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Who Will Be Forced to Walk the Plank on November 4th?

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Who will Trump force to walk the plank after the election?
(h/t Stacey Harvey for the image, [CC Attribution-NoDerivs 2.0 Generic (CC BY-ND 2.0) ]

Win or lose, Donald Trump will be looking for vengeance once the election is over. Either he will lose, and want to punish those he deems responsible, or he will win and want to punish the folks he’s had to put up with despite their failures to do what he wanted. One way or another, Trump will want to make certain people pay and pay dearly after the voting is over.

It might be to get rid of people who have angered him by not being sufficiently publicly loyal and submissive.

It might be to get rid of people who angered him by not being sufficiently good at making Trump look good before the election.

It might be to get rid of people who angered him by making him look bad, indecisive, or (gasp!) wrong.

It might be to get rid of people who stood up to him in private and made him back down on something, even if that backing down was only done in private.

It might be to get rid of people who stood up to him in public, and he had to simply take it at the time because Trump would have paid a price if he got rid of them when it happened.

Put me down for Trump demanding that the following people be forced to walk the plank:

  • Doctors Tony Fauci at NAIAD, Stephen Hahn at FDA, and Robert Redfield at CDC, along with HHS Secretary Alex Azar for not keeping these disloyal doctors in line;
  • Bill Barr for failing to deliver any indictments and convictions of any Bidens or Clintons, John Durham for dragging his feet on his reports that would have made that happen, Christopher Wray for being the FBI director and generally annoying, whoever approved letting Andrew Weissmann reveal that Manafort was breaking the gag order in his case by communicating with Sean Hannity, and a host of other US Attorneys who didn’t behave according to Trump’s rules;
  • General Mark Milley for publicly apologizing for taking part in the infamous Bible-waving photo op created by driving protesters out of Lafayette Park with chemical agents, various generals and admirals who refused to back Trump’s call to deploy US troops to American cities he didn’t like, and Secretary of Defense Mark Esper for not keeping these military folks in line;
  • Dr. Sean Conley, for not being more deceptive with the press around Trump’s COVID-19 status;
  • Mark Meadows for undermining Conley’s initial “he’s doing great” press remarks, as well as for more generally not keeping the WH functioning smoothly (as if that were possible, given his boss);
  • Mike Pompeo for failing to get Ukraine to do Trump’s bidding, as well as for not keeping folks like Fiona Hill in line.

But I must admit this is an incomplete list. Who else do you think might be on Trump’s Naughty List? Add your own thoughts in the comments.

Note: I also left off the list a bunch of folks like Mitch McConnell, Andrew Cuomo, Savannah Guthrie, and Cy Vance that Trump would demand walk the plank, but who remain outside his ability to make that happen. I also didn’t include Ivanka, Jared, Don Jr, or Eric, as he can’t fire his family. Though of course, he could disinherit them . . . for whatever that’s worth.

Friday: The End of the World

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I wake up in the morning and I wonder
Why ev’rything is the same as it was
I can’t understand, no, I can’t understand
How life goes on the way it does

— excerpt, The End of the World, written by Arthur Kent and Sylvia Dee

Jazz version of this song first released by Skeeter Davis in 1962 performed here by Postmodern Jukebox’s Scott Bradlee and band with Niia’s vocals.

A few people in my timeline have asked over the last several months, “Is this the end of the world, or does it just feel like like it?”

It’s the end of something, that’s for sure.

Z is for Zika

I can’t make this clear enough to Congress: you’re playing with lives here, and it’s going to be ugly. It will affect your families if anyone is of childbearing age. I haven’t seen anything in the material I’ve read to date that says definitively studies are underway to verify transmission from Brazil’s Culex quinquefasciatus to humans. There’s a study on the most common U.S.’ Culex pipiens species which showed weak transmission capabilities, but once it’s proven quinquefasciatus can transmit, it’s just a matter of time before more effective pipiens pick up and transmit the virus, and they may already have done so based on the two cases in Florida. GET OFF YOUR BUTTS AND FUND ADEQUATE RESEARCH PRONTO — or risk paying for it in increased health care and other post-birth aid for decades.

