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BMS: Breast Milk Substitute? Big Messy Situation [UPDATE-1]

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[NB: check the byline, thanks. Updates will appear at the bottom of this post. /~Rayne]

For starters, let me point out the Biden administration has been trying to resolve the current infant formula crisis.


Other media outlets have done a decent job analyzing and reviewing the underlying causes of a disastrous shortage of infant formula in the U.S.

The causes include Trump maintaining bullshit tariffs on Canadian dairy products, COVID interruptions, and the oligopoly of formula producers which came about through the usual capitalistic method of regulatory capture leading to exclusion of competition and an insufficiency of monitoring for food safety.

The short term fixes may not be immediate; China, for example, manufactures formula but it has been struggling with COVID. It’s also had problems in the past with adulteration of infant formula.

Canada is the most obvious closest source but it will take rapid unwinding Trump’s tariffs to allow Canadian formula to backfill demand.

Meanwhile shelves are rapidly emptying depending on location across the country.


Mothers in particular are frantic because they are not only worried about ensuring a regular supply of formula for their infants, but they are being harangued and shamed for not breastfeeding even though breastfeeding isn’t a universal option for all mothers and infants.

This tweet by Midler is extremely disappointing. There are so many reasons why women can’t breastfeed yet they are constantly pressured for not doing so even by other women who should know better.

This is a really excellent thread by a historian on infant formula and breast milk substitutes which explains some of the reasons why parents have not been able to offer breast milk throughout history.


Much of the ignorance about infant feeding and subsequent harassment of mothers is rooted in Americans’ inadequate education about human reproduction as well as basic biology. Adults who’ve graduated from high school should know that mammals produce milk in response to a pregnancy, and once nursing has stopped so, too, does maternal milk production.

A mother can’t simply choose to breastfeed if she had to stop for any reason like difficulty with infant latch on, physical disability, illness, return to work where she can’t readily pump breast milk in privacy, so on.

The worst examples of pressure come from men who know absolutely nothing about breastfeeding having no uterus or birthed a child, and having no breasts. They know nothing of the stress of learning how to feed a newborn, mastering the intricacies of breastfeeding brassieres, learning how to do so in view of others as necessary, how to deal with curiosity or disgust by others who are offended by breastfeeding, how to pump and store breast milk, how to deal with chapped and bleeding nipples as well as unwanted letdown of milk, how to handle the first few times an infant bites its mother’s nipples, and dealing with constant advice and criticism about breastfeeding one’s child from family, friends, and total strangers.

And yet they feel they can lecture women saying, “Just breastfeed the kid.”

The stress new mothers deal with in this country is enormous. It’s no wonder we have a couple generations of anxious children and adults when they literally nurse on this as infants.

~ ~ ~

This situation isn’t going to get better overnight. It’s going to take at least a couple of months before production is up to demand levels and safe for infants.

What are parents who can’t breastfeed and can’t find formula supposed to do?

The White House put together a fact sheet which contains resources for locating formula.

https://www.hhs.gov/formula/index.html

For some parents the first step is finding a breast milk bank nearby; the fact sheet includes a link to

https://www.hmbana.org/find-a-milk-bank/overview.html

But even with all these resources there may be parents who can’t locate formula and are too far from the nearest breast milk bank. In Michigan, for example, there are two banks listed but both are more than 9 hours drive from the largest city in the Upper Peninsula, and the closest to Detroit is still more than an hour’s drive.

What do these parents do?

Having a handful of young friends who are expecting a child within the next six months, I did some research on how we used to feed infants before commercial infant formula was so prevalent.

First, I checked both the World Health Organization and UN’s UNICEF to obtain any resources they offered parents as breast milk substitutes in the event of an emergency.

UNICEF was unhelpful. Their material focused on ready-to-use formula in lieu of breastfeeding, only after pages and pages of material emphasizing human breast milk as a preference over formula. The organization has rightfully worked hard to emphasize breastfeeding as the safest and most reliable method for feeding infants in no small part because breast milk contains bioactive agents formula does not. The organization has fought globally against corporations which have undermined breastfeeding in order to sell commercial infant formula. But for the U.S.’s current situation UNICEF’s policy doesn’t work.

WHO was marginally better; a 43-page brochure spent 39 pages repeating over and over how human breast milk was the best choice for infants, nearly ignoring crises where breast milk and formula were not options.

Thankfully, on page 39 there was a recipe for making an alternative suitable for nursing infants — it consisted of water, evaporated milk, and sugar.

