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Nurse defies Ebola quarantine in U.S.; rides bike

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By ROBERT F. BUKATY

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Selfish, self-serving, and reckless.

8 ( +18 / -9 )

Yea, she does not seem to have the masses in her concerns. What if she carries the virus?

0 ( +7 / -7 )

This is what gets me with these selfish people. They need to haul her butt up, lock her until there is 100% proof that she is NOT carrying ANY signs of the virus anymore.

-7 ( +5 / -12 )

She has no symptoms. She is following CDC procedures and ensuring she is symptom free each day. Ebola cannot be spread unless symptoms are present. I think conflating it all with personal freedoms and constitutional rights is a bit silly personally but she is correct in objecting to measures that are not grounded in science and simply grounded in fear.

She is being a responsible and informed human being.

7 ( +15 / -9 )

From what I've read in the American news, she's not too popular there these days. If she wants to run free, let her, but if she does happen to show symptoms...well too bad for her. Lock her in a warehouse and let her die a painful death knowing how many people she probably infected by her selfish reckless behavior.

-13 ( +3 / -16 )

Would it really hurt her to just self-quarantine for a few days? Really?

Now, what if she DOES become symptomatic, like the doctor in NY? Then what?

8 ( +13 / -5 )

From what I've read in the American news, she's not too popular there these days. If she wants to run free, let her, but if she does happen to show symptoms...well too bad for her. Lock her in a warehouse and let her die a painful death knowing how many people she probably infected by her selfish reckless behavior.

I get it, but a bit harsh, yeah, she's taking a risk, but at the same time, putting the rest of the public at risk that's what gets me, the woman just insists on her rights and feels like everyone is trampling on her civil liberties, which in essence they are, but come on now, look what we're dealing with. Her selfishness is potentially and possibly putting us in danger at least until we know she is 100% Ebola FREE.

-1 ( +4 / -5 )

We continue to hear this: "People can’t be infected just by being near someone who’s sick."

That should be "near someone who's sick and passive."

Actually, you can be infected if the person vomits suddenly, or sneezes in your direction, or somehow splashes droplets of their bodily fluids around, like rubbing their eyes and then shaking hands with you, etc.

Just saying.

7 ( +8 / -1 )

WolfpackOCT. 31, 2014 - 08:15AM JST Selfish, self-serving, and reckless. And Bass: Did you two miss that she is working for Doctors Without Boarders? That is NOT selfish or shelf serving, plus she is following all CDC procedures. I guess you believe you know more about Ebola than the CDC.

-1 ( +5 / -6 )

Step away from the bike and put the ebola down! last warning!

1 ( +2 / -1 )

Hickox contends there’s no need for quarantine because she’s showing no symptoms. She’s also tested negative for the deadly disease, though it can take days for the virus to reach detectable levels.

Hickox had a temperature reading of over 100 deg F (normal is considered 98.6 F). That, plus the fact that she was recently exposed to the ebola virus, triggered the need to quarantine. Blood test results can take several days (or a week?). Hickox appears to be very selfish and willing to expose others to a potentially deadly virus.

-1 ( +4 / -5 )

On one hand, if she is infected with the viruis she should stay at home.

On the other hand, this is the United States of America, and it is her right as a citizen who has not commited a crime, to have free agency and allowed to travel freely.

The state of Maine is really screwing with the citizens rights in ways they should not be allowed to, using ebola as a excuse. Imagine if suddenly they believed the common cold could spread in a dangerous fashion; Anybody with the illness would be treated like a criminal, forced into isolation after the state detains them with a no knock warrant. I am frankly appalled nobody else is talking about the dangerous precedents the USA has been setting this past year, going up and far beyond the powers they were granted.

This is absurd to the highest degree.

1 ( +4 / -3 )

New England Journal of Medicine published an editorial this week against mandatory Ebola quarantines. It's hard to say who's right here.

3 ( +5 / -2 )

"New England Journal of Medicine published an editorial this week against mandatory Ebola quarantines. It's hard to say who's right here."

I know, on the one hand, we have the CDC and the NEJOM, and on the other we have, wait on it, internet commenters. A tough call, for sure.

5 ( +7 / -2 )

Really selfish. The quarantine is not punishment or a rights issue, it is a matter of social responsibility. One should think a nurse would understand that.

-1 ( +4 / -5 )

Setting a precedent? As long as she is happy with the idea of thousands of copy-cats from now on.

0 ( +3 / -3 )

If it makes any difference, the Maine governor who is overseeing the quarantine is a Republican embroiled in a tight election race. Why do I have a nagging feeling that the whole ebola furor is going to quiet down after the elections next Tuesday? Chris Christie could camp out at the airport to personally oversee the arrest of returning medical workers if it helps his party pick up a few wins in the midterms.

3 ( +6 / -3 )

I know, on the one hand, we have the CDC and the NEJOM, and on the other we have, wait on it, internet commenters. A tough call, for sure.

It isn't quite that simple though. The NEJOM, to the layman like me at least, seems to have adopted a condractictory position. In the editorial claiming we shouldn't quarrantine because there are no symptoms. But in a different study claiming that people can carry the disease without a fever (http://www.latimes.com/nation/la-na-1012-ebola-fever-20141012-story.html#page=1).

0 ( +2 / -2 )

New England Journal of Medicine published an editorial this week against mandatory Ebola quarantines. It's hard to say who's right here.

@Nessie Yes, it is extremely difficult to choose who is right. Is it the medical professionals and scientists who studied these things and deal with them on a daily basis, or is it the politicians supported by the terrified masses, who maybe took a college level health course and got a C plus?

How long do we have to decide?

people aren’t contagious unless they’re sick

5 ( +6 / -1 )

I am not sure I follow the thinking of my government sometimes. We have entered the flu season. They urge all people to get a flu shot, and to stay home if you feel sick. We have a good idea of how the flu is transmitted and we have a somewhat good handle on how to combat it. Yet, we don't know much about Ebola, and scientist have seen how it has been changing. So why not stay home for 21 days to make sure that you are not carrying the virus?

If she was in the area, and saw how the fight against the disease was to put people in quarantine, then why not follow those procedures when you come back home?

For the record, the government do have the right to compel you to do certain things, such as 1) conscription (i.e. draft), where every male at age of 18 has to register for selective service in order to receive federal financal aid for school; 2) quarantine for illness, and 3) jury duty. Try to avoid the summons to appear in court for jury duty and you will be in contempt of court and could wind up in jail. So for her to say that her rights are being trampled are way off.

1 ( +4 / -3 )

It's really simple for me. You're a medical professional working as a volunteer in a Ebola hot zone, then come home to a country knowing that your country is worrying after several clear protocol blunders with doctors and nurses that may have potentially spread the virus to hundreds of others and yet proceed to flaunt "your rights" because you aren't symptomatic?

You are completely unprofessional and should not be trusted to work in public health ever again.

2 ( +9 / -7 )

Let me use an simple analogy to make this situation easier to understand.

You are working in a company and it is very important to keep the computer systems safe. For that you go and spend a few days in a cyber-security course dealing with really dangerous threats and how to deal with them. Unfortunately when you come back to work, someone that apparently knows nothing about computers convinced everybody that the only secure thing to do is to use exclusively internet explorer for everything because its the safest thing in the world.