Still Brexin’ it

Clean-up duty

  • Looking for MH370 in all the wrong places — for two years (IBTimes) — Bad suppositions? Or misled? Who knows, but the debris found so far now suggests the plane may have glided across the ocean in its final moments rather than plummeting nose first.
  • Enbridge settles $177 million for 2010 oil pipeline rupture (ICTMN) — Seems light for the largest ever oil spill inside the continental U.S., and their subsequent half-assed attempts to clean up the mess. Check the photo in the story and imagine that happening under the Straits of Mackinac between Lakes Huron and Michigan. How did it take them so long not to know what had happened and where?
  • Broadband companies now have a real competitive threat in Google Fiber (USAToday) — It’s beginning to make a dent in some large markets where Google Fiber’s 1Gb service has already been installed. But it is slow going, don’t expect it in your neighborhood soon. You’re stuck with your existing slowpoke carriers for a while longer.
  • Cable lobby counters FCC pressure on set-top boxes (Ars Technica) — Sure, they’ll yield to the FCC on set-top boxes, but they won’t offer DVR service and each cable provider with 1 million subscribers or more will be responsible for their own apps. Cable lobby claims copyright issues are a concern with the DVR service; is that a faint whiff of MPAA I smell?

Beach-bound longread
Check out this piece in WIRED: David Chang’s Unified Theory of Deliciousness. I’m hungry after reading just a portion of it.

Hasta luego, mi amigas. Catch you Monday if the creek don’t rise.

CDC: Zika Virus Confirmed as a Cause of Microcephaly

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CDC director Dr. Tom Frieden confirmed Wednesday that the flavivirus known as Zika is a cause of microcephaly and other severe fetal brain defects.

The confirmation is based on an evaluation of available data for potential teratogenic effects. Using both Shepard criteria and Bradford Hill criteria, researchers proved prenatal Zika virus infection has a causal relationship with microcephaly and other serious brain anomalies.

The first set of seven criteria used in the assessment were developed by Dr. Thomas Shepard to assess an agent’s teratogenicity — the ability to cause birth defects. The criteria of proof are:

1. Proven exposure to agent at critical time(s) in prenatal development

2. Consistent findings by two or more epidemiologic studies of high quality

a. control of confounding factors
b. sufficient numbers
c. exclusion of positive and negative bias factors
d. prospective studies, if possible, and
e. relative risk of six or more

3. Careful delineation of the clinical cases. A specific defect or syndrome, if present, is very helpful.

4. Rare environmental exposure associated with rare defect. Probably three or more cases.

5. Teratogenicity in experimental animals important but not essential.

6. The association should make biological sense.

7. Proof in an experimental system that the agent acts in an unaltered state. Important for prevention.

______
Note:
Items 1~3 or 1, 3, and 4 are essential criteria.
Items 5~7 are helpful but not essential.

Shepard criteria summary:

1. The microcephaly and other brain defects observed in infants and fetuses were consistent with maternal Zika infection during first and second trimester of pregnancy. Mothers exhibited symptoms, and/or had infections confirmed by labs, and/or had traveled to areas where Zika was endemic. This criterion was met.

2. Data documenting the location of Zika virus infections and the subsequent incidence of microcephaly in those areas was supported by two epidemiologic studies. But as sample sizes were too small and controls were lacking, this criterion has not yet been met.

3. Cases manifesting with a very specific defect (an atypical microcephaly) or syndrome (a narrow range of neurological defects in tandem with microcephaly) satisfied this third criterion. With Zika infection, microcephalic cases displayed adequate bone tissue and scalp skin production, but ‘collapsed’ due to the disrupted development of fetal brain tissue. This is not common in other microcephalies.

4. An adequate number of cases fulfilled the criteria of rare exposure and rare defect — one example cited was that of a pregnant woman who traveled for a week to areas where Zika was not endemic. She tested positive for Zika during her second trimester, and the fetus displayed brain defects associated with Zika after the infection.

5. Studies for this criteria — teratogenicity in animal models — are still under way. This criterion is not yet satisfied.

