Thursday, October 30, 2014

An Inconvenient Truth

Another at-bat for Common Sense:
TRENTON — After days of blistering criticism from the ACLU, the CDC and even the United Nations secretary general over Gov. Chris Christie’s new, 21-day mandatory quarantine policy for all healthcare workers exposed to Ebola, the New Jersey governor has gotten a much-needed vote of support from a heavyweight name in the medical community: Nobel Prize-winning doctor and medical researcher, Dr. Bruce Beutler.

Dr. Beutler, an American medical doctor and researcher, won the Nobel Prize for Medicine and Physiology in 2011 for his work researching the cellular subsystem of the body’s overall immune system — the part of it that defends the body from infection by other organisms, like Ebola.

He is currently the Director of the Center for the Genetics of Host Defense at the University of Texas Southwestern Medical Center in Dallas — the first U.S. city to treat an Ebola patient and also the first to watch one die from the virus. In an exclusive interview with NJ Advance Media, Beutler reviewed Christie’s new policy of mandatory quarantine for all health care workers exposed to Ebola, and declared: “I favor it.”

Unfortunately, while the doctor’s support might provide much-needed credibility for Christie as he threatens to quarantine ever more healthcare workers returning from the Ebola fight in West Africa, it also comes with some chilling words.
“I favor it, because it’s not entirely clear that they can’t transmit the disease,” Beutler said, referring to asymptomatic healthcare workers like Kaci Hickox, a Doctors Without Borders nurse returning from treating Ebola patients in Sierra Leone who was quarantined in New Jersey for 65 hours before being transported to her home state of Maine on Monday afternoon.

“It may not be absolutely true that those without symptoms can’t transmit the disease, because we don’t have the numbers to back that up,” said Beutler, “It could be people develop significant viremia [where viruses enter the bloodstream and gain access to the rest of the body], and become able to transmit the disease before they have a fever, even. People may have said that without symptoms you can’t transmit Ebola. I’m not sure about that being 100 percent true. There’s a lot of variation with viruses.”
In fact, in a study published online in late September by the New England Journal of Medicine and backed by the World Health Organization, 3,343 confirmed and 667 probable cases of Ebola were analyzed, and nearly 13 percent of the time, those infected with Ebola exhibited no fever at all.
Why, then, does he think the CDC would so emphasize Ebola is not communicable in patients without symptoms?
“There’s some imperative to prevent panic among the public,” says Dr. Beutler, “But to be honest, people have not examined that with transmissibility in mind. I don’t completely trust people who’d say that as dogma.”

As such, allowing home confinement for medical workers exposed to Ebola but currently without symptoms was, as Beutler put it, “a move away from goodness,’ as an engineer might say.”

The U.S. Centers for Disease Control and Prevention changed direction and called for voluntary home quarantine for workers with the highest risk for Ebola infection. However, it also specified that most medical personnel returning from Sierra Leone, Liberia and Guinea would not need to be kept in isolation, as Hickox had been ever since she arrived at Newark International Airport on Friday up until her release and transfer to home quarantine in Maine early Monday afternoon.

“Even if someone is asymptomatic you cannot rely on people to report themselves if they get a fever,” said Dr. Beutler, adding, “You can’t just depend on the goodwill of people to confine the disease like that – even healthcare workers. They behave very irresponsibly.”

Christie has repeatedly pointed to the fact that NBC’s chief medical editor, Dr. Nancy Snyderman, after returning from Ebola besieged West Africa, was spotted violating her voluntary quarantine to get takeout from a Princeton eatery last week.

Despite her forced detainment by the New Jersey health department, Hickox insisted hat she was “feeling physically healthy” and except for a single, non-contact thermometer reading that registered her as having a 101 Fahrenheit fever, has had normal 98.6 F temperatures ever since her quarantine began.

“These are no arguments at all,” said Beutler. “Anyone could say that about any disease. It doesn’t matter that she was afebrile – she should be quarantined for 21 days.”

Hickox has complained that “her basic human rights were violated” and has since retained a civil rights attorney, but Beutner says he is puzzled by the argument.

“These people act like they are returning as conquering heroes — and they should be treated as conquering heroes, but part of being a conquering hero means making sure no one gets infected by you. Just look at the the foolish quarantine where astronauts came back from the moon [where there were no germs] and in this case, we know there is an infection.”