If you know that this measure is wrong, unnecessary and even dangerous, your real responsibility (the best for your company) is to do anything possible to stop the nonsense as soon as possible.

Nurse Hickox knows much more about Ebola than the people making this exaggerated policies, knows also that letting them continue will hurt the number of people that will volunteer to work against Ebola in Africa (because nobody wants to be subjected to superstitions that can easily be proven wrong). She has proved that she can do sacrifices in order to do the right thing (such as volunteering to go to Africa to contain the Ebola outbrake) so again she chose to be wrongly perceived as irresponsible and selfish in order to bring attention to a foolish measure that only respond to irrational fears disregarding what the experts recommend.

She could just easily lay low and let the ignorant keep pushing people around in order to have an easy life, but she knows that doing that would be negative in the effort against Ebola and in the long term would increase very importantly the risk of having uncontrollable outbreaks in America so she raised her voice and is doing a great service to protect her country.

4 ( +8 / -4 )

Not feeling safe right now

-2 ( +1 / -3 )

Selfish... unless she has been given the all-clear after the incubation period is well and truly over she should not be allowed out in public.

0 ( +3 / -3 )

I can understand this nurse not wanting to be confined as she is not showing symptoms and Ebola is said to be contagious only when symptoms are present. But most of what I've read about Ebola say early symptoms include SUDDEN onset of fever, weakness, muscle pain, headaches and a sore throat. So what might happen if she experiences such a sudden onset while out and about and interacting with people? I have had a sudden onset fever and it truly was sudden, one minute I was working and feeling fine, the next I was in a daze with my head on the desk. It just seems prudent for her to stay at home at the least, although if her bike rides involve no contact with people (or at least normally when she's not being followed by a pack of media people), I suppose that could be allowed.

1 ( +3 / -2 )

Honestly, let the woman live her life, she is not threatening, this woman wants to have the freedom promised in America,and it is being restricted by fear. If she is not worried why should we be? She is after all the one who spent time in Africa, she has probobally seen many cases,she knows the symptoms, she would know if she had them. If you try to convince her that she has it and that she should be in quarantine, her anxiety about the situation, could cause symptoms( not at all related to Ebola). 4 cases does not mean the apocalypse is coming. Just pray for the people in Africa, for their safety and health. Why are we so absorbed in our own health,that we ignore the health of others?

1 ( +5 / -4 )

A simple blood test would tell if she had ANY virus and would end the whole problem. Why she won't do that I can't understand. In the meantime I don't know if it's funny or sad to watch people panic over what is, essentially, nothing. Ignorance. Pretty soon they'll be burning witches again....

0 ( +1 / -1 )

I argued about this with my wife, who's Japanese. Her opinion was basically this: "She and others like her should be quarantined until they're clearly not a danger to society at large. Furthermore, the government should compensate them in some way financially for their contribution and to encourage them and others to volunteer to go to W. Africa." My own opinion: "She and others like her should not be quarantined. If health professionals who are basically volunteering like this are discouraged from going, then, without their help, the problem in West Africa will become worse. Thus, the spread of the Ebola virus is likely to increase as a result of such a quarantine, and I don't think any government financial compensation would make a great difference in how these health professionals would view a mandatory quarantine. They want to get on with their lives."

It's a tough question which boils down to most effective yet least dangerous manner of how we (collectively) respond in combatting and preventing the spread of this dreadful disease.

2 ( +2 / -0 )

So, because she volunteered she should be left alone... even though she hasn't been given the all-clear and she's riding about on a bike? Sorry, but that quarantine period is there for a reason... not just to annoy her.

I still think she's being rather selfish... no idea what would happen here in the UK... we aren't as stroppy about being told what to do as Americans are, lol Pretty sure a nurse wouldn't be permitted to break out of quarantine and go cycling about.

-1 ( +3 / -4 )

“I’m not willing to stand here and let my civil rights be violated when it’s not science-based,” she said Wednesday evening.

She's, uhh, got a pretty darned good point here. If there is no scientific basis for the quarantine, then why enforce it? Just to make the public "feel" better? That's simply stupid and only serves to perpetuate misinformation about how the disease is actually transmitted and spread.

Also, it bears noting that Ms. Hickox volunteered for Doctors Without Borders in an ebola hotspot. That's about as far from selfish as a human being can get. On the contrary, the folks who are bleating about her so-called selfishness for not allowing them to indulge and wallow in a clear ignorance about the pathology of ebola, an ignorance born from placing a bit too much emotional investment into AMC's the Walking Dead, are the ones being patently selfish here.

5 ( +8 / -3 )

So why is she testing herself daily? And what happens if she does start showing symptoms while she is out in public? She says "oops" then heads home?

-5 ( +1 / -6 )

As she was in contact with terminally ill Ebola patients, she could still get sick with Ebola. If she gets sick and is tested positive for Ebola, it will necessary to trace all her contacts within some time window. This is a difficult, expensive, and error prone task, but contact tracing is the key to Ebola control. That is why it is necessary to minimize contacts to a few special people.

As for precedent, the live-in relatives of Duncan were all put in quarantine. She should follow precedent rather than claim exception because she is a doctor.

She lives in a beautiful sparsely populated area where she can go bicycling and not meet anybody, whereas a returnee living in a cramped apartment in NY city does not have that option. She is trying to develop a principle based on her special case which does not hold in general. The catalyst for the quarantine order was a NY city doctor who did get sick, but had gone out to get pizza shortly before. She cannot undo that doctors actions. She cannot stop others from having poor judgement.

She certainly did a service by volunteering as an Ebola doctor, but now is claiming that experience as basis for exceptional entitlement. That is snobbery and elitism.

She is damaging the image of Ebola volunteers and discouraging people from volunteering because they won't want to be associated with her actions. She should be fighting Ebola, not some petty battle of her own.

Ask not what your country can do for you, ask what you can do for your country.

-5 ( +1 / -6 )

Yes, all Americans should live in fear like your masters tell you to do. Honestly, she's got bigger balls than the rest of the public and probably more brains too.

2 ( +3 / -1 )

And what happens if she does start showing symptoms while she is out in public? She says "oops" then heads home?

Yeah. She goes home. Because the science tells us she IS NOT infections when she starts "showing symptoms."

4 ( +5 / -1 )

She is selfish stupid idiot cow. She should know better about Ebola disease is how seriously threatening to human.

-5 ( +1 / -6 )

I cannot believe a health care worker would ignore a medical quarantine, especially when the incubation period has not passed. Is SHE STUPID??

-3 ( +2 / -5 )

@Owain T. Yamanaka

Showing consideration to others is better than than living with a chip on your shoulder. Neither big balls nor big brains guarantee emotional intelligence - they are independent qualities.

-2 ( +1 / -3 )

http://www.cdc.gov/sars/quarantine/exec-2004-04-03.html

The Federal Law is very clear on this and states she can be arrested and detained.

April 4, 2003 By the authority vested in me as President by the Constitution and the laws of the United States of America, including section 361(b) of the Public Health Service Act (42 U.S.C. 264(b)), it is hereby ordered as follows: Section 1. Based upon the recommendation of the Secretary of Health and Human Services (the "Secretary"), in consultation with the Surgeon General, and for the purpose of specifying certain communicable diseases for regulations providing for the apprehension, detention, or conditional release of individuals to prevent the introduction, transmission, or spread of suspected communicable diseases, the following communicable diseases are hereby specified pursuant to section 361(b) of the Public Health Service Act: (a) Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named).