6. This criterion is met as the causal relationship makes biologic sense.

7. This criterion does not apply to infectious agents.

The essential Shepard criteria have been met for proof of teratogenicity.

Bradford Hill criteria summary

Of the nine criterion — the strength of association, consistency, specificity, temporality, biologic gradient, plausibility, coherence, experiment (on animal models), and analogy — only two criterion are not applicable or not available. The remaining seven criterion were met in much the same manner as the Shepard criteria 1, 3, 4 were met.

What’s next

A spectrum of additional fetal abnormalities has not yet been fully identified in association with Zika infection. This will become clear once some pregnancies being monitored reach term.

We don’t yet know if Zika virus affects adult neurological tissues; some cases of Guillain-Barre Syndrome (GBS) have been reported in areas where Zika is endemic. GBS has occurred in patients after viral infections where neurological tissues have been affected; it would make biologic sense for there to be a causal relationship between Zika and GBS. However, GBS has occurred in patients long after an initial infection, making it difficult to see obvious relationships without further screening and testing.

A Zika vaccine may be some time off; of the flavivirus family, only yellow fever and a couple of encephalitis viruses have vaccines while others like West Nile and dengue do not.

Mosquito control varies widely from state to state, let alone by county or municipality. We do not know if it is adequate to ensure Zika’s spread via Aedes aegypti and Aedes albopictus mosquito species is limited. U.S. experience with the spread of West Nile Virus may be informative.

Funding for additional research, education, training, vaccine development and mosquito control, as well as funding increases for birth control are much needed, But the GOP-led Congress will likely avoid this issue during the remaining days it is in session this election year.

In the meantime, if you’re around mosquitoes in warmer areas of the U.S., are pregnant, plan to be pregnant, or might get someone pregnant, check the CDC’s guidelines on Zika.

Tuesday Morning: Toivo’s Tango

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Did you know the tango evolved into a Finnish subgenre? Me neither, and I’m part Finn on my mother’s side of the family. Both my grandmother and great-grandmother spoke Finn at home after their immigration to the U.S., but apparently never passed the language or Finnish music on to my mother and her siblings. The Finnish tango became so popular a festival — the Tangomarkkinat — was established to celebrate it.

The tango makes its way back again, nearly 9000 miles from its origin to Finland, in this music video. The performer featured here is a very popular Argentine tango singer, Martin Alvarado, singing in Spanish a popular Finnish tango, Liljankukka, written by Toivo Kärki. If you search for the same song and songwriter in YouTube, you’ll trip across even more Finnish tango.

Let’s dance…

Police raid in Belgium today
There were more arrests in Belgium today in connection to Paris attack in November. Not many details yet in the outlets I follow, suggesting information is close to the vest; there was more information very early, which has now moved off feeds, also suggesting tight control of related news. A raid in the southern Brussels suburb of Uccle resulted in the arrest of three persons now being questioned. This raid follows the arrest last Friday of Mohamed Abrini, who has now admitted he is the man seen in security camera video as the ‘man in the hat’ observed just before the bombing of the Brussels’ airport. Thus far, intelligence gathered from suspects and locations indicates a second attack had been planned, attacking the Euro 2016 football championship. Worth noting the media has now been reporting only the given name and a family name first initial for some of those arrested recently.

Up All Night growing, annoying some Parisians
This Occupy movement subset called ‘Up All Night’ or ‘Night Rising’ (Nuit debout) has been rallying during evening hours, protesting austerity-driven labor reforms, France’s continued state of emergency after November’s terrorist attacks, and more. The number of protesters has grown over the last 12 days they have taken to the streets, driven in part by the Panama Papers leak. The crowd has annoyed those navigating the area around the Place de la Republique where the Nuit debout gather. (More here on video.)

Upset over Burr-Feinstein draft bill on encryption continues
The Consumer Technology Association (CTA) issued a statement last night conveying their displeasure with this proposed bill which would mandate compliance with law enforcement access to encrypted digital content. The CTA’s 2200 members include Apple, Google, Microsoft, and any consumer electronic technology manufacturer featured at the annual Consumer Electronics Show each year. This formal statement follows a wave of negative feedback from technology and privacy experts since the draft bill was revealed late last week.