From a global perspective, it’s unlikely that the virus will take hold as an epidemic in the U.S., but in Africa, Beutler says it already “has gone ballistic – way, way beyond the past epidemics. One could project that maybe millions could be infected. It may be that it won’t spread like wildfire in the United States but even if one or two more people die, it will be too many.”

So, does Gov. Chris Christie have it right?

“I’d be a little bit more strict than he is being,” said Beutner, “I realize this would be inconvenient, but I don’t think it would prevent treating the disease.”

Christie has not been willing to publicly explain how home quarantine would work in cases like, for example, where a healthcare worker also had children at home.

“You’re in your home,” Christie deadpanned to the question when asked it was asked of him in Groton, Connecticut Monday night, “and you’re quarantined.”

“I know at times that you all would like to make things a heck of a lot more complicated than they are,” said Christie, “In home quarantine means: In-home. Quarantine. If they are asymptomatic, they can be quarantined in their home.”

Beutler disagrees with this, saying “the ideal scenario is where a patient is isolated from all family members,” preferably in an specialized hospital ward, not in a home.

The thought of an afebrile parent passing Ebola on to a child – as ostensibly can happen 13 percent of the time, “would disturb me. The point of quarantine of is to make sure they [Ebola viruses] are not carried elsewhere. It’s a little bit frustrating. Some of the things that are being done are not completely motivated by safety. For some reason, there’s an imperative to maintain open borders no matter what – to err on the side of total individual freedom rather than on the side of public health,” he said, adding, “If you really want to isolate a disease, then you have to isolate the people who carry it.”

SCIENCE, bitchez.


Emily Disraeli said...

Funny that .Gov does not want me to have my individual freedom of owning a firearm but will fight to the death in favor of my individual freedom to infect as many people as I desire.

The world seems to be running backwards and I can't get off....

A Texan said...

What I find astonishing is the number of people who think that in-home quarantines are just fine. Yeah, asswipes, the very first people that you will infect will be your own family.

Quite aside from the issue of then spreading the disease to others (friends, school kids, etc.), WTF is going through their minds? Not much, apparently.

42 days ACTUAL quarantine, in a sealed trailer, for ANYONE coming from West Africa - whether a doc who worked on Ebola patients or someone who never even saw, let alone came near, an Ebola patient. 70% lethality and a doubling of infected people every 3 weeks, folks - we can't take chances with this!

Think World War Z without the zombies. THAT is the level we will get to if nothing storng is done SOON to stop the spread outside of West Africa.

Aesop said...

They're going to dick around with this until they get a good solid cluster of 10-20 patients, then the reaction will be like a 5-year-old poking a sleeping grizzly pear with a pointy stick when the bear arouses.

Just as tragic, just as bloody, and nearly as short.

Anonymous said...

Texan -

I can't even convince my own friends (who are intelligent and SHOULD know better) that this has a chance of becoming a cluster or clusters here, which would cause a hell of a breakdown, let alone, God forbid, when it reaches India or China.

I've posted link after link, study after study, commented on "droplet vs. aerosol" with links to that (NY Post finally said something today but because it's the Post nobody's gong to pay attention yet -, I've posted about ACTUAL science until my fingers were blue.

My friends are well educated, some in the sciences, some nurses. If I can't convince them with PLOS and Lancet links, then I have determined what is going through their minds is something like, "Nope nope nope nope nope." It must be. I have no other explanation for the (I hate to say it) willful stupidity I'm seeing in people around me. That or they're "too cool" to get Ebola. I have about 5 friends actually listening, understanding, and reading the links, out of 75. Some others have stopped talking to me completely and think I'm bonkers as I sound the alarm bell because everything I'm saying goes against what their politicians tell them, or something. (You know this country is out of order when politics gets involved in a discussion about virii - I mean seriously people, priorities).

I sometimes wish Ebola HAD a symptom that made people, a least temporarily, look like zombies so people would take this as seriously as it should be damn well taken. People are afraid of zombies, which are scientifically impossible, but they're not concerned, for some reason, about a virus that ends in a gruesome and extremely painful death 70-90% of the time.

Go figure. So the thought of even an in-home quarantine is IMPOSSIBLE for these people, let alone the kind tt SHOULD done to contain this.

This time I'll put my name down. :) Thanks for the rant room Aesop, and you are 100% right on about the bear.


Anonymous said...

The chance of this disease in its current form taking hold in SE Asia and China is very small. If its one thing those nations know how to do its enforce the needs of the group over individual rights - the necessary cultural framework for effective quarantine measures.

The only people in the States currently at a small but measurable risk are front line health workers.