NOTICE Executive Order 13295 was amended on July 31, 2014. Subsection (b) was replaced with the following: "(b) Severe acute respiratory syndromes, which are diseases that are associated with fever and signs and symptoms of pneumonia or other respiratory illness, are capable of being transmitted from person to person, and that either are causing, or have the potential to cause, a pandemic, or, upon infection, are highly likely to cause mortality or serious morbidity if not properly controlled. This subsection does not apply to influenza."

-3 ( +2 / -5 )

@JTDanMan ... Because the science tells us she IS NOT infections when she starts "showing symptoms."

New England Journal of Medicine, Clinical Illness and Outcomes in Patients with Ebola in Sierra Leone : Supplementary Appendix, http://www.nejm.org/doi/suppl/10.1056/NEJMoa1411680/suppl_file/nejmoa1411680_appendix.pdf

Table S5 shows only 25 out of 36 fatal cases show fever - it seems a remarkable number, they have also listed 89% as the number who did show fever so there is an error there somewhere as 25/36 is 0.69 not 0.89

Figure S8 shows body temperature vs. days for 6 patients, 3 fatal and 3 non-fatal.

Look at fatal case C. On day 1, temperature is measured above normal once (38 C), and then returns to normal all through day 6. On day 7 the temperature rises above normal again (38 C), it is the last day of measurements.

In 2 of the 3 non fatal cases, the temp never goes out of the normal range.

-2 ( +0 / -2 )

But most of what I've read about Ebola say early symptoms include SUDDEN onset of fever, weakness, muscle pain, headaches and a sore throat. So what might happen if she experiences such a sudden onset while out and about and interacting with people?

Still no problem because of two reasons, the first is that the onset of symptoms will not make her instantly infective and the second is that normal everyday interaction will not spread the disease even after she becomes contagious, that require people to be in contact with her body fluids.

A simple blood test would tell if she had ANY virus and would end the whole problem. Why she won't do that I can't understand.

Blood test can't show the disease until a certain level of viruses (or antibodies) are present in blood, when that happens the person already feel sick so it can't be used to see if an apparently healthy person is positive or not, first she would feel sick and later she would become positive

As she was in contact with terminally ill Ebola patients, she could still get sick with Ebola. If she gets sick and is tested positive for Ebola, it will necessary to trace all her contacts within some time window. This is a difficult, expensive, and error prone task, but contact tracing is the key to Ebola control. That is why it is necessary to minimize contacts to a few special people.

It is not necessary to track everyone she met, only those in some risk of coming in contact with large quantities of her body fluids after she got sick, generally speaking close family. Those riding with her on the train 2 days before the first symptom? the only reason to track them is to keep the public feeling something is being done, medically there is no meaning in doing it. People can even live for days with a symptomatic patient without getting infected (before the bleeding, vomiting, etc. begins).

As for precedent, the live-in relatives of Duncan were all put in quarantine. She should follow precedent rather than claim exception because she is a doctor... She is trying to develop a principle based on her special case which does not hold in general.

Oh no, she is trying to demonstrate that the precedent is baseless and dangerous to the effort against the disease, precisely because her case is NOT special (is shared with dozens of volunteers) it has value to demonstrate that the precedent is simply wrong and should be discarded as soon as possible.

I cannot believe a health care worker would ignore a medical quarantine, especially when the incubation period has not passed. Is SHE STUPID??

Well, the problem is that it is not a medical quarantine (evidently since all medical authorities have declared against it), its a political/propagandist quarantine. I find very interesting how the general public immediately jumps to a very unlikely conclusion (that a person of proved capacity and moral value suddenly became a stupid jerk) instead of considering even for a moment that she may be right and the quarantine wrong, fear and rational thinking are polar opposites.

The Federal Law is very clear on this and states she can be arrested and detained.

Thats the thing, the government have to prove that she is in danger to be infective in order to arrest her, but all medical professionals tell this is not truth, so they have to go back and let her go out. By breaking the quarantine she proved that it is baseless and forced the government to implicitly accept its doing things against medical authorities professional advise.

New England Journal of Medicine, Clinical Illness and Outcomes in Patients with Ebola in Sierra Leone : Supplementary Appendix, http://www.nejm.org/doi/suppl/10.1056/NEJMoa1411680/supplfile/nejmoa1411680appendix.pdf

The quoted paper is totally irrelevant to this situation because fever is not the only symptom. Putting aside the criticism of the conclusions that are already discussed in the news about the article (problems in the methods to detect changes in temperature), she would have many different and clear symptoms apart from fever. Generally speaking she would feel very sick first, and then become contagious.

Fever is used to detect patients because you don't have to ask any questions, just take it, so even if somebody is trying to escape a quarantine with bad intentions he can be detected as already sick and put in quarantine. In this case she is a health professional and its in her best interest to seek help if she becomes sick. Even if there were no fever at all, if she suddenly feel tired, weak, with muscle pain etc. she would immediately recognize she got something and that it might be Ebola, she would then have still plenty of time to go into a real medical quarantine without putting anyone at risk.

4 ( +6 / -2 )

She's, uhh, got a pretty darned good point here. If there is no scientific basis for the quarantine, then why enforce it? Just to make the public "feel" better? That's simply stupid and only serves to perpetuate misinformation about how the disease is actually transmitted and spread.

This is just mind-numbing lunacy! Dr. Spencer lied when he said, he didn't have any symptoms went all over the place, came into contact with people, went bowling. He was asked, have you been out, and he replied that he was quarantining himself. His Metrocard was comphiscated and it was discovered that Spencer did indeed travel around NYC. The same goes with Dr. Nancy Snyderman, lied and got a maid fired because she lied about her Ebola quarantine and now Hickox is just throwing up her middle finger?? Why NOT enforce the quarantine since there is NO scientific base to fully know. Wouldn't it be safer to error on the side of caution, rather than take a chance? It's NOT Guantanamo and she wouldn't be there forever, just 21 days. She can get all the best DVD and TV shows and best Italian take out or Chinese, whichever, relax use Facebook and other social media outlets to communicate and wait patiently. Pham did it and she's fine. But these people are extremely selfish and DO NOT care about anyone but their right to do whatever they want. If it's the common cold, fine, go out and wear a mask, try not to cough on people. But Ebola is NOT the common cold! Again, with the government and DWB and the CDC not taking a very hard and serious look at the seriousness and the deadliness of this disease and constantly changing protocols, you will never get this thing under control!

Also, it bears noting that Ms. Hickox volunteered for Doctors Without Borders in an ebola hotspot. That's about as far from selfish as a human being can get.

And out of 28 of those doctors 18 contracted Ebola. A Noble and selfish effort, I agree, but once you've been diagnosed, you should be taken to a quarantine facility until further notice (21 days) mandatory because the safety of the public takes the highest priority over the selfishness of a few inconsiderate individuals.

-5 ( +1 / -6 )

This is just mind-numbing lunacy! ...... Why NOT enforce the quarantine since there is NO scientific base to fully know. Wouldn't it be safer to error on the side of caution, rather than take a chance?... these people are extremely selfish and DO NOT care about anyone but their right to do whatever they want...the safety of the public takes the highest priority over the selfishness of a few inconsiderate individuals.