I recalled my youngest sibling adopted at 3 months of age in the early 1970s not consuming commercial formula. Instead they consumed a recipe based on cow’s milk, and this recipe in WHO seemed very similar.

Fortunately, I still have a resource to validate the recipe was the same or very similar. I called my 82-year-old mother and asked her what parents did before casual infant formula was used widely. I told her what I’d found at WHO.

“That’s what you drank,” she said. “That’s what you, your natural siblings and adopted sibling drank. Evaporated milk, water, and sugar, though we used corn syrup instead of sugar to avoid constipation. Oh, and you had infant oral vitamin drops.”

We spent a half hour talking about the hows and whys — she had been working full time as a registered nurse and couldn’t breastfeed her kids. Breastfeeding wasn’t widely seen as socially acceptable either if a mother had to feed an infant outside of the home.

Hygiene was emphasized — ensuring the bottles, lids, and nipples were sterile, that all formula recipe ingredients were heated to kill pathogens and bottled while hot to ensure the formula was safe to consume, along with prompt refrigeration.

Apart from human breast milk having evolved to best suit human infant needs, hygienic production, bottling, and storage are the key reasons why WHO and UNICEF place a premium on breastfeeding over formula and alternatives. Depending on location in the world, the only safe food for an infant may be breast milk especially since water for dry formula mix or use with concentrated canned formula may not be clean.

But one or two generations of Americans were fed canned cow’s milk diluted with water with additional calories supplemented by sweetener. In a pinch we can do it again — at least until the canned milk production supply chain breaks down.

~ ~ ~

CAVEAT: I am NOT a health care professional. I am providing the following on an informational basis which should not be used as a substitute for discussion and guidance with a qualified health care professional.

After talking with my mom I’m sharing what I found on the internet which was what doctors and hospitals used to send home with their new parents as instructions for feeding their new infant, along with the WHO recipe.

Vitamins: For anyone nearing their due date or who has an infant under the age of 6 months: contact your pediatrician or health care provider for a recommendation on infant liquid multivitamin drops and whether they recommend them with or without iron if an alternative to infant formula or breast milk is necessary. Multivitamin drops will supplement what an alternative to formula can’t provide should breastfeeding not be an option.

Nutritional differences: Keep in mind that the evaporated milk alternative is not identical to breast milk; it has more far more protein, for example, which may be more taxing on human kidneys. Compare these different forms of cow’s milk to human breast milk:

Human breast milk (per 8-oz cup): 171 calories, 17 grams carbs, 17 grams sugar, 2.5 grams protein, 11 grams fat

Gut flora: Also keep in mind that a change in diet means a change in gut flora; an infant can become constipated or have other health issues like allergies due to a corresponding change in immune system signaling. Parents should consider broad spectrum probiotics in their own diet because they will pass on their flora through normal contact with their infant. I introduced my children to plain unsweetened yogurt as soon as our family GP approved the addition to their diet (about 6 months); yogurt with live culture is a probiotic food.

WHO’s alternative:

Note that this formulation allows for the use of boiled cow’s milk. NEVER use raw cow’s milk. It’s safest to boil pasteurized cow’s milk. The formulation also allows for canned evaporated milk once it has been reconstituted to the same concentration as fresh milk, and then diluted further per this recipe.

Past examples: These are examples of instructions routinely sent home with new parents in the 1940s through the early 1960s.

[Instructions provided on discharge to new parents in 1945.]

Here’s an excerpt from a paper published in 1957 on evaporated milk in infant feeding.

And an instructional video on how infant formula was prepared at home during the 1950s at this link.

Some recipes like WHO’s call for sugar, but many older recipes refer to corn syrup as a sweetening alternative because it prevents or resolves constipation in some infants.

At least one recipe published by a mommy blog refers to blackstrap molasses as a sweetener because it contains iron and other trace minerals not found in white sugar or white corn syrup.

NEVER use honey. It should NEVER be offered to infants less than a year old due to the risk of botulism.

Parents whose infants and toddlers experience problems with cow’s milk may want to try goat’s milk which is available in canned evaporated form. (There are commercial infant formulas made from goat’s milk.)

NO to Plant-based milks: plant-based milk products like soy or almond milk are NOT appropriate substitutes for commercial infant formula or breast milk. Their nutritional content is in no way similar.

WATER SAFETY: water used to prepare evaporated cow’s (or goat’s) milk formula must be sanitary — heated at a high enough temperature long enough to kill pathogens. Even when mixed with powered infant formula, water should be heated to 158 degrees Fahrenheit/70 degrees Celsius.