The hyperbole of this website does make for interesting reading, though!

Yojimbo said...


I have a friend who works at a top level hospital in Boston. He said that "the head of emergency preparedness at this hospital said you'd have a far greater chance of getting hit by lightning than ever getting Ebola. Pandemic likelihood virtually zero. Said they would stake their reputation on it."

It is actually this hubris and belief in their ability to control nature and chaos that I find deeply troubling.

I hope they are correct, but I think they are not.


Anonymous said...

Anonymous @9:51 -

For what that's worth, of course.

Aesop said...

@Anonymous 9:51
Yeah, and the risk of nuclear power plant accidents are similarly extremely small.

Live by statistics, die by statistics.

Even the Powerball Lotto pays off eventually.

Here's your penance:

Anonymous said...

The trouble is most Americans believe the 'exceptional' propaganda meme thats indoctrinated into them from birth.
Seems the ebola virus is unimpressed.
Hubris can and will kill.

Rob Crawford said...

Um, 'Anonymous', you've misunderstood what "exceptional" means in that context. No one ever believed the US is immune to diseases. Well, no one with a brain.

What "exceptional" means is that the US is founded on a set of values rather than a common ancestry.

Anonymous said...

The claim that the WHO study in the NEJM says that nearly 13% of Ebola patients had "no fever at all" is false. It makes no such claim. It is either an amateurish interpretation of the study, or a deliberate attempt to deceive.

The study simply reports that fever is reported in 87.1% of the initial screenings of people that wind up diagnosed with Ebola. That is not the same thing as saying 13% did not have a fever.

From the report a fever is defined as a temperature of 101.5F and above. More importantly as noted in the study, because many of the health care workers in the field do not actually have a medical thermometer, the notation of a fever comes from asking the patient if they think they have a fever.

Using the study to make any claims about the percentage of patients that do or do not have a fever is ludicrous.

Anonymous said...

I think he was saying we are taught from an early age that bad things happen to everyone "except" you. We watch the news and think none of that stuff could ever happen to me personally.

Aesop said...

@Anonymous 1:05
Unfortunately, all that brilliant analysis is undone by other NEJM studies also published, which document that absence of fever, with no disqualification of the vital signs recorded, such as this one:
and this one:

both of which note that temperatures were measured, not subjectively guesstimated.

Additionally, since fever is one of the clinical rule-ins used in the field, it's conceivable and highly likely that an additional number of actual Ebola cases were incorrectly ruled out there initially, precisely because upon initial presentation the patients lacked a fever. Which has the dual effects of increasing mortality, and spreading the disease at the same time.
(For laymen, that would be described medically as "bad".)

And, unfortunately, undermines everything you just said.

There's a lot going on with this. We have to keep up.

Anonymous said...

Anonymous @1:05

You have read this study then:

For case definitions the fever is in actuality 38 C which equals to a 100.4 F temperature (see pp. 1489).

"The study defined fever as 38 degrees Celsius — 100.4 degrees Fahrenheit.

"To create the fullest possible picture of the unfolding epidemic," the authors said, they collected additional information from "informal case reports" and other sources.

The researchers described imperfections in some of the data. In a footnote, they wrote that "in practice, healthcare workers at the district level often do not have a medical thermometer and simply ask whether the person's body temperature is more elevated than usual."

Yet the lead author, Dr. Christl Donnelly, a professor of statistical epidemiology at Imperial College London, stood by the findings on the prevalence of fever.

Asked by email whether the study found no fever in 12.9% of confirmed and probable cases, Donnelly replied: "Yes."

I believe that the lead author meant exactly what he said, though if his answer is amateurish, then by all means have at him.

Aesop said...

I'ma go with the odds being that Dr. Beutler didn't win a Nobel Prize in medicine by being amateurish in his precise field of expertise.

They save those awards for the Peace Prize candidates.

Anonymous said...

No brilliant analysis involved, and there is no claim made regarding fever at initial screening. I'll just repeat the point of the post, which is the last sentence. Referring to the 09/23 study.


Do you understand that as far as conclusion you might draw from looking at this study that the actual percentage of patients presenting without fever could just as easily be 20%. From my personal experience (which I'll admit doesn't count for that much) my sense of whether I have a fever doesn't correlate very well at all with my actual temperature.

My post makes no claims about what percentage of patients initially showing fever. So I'll repeat the point of the post again. Referring to the 09/23 study


Infinitely more valid as a basis for making claims regarding initial fever is the 10/29 NEJM paper.