But if it were a gun, not a virus, it would be her gawd-gibbun right to do whatever she pleased?

Interesting that it seems all the people who defend unrestricted access to guns as a 'right' are quick to strip this nurse of her 'rights'.

Having said that, I agree; if there's any chance at all of her spreading infection, she should stay quarantined until she's given the all-clear, even if she finds it restricting.

-3 ( +3 / -6 )

But these people are extremely selfish and DO NOT care about anyone but their right to do whatever they want.

Exactly the opposite, If she were selfish she could just lay low until 3 weeks pass and will not get harassed by people who simply don't know anything about infectious diseases like she does, but since she is not and knows that this quarantine will INCREASE the risk of Ebola outbreaks in America she does what she can to stop the nonsense. Of course people dominated by irrational fear will never understand that, no matter that every public health professional is saying so.

Having said that, I agree; if there's any chance at all of her spreading infection, she should stay quarantined until she's given the all-clear, even if she finds it restricting.

Working with Ebola patients is a way more restricting than a simple quarantine (wearing the full protection equipment properly and following strict protocols of conduct for hours every day for long weeks) but she choose to do it voluntarily, that is NOT the problem. The problem is that there is no REAL chance of her spreading nothing, all involved professional are saying that the quarantine is both irrational and useless. And even more, that it will be an extra obstacle to bring the urgently necessary volunteers to Africa to stop the outbreak before it goes global.

But no, people still prefer to believe the opposite based on comments of people who have never seen a patient nor have published really detailed studies about how Ebola its transmitted, in that case why not quarantine the 100% of the population? There is always a chance you are already infected (by walking on the street where somebody else that was not symptomatic but infected was also walking) so if you can't eliminate "any chance" (even if it is microscopic) why are not we all under quarantine?

People misunderstand when scientist can't say that there is zero risk (impossible to probe) thinking that anything above zero is a lot. In reality she have almost exactly the same probability of transmitting the disease while asymptomatic as anybody else.

4 ( +6 / -2 )

Having said that, I agree; if there's any chance at all of her spreading infection, she should stay quarantined until she's given the all-clear, even if she finds it restricting.

Exactly!

chikv

That was just satirical nonsense.

-3 ( +1 / -4 )

@Nessie Yes, it is extremely difficult to choose who is right. Is it the medical professionals and scientists who studied these things and deal with them on a daily basis, or is it the politicians supported by the terrified masses, who maybe took a college level health course and got a C plus?

A bit of sarcasm to brighten my day? NEJM is a journal for health-care professionals, so they will have a slant towards less restrictions for such professionals. They'll also give them the benefit of the doubt when it comes to self-reporting symptoms. But it doesn't take a medical degree to know that people are likely to downplay their symptoms or avoid reporting them. People lie to themselves all the time about their health, even when it's against their best interests. The NEJM editorial avoided this fact by pointing to the one person who did the right thing and did report his fever. A sample size of 1, otherwise known as highly anecdotal. So I don't think it's the no-brainer you make it out to be.

Here's the editorial.

http://www.nejm.org/doi/full/10.1056/NEJMe1413139

0 ( +2 / -2 )

Here is the link for a detailed Ebola report given by NEJM, The link I gave before was missing the underscores:

New England Journal of Medicine, Clinical Illness and Outcomes in Patients with Ebola in Sierra Leone : Supplementary Appendix, http://www.nejm.org/doi/suppl/10.1056/NEJMoa1411680/suppl_file/nejmoa1411680_appendix.pdf

This report shows that consistently high body temperature is not a 100% reliable warning preceding severe Ebola.

In particular see Figure S8, case C. A patient has an abnormal fever on only two days, day 1 and day 7. The abnormal fever is not even terribly high, only 38 C. The rest of the days 2 through 6 the fever is in normal range. The patient died of Ebola, there are no measurements after day 7.

Table S5 shows that in a significant fraction of fatal Ebola cases no abnormal fever was measured, and in non fatal cases most cases did not display a fever.

By NEJM's own data therefore, fatal Ebola is not always reliably preceded by a fever, and non-fatal Ebola is usually not.

NEJM's editoral assertion that quarantine for doctors is unnecessary presumes that doctors with ideal behavior and judgement will react in time as they measure fever three times daily. But the NEJM editor ignores the data in the NEJM report referenced above, data which shows unreliability of fever as an indicator. If NEJM can show denial, then surely a young rookie doctor can show denial in self diagnosis also - adding yet more delay.

Quarantine is not an obstacle in addressing the Ebola problem. The problem is that the west relies entirely on volunteer doctors working through NGOs like MSF, and the west has not taken any action to bring medicine to bear to the problem. It is laissez faire strategy. The doctor quarantine issue would not be there if the US government had organized a voluntary paid brigade of doctors, allowing them to work under MSF or some other NGO at the other end. Furthermore, if the US govt had offered multi-decamillion dollar rewards for medicines to mitigate Ebola, we would already have seen some action in the field.

China is or will be proving soon that it is possible:

"China has also dispatched hundreds of aid workers to Africa to combat Ebola including health experts and medical staff."

"Sihuan Pharmaceutical Holdings Group Ltd., a Chinese drug maker with military ties, has sent several thousand doses of an experimental Ebola drug to Africa and is planning clinical trials there."

http://ewn.co.za/2014/10/31/China-to-send-army-unit-to-fight-Ebola-in-Liberia

-1 ( +1 / -2 )

But it doesn't take a medical degree to know that people are likely to downplay their symptoms or avoid reporting them. People lie to themselves all the time about their health, even when it's against their best interests.

The problem is that the people subjected to this irrational quarantine are exactly the kind of people who will not make the mistake of downplay their symptoms, its like saying that since people drown in pools all the time Olympic swimmers must also drown in pools frequently. All professional health workers know by hearth the importance of detecting the disease to improve importantly the survival rates, they know how to detect those symptoms easily and have a strong sense of duty to act against the spreading of the outbreak, by treating patients they have seen the irresponsible behavior of people that feel they will never get sick and keep spreading the virus. It is contrary to reason to think that they will act like like it is nothing.

The NEJM editorial avoided this fact by pointing to the one person who did the right thing and did report his fever. A sample size of 1, otherwise known as highly anecdotal. So I don't think it's the no-brainer you make it out to be.

Anecdotes are the lowest level of evidence, but still are better than sample sizes of 0. How many health workers became symptomatic in EUA and went hiding his symptoms?

This report shows that consistently high body temperature is not a 100% reliable warning preceding severe Ebola.

Again, as in my last response, the report has been seriously criticized because of faulty equipment and techniques underestimate the body temperature in the field, those reasons would be absent in EUA. And even if the feverless Ebola were corroborated, there are a plethora of other symptoms that the report make no effort in denying. So any person, even without any medical training, can still know they are getting sick even without fever.

You keep repeating the same report as if fever was the only early sign and the results were certified and irrefutable neither of those two things are true.

Quarantine is not an obstacle in addressing the Ebola problem. The problem is that the west relies entirely on volunteer doctors working through NGOs like MSF, and the west has not taken any action to bring medicine to bear to the problem.

