World News

EBOLA Serial 2014


15th December 2014

Time to end the Ebola Serial?

The CDC graph of cases in Sierra Leone is still reaching for the sky, but Liberia and Guinea were levelling off at December 10.

TIME's choice for Person of the Year is the Ebola Fighters. The thesis is that these doctors and nurses courageously risked their lives in a fight to save the world. Kind of neat to see doctors and nurses revered as heroes. And the narrative works. The world really was threatened by ebola. And fighting the bleeding eyed monster was deadly scary.

Of course, the past tense and congratulatory tones may not be appropriate. The epidemic is not over. While ever there are patients outside treatment centres there is a risk of spread. This whole disaster started from one case.

Christmas time is leading everyone to hope it is coming under control. And it might be. Hopefully, soon, there will be 42 days, 2 incubations, without a new case.

Time will tell.

Dr Peter Roberts
ASEM NSW Councillor

28th November 2014

It is hard to decipher the graphs on the CDC web site to see if the growth in cases is reducing or not. They are cumulative, so it doesn’t make a lot of sense that the count went down at one point. But, just maybe, you can talk yourself into saying it looks like it might be levelling out. Certainly national borders seem to be holding. If each case infects less than one other on average, then the epidemic will end. But it can still infect lots more in the meantime.
Ebola related songs are spreading. It turns out a collection of African singers got together to perform a song aimed at educating the public about measures to prevent spread, as well as raising money. A truly international effort involving Kandia Kora from Guinea, Tiken Jah fakoly from Ivory Coast, and Amadou and Miraim from Mali and others. They had done this before Sir Bob and Bono made their announcement. Put “Africa Stop Ebola” into you tube to hear it.
It includes lines (translated from the mostly French) like;
“Africa is full of the sadness of seeing our families die
Let’s not touch our sick
Let’s not touch corpses…”.
And “I assure you the doctors are going to help you…”
And “You can’t greet people
You can’t kiss people
That doesn’t mean a person makes you feel ashamed
It’s, in truth, a reality.”

And teleconferences about ebola planning are reaching epidemic numbers. Community anxiety and concern is giving way to fatigue. The growth in newsworthiness has definitely settled

Dr Peter Roberts
ASEM NSW Councillor

17th November 2014

Now Mali has “a few cases” according to the CDC as of November 13. But no infected dogs or cats. Monkeys and bats yes; but so far so good for dogs and cats, all across West Africa.

Stokes, of MSF, quoted in Bloomberg Business Week, says, “In November we’re going to test three new drugs at our centres…The possibility of real treatment? That is giving us hope.”

And the same article says that when the Australian Government offered MSF $2.18 million in September, it told them to keep their money. Instead it issued a sharp rebuke for a “lethally inadequate response” and respectfully requested that the Abbott administration send trained personnel.

Sir Bob Geldoff, former Boomtown Rat, once sang in his Great Song of Indifference:

I don’t care if the Third World fries
It’s hotter there I’m not surprised
Baby I can watch hole nations die
And I don’t mind at all.

That was after he’d achieved greatness with organising musical aid for Africa.

Now he’s working with Bono and One Direction and others to re-work the indifferent song Let Them Know it’s Christmas, to raise money for Ebola.

It all depends on people respectfully paying rather than downloading the song illegally. If only he’d explain to Australians how to download something legally.

So fear monkeys and bats, ignore dogs and cats, and respect the rat. And share Stokes’ hopes.

Dr Peter Roberts
ASEM NSW Councillor

10th November 2014

Douze is French for twelve and une douzaine is a dozen. Mali has just one case of Ebola but the whole of affected West Africa is up to fifteen thousand. And next door Cote D’Ivoire is on zero. The incubation median is seven days but can be up to twenty one days. So if Mali has no new cases in forty (French; quarante) or so days, being two incubation periods, they will be considered free of it. Une quarantaine.

Put “ACEM ebola seminar” into You Tube to see the presentation from last week YouTube/ACEM. They talk about an early “dry” stage with fever, fatigue and headache; and a late “wet” stage. The bleeding is mostly an ooze from the gums and epistaxis. Infectivity relates to the amount of fluids being produced.

So how infective is it? Close household contacts got it 20% of the time. In Africa, close household contact means directly caring for the patients. “Any” household contact gets it 5% of the time.

