We've heard about a lack of medical infrastructure in the African nations having the Ebola outbreak now. That the accompanying poverty and lack of technology adds to the problem. How they, among other things, complicate getting the disease in check. But in the first case of Ebola in the U.S., we've also had some problems with diagnosis and possibly, with adequate containment. Problems that we really shouldn't have had.
Follow me below the orange Ebola shepherd's crook virus for some thoughts on what might have contributed to this.
In diaries published yesterday here on Daily Kos
http://www.dailykos.com/...
http://www.dailykos.com/...
some people were discussing problems with the response of the hospital to the Dallas Ebola patient, the management of his family and the apartment in which they are staying.
The criticisms were primarily directed against the Texas Health Presbyterian Hospital, Centers for Disease Control (CDC), against the Dallas Department of Health and Human Services (DHHS) and the Texas Department of State Health Services (DSHS).
Clearly the hospital had issues with correctly diagnosing the patient, Mr. Duncan, on his first visit. He apparently told the triage nurse that he was visiting from Liberia. That and his abdominal pain should have set off alarms. The CDC recommends that patients presenting like this be isolated, examined and tested for Ebola. Instead, he was given antibiotics and released. He returned much more seriously ill two days later and was admitted after he told paramedics and hospital workers that he was from Liberia.
Later it came to light that his partner and three children had been directed to remain in their apartment even though they were not displaying any symptoms of Ebola. The DHSS was supposed to monitor them by taking twice daily temperatures. However the DHSS failed to consider how this family was supposed to eat and how Mr. Duncan’s soiled sheets, towels and clothing were supposed to be removed or cleaned. Apparently, these problems were not given serious consideration by either the Dallas DHSS or DSHS until a story about the situation appeared on CNN. Interestingly, from what I can gather, the paramedics who transported Mr. Duncan to the hospital were asked to stay home from work, were examined and tested for Ebola. Being found to be negative, they are not on house arrest. Mr. Duncan’s family was not given the same option and are being forced to remain at hime under police guard.
There were definitely several problems with how the hospital handled Mr. Duncan’s initial presentation to the hospital. The failure of both the Dallas DHSS and Texas’ DSHS to care for the patient’s family is inexcusable.
I commented yesterday that, in the latter case, the Texas agencies are the ones that should have proceeded to make sure that the patient’s family members were treated properly. As the local and state health agencies, they have the mandate to handle quarantine and other public health issues in their jurisdictions. For example, the Dallas DHSS got a court order forcing the family to remain at the apartment and not receive any unapproved visitors. That is one of the items that is under the purview of the Dallas DHSS and the Texas DSHS. That is not the role of the CDC. The CDC is there to investigate the outbreak, collect data, make recommendations, offer guidelines, share its expertise and perform similar functions as an epidemiological and public health arm of the government.
But why did these failures occur in the first place? The hospital should have been well prepared to follow the CDC’s guidelines on how to detect, isolate and diagnose Ebola patients. The local health agencies should have had plans in place to identify and eliminate problems with quarantining possible Ebola victims in a home (not hospital) setting, providing monitoring services for them, feeding them and handling other logistics problems. My thoughts were that Texas has been trimming its public health services budget for years along with its budgets to other forms of state infrastructure. It appears that the Dallas HHS and DSHS may have had funds cut that could have made them less effective. They may not have adequate staffing to handle these issues. As of last hight, a judge from Dallas who is also head of Texas’ branch of Homeland Security), along with people named by him, have been called in to assist with the issue of taking care of the patient’s family.
http://www.cnn.com/...
Besides possible budget issues, it is a well-known fact that Texas government is not happy with most things that Washington does. Perhaps part of this problem may stem from some animus from the Texas government directed against Washington. That's certainly been apparent over the last several years. I hope that this wouldn’t interfere with a health care emergency like this, but it is a possibility when politicians try to score points off of highly publicized situations.