There is no need of choosing, both are obstacles that have to be solved. Of course one solution (to bring organized and professional health workers to fight the disease) requires quite a lot of money, the other solution is free, or even will save money by removing an illogical and baseless measure that helps no one. I can totally see why the first is difficult to put in order, for the second one the people responsible just have to listen to professionals instead of their own fears and that would be it.

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http://dailycaller.com/2014/10/27/released-ebola-nurse-kaci-hickox-works-for-cdc-her-lawyer-is-a-white-house-visitor/

Here’s an overlooked factor that could have contributed to her White House-backed release: Hickox is an official CDC Epidemic Intelligence Service (EIS) officer who performed work for the CDC in recent months.

Hickox was a Class of 2012 member of CDC’s two-year EIS officer training program, according to the official program for CDC’s 2014 EIS Conference (p. 98), which was held from April 28 to May 1, 2014. Hickox was featured in a photograph in the program

Hickox was listed as an “EIS officer” for the CDC in program materials for a CDC course she taught in July 2014. She was specifically listed as an active “EIS officer” as recently as July 18, 2014, according to CDC documents.

Hickox was a presenter at the CDC conference this spring, according to the program’s list of presenters (p. 103).

Hickox taught an April 29 session called “Contact Investigation of Health Care Personnel Exposed to Maternal and Neonatal Tuberculosis—Clark County, Nevada, 2013″ at the conference (p. 3).

If this the the same weaponized ebola strain that the CDC has a patent (and vaccine) to then this lady is probably correct in that there is nothing for her to worry about, -but for everyone else?

-2 ( +1 / -3 )

Now, what if she DOES become symptomatic, like the doctor in NY? Then what?

Well she would just go to the bus stop and ride the crowded bus over to the nearest hospital so she can be properly quarantined and treated for a highly infectious disease with a 70% mortality rate. No big deal.

0 ( +3 / -3 )

The science shows Ebola can’t be spread through casual contact, particularly if a patient shows no symptoms. The science of it is not difficult to understand, if you are scientifically literate. The Chicken Littles here and elsewhere are ignorant the science and ignorant of their ignorance.

Some say, "You can be sick and not show symptoms." Yeah, and that don't make you infectious. Just like you can carry malaria for years and not be vector. Ignorance.

Others say, "bla bla bla bla maybe, bla bla bla bla perhaps, bla bla bla bla bal, could be. And you can't say I'm wrong. Its possible." Yeah, that is not how science works. And certainly not public health. Ignorance.

Most say, "Close the border!!!!" Now that is just stupid. If someone wants to fly from A to B and can't, they will fly from A to C and then B.

Some screech, "70% mortality rate!!! Yeah, if untreated." Ignorance. Hysterical ignorance.

People have every right to think what they want. But that don't make them right. Just right wing.

Ignorant, scientifically illiterate, and hysterical. Hysterical is the word.

Conservatives are hysterical.

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The science shows Ebola can’t be spread through casual contact,

-that's not what the CDC is saying in regards to the eBola virus.

http://www.cdc.gov/vhf/ebola/transmission/index.html

When an infection does occur in humans, the virus can be spread in several ways to others. Ebola is spread through direct contact (through broken skin or mucous membranes in, for example, the eyes, nose, or mouth) with:

a1. blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with Ebola

a2. objects (like needles and syringes) that have been contaminated with the virus

a3. infected fruit bats or primates (apes and monkeys)

0 ( +2 / -2 )

A brave person who is refusing to let herself become a victim of politically driven fearmongering. She is standing up not only or her own rights, but for the rights of all who would volunteer to help out in this crisis.

She should get a medal.

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Please try and control your fear. She lives in a sparsely populated part of the country. If it was not for the reporters there is no one near her. She is a very very small risk. How about all of those people in the apartment with the poor guy who died from Ebola? He was active rick to spread (very sick from it) and they did not get it. So lets try and control your fears.

2 ( +3 / -1 )

Land of Chaos is at it Again,,LO

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cleo - But if it were a gun, not a virus, it would be her gawd-gibbun right to do whatever she pleased?

Interesting that it seems all the people who defend unrestricted access to guns as a 'right' are quick to strip this nurse of her 'rights'.

Is this an attempt to strawman, or even derail the discussion of ebola quarantines or quarantines in general?

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@chikv ...

The fact that data I reference is published in the New England Journal of Medicine is an indication that it should be taken seriously. There is no note in the article about the temperature data possibly being unreliable. You say "it is not certified", but it was published in the same journal which you referenced as a reliable source of scientific knowledge.

Here is another case study: "The Lion Heart Foundation has asked for repatriation after a potential contamination of the employees in Yele with Ebola virus during treatment of an infectious patient. The patient, who initially showed no symptoms of Ebola, turned out to be contaminated. Our heart goes out to all employees in the Lion Heart Medical Centre." (http://www.smarter-hospital.nl/index.php/en/home)

This information comes from a group dedicated to eliminating Ebola at the source in Africa. (Elsewhere it was reported that in the Lion Heart case five African nurses unexpectedly contracted and died from Ebola in this incident.)

Scientifically speaking, it is fair to say that "most of the time" transmission will not occur when the patient does not have a fever. "Most of time" is not the same as "all of the time". The scientific evidence for "all of the time" is lacking, and there is scientific evidence to the contrary. "Scientific method" means relying on physical measurements. Science allows for hypothesis to be overturned when warranted by physical data.

I have no political motivation other than to see a public consensus focused on directing resources towards eliminating Ebola in the affected regions as soon as possible. Quarantine which is both scientifically based and practical is required to eliminate Ebola panic and keep public consensus focused on eliminating Ebola worldwide.

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The fact that data I reference is published in the New England Journal of Medicine is an indication that it should be taken seriously.

Of course it should be taken seriously, that is completely different than just believed without confirmation, especially when many other articles say exactly the opposite and there is an explanation available why this data is not as reliable as this article assume it is.

There is no note in the article about the temperature data possibly being unreliable. You say "it is not certified", but it was published in the same journal which you referenced as a reliable source of scientific knowledge.

That is the criticism, It has been described in previous studies (not only on Ebola) about the danger of assuming that temperature measurement in the field is always exact without appropriate controls, nevertheless this study does exactly that and don't even mention this problem. When other researchers put in effect controls to make the measurement reliable then the Ebola without fever disappear. For some reason the reviewers of the NEJM let this obvious problem with the manuscript remain but post-publication peer review has not.

Scientific knowledge is not decided on a single article, its the sum of the evidence collected by several studies precisely because nobody is perfect. If every study but one shows something and the one in discrepancy have already identified methodology problems it is safe to assume that the others studies better designed are correct.

I know that scientific results interpretation can be hard fro people that is not a professional, but when all the people that dedicate their lives to study a disease have exactly the opposite conclusions after reading the same studies as you it may be best to assume that they know what they are doing and you may be underestimating (or overestimating as in this case) the evidence.

AND for the third time, EVEN without fever an Ebola patient would have many other symptoms before it can be considered contagious, the NEJM article would have importance about ways of detecting disease against the will of the person who is sick (using objective signs) but in this case the health professionals have every reason to go to a hospital and be quarantined the moment they feel something wrong. Fever or no fever the other symptoms would make anybody feel very sick, so fever alone have no importance. You need to find first and article proving Ebola contagious patients in the absence of ANY SYMPTOM to try to justify the quarantine.

Here is another case study: "The Lion Heart Foundation has asked for repatriation after a potential contamination of the employees in Yele with Ebola virus during treatment of an infectious patient. The patient, who initially showed no symptoms of Ebola, turned out to be contaminated. Our heart goes out to all employees in the Lion Heart Medical Centre." (http://www.smarter-hospital.nl/index.php/en/home)

??? What do you want to say with this? "Initially" is not the same as "ever", its pretty obvious that people will get infected with Ebola and first show no symptoms, after the incubation time they will begin to show several and a few days later they will become contagious themselves. That does not support at all the irrational quarantine before symptoms that is being put in place. So again, your "another case" proves that quarantine can be done after the onset of symptoms without any risk.

Scientifically speaking, it is fair to say that "most of the time" transmission will not occur when the patient does not have a fever. "Most of time" is not the same as "all of the time".

The problem is that scientifically it is impossible to say "always" or "never". In the same way it is said that "most of the time" transmission will not occur from healthy people that had no apparent contact with any Ebola patient nor had leaved the country. If you want to quarantine people on a small chance that have never been described in the literature just because it may be true then it is equally justified to quarantine every single person living in America (and not only for 21 days because it would be also only fair to say that this period would be considered safe "most of the time")

The scientific evidence for "all of the time" is lacking,

And will be lacking forever in all findings of biological sciences, find me a peer reviewed paper in a pubmed listed journal that describes their results using words like "always" or "never" and then you can begin to use the "all of the time" argument.

and there is scientific evidence to the contrary. "Scientific method" means relying on physical measurements. Science allows for hypothesis to be overturned when warranted by physical data.

You have a very wrong idea about scientific method, in your definition every result done on pain (or emotions, depression, etc) would be non-scientific because it deals with things that can not be measured physically. And yes enough evidence can overturn previous conclusions, but a single article, retrospective, with less number of patients as other studies, and more importantly without controlling for a known problem on the measurement without a valid reason definitely is not enough evidence. More so when you think for 5 minutes and realize that lack of fever and asymptomatic are two very different things.

Quarantine which is both scientifically based and practical is required to eliminate Ebola panic and keep public consensus focused on eliminating Ebola worldwide.

It is not scientifically based, even when your personal opinion is different I still think is safer to listen to what the scientist think is valid or not (do you think that you are doing a better job at reading the literature than every scientist in the CDC or WHO that have dedicated their lives to control infectious diseases?) And also, if you want to consider theoretical cases not yet described anywhere (an asymptomatic patient that can spread the disease) just because it has not been proven as impossible then it is not practical at all because that approach would immediately include every single person in the country (because you can't prove that healthy people can transmit the disease the same day they contacted other healthy people that have it)

As the scientific consensus says people have to be very symptomatic before they become contagious, a single article where patients were not detected with fever (not the same as without fever if you can notice) does not change it, even if it were demonstrated as true.

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Of course it should be taken seriously, that is completely different than just believed without confirmation, especially when many other articles say exactly the opposite and there is an explanation available why this data is not as reliable as this article assume it is

Please show me where I can find the other reports you mention.

The following kind of data (at least) taken 3 times daily would be helpful in calculating risk : TEMP., EBOV TEST, VIRAL LOAD, starting when all three are normal (not sick) values (once EBOV TEST is positive, it does not need to be taken again). If such tables of data for a random 100 patients, along with notes about the patients, abnormal pre conditions, age, etc., were available, that data would speak for itself. Conversely, if that data is not available, we are not yet at the point to be able to say that quarantine for directly exposed people is not necessary.

I think it is very difficult to get that data. To be taking blood samples, even once a day, from an Ebola-sick person, while giving them no effective medicine in return, is ethically problematic. In addition, the health worker-patient contact necessary for such sample taking is risky for the medical personnel. Also, I expect measuring VIRAL LOAD is expensive in terms of resources.

If/because the necessary data is not available, quarantine is necessary.

Now I will explain why I am doubtful about "expert" opinion which is not willing or able to provide data to back it up.

Medical Organizations: Medical organizations are comprised mostly of doctors, who as a group are biased towards doctors interests. It is in doctors (short term) interests not to be quarantined, drug tested, or subject to constraints on how much additional costs they can add to an operation while the patient is on the table, etc. Doctors rights to act act in their own interests should not be denied, they should just be balanced with interests of others, which means the word of medical organizations should not be treated as holy words, but as human words, subject to human nature.

Ebola field workers: Ebola field workers are working in a crisis situation. They need a simple working standard to carry on their work. The standard has to be practical - the criterion is to save lives, so if more lives are saved because of this criterion then are lost, it is acceptable. However, that same standard is not suitable outside of the Ebola affected area. We - and the Ebola workers- cannot afford to have a chance infection.

Finally, how much burden/cost is in a 3-week quarantine? Firstly, we must think about work and salary. Being doctors, most of them will work with sick people. The idea of doctors who have been exposed to Ebola working with sick people who may have already weakened immune systems open a whole new can of worms. Let's not open that can - I will just presume for now that no Ebola exposed doctor would work with sick patients. So the returnees cannot work in a hospital or doctors office for three weeks anyway.

However, they can do desk work, file reports, write proposals and apply for grants for Ebola related projects, etc. All of this can be done easily from quarantine.

The 20's age need to party in public: The urge is perfectly understandable. Especially after the stress of working in Africa with Ebola patients. However, it must be avoided. It is not a matter loss of liberty and freedom - it is merely delayed gratification. Only 3 weeks. Ideally, those Ebola workers like Dr Hickox with big country houses, would offer a place to stay to the likes of Dr Spencer, who was stuck in a NYC apartment.

So it seems to me that a 3 week quarantine need not be a burden at all. Of course if the definition of quarantine includes public partying it is going to create a big flap and media attention which cause a lot of social problems which will turn other returnees quarantines into a kind of media hell. (And in the worst case, it affects the outcome of US midterms). So that should be avoided.

End

(PS, A single persons subjective self evaluation of symptoms is unreliable and error prone - the same would be true of a single psychological analysis. In both cases the errors are reduced over large number of patients allowing for statistical studies. But we are now talking about the non-negligible probability that a single case will be in error.)

-1 ( +0 / -1 )

Please show me where I can find the other reports you mention.

http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_247-270.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2536233/ http://jid.oxfordjournals.org/content/179/Supplement_1.toc http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532309/

And so on for dozens and dozens of articles, problably best to deal with reviews that are faster to read and evaluate and have the appropriate references, like in http://www.cdc.gov/vhf/ebola/transmission/human-transmission.html

The following kind of data (at least) taken 3 times daily would be helpful in calculating risk : TEMP., EBOV TEST, VIRAL LOAD, starting when all three are normal (not sick) values (once EBOV TEST is positive, it does not need to be taken again). If such tables of data for a random 100 patients, along with notes about the patients, abnormal pre conditions, age, etc., were available, that data would speak for itself. Conversely, if that data is not available, we are not yet at the point to be able to say that quarantine for directly exposed people is not necessary.