So why did nurses in Spain and Texas catch it. It is still presumed to be poor training or supervision in taking the PPE off. Back then, the CDC wasn’t emphasising PPE with no bare skin. Still, there are many recorded cases, including at least one where there was no knowledge at the time that it was ebola, where there has been no secondary transmission.

The job for small hospitals might be to assess an unwell traveller and exclude ebola. Start the assessment by withdrawing to a safe distance and taking a history. Hands on, like blood testing at the request of ID physicians, requires two staff in a “buddy system” and a scout. So we are up to three staff to assess a patient. Ebola is excluded if they haven’t been to the right countries, or no fever for more than 24 hours, or negative bloods for ebola =/- repeat at 72 hours, or an alternative diagnosis is made. Malaria or sepsis is more likely even if they have been to West Africa.

And take heart; most health care workers who caught it in West Africa caught it at home. Caring for neighbours. Now they give them PPE to take home. The biggest risk now is in taking the mask and goggles off.

So, practice with other infectious diseases (TB, VRE, Gastro) using ebola standard PPE.

Dr Peter Roberts
ASEM NSW Councillor

4th November 2014

MSF, cited in Business Week, said it was as if recovered ebola patients have super powers. Immune from ebola, they can care for infected patients, including bathing and comforting children, without fear.

Australia is hoping Captain America will save us, rather than sending our own teams to limit the spread. (After all, he got over more illnesses than you’d know.)

If we don’t stop it where it is, the economic cost to the world is trillions, according to Warwick McKibbin. It seems that closing borders, giving up travelling and trading is bad for economies. And it might be harder to track patients if they have to lie about where they have been.

So we continue to get ready for it here. We sacked the chemotherapy gowns that leak and ordered the tyvek suits.

So far the Australian Government has refused to send volunteers, but the SMH says they are about to agree. Maybe then, the early indications that the rate of spread is slowing will hold true.

And the courts freed the US nurse volunteer from forced quarantine. The judge said that because she was not currently infective with ebola she could go home, to the disappointment of some.

These volunteers are the real super heroes who might save us.

Dr Peter Roberts
ASEM NSW Councillor

28th October 2014

This was the week of panic versus complacency.

In New York, a nurse was criticised on line after she complained that she was forced into quarantine despite no fever by accurate measure. Panic.

According to SMH, Mr Dutton criticised Labor’s foreign affairs spokeswoman as “hysterical” for her criticism of the government’s response to Ebola.

And the migration minister blocked the arrival of refugees from West Africa according to SMH.
For the migration minister’s form check out

At my hospital we did some signs. “Stop. If you have recently been to West Africa…” “Arretez! Si vous avez visite Afrique de L’Ouest …”

And we did inservices with gloves, gown, gum boots until we get the overshoes, balaclava until we get the hoods, mask, goggles face shield, and gloves again. A slurp of secret fluorescent paint and a UV light. Even with 8 of us supervising the doffing there was a glow on the hair, a spot on the cheek.

We need practice. We don’t have to be perfect until we do. But we want to be just on the panicky side of safe.

Dr Peter Roberts
ASEM NSW Councillor

20th October 2014
During the last week, hospitals across Austrazealand struggled to work out what to do, to prepare for Ebola. What personal protective equipment? Which protocols? Training?

The usual Victory PPE and Victory isolation room won’t cut it if we really get a case. But all this planning, purchasing and training is costly and wasted if we never do get a case.

The experience in Texas has been sobering; one patient presented after flying in from Liberia, two of his nurses are now patients, and the local public health unit is tracing lots of contacts.

It seems obviously terribly important to stop Ebola spreading here, and theoretically possible but actually difficult to do so.

The nation has checked 724 people at Australian airports, tested 11, and all were negative; according to The Australian. Presumably a case will present somewhere in NZ or Australia before this epidemic is over. So at my hospital, the infection control nurse, the ED nurse manager, an interested Hospitalist and I sat at the messy round table in my office to try to work out what to do.

To prevent or limit spread we will need doctors and nurses to agree to help out. And they won’t be lining up unless they are trained to the point of confidence.

We reckon training will involve:
• Use of a supernumerary staff member purely to supervise donning and doffing.
• Ebola standard PPE including gum boots, hood, mask, face shield, thick gown, and double, taped gloves.
• Someone who really knows what works safely to teach us.
• A workshop day with education, practice, and testing with fluorescent paint and UV light.

And that will be expensive. So it might be limited to a team of a few doctors and a dozen or so nurses. All to be able to assess a patient in isolation and transfer to an Ebola treatment centre. (Or not, if the patient turns out to have malaria or something.)