~ ~ ~

I’ve already seen lectures and scolding about breastfeeding being best along with more finger wagging about homemade formula because it’s not as healthy as ready-to-use infant formula or powdered infant formula.

To which I say refer back to the tweet thread by Phil Hernandez near the top of this post and look closely at the photos of the shelves taken in Norfolk VA. There’s exactly one breast milk bank listed for the entire state of Virginia and it’s in Norfolk as well.

What the hell are American parents with infants supposed to do when there’s not enough breast milk or commercial formula to go around?

Especially when the U.S. has plenty of evaporated cow’s milk on the shelves while producing too much cow’s milk altogether.

~ ~ ~

UPDATE-1 — 11:15 PM EDT —

Transportation Sec. Pete Buttigieg appeared on CBS’s Face the Nation this morning and was asked about the infant formula situation.


He nailed it when he says we have a capitalist system and the government doesn’t make formula. The right-wing has decided it wants to use this capitalist system failure as a means to attack the Biden administration, but the entire regulatory system has been constructed to serve corporations more so than the people who consume products (with the majority of corporations’ support going to the GOP and its candidates).

One only need look at OpenSecret’s data on Abbott Laboratories and Abbott Nutrition‘s campaign contribution history to both major parties to see part of the infant formula industry’s regulatory capture process at work.

The right-wing in this country needs to make up its mind: its political apparatus is either going to stand behind a free market, or more socialized government intervention when competition fails. It only seems to be settled on government getting the way overreaching into women’s uteruses and trans persons’ bathroom stalls and obstructing Black Americans’ access to the voting booth.

What’s particularly irritating about today’s Face the Nation segment is that Buttigieg isn’t the Commerce Secretary or the Health and Human Services Secretary, or the FDA Director.

He’s a concerned adoptive father who told CBS the infant formula situation “is very personal for us,” referring to his two nine-month-old infants.

But sure, let’s beat up on a parent who already has enough to worry about and isn’t responsible for the problem in his day job.

Preparing For The Inevitable Coronavirus Disease 2019 Outbreak

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Jim here.

I am quite late to getting to a post on the new coronavirus, but headlines yesterday finally forced me to move ahead and gather info today. First, watch this incredibly informative video from the World Health Organization. It gives very good information on the biology of the virus and what’s going on in the outbreak:

Although Donald Trump and his media partners have been denying that Coronavirus Disease 2019 (COVID-19) is a real cause for concern, there were multiple statements yesterday from US health officials that ranged from quite alarming to somewhat more reassuring. The announcements were summarized well by the Washington Post. Perhaps the most attention was paid to portions of what Dr. Nancy Messonnier provided in a telephone briefing yesterday morning. Dr. Messonnier is the Director of the National Center for Immunization and Respiratory Diseases. A recording of the briefing and a full transcript can be found here.

Of most note from the briefing is when Messonnier stated:

Ultimately, we expect we will see community spread in this country.  It’s not so much a question of if this will happen anymore but rather more a question of exactly when this will happen and how many people in this country will have severe illness.

So, yes, spread of COVID-19 in the US is inevitable. Messonnier continued, discussing what can be done to try to contain the disease. Because there’s no vaccine or specific treatment for the virus, control has to be through what is termed non-pharmaceutical interventions or NPIs:

There are three categories of NPIs.  Personal NPIs which include personal protective measures you can take every day and personal protective measures reserved for pandemics.  Community NPIs which include social distancing measures designed to keep people who are sick away from others.  And school closures and dismissals.  And environmental NPIs which includes surface cleaning measures.

It’s in the category of potential community NPIs where the biggest concerns start to appear:

Now I’d like to talk through some examples of what community NPIs look like.  These are practical measures that can help limit exposure by reducing exposure in community settings.  Students in smaller groups or in a severe pandemic, closing schools and using internet-based teleschooling to continue education.  For adults, businesses can replace in-person meetings with video or telephone conferences and increase teleworking options.  On a larger scale, communities may need to modify, postpone, or cancel mass gatherings.

Messonnier expanded on the disruptions:

Secondary consequences of some of these measures might include missed work and loss of income.  I understand this whole situation may seem overwhelming and that disruption to everyday life may be severe. But these are things that people need to start thinking about now.