At times in the past, both within and outside of the U.S., the CDC has been viewed as competition by local governments and government agencies. Sometimes, the locals feel as if their work, training and skills are not appreciated. That the CDC has the reputation and authority to ride roughshod over those on the local scene. This can create some tension and hard feelings between the groups involved and might produce delays in sharing information and conflicts between the organizations involved. Instead of the groups trying to interdigitate completely and act seamlessly, there may be some rough edges, instead. Those may lead to delays in reaching a specific goal.
Any or all of those may be playing a role in Dallas.
At hospitals where I’ve worked, including in emergency eooms, when the local health department or CDC sends out information on something like this, the hospital evaluates the guidelines. Then those guidelines are widely disseminated throughout the hospital. Following that, at least one drill is held, usually hospital-wide. During that drill, personnel act out their roles as if this situation were actually occurring. After the drill, a critique is held where the drill is dissected and possible mistakes, bottlenecks and other problems are isolated and repaired. Whether Texas Health Presbyterian Hospital did that or not, is unknown. My suspicion is that, if they had, the problems that were seen in the patient’s first visit on September 25th might not have occurred. A spokesman for the hospital's parent corporation admitted that there were issues with the patient was handled. I hope that other hospitals in the U.S. that might not have become familiar with the CDC directives will do so immediately and at least carry out a simulation of how to react in the event that a patient who is suspected of having Ebola arrives at the emergency department, clinic or other area of the hospital.
Interestingly, on October 1st, Mother Jones did an article on what effects the sequestration had on the current Ebola crisis.
"I have to tell you honestly it's been a significant impact on us," said Fauci [Anthony Fauci, M.D., Director, NIAID] "It has both in an acute and a chronic, insidious way eroded our ability to respond in the way that I and my colleagues would like to see us be able to respond to these emerging threats. And in my institute particularly, that's responsible for responding on the dime to an emerging infectious disease threat, this is particularly damaging." Sequestration required the NIH to cut its budget by 5 percent, a total of $1.55 billion in 2013. Cuts were applied across all of its programs, affecting every area of medical research.
(emphasis mine)
[ . . . ]
also argued that the epidemic could have been stopped if more had been done sooner to build global health security. International aid budgets were hit hard by the sequester, reducing global health programs by $411 million and USAID by $289 million.[Roughly the amount that the World Health Organization projects that it will take to contain the current Ebola outbreak.] "If even modest investments had been made to build a public health infrastructure in West Africa previously, the current Ebola epidemic could have been detected earlier, and it could have been identified and contained," she said during her testimony. "This Ebola epidemic shows that any vulnerability could have widespread impact if not stopped at the source.”-
(emphasis mine) Dr. Beth Bell, director of the CDC’s National Center for Emerging and Zoonotic Infectious Diseases.
http://www.motherjones.com/...
Perhaps, had the sequester not occurred, or had all of the budget cuts been restored in a timely fashion, the Dallas case, and its attendant problems, might never have occurred. The African Ebola outbreak might have been more expeditiously managed and it might never have reached epidemic proportions in the first place.
Additional Ebola information:
From the CDC (updated yesterday): http://www.cdc.gov/...
A series of articles on Ebola (editorials, human interest, hard science) all free from the New England Journal of Medicine http://www.nejm.org/...
A one hour podcast on the Ebola outbreak in the US and Africa by the Harvard School of Public Health with audience questions.
http://theforum.sph.harvard.edu/...
12:33 PM PT: Some additional free articles on Ebola.
http://jama.jamanetwork.com/...
http://jama.jamanetwork.com/...
Brief video on Ebola basics: http://www.thedoctorschannel.com/...
12:52 PM PT: CDC is re-emphasizing the need to inquire about recent travel to Africa in this advisory (an "advisory" provides important information that may or may not require immediate action): http://emergency.cdc.gov/...
6:14 PM PT: WOAH! Thanks for the kind words and recs!
6:39 PM PT: Texas Health Presbyterian Hospital releases information on patient's first visit. http://dfw.cbslocal.com/...