INFECTED MAN FROM MONROVIA
MISDIAGNOSED IN DALLAS E.R. DESPITE SHOWING
SIGNS OF EBOLA
THOMAS DUNCAN THE MAN WHO CARRIED
EBOLA FROM LIBERIA TO TEXAS.
PATIENT “X” IF EBOLA SPREADS IN AMERICA.
Authorities weigh the options of indicting him as a criminal
for falsifying his travel documents.
TAGS: EBOLA, EBOLA IN UNITED STATES,
THOMAS DUNCAN CARRIED EBOLA FROM MONROVIA TO DALLAS,
DOZENS OF OTHERS IN ISOLATION,
HOW MANY PEOPLE DID INFECTED DUNCAN INTERACT WITH?
SIMILARITY TO AIDS CRISIS, TRAVEL BAN CONSIDERED
(Friday October 3, 2014 NYU Medical Center, NYC) On Wednesday Dr. Jay Varma the Deputy Commissioner of the New York City Health Department told the New York Daily News that “The way to control Ebola is the same way we control measles or syphilis — we diagnose, isolate and treat them.” Dr. Varma continued that if there was an outbreak of Ebola within City limits, "We have an army of disease detectives whose job it is to stop disease from spreading.” That sounds reassuring but pathogens such as viruses like Ebola are among the most mysterious and deadly semi-life forms on Earth.
Aside from being transmitted via direct contact with the blood or other body fluids of an infected individual, studies have shown the virus can exist outside a human body on a surface such as an armrest, airplane seat, door handle or any other solid surface for up to two hours. Now that is something to consider.
EBOLAVIRUS IN THE UNITED STATES
This is literally the fodder of nightmares and horror films. A virus, a primitive microscopic cluster of proteins infects a local population in some of the deepest, darkest jungle environments in Africa and it is carried unknowingly by a single individual, Patient “X”, who has been positively identified as Thomas E. Duncan, into the United States. Patient X had direct contact with who knows how many people in airports and on the four flights that brought him from Monrovia, Liberia, via Brussels and Dulles Airport outside Washington, DC and ultimately to his final destination of Dallas, Texas.
There remains a fair amount of confusion regarding Patient X and his initial visit to the emergency department at Texas Health Presbyterian Hospitals in Dallas shortly after his arrival in Texas. For whatever reason (s) he was sent home from that emergency department visit with an antibiotic and some pain relievers. He returned within 30 hours to the emergency department this time presenting with florid symptoms of the deadly disease. As epidemiologists and other CDC investigators are engaged in the daunting task of locating those who may have had some degree of contact with Patient X during his lengthy, multi-leg travels home, many others at the CDC and NIH virology and infectious disease departments are working on the many and clinical, treatment, and societal aspects a wide scale Ebola outbreak would present. As they work on the problems, the challenges are daunting.
Those of us of a certain age can recall a similar medical mystery, an outbreak of a “new” disease that was as frightening as it was clinically confounding. Physicians in New York City and San Francisco initially began reporting increasing numbers of young homosexual men presenting with an odd malignancy - Kaposi’s Sarcoma – as well as an ill-defined syndrome that included deficiencies in their immune systems. The immune cells that were depleted were of a specific variety, T-cells, cells vital to the effectiveness of the entire immune system. Some of this growing patient population exhibited other uncommon symptoms particularly PCP pneumonia– a typically benign organism that lives in all of our lungs without event but in the men with compromised immune systems, this opportunistic disease was often proof positive of the presence of what would later be known as Acquired Immune Deficiency Disease or, commonly, AIDS.
At the time the AIDS crisis hit full force in NYC there was much misinformation and disinformation that it created confusion and fear among professions from Police and Fire Fighters, EMT’s, funeral parlor morticians, nurses and other health care workers as well as among a general public looking for some place to assign blame. The word AIDS was enough to strike fear in the hearts of many in the “vulnerable “populations who were assigned to care for them and handle their bodies once they died. It seemed that every new missive from a public health official only created a host of new fears. The protective standard observed by health care professionals and those who came into contact with such people like Cops, was “BBF” – the acronym for Blood and Body Fluid Precautions. This proved to be an inadequate protocol in the face of what felt like an ever expanding epidemic, and eventually it gave way to the practice of “Universal Precautions”: treat every person you came in contact with as if they were infected.
AIDS was now a household word especially for young sexually active people be they heterosexual or homosexual. Condom sales went through the roof and, as the population of those stricken and dying continued to escalate, there was backlash against specific groups based largely on the rampant disinformation. Certainly, homosexual men bore the brunt of the scorn, intravenous drug abusers who tended at that time to be predominately Black and Latino were ostracized and at one time a dubious theory blaming recently arrived Haitian immigrants were designated as the carriers of this yet to be identified pathogen.
There have literally been volumes written about how the HIV virus, a rare “retrovirus” was identified as the causative agent. To this day many eminent doctors and scientists do not believe HIV causes AIDS. There remains almost as much unknown at this point about the etiology of Ebola and where ever a gap of clear cause and affect exists, it is filled rapidly with bad pseudoscience, half-baked theories and conspiracies. Yes, more is known about Ebola at this time than was known about AIDS in a similar time line but that will do little to allay the concerns of the public. But through stringent efforts in the homosexual community to stop the transmissibility of AIDS by some of their promiscuous behavior, as well as doctors and researchers in America and France, the outbreak became contained. Or so it was thought until young children, hospital surgical patients who had received blood transfusions or other blood products began presenting with the sure signs of AIDS. AIDS had gotten into the blood supply and blood itself as well as several products derived from it such as lifesaving clotting factor to treat hemophiliacs opened the public and what had been up to that point, a Presidential administration that had not dared to so much as utter the word “AIDS” publically. Once the face of AIDS changed from gay sexually active men and minority IV drug addicts, to young children living with a deadly disease infected by AIDS via the sera used to treat them, the entire public was forced to recognize the folly of believing a pathogen of any kind would remain isolated to one or two marginalized segments of the population.
The reports that have been dispatched by the media from Liberia, Sierra Leone, and Guinea are enough to concern even the most skeptical among us. Oddly, it was only 16 days ago we wrote in this space about the health care surveillance system in New York City and other large America cities. The fact that this traveler from the “hot zone” was not truthful in providing answers to some of the questions asked along his way is not to be unexpected. Perhaps Patient X already had an inkling that he had been exposed to the lethal virus. His natural instinct would likely have been to get home to America as fast as possible. This begs the question, who can we monitor all the points of entry be they international airports or the notoriously porous southern border we share with Mexico?
As every detective knows, tracking down leads, trying to locate individuals, the movements, transactions and interactions of a wanted person and his or her known associates, or simply a “person of interest” in the parlance of the day, is a time consuming, man-hour chugging matter of shoe leather investigating. The Field Epidemiology Teams that are dispatched to places an outbreak has occurred are medical detectives. Typically, in the past, within the first weeks of signs of an outbreak of Ebola or one of its related illnesses, the World Health Organization (WHO) often working with our CDC and Doctors Without Borders (DWB) arrive on the scene as quickly as possible to do the all-important, elementary steps of isolating the town or village where Ebola has struck and quarantining those most obviously infected. In almost every case in the past it was relatively simple to cordon off the town and then begin to treat as best they could those suffering the wasting ravages of a disease that can have a mortality rate of 90%. That is a staggering statistic.
Once these initial steps are taken those most sickened by the virus die and those who were infected but managed to survive appear to have “immunity” to it. With no new unexposed potential victims to infect, that particular outbreak burns itself out. The Ebola virus is left to return to its natural host to await another chance to cause an outbreak.
EBOLA AND NATIONAL SECURITY
Viruses, as far as pathogens are concerned, are very different from bacteria, fungi, and parasites. They are small collections of amino acid produced proteins assembled not by cellular DNA material but rather by RNA, the pseudo-negative template of raw DNA. They cannot live by any definition of the word except in a host’s cell. They insinuate their way into cells, use that cells genetic machinery to replicate themselves until they are of sufficient quantity to fully crowd that cell to the breaking point when all those untold copies of that virus are released into the host blood stream. This method of subatomic machination makes viral borne illnesses among the most difficult for medical science to treat.
Viruses can be as difficult to identify due to the fact that they remain hidden as they replicate in the host cells. Each cell they infect becomes a virtual clandestine virus factory and will not be vacated until the virus, now exponentially multiplied, vacates the now useless host cell. But, as with other pathogens, there is a wide variety of viruses. They range in severity from the “common cold” causing rhinovirus, up through the spectrum of mortality to the hemorrhagic viruses including Lassa fever, Dengue fever and Ebola.
Viruses’ can also present a particular diagnostic challenge. While replicating in the host cells, the outer membrane of those infected cells serve as “good cover” for the virus factory just beyond that thin membrane. But, it is that membrane and its receptors and other immune system gadgetry that is more than adequate to protect the immune system from any suspicious intracellular activity. As in Ebola, this “latency” period, the time between acquiring the infection until the onset of the initial symptoms can be as long as three weeks. With a three week head start, once symptoms are obvious the disease process is already well established and replicating at an exponential rate. The virus has the upper hand in this scenario and typically always does.
Ebola as it is in nature is not a likely choice for bio-terrorism; it is too fragile outside its host and native environs and requires “blood to blood” contact for transmissibility. But it does represent the potential of what a similarly lethal pathogen could do to a wide population if deployed.
Already some experts in CDC and NIH are ringing the warning bells that this “strain” of Ebola, more robust than that which caused the most previous outbreak may have in fact already mutated simply as a result of its generational development. If this is the case, and if this new strain of Ebola has acquired new RNA components, it could become an epidemic of epic proportions if it reaches the United States. It has already killed almost 4,000 people in its native environs of Africa. If such a strain was introduced into the American population the majority of whom have absolutely no immune protection from other Africa-based illnesses, the mortality rate could be higher than anyone or any specific computer model has predicted.
DUNCAN IN DALLAS
IT’S A SMALL WORLD AFTER ALL.
PATIENT "X”, THOMAS DUNCAN TRAVELED FROM THE
HOT ZONE OF MONROVIA TO DALLAS TEXAS
WITHIN 33 HOURS
Yes, Ebola is here. Thomas Duncan was not the first Ebola stricken patient to arrive in the United States; there have been several doctors and health care providers who became infected while toiling in the hot zone who have been transported back to the United States for life saving treatment. Duncan is, however, the first private citizen to depart from a hot zone bound for America. This simple fact, and this fact alone, places him, at this time, in a category all his own. He came here of his own volition totting along a lethal virus; a virus with the potential to kill millions of Americans. Again, we do not know if he was aware that he was infected, serving as a new age “Typhoid Mary” but the fact remains he came here travelling through some of the busiest airports in the world. How are his contacts ever to be tracked? What about their contacts? The epidemiology becomes an exponentially increasing radius of people interacting with other people be they family, neighbors or friends and coworkers. This is the nightmare scenario. This is the reality of a virus from far away coming into an entirely different environment, a completely new ecological system populated by people with no natural immunity or previous exposure to Ebola.
Hopefully Mr. Duncan recovers and is able to provide some of the much needed answers to the many questions surrounding his exposure in Liberia, his travels from Monrovia, and the initial onset of his symptoms. Just having identified Mr. Duncan as the vector of the dissemination of this Ebola outbreak which is spreading at a never before seen rate through at least three West African countries, is of vital import.
We do not intend to be redundant but it seems some serious issues need to be addressed time after time. The very fact that Ebola is in the United States illustrates weaknesses in our national security. This past week has blackened the eyes of our national security in more than one way. We have learned of amazingly disturbing truths regarding the actual personal security of our President and his family. Moreover, the media, particularly the Washington Post has reported in detail the blatant errors of the Secret Service and how close to real deadly peril our President has been in. We have heard the news that Ebola is here and, given all the systemic failures of our federal government we have no reason to believe their reports and trust them after having been misled in matters as serious as preemptive war and now an ill-defined mission fought from the air against the Islamic State in Iraq, Syria and most likely Turkey.
A linked chain is only as strong as the weakest link. We have many adversaries; some more formidable than others, some more visible than others. Ebola demands as much attention from our national security apparatus as does ISIS, ISIL or the Islamic State. Those barbarians who decapitate innocents to incite a wider war with us possess a lethality as acute as Ebola but on a more limited scale. In any event, we are in a state of war; our homeland remains vulnerable to an array of threats straight out of Dante’s Inferno.
Vigilance, in every setting, in every sense of the word, in all aspects of affairs, foreign and domestic remains the watchword of the day. “See Something, Say Something.”
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