So, yes, there may well be significant disruptions to everyday life in parts of the US. We of course don’t know when this would occur, or where in the US it would be. But this is a good time to start thinking about how a disruption to moving around for a couple of weeks would affect you. Here in Florida, we regularly have to prepare for a week or more of loss of electricity during hurricane season. Preparing for community control measures would be a bit different. Right now, my thoughts for our household are that I will stockpile a few extra large cuts of meat in the freezer. These are things I’d eventually use anyway, so it won’t hurt to have them around. I’ll increase a few of the pantry items that I wouldn’t otherwise increase until the start of hurricane season. I’ll beef up my supplies for baking bread. If a disruption starts looking more likely locally, I’ll even add some frozen veggies to my stockpile, but for now I’m going to rely mostly on my ongoing CSA supply.

But I’m not going to rush out and buy an N95 respirator facemask. The current recommendations from CDC do not recommend facemasks for the general public. They are only recommended for people who are sick or for those who are caring for someone who is sick. This and the other CDC recommendations for treatment and prevention can be found on this helpful page.

The key thing to remember in trying to avoid catching COVID-19, as described in the video above and on the CDC page linked just above, is to avoid being very close to sick people. The guideline mentioned is six feet. If you see someone who looks symptomatic, it shouldn’t be too hard to stay six feet from them. Also, if the virus is known or suspected to be in the area where you are, be especially careful to keep your hands below your shoulders at all times and to wash your hands frequently if visiting public places. As CDC describes here, transmission is thought primarily to be through aerosol droplets such as sneezes and coughs, but it remains possible that the virus could be picked up by touching contaminated surfaces.

Finally, people are also quite concerned about the prediction discussed here by Professor Marc Lipsich, an epidemiologist at Harvard. He has stated that it’s possible that a COVID-19 pandemic could result in 40-70% of people world-wide becoming infected. As Lipsich points out, however, that estimate must be coupled with the realization that we currently have no good estimate for what percentage of people who become infected develop few or no symptoms. In fact, moving out from his discussion, there currently are widely ranging estimates of what percentage of infected people die. Inside Wuhan, where the virus first emerged, estimates now are that 2.8% of those infected die. Outside Wuhan, however, that number drops to 0.18%, a difference of over 15-fold. For a discussion of how early we are in the process of understanding the epidemiology of this virus and why these numbers differ, see this paper.

For perspective, it appears that COVID-19 spreads far more efficiently than SARS and MERS, but conversely, SARS and MERS killed a higher percentage of those infected. We see more COVID-19 deaths because many more people have been infected.

The featured image for this post is in the public domain and comes from CDC. Here is the caption CDC provides: “This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses. Note the spikes that adorn the outer surface of the virus, which impart the look of a corona surrounding the virion, when viewed electron microscopically. A novel coronavirus, named Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), was identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in 2019. The illness caused by this virus has been named coronavirus disease 2019 (COVID-19).” Credit for the image goes to Alissa Eckert, MS, Dan Higgins, MAM.

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.

CDC Director: “Zero Risk” to Passengers on Flights With Dallas Ebola Patient

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Although not yet widespread, panic and disinformation are emerging surrounding the case of the first patient to have been diagnosed with Ebola while in the United States. The worst of the hysteria surrounds the fact that Thomas E. Duncan flew from Liberia to the United States on a trip that required 28 hours, ending at the Dallas-Fort Worth airport on September 20. It is known that Duncan was screened in Liberia and found not to have a fever when he boarded the first flight. Persons infected with Ebola but not yet exhibiting symptoms are incapable of spreading the disease, primarily because the disease spreads through direct contact of mucous membranes or open wounds with bodily fluids and symptom-free patients are not yet vomiting or having diarrhea, so no virus-carrying fluids are being produced or at risk of being spread in ways that other people will come into contact with them.

On Tuesday, the Director of the CDC, Dr. Tom Frieden, stated outright that there is zero risk to passengers who were on a flight with Duncan:

A national public health official today said there was “zero risk of transmission” of Ebola on a commercial airline flight that a Dallas patient who has tested positive for the disease flew on from Liberia earlier this month.

Centers for Disease Control and Prevention Director Tom Frieden said today in a live briefing from Atlanta that the person — a male who remained unnamed — showed no symptoms before boarding the plane and was not contagious. The CDC doesn’t “believe there is any risk to anyone who was on the flight at that time,” he said.

Despite Frieden’s clear statement that other passengers face no risk, the press continued to hound CDC and the airlines until Duncan’s itinerary was released. While CBS was moderately responsible in their coverage of the flight information, the Daily Mail asked breathