCW can self-monitor. Perhaps a compromise would be for HCW to spend the first 11 days of his/her quarantine in West Africa at an Ebola-free site and the last 11 days of their quarantine in their homes in the U.S. strictly isolated and monitored by state health officials. RT-PCR testing to be performed on Day #1 of quarantine, just prior to flight out of West Africa, upon arrival at home in U.S., and on Day #22 of quarantine. The HCW could be transported from airport to home by specially prepared ambulance. This is a complicated compromise, but now is election season, and the quarantines are all in states where governors are in tight races, especially Illinois and Florida.
3. USA Today reports that the military will have portable isolation units available for evacuating U.S. troops with suspected or confirmed EBOV from West Africa by C-17 or C-130. These air transports can carry 8 to 12 portable isolation units for patients and 4 isolation units for HCW.
4. Ebola workers in West Africa and scientists here and abroad have established a website called Ebola Deeply, which is dedicated to correcting misinformation on EBOV in West Africa, distributing digitally scientific information about EBOV, and establishing lines of communication between all of the NGOs and countries and WHO working in West Africa. See the website at: http://www.eboladeeply.org.
l. PLoS Currents Outbreaks published on-line yesterday an article by Volz and Pond entitled ‘Phylodynamic Analysis of the Ebola Virus in the 2014 Sierra Leone Epidemic’. See: http://currents.plos.org/outbreaks/article/phylodynamic-analysis-of-ebola-virus-in-the-2014-sierra-leone-epidemic/ for the article. I asked a colleague in Ebola research to explain the article to me. This researcher responded with the following explanation: “Erik Volz and Sergei Pond present new findings in PLoS Current Outbreaks based on published virus sequence data from 78 Ebola patients in Sierra Leone. They show evidence of adaptive evolution affecting the L and GP protein of the virus, and show evidence of superspreading and extreme variance in the number of transmissions per infected individual during the early epidemic in Sierra Leone. They also revisit R0 based on sequence data, but note it it sensitive to the unknown latent infectious period.”
2. Dr. Racaniello on his Virology Blog this week discusses whether the Reston virus could be used to generate a vaccine against Ebola Zaire; how Firestone in Liberia controlled an outbreak of EBOV within its rubber plantation; and how our skin covering protects us against EVOV. See: https://col128.mail.live.com/?tid=cm3Njp-lNb5BGMrQAiZMJJ9g2&fid=flinbox for detailed answers to these questions.
3. Medscape Radiology has produced a CME Activity for clinicians on how to prevent EBOV spread in hospitals and clinics. See: https://col128.mail.live.com/?tid=cmnuxckpVb5BGPY9idZ181Xg2&fid=flinbox for the CME Activity.
4. Reuters reports that Illinois, New Jersey, and New York have declared a mandatory 21 day quarantine for HCW and others returning to U.S. from Liberia, Guinea, and Sierra Leone if they have had contact with EBOV patients. The quarantine was disorganized for the first HCW.
5. The Lancet on 25 October contains an article entitled ‘Ebola control: effect of asymptomatic infection and acquired immunity’ by authors from University of Texas and University of Florida. The authors recommend a study in country which EBOV patients receive transfusions from asymptomatic seropositive individuals in country to see whether such individuals have protective immunity. See: DOI: 10.1016/50140-6736(14)61839-0 for this article.
6. THE WEEK October 31, 2014, contains as its ‘The last word’ an article about physicians of International Medical Corps fighting EBOV in Liberia. A break in protocol is noted in the article when a physician’s googles moved so that skin was exposed between the goggles and his facemask. This is the third instance of this type of skin exposure I have read about; one of the instances occurred in one of the two nurses from Dallas who contracted EBOV. The article is on pages 40-41 of the issue. IMC and MSF need to make a guideline change so that disposable hoods and PAPRs are substituted for the current guidelines.