Odds and ends

  • Cellebrite makes the news again, this time for a ‘textalyzer’ (Ars Technica) — Huh. What a coincidence that an Israeli company attributed with the cracking of the San Bernardino shooter’s iPhone 5c is now commercializing a device for law enforcement to use on drivers’ cellphones. Do read this piece.
  • DARPA still fighting for relevance with its Squad X initiative (Reuters) — Not a single mention of exoskeletons, but enough digital technology to make soldiers glow in the dark on the battlefield.
  • Microsoft’s director of research calls some of us chickenshit because AI is peachy, really (The Guardian) — Uh-huh. This, from the same company that released that racist, sexist POS AI bot Tay not once but twice. And we should all just trust this stuff in our automobiles and in the military. Ri-ight.
  • Farmers watching more than commodities market and the weather (Fortune) — Chinese IP rustlers are sneaking commercially-developed plant materials back to PRC. Hope the Chinese realize just how likely American farmers are to use firearms against trespassers.
  • CDC’s deputy director on Zika: “Everything we look at with this virus seems to be a bit scarier than we initially thought” (Reuters) — I swear multiple news outlets including WaPo have changed the heds on stories which originally quoted this statement. Zika’s observed destruction of brain cells during research is really distressing; so is Zika’s link to Guillain-Barre syndrome in addition to birth defects including microcephaly. In spite of the genuine and deep concern at CDC over this virus’ potential impact on the U.S., the CDC is forced to dig in sofa cushions for loose change to research and fight this infectious agent. Absolutely ridiculous, like we learned nothing from our experience here with West Nile Virus.

That’s it, off to mix up my tango with a whiskey foxtrot. See you tomorrow morning!

Wednesday Morning: Full of Whoa

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CapagnoloFrontBrakes_BillGracey-FlickrWhoa. Halt. Stop. The brakes need firm application, even mid-week.

Zika virus infects media with crappy reporting
I can’t tell you how many times in the last 24 hours I yelled at my computer, “Are you f****** kidding me with this crap?” With so many news outlets focused on hot takes rather than getting the story right, stupidity reached pandemic levels faster than mosquito-borne viruses. And all because Dallas County health officials and the Center for Disease Control used the words “sexually transmitted” in reference to a new Zika case in the U.S.

The following sampling of heds, tweets, and reports? WRONG.

  • US reports first case of sexually transmitted Zika in Texas (Gizmodo, io9)
    [Not the first sexually transmitted case in the U.S., just the first in Texas]
  • First US case of the Zika virus infection was sexually transmitted, officials say (Verge)
    [Not the first U.S. case of Zika virus]
  • The first known case of the #ZikaVirus contracted within the US confirmed in Dallas (Newsweek)
    [Not the first known case of Zika contracted within the U.S.]
  • The first case of the #ZikaVirus contacted within the US was through sexual transmission (Newsweek)
    [Neither the first sexually transmitted case in the U.S. or the first contracted within the U.S.]
  • The First Sexually Transmitted Case of the Zika Virus Is Confirmed in Texas (Slate)
    [Not the first sexually transmitted case in the U.S.]

The first case in which Zika virus was contracted inside the continental U.S. occurred in 2008. This was the first sexual transmission of the virus in the continental U.S. as well. Scientist Brian Foy had been studying Zika in Senegal during an outbreak; he had been infected by the virus, became ill, and was still carrying the virus when he came home to Colorado. His wife became infected though she had not traveled abroad, had not been bitten by a mosquito, and children residing in their home did not contract the virus. More details on the case can be found here.

The first cases of Zika virus in the U.S. in this outbreak were not locally transmitted inside the U.S., but contracted outside the continental 48 states and diagnosed on return here. States in which cases have been reported include Hawaii, New York, Virginia, Arkansas, Florida, and now Texas — in the case of the traveler who brought the disease home and infected their partner through sex.

It’s incredible how very little effort many news outlets put into researching the virus’ history or the case in Texas. Bonus points to Newsweek for trying to get it wrong in multiple tweets for the same story.