And BTW, the second hand reporting of a response to an email, in which zero context is provided carries only a slight amount of weight as far as I'm concerned. If that discussion is online somewhere I would certainly be very interested in reading it.

An - 1:05

Anonymous said...

**The only people in the States currently at a small but measurable risk are front line health workers.


October 30, 2014 at 9:51 AM**

If you had ever worked with certain patient populations your flip attitude would be adjusted quickly. Having experience with the habits and behavior of certain populations does not create a mindset of hyperbole, it creates a mindset of reality. Perhaps those of you who wish to offer our lives on the altar of your PC delusions could sacrifice yourselves first and show us all how its done.

We'll keep a supply of body bags on hand.

Maggie RN

Anonymous said...

Regarding fever. It is not an accurate test of Ebola patients.
101 is a fever?? NOT for me.
I have a 96° normal temperature.
In fact, I had a cold, had pre-cancer surgery scheduled, and it made my cold worse, I sneezed and coughed and tore open stitches, I hemorraged, and was taken to the hospital again.
All because they found me with a 100° temperature and proceeded with surgery, when I really had a 3° fever; surely because my illness had weakened my immume system no doubt.
My point is not everyone has the same reading when feverish.
I totally believe in 21 day quarantine for anyone returning from these ebola-ravished countries, medical profession or not.

Anonymous said...

Anyone who thinks we can afford to lose a few of our front line medical staff, should go to their local emergency room and LOOK THE FUCK AROUND. See all those shiftless layabouts working on their tans?

No, I didn't think so.

Our healthcare system is already strained by normal every day demands. Holidays, weekends, or sometimes just a bad day will absolutely FILL our ERs and available beds.

The only time you WON'T see it, is at TPH in Dallas, after treating an Ebola patient. That cleared the ER, a 50 bed wing, and sidelined 77 staff. It EMPTIED the hospital as anyone who could go elsewhere or delay treatment did.

One case in each major city in the US will destroy healthcare (ER and serious) as we know it. Think about losing the only level 1 trauma center in town. Think about how many people will die as an IN-direct victim of ebola, simply because all the resources got eaten up before they could get the care they need.

Aesop has written about it here before. RTWT.


Anonymous said...

Nick, your first statement of "It EMPTIED the hospital as anyone who could go elsewhere or delay treatment did" implies, correctly in my opinion, that if a similar hospital is a level 1 trauma center, what it will lose will be the elective and subacute patients. The guy whose aneurysm is rupturing or who's bleeding out from an MVA will still go to such a center DESPITE Ebola patients there, because for him it's still better to roll the dice on dying later than dying now. When you truly can't delay treatment, Ebola is of lesser importance.
Bill K.

Aesop said...

Actually Bill, the first thing THP-Dallas did was start diverting ambulances away.
So the truly critical patients likely won't even be taken there.
Hereabouts, it would go out on the county-wide hospital Alert Network, and the hospital would be closed for "internal disaster".

Shortly after that, THP-D completely closed their ER, due in no small part to
a) contamination, and risk of cross-contamination (a happy conjunction of Risk Management and Infection Control staff agreeing)
b) staff exposures, walk-outs, and threats to do so.

Monday morning quarterbacking I've seen pretty much agrees that's how it's going to go anywhere else, too.

We have three trauma hospitals in this county, 1@ large, medium, and small, loss of any one of which would cripple the entire county. There's no slack at all.

Anonymous said...

Hi Bill,

You are right about the electives, and it was reported at the time. In Maine, it was reported that people were canceling appointments for all kinds of things.

Sometimes, even a lifesaving surgery can be delayed (heart valve replacement, for example) by the patient.

I'm sure there will be lots of folks who need surgery, who will just say, "not now" and that decision will end up costing lives.

I'll grant that they are making a choice. But anyone except the most oblivious will recognize the increased risks, and unfortunately, it looks like senior and highly skilled staff end up dedicated to the ebola ward, and are then not available for other procedures - for 40 days. That is another risk factor to consider.

So if I knew that there was a potentially fatal infection present, and I'd be cared for by the "B" team (who may still be VERY good) I'd be looking elsewhere. I think I'm not alone.

The economic impact on the affected hospitals will be enormous too, which will have long term repercussions no matter what happens with ebola.


BTW, even after TPH reopened their ER the were reporting wait times of 0. That is unheard of and means there was NO ONE there.... I haven't heard if it has returned to normal, eventually it probably will.