I am terribly sorry but your methodologies are very 18th century science, extremely crude and primitive and not in the very least necessary. Helpful? maybe, but completely valid conclusions can be taken with much less data in a much more realistic protocol using appropriate number of samples and statistical methods. Maybe for a high school level scientific method class this would be acceptable, but for serious research feels like finger counting instead of using calculators. And again, using the same argument "we are not yet at the point to be able to say that quarantine for apparently NOT exposed people is not necessary" (or else, show me the article where your protocol was used and 100 random apparently not exposed people did not developed Ebola)

I think it is very difficult to get that data. To be taking blood samples, even once a day, from an Ebola-sick person, while giving them no effective medicine in return, is ethically problematic. In addition, the health worker-patient contact necessary for such sample taking is risky for the medical personnel. Also, I expect measuring VIRAL LOAD is expensive in terms of resources.

Wrong in all assumptions, taking blood samples hardly increases the risk of taking care of a Ebola patient, when taking care of a protocol of 1000 details, one or two extra are not really significative. Also there is absolutely no need to deny effective treatment, as long as you are controlling viral load the expected variability on response to treatment would not bias the results. There are much more risky activities for health workers (beginning with taking out their PPE) and measuring viral load is much more easily done with a quantitative real time PCR with each sample consuming 50 microliters or less of solution, having 300 tubes instead of 50 in a reaction will not increase the cost so much. So it seems that most of your erroneous ideas about Ebola comes from simple (and expected) ignorance about scientific methods, you should then familiarize deeply with them before making conclusions or defer them to the people whose job is precisely know about it such as all the people in the WHO, CDC, Pasteur institute, etc. etc.

If/because the necessary data is not available, quarantine is necessary.

Wrong, we have no data available about transmission rates on apparently unexposed people. Does that mean that we need to quarantine everyone? again, think about it. (by the way, yes we have the data, quarantine is not necessary before symptoms appear, even with symptoms different from fever).

Now I will explain why I am doubtful about "expert" opinion which is not willing or able to provide data to back it up...

Again, the problem is deep ignorance about epidemiology, public health and so on. (and separately about ignorance on published evidence, very different from lack of evidence) The problem begins with defining CDC, WHO and so on as "medical organizations" when they are instead "public health organizations" where a lot of different professionals work, from doctors to nurses, scientist, social workers, administrators, communicators and so on. Then you use the argument of "they may be wrong because they are humans" but fail to provide proof of any wrong doing in this case (it is possible? yes, but if you want to change policies first you have to prove they are wrong, not just that they "may" be wrong). It is also extremely short sighted to think that policies are developed the same for all enviroments and situations, for many of those professionals the only point of their careers is to adjust known medical knowledge to specific and detailed situations so it would be still useful. Nobody is taking believable, realistic risks in America, (at least with Ebola) if you want to consider any exposed people the same as infectious then you have to consider also any apparently non-exposed people (meaning everyone) as contagious also, that is also another risk and you said it can't be tolerated. You have to choose, or you put a realistic risk (ignore theoretical risk not observed in decades of studies) or you consider everything a risk, you cannot have both.

It is not a matter loss of liberty and freedom - it is merely delayed gratification.

Again, it is a matter of obstaculizing the only available resource we have to avoid a pandemic, you put an irrational quarantine to avoid a theoretical risk and but by doing that you increase a very real and important other risk. Its like promote smoking because you think there is a possibility of bacteria sensitive to nicotine so you would be preventing pneumonia.

(PS, A single persons subjective self evaluation of symptoms is unreliable and error prone - the same would be true of a single psychological analysis. In both cases the errors are reduced over large number of patients allowing for statistical studies. But we are now talking about the non-negligible probability that a single case will be in error.)

If you are not going to believe the medical judgment of trained and motivated health workers with extensive practice about an infectious disease and direct input on their own symptoms you should not believe in anyones else, then automatically every single person in the world is suspected to be in contact with a symptomatic Ebola patient, and so it should be quarantined, because of course the possibility of any one of them having real contact exists and you want to consider this probability non-negligible.

Cut off values exist for a reason, you can choose practical, safe and reliable cut off values based on science or impossibly low cut off values based on theoretically sound but undescribed possibilities, what you cannot have is both, specially when using the impossible ones hurts the fight against the disease.

TLDR version.

You want to quarantine asymptomatic people? First you have find at least one case when an asymptomatic patient transmitted the disease. There has been none described until now, so no need to increase the chance of getting Ebola in America from all over the world by this theoretical case.

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Clinical Manifestations and Case Management of Ebola Haemorrhagic Fever Caused by a Newly Identified Virus Strain, Bundibugyo, Uganda, 2007-2008

Similar to some previous filovirus outbreaks, this study population only comprised adults (20?66 years) [49], [74], [75]. All study patients reporting contact reported direct contact (11/14) or direct contact with a potentially infected corpse during funeral practices (3/14). Direct and funeral contacts were frequent opportunities for disease transmission in previous filovirus outbreaks [33], [49], [75]-[78]. However, 46% (12/26) of our study population reported no known contact history. This may be due to non-rigorous patient interviews during high-workload periods on the Ebola ward. Considerable amounts of routine data were missing (e.g. 54%, or 14/26 of study subjects did not have their occupation recorded), indicating shortcomings in data collection. Alternatively, primary or unnoticed secondary transmission could have occurred. Available data preclude decisive conclusions.

The last sentence speaks for itself, although the author also makes it clear his own hypothesis. Fortunately, as a scientist, he does clearly separate his hypothesis from the conclusion provided by the data.

Ebola Heamorrhagic Fever in Sudan, 1976

... Of the six factory employees, 5 worked in one particular end of the cotton factory. Extensive discussions withfriends and families of these workers did not reveal any possible link between them except the factory. None had cared for pre-existing cases of the disease, none had a previous illness for which they might have received an injection with a contaminated needle, and none had any known contact with monkeys or any other wild animal. Their houses were widely scattered over the area, and their social circles very different. Since their only link was the cotton factory, the investigation for an animal reservior of infection was concentrated in Nzara and specifically in the cotton factory factory itself. The result of this investigation will be reported elsewhere.

The author failed to mention another obvious possibility - that one of workers contracted Ebola outside the factory and transmitted it to the others inside the factory. A later report, on the occasion of a new case in Nzara in 1979, indicates that in the 1976 outbreak, "no animal resource was found inside the factory" [Ebola virus disease in southern Sudan: hospital dissemination and intrafamilial spread, Bulletin WHO, 1983]

It is also a fact that the various Ebola outbreaks have demonstrated a difference in distribution of symptoms. For example, prevelance of fever has in the past been reported as being present in anywhere from 100% down to 80% of cases whereas in the current outbreak the prevelence of fever is reported as being even less [Clinical illness and outcomes in patients with Ebola in Sierra Leone. N Engl J Med. D ].

Therefore, conclusions about transmission probability could vary between outbreaks. The current outbreak, unlike previous outbreaks, did not spontaneously die out after seven or so generations of virus transmission, as it had done in previous outbreaks. One hypothesis for this phenomena is incremental change (compared to previous outbreaks) in the virus such that transmission can occur earlier than in previous outbreaks. Specifically that in a sufficient fraction of cases the viral load, (and/or the percentage of effectively packaged virions within the viral load), in the first two days becomes sufficiently high to increase the probablity of transmission through casual contact or fomites.