Best reporting I’ve read so far has been WaPo’s piece on the new Dallas cases, and WIRED’s collection of Zika reports. The CDC’s site on the Zika virus can be found here.

Gonna’ be a massive Patch Day for F-35 sometime soon
Whether or not Monday’s earthshaking sonic booms over New Jersey were generated by F-35 test flights, there’s still a long and scary list of bugs to be fixed on the fighter jet before it is ready for primetime. Just read this; any pilot testing these now is either a stone-cold hero, or a crazed numbnuts, and they’d better weigh between 136 and 165 pounds to improve their odds of survival.

Oral Roberts University mandates students wear FitBits for tracking
Guess the old “Mark of the Beast” is interpreted loosely at ORU in Oklahoma. Fitness is measured on campus by more than theological benchmarks. Begs the question: who would Jesus monitor?

The last straw: Fisher Price Wi-Fi-enabled toys leave kids’ info out in the open
Fisher Price is the fourth known manufacturer of products aimed at children and their families in which the privacy and safety of children were compromised by poor information security. In this case, Smart Toy Bears are leaking information about their young owners. Maybe it’s about time that either the FCC or FTC or Congress looks into this trend and the possibility toy makers are not at all concerned with keeping their youngest customers safe.

EDIT: #FlintWaterCrisis
Forgot to note the House Oversight and Government Reform Committee will hold a hearing on lead contaminated drinking water in Flint, Michigan at 9:00 a.m. EST. C-SPAN3 will carry the hearing live.

Tap the brakes a few more times before you take off, eh? It’s all downhill from here.

Ebola Outbreak Finally Receding in Sierra Leone; CDC Modeling Was Incredibly Accurate

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Back in late September, just a week before Ebola panic hit a peak in the US when a patient in Dallas was diagnosed with the disease, the CDC produced a remarkable study in which they modeled the expected number of Ebola cases both with and without intervention. That study received a huge amount of press coverage, primarily because the model predicted that without intervention by public health authorities, as many as 1.4 million people could be infected. By contrast, with a program of isolating infected patients and educating survivors on proper burial techniques, the model showed that the outbreak would be much less widespread. The modeling projected cases through yesterday’s date, January 20.

Less reported in the media at the time was the projected number of cases under the scenario of intervention. The model predicted an actual number of cases between 25,000 and 30,000 by this week and a reported number of cases of nearly 10,000. Here are the two projections placed alongside one another:

CDC modeling of projected number of Ebola cases without (left) and with (right) improved patient isolation and safe burial practices.

CDC modeling of projected number of Ebola cases without (left) and with (right) improved patient isolation and safe burial practices.

The latest data from WHO indicate just over 21,000 cases as of January 11. That is a remarkable achievement by the team that developed the model. The observed actual number of reported cases fell squarely within the range predicted by the model. With the influx of health professionals to the region to provide care for infected patients, it seems likely to me that the correction factor applied in the CDC model to correct from the reported number of cases to the actual number would be very different now, so that the reported number and actual number would be much closer to one another, making the prediction even more accurate.

Last time I posted on progress in stopping the spread of the virus, we saw that the rate of appearance of new cases was dropping rapidly in Liberia but was still accelerating in Sierra Leone. The good news is that the improved practices have finally been implemented sufficiently in Sierra Leone that the rate is now dropping there. Here are the plots of weekly new cases in the two countries from the latest WHO Situation Report:

Weekly number of new cases of Ebola in Liberia (left) and Sierra Leone (right). Control of the virus was achieved about two months later in Sierra Leone than in Liberia.

Weekly number of new cases of Ebola in Liberia (left) and Sierra Leone (right). Control of the virus was achieved about two months later in Sierra Leone than in Liberia.

Although the battle is not yet over, all indications are that the outbreak is well past the worst phase and should end soon. Considering how closely the CDC model predicted the eventual size of the outbreak with the control measures that were implemented, it seems safe to say that the world would have witnessed a truly horrific level of spread of the virus had improved safety measures not been implemented. As of the January 14 WHO Situation Report, a total of 825 health care workers have been infected, with 493 of them dying. Without their sacrifices, many more would have been lost.

Ebola Outbreak Receding in Liberia, Still Strong in Sierra Leone

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Back in late September, the press had a field day with a mathematical model developed by CDC that estimated that if left unchecked, the Ebola outbreak in West Africa could wind up infecting over 1.4 million people. Almost missed in the hysteria over that high number was the fact that this same model predicted that even with key public health measures (patient isolation, monitoring of at-risk population who had contact with infected people and safe burial practices) falling short of 100% implementation, the outbreak could be brought under control around January of next year.

Word has been leaking out for a while now that the rate of new Ebola infections in Liberia is falling. Reports in the Washington Post on October 29 and November 3 told us as much. A chart in the WHO Situation Report for November 5 drives home just how dramatic the decline in new cases has become:

WHO Ebola Situation Report November 5, 2014

WHO Ebola Situation Report November 5, 2014

As can be seen in the chart, the rate of new infections for the two most recent weeks is less than one fourth the rate at the peak of the outbreak. Unfortunately, the news for Sierra Leone is not as good. While the rate of new infections may be leveling off, it is not yet falling appreciably:

WHO Ebola Situation Report November 5, 2014

WHO Ebola Situation Report November 5, 2014

Digging into the WHO report a bit further, we can find some evidence for how this dramatic drop in new cases has been brought about. We see that 52% of cases are now isolated. The WHO target for December 1 has been set at 70%, with a target of 100% by January 1. When it comes to management of dead bodies, though, the December 1 target has already been surpassed. WHO reports that 87% of the dead are being “managed in a safe and dignified manner” while the targets were set at 70% for December 1 and 100% for January 1. Also, although no benchmarks are reported, WHO states that 95% of registered contacts were reached daily (although in the text of the report, there are suggestions this number may be somewhat overstated).

It should come as no surprise that progress in implementing these basic measures has had a huge impact on bringing down the rate of new infections. It fits perfectly with the CDC mathematical model and it also addresses the known biology of Ebola infections. Patients are most infectious at or near death, so establishing safe burial practices is vitally important. Conversely, identifying infected individuals through daily monitoring of the at-risk population and then isolating infected individuals once symptoms begin means that far fewer people are exposed to people producing large amounts of virus.

Sadly, those who remain exposed are the health care workers who are providing care to those who are infected. Despite shortages of equipment and supplies, WHO and other organizations are doing their best to overcome those shortages and to beef up training to reduce risk to these brave people on the front lines in the work to control the virus. As of this November 5 report, 546 health care workers have been infected, with 310 of them dying. Only four new infections were reported for the week ending November 2, so it is hoped that this rate is also dropping.

Had the alarmists who insisted that this was a new super-strain of Ebola capable of airborne transmission (or even a strain developed in a bioweapons laboratory), it is doubtful that these basic public health measures would have had such a dramatic impact on the rate of new infections. Perhaps those folks can go back to railing about chemtrails or the evils of vaccines, because basic boring science appears to be on the road to controlling the current outbreak before all of mankind succumbs.

In the meantime, we are at about two weeks into the three week incubation period both for anyone “exposed” by Craig Spencer or for Kaci Hickox (or anyone she “exposed”) to show symptoms. No reports of transmission so far, and the odds of any cases showing up are dropping very rapidly from the already very low levels where they started.

New CDC Hospital Ebola Guidelines Fall Short of WHO Guidance on Personnel Flow

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I’m either a lone voice in the wilderness or just another angry old man shouting at clouds on this, but, to me, the issue of personnel flow inside a facility treating a patient for Ebola is critical. Texas Health Presbyterian Dallas got that issue terribly wrong in the case of Thomas Duncan, and now, although they provide very good guidance on the issue of personal protective equipment and its use, new guidelines just released by CDC sadly fall short of correcting the problem I have highlighted.

The issue is simple and can even be explained on a semantic level. If a patient is being treated in an isolation ward, that isolation should apply not only to the patient but also to the staff caring for the patient. As I explained previously, National Nurses United complained that health care workers at Texas Health Presbyterian Dallas treated Duncan and then continued “taking care of other patients”.