Communicable Disease Network of Australia (CDNA) guidelines were endorsed by CDNA and AHPPC (Australian Health Protection Principal Committee) on 3/10/14.

To be a “person under investigation” you need clinical evidence and limited epidemiological evidence. A temp of >38 C is needed for clinical evidence. (I guess if it is 37.9 or 38.0 you take it a few more times.) And you can “consider” headache, muscle pain, D and V, or bruising.

You put them in isolation, work out the epidemiological risk (level of exposure), clinical features, and contact public health before doing any lab testing. There is an appendix on their website with a tick box form for the assessment.

They need a single room with a private bathroom and an anteroom. Staff need a fluid repellent surgical mask, disposable fluid resistant gown, gloves, and goggles. But then it says, “complete protection from splashes may be achieved by covering all skin…face shields, overalls, disposable shoe coverings and leg coverings. Double gloving might also be considered.” Avoid aerosol generating procedures and add a P2/N95 respirator if you have to.

The NHMRC website has a description of the process for donning and doffing, NHMRC Guidelines. It looks tricky to get perfect without the use of double gloves and ties that can be torn apart at the back.

Routine cleaning is with sodium hypochlorite solution 1000 ppm, or 5000 ppm for spills. Terminal cleaning is the entire room with a neutral detergent, then sodium hypochlorite, and dispose of everything.

Dr Peter Roberts
ASEM NSW Councillor

13th October 2014
The country count is: 7 with confirmed cases. On October 10 there were 8033 cases recorded. And Sue Ellen Kovac, the Australian volunteer nurse who thankfully tested negative, points out that 40000 people have family members who have either died or become infected. The Cochrane RCT count is 3.
The CDC points out that the epidemic ends when 70% of patients are in medical care facilities or Ebola Treatment Units (ETUs) or somewhere else with effective isolation.
And the Brisbane Times reports that Cairns and Hinterland Hospital Nad Health Service Chief Julie Hartley-Jones has announced that 2 doctors have been stood down on full pending the results of a review.
What do the Cochrane RCTs say? In 21 people, a DNA vaccine with plasmids coding for 2 strains and nucleoprotein was safe and immunogenic. And another coding for envelope glycoproteins was safe and immunogenic. And ZMab plus interferon seems to work in non-human primates.
Well, what should rich countries like Australia do? Sending professionals to West Africa risks bringing the disease home. Not sending them risks further spread, epidemic…

Dr Peter Roberts
ASEM NSW Councillor

8th of October 2014
On 8/10/14 the Sydney Morning Herald published 3 articles on Ebola. The first, sub headed “medical staff trained”, is best read with a world war 2 news real voice. In the tone of saying our boys will be home by Christmas. “The federal health department says the risk of an outbreak in Australia remains very low, and our infection control mechanisms in our hospitals are first rate.”
Unfortunately, I’ve seen the audits which show that we have a spot of bother with hand washing.

Westmead Hospital is the designated hospital for the treatment of Ebola in NSW.
Vicky Sheppeard, director of NSW health communicable disease branch says “While Ebola is a very serious disease, it is not highly contagious. It is not like influenza. It is not caught through coughing or sneezing. It is only caught through contact with bodily fluids of an infected person or animal.”
Curiously then, the next paragraph mentions that 3400 people have died from it, mostly in Guinea, Sierra Leone and Liberia.
Mostly. There are four cases in USA. And another article, from Spain, is headlined “Nurse first to get Ebola out of Africa. The nurse had treated a priest repatriated to Madrid with Ebola.
The third article might actually get the attention of the West. It mentions money. It says “West African crisis hits cocoa prices,” and goes on “Experts say if an outbreak occurs, bean prices will surge beyond the 3.5 year high reached in September and affect retail chocolate prices.”
There seems to me to be a failure to acknowledge a problem here. The international SOS web-site accessed today says that in Liberia and Sierra Leone at September 30, 2014 there were 8000 reported cases. And the real number is likely 2.5 times that. And it is doubling every 3 weeks or so.
A million by February 2015.
Conversely there are 4 experimental treatments and two experimental vaccines. And if 70% of infected people are in appropriate settings by late December 2014, the epidemic in Sierra Leone and Liberia will be nearly over in February 2015.
So......It is possible for the world to bring this under control..... Or not?

Dr Peter Roberts
ASEM NSW Councillor

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