Indeed, again referring to current outbreak data [Clinical Illness...] above, we see that in the displayed data in the figure Ebola virus load in Sierra Leonean patients over time, on day one, 3 out of 7 end-fatal cases measured 10^8-10^9 viral genomes/ml, rising to 4 out of 7 on day two. The maximum load ever measured is less than 10^10, so 10^8 represents greater than 1/100 of the maximum load. Patients have been recorded dying with loads as low as 10^7.

This level of viral genomes / ml does appear to be higher than the data chosen by the CDC for display in your recommended summary [Review of Human-to-Human Transmission of Ebola Virus, CDC] which comes from [Rapid diagnosis of Ebola hemorrhagic fever by reverse transcription-PCR in an outbreak setting and assessment of patient viral load as a predictor of outcome. Journal of Virology. Apr 2004], which is data from a different outbreak over 10 years ago which did spontaneously die out.

There are still so many unanswered questions: Why do some areas in west Africa show antigen/antibody presence in 18% of the population even though these people have no recollection or record of being exposed to Ebola cases? Why have previous outbreaks died out spontaneously with successive infections seemingly becoming less virulent? Why was this outbreak different? Lots and lots of hypothesis, very few certainties.

First you have find at least one case when an asymptomatic patient transmitted the disease.

This is a misrepresentation of what I have said. It is human nature to err in underestimating symptoms for a couple of days, and objective temperature measurement does not reliably show fever even in presence of Ebola.

There is the "Lion Heart" case I mentioned, where the Dutch Lion Heart clinic was closed due to infection from an apparently asymptotic case who had no fever, reportedly leading to infection and death of 5 African nurses. Probably s/he had minor symptoms but didn't report them, and she was not visibly symptomatic.

Let me discuss a hypothetical case of a very young 20 something doctor returning from Africa. A busy person, travelling through time zones, stressed out from very hard work in an Ebola clinic, fatigued anyway, could feasibly mistake the achy muscles and tiredness, even a slight headache, as normal. Temperature measurement shows no abnormality. Swallowing a few ibuprofen or Tylenol along with a cocktail seems to make things better. But the clock is ticking.

Do you remember when Pres Bush came to Japan, and vomited during his official sushi dinner with the Japanese Prime Minister? He must have felt bad beforehand but being busy suppressed his sick feelings.

One more thing to consider: the possibility of unfortunate confluence. Suppose said doctor with minor-symptom Ebola but high enough viral load, who thinks they are just suffering from normal time lag, decides to nibble on a healthy salad, which unfortunately is just slightly on the old side. Within a few hours, Ebola fatigue, time lag fatigue, and a stomach with an unrecognized but not really dangerous microbe bloom combine to cause the person to vomit on crowded public transportation. If it happened you would have to say it was predictable.

0 ( +0 / -0 )

The last sentence speaks for itself, although the author also makes it clear his own hypothesis. Fortunately, as a scientist, he does clearly separate his hypothesis from the conclusion provided by the data.

Yes, that is exactly, an asymptomatic Ebola spreader is your hypothesis and its not based in any real data but only on possibilities, so it can't be used to put in order any measures, such as general quarantine for asymptomatic people. Also, unnoticed transmission is not incompatible to come from fully asymptomatic patients. It is fine to think about other possibilities, but not to make policies based on the least probable of those.

The author failed to mention another obvious possibility - that one of workers contracted Ebola outside the factory and transmitted it to the others inside the factory.

One possibility is that they all got infected in the common place they all shared, something easy to prove possible, they all get similar incubation times but begin their symptoms at different times because they did not contact with the reservoir at the same time. The other possibility is that the first sick patient transmitted the disease during his apparently short incubation time, then the other patients all inexplicably all get very long incubation times and came sick long time after their contact with the first patient stopped, and then transmit the disease and the incubation times for the secondary (tertiary on your theory) suddenly become short again. It is clear which explanation holds better with the evicence.

It is also a fact that the various Ebola outbreaks have demonstrated a difference in distribution of symptoms.

And again that is much more easily explained by lack of controls necessary to evaluate how reliably you are measuring the temperature. No controls even when they have been described as necessary? then temperature measurement is to be taken as a unreliable data, specially when measured in the middle of an epidemic with much less than ideal facilities and instruments. This for example is totally different in situations like in EUA, where temperature measurement is much more reliable and this kind of phenomenon is not observed.

And again, statistics on lack of fever are totally different from lack of symptoms. There is no report of a contagion coming from a symptom free person, so this possibility remains negligible, especially when the mechanism of contagion depends of viral loads as high as in Ebola (not compatible with a person feeling healthy)

One hypothesis for this phenomena is incremental change... such that transmission can occur earlier than in previous outbreaks. Specifically that in a sufficient fraction of cases the viral load, (and/or the percentage of effectively packaged virions within the viral load), in the first two days becomes sufficiently high to increase the probablity of transmission through casual contact or fomites.

Lack of evidence to base a theory even after exhaustive researching should be a strong indicator that the null hypothesis (that this mechanism is actually not present) may be true. Also, even if this is the case the “earlier” still means two days after hospitalization. Assuming that a patient went to the hospital immediately after feeling sick it would still give plenty of time to be quarantined without becoming infective himself (and the report don’t specify when the most important symptoms began, it focused only on the sign that don’t increase the infectivity by itself)

This level of viral genomes / ml does appear to be higher than the data chosen by the CDC for display in your recommended summary [Review of Human-to-Human Transmission of Ebola Virus, CDC] which comes from [Rapid diagnosis of Ebola hemorrhagic fever by reverse transcription-PCR in an outbreak setting and assessment of patient viral load as a predictor of outcome. Journal of Virology. Apr 2004]

Did you check the materials and methods? differences between a rapid method and a gold standard should be easy to spot, but more importantly sensitivity and reliability of diagnostic methods increase rapidly over time, in virology 10 years are extremely far apart. We need to compare methods on both papers to see if the difference in detection can be transformed in differences on viral titers. But more importantly, with so high viral loads to remain asymptomatic is even less possible, it does not matter how fast the virus loads increase the rapid increase has to be preceded by a worsening of the symptoms on the same level. So the patient would feel not bad but terrible at least one day before becoming infective and probably much more. (because you have to get the body fluids out in order to get the high viral loads in contact with other people). People becoming infective a day or two after being hospitalized? can be believed easily in the Sierra Leone environment, where people resist to go to the hospital (they fear isolation with Ebola patients). Becoming infective a day or two before any symptom appear? that is completely different and there is no evidence of that even in this report that you so much like to reference.

This is a misrepresentation of what I have said. It is human nature to err in underestimating symptoms for a couple of days, and objective temperature measurement does not reliably show fever even in presence of Ebola.

No it is not, you want to support policies based on something that has not been observed nor reported anywhere in decades of study just because it is a possibility. And objective is not the same as reliable the same as fever is not the only symptom of Ebola.

There is the "Lion Heart" case I mentioned, where the Dutch Lion Heart clinic was closed due to infection from an apparently asymptotic case who had no fever, reportedly leading to infection and death of 5 African nurses. Probably s/he had minor symptoms but didn't report them, and she was not visibly symptomatic.

I already clarified that this is completely incorrect, the original patient was not symptomatic AT THE BEGINNING, the same as every other patient in the world (that is called incubation time), the secondary infections occurred because of contact AFTER she became symptomatic. None of the contacts she had before she felt sick and was hospitalized got the disease. There is nothing special about that case and as such it did not attract attention importantly.

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