Allowing care providers to go back to treating the general patient population after caring for an isolated patient is in direct contradiction to one of the basic recommendations by WHO in a document (pdf) providing guidance for treatment of  hemorrhagic fever (HF, includes Ebola):

Exclusively assign clinical and non-clinical personnel to HF patient care areas.

By exclusively assigning personnel to care of the isolated patient, then the isolation is more complete.

The new CDC guidelines, released on Monday, offer updated recommendations on the types of personal protective equipment (PPE) to be used and how it is to be used. The guidelines also stress the importance of training on effective PPE use prior to beginning treatment of an Ebola patient. Unfortunately, though, the guidelines still leave open the possibility of health care workers moving between the isolation area and the general patient population.

In the preparations before treatment of an Ebola patient commences, the guidelines state:

Identify critical patient care functions and essential healthcare workers for care of Ebola patients, for collection of laboratory specimens, and for management of the environment and waste ahead of time.

And then once treatment begins, we have this:

Identify and isolate the Ebola patient in a single patient room with a closed door and a private bathroom as soon as possible.

Limit the number of healthcare workers who come into contact with the Ebola patient (e.g., avoid short shifts), and restrict non-essential personnel and visitors from the patient care area.

So the facility is advised to identify the “essential” workers who will provide care to an Ebola patient and to limit the number of personnel coming into contact with the patient. And even though the patient is to be in an isolated room, the guidelines still fall short of the WHO measure of calling for the Ebola treatment staff to be exclusively assigned. Precautions for safely removing the PPE are described, but once removed, the workers presumably are free to go back to mixing with the general patient population. Hospitals are cautioned against allowing large numbers of care providers into the room and to avoid “short shifts”, but there still is no recommendation for workers to be exclusively assigned to the isolation area.

The first thing that comes to mind in this regard is to question whether the CDC recommendations fall short of the WHO call for exclusive assignment in order to allow US hospitals avoid the perceived expense of dedicating a handful of personnel to treatment of a single patient. Is the ever-constant push to reduce personnel costs responsible for this difference between CDC and WHO guidelines? In the US healthcare system, it appears once again that MBA’s can carry more weight than MD’s on critical issues.

Texas Hospital Violated Basic Precaution in WHO Ebola Patient Treatment Guidelines

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The incompetence of Texas Health Presbyterian Hospital Dallas is staggering. In following today’s rapidly developing story of a second nurse at the hospital now testing positive for Ebola, this passage in the New York Times stands out, where the content of a statement released by National Nurses United is being discussed (emphasis added):

The statement asserted that when Mr. Duncan arrived by ambulance with Ebola symptoms at the hospital’s emergency room on Sept. 28, he “was left for several hours, not in isolation, in an area where other patients were present.” At some point, it said, a nurse supervisor demanded that Mr. Duncan be moved to an isolation unit “but faced resistance from other hospital authorities.”

The nurses who first interacted with Mr. Duncan wore ordinary gowns, three pairs of gloves with no taping around the wrists, and surgical masks with the option of a shield, the statement said.

“The gowns they were given still exposed their necks, the part closest to their face and mouth,” the nurses said. “They also left exposed the majority of their heads and their scrubs from the knees down. Initially they were not even given surgical bootees nor were they advised the number of pairs of gloves to wear.”

The statement said hospital officials allowed nurses who interacted with Mr. Duncan at a time when he was vomiting and had diarrhea to continue their normal duties, “taking care of other patients even though they had not had the proper personal protective equipment while providing care for Mr. Duncan that was later recommended by the C.D.C.”

From the context of both the New York Times article and the nurses’ statement, it seems most likely that this movement of nurses from treating Duncan to treating other patients took place during the period after Duncan was admitted to the hospital and before the positive test result for Ebola was known. However, from the nurses’ statement showing that at least some of the personnel on duty realized Duncan almost certainly had Ebola, proper isolation technique should have been initiated immediately.

And that movement of nurses from a patient who should have been in isolation back into the general patient population is a huge, and obvious, error. Consider this publication (pdf) put out in August by the World Health Organization, summarizing precautions to be taken in care of Ebola patients. The very first page of actual content, even before the section labeled “Introduction”, is a page with the heading “Key messages for infection prevention and control to be applied in health-care settings”. The page lists nine bullet points about dealing with ” hemorrhagic fever (HF) cases” (hemorrhagic fever diseases include Ebola). Here is the third entry on that list:

Exclusively assign clinical and non-clinical personnel to HF patient care areas.

There really is no point in saying a patient is isolated if staff are freely moving back and forth between the isolation area and the general patient population. I’m wondering how long it will be until there is a whole new management team at Texas Health Resources, the parent firm for the hospital.

Bigger Problem in US Than Ebola: Enterovirus D68 Spreading Respiratory, Paralytic Diseases in Children

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Electron micrograph of enterovirus particles. Photo by Linda M. Stannard, University of Cape Town as reproduced in Wong's Virology online.

Electron micrograph of enterovirus particles. Photo by Linda M. Stannard, University of Cape Town as reproduced in Wong’s Virology online.

It has now been five days since we learned that Thomas Duncan, who came to Dallas from Liberia, tested positive for Ebola. His condition has been downgraded to critical, but so far none of his contacts have come down with Ebola symptoms. Because those most likely to have been infected by him are now under close observation and have limited contact with others, it seems quite likely the disease will not spread in the US beyond the small handful of people under close monitoring.

By contrast, the US is in the midst of an ongoing outbreak of a virus that has put many children into intensive care units with severe respiratory illnesses. A handful of children in Colorado initially having respiratory illness have progressed to paralysis of some limbs and have tested positive for the virus. Four children who died from severe respiratory illness have tested positive for the virus but the CDC states that the role of the virus in these deaths is not yet known. Late yesterday, a medical examiner in New Jersey stated that the virus was the cause of death for a four year old boy.

The virus involved in this outbreak is Enterovirus D68. Background on the virology of enteroviruses in general can be found here, courtesy of Wong’s Virology online. There are five groups within the enterovirus genus. By far, the most well-known group is the one that comprises the polioviruses. Enterovirus D68 falls within the newest group of enteroviruses that are designated with numbers.

These are some of the smallest and simplest viruses known. The viral particle contains only a single piece of RNA. Inside the host cell, this RNA is turned into a single protein that then is capable of chopping itself into the four smaller proteins found on the viral coat. There is no membrane around the virus and the particles are stable at acid pH, so inactivation is best achieved with bleach or other disinfectants whose label say they are active against non-enveloped viruses.

The CDC released information on the outbreak on September 12, noting that hospitals in Kansas City and Chicago first alerted CDC to unusual numbers of children presenting with severe respiratory symptoms. The latest CDC information on the outbreak includes:

From mid-August to October 3, 2014, CDC or state public health laboratories have confirmed a total of 538 people in 43 states and the District of Columbia with respiratory illness caused by EV-D68.

The report continues:

EV-D68 has been detected in specimens from four* patients who died and had samples submitted for testing. The role that EV-D68 infection played in these deaths is unclear at this time; state and local health departments are continuing to investigate.

The difficulty for healthcare providers with this virus is that symptoms for those infected can range from very mild to severe. As also seen with poliovirus, only a small fraction of those infected get the most severe form of the disease. In the current outbreak, a very high proportion of the children with the worst respiratory symptoms already suffered from asthma:

Of the 19 patients from Kansas City in whom EV-D68 was confirmed, 10 (53%) were male, and ages ranged from 6 weeks to 16 years (median = 4 years). Thirteen patients (68%) had a previous history of asthma or wheezing, and six patients (32%) had no underlying respiratory illness.

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Of the 11 patients from Chicago in whom EV-D68 was confirmed, nine patients were female, and ages ranged from 20 months to 15 years (median = 5 years). Eight patients (73%) had a previous history of asthma or wheezing.

Parents and school administrators are being encouraged to monitor children with asthma more closely during this outbreak and to be especially vigilant about measures to prevent spread.

Transmission of the virus, according to CDC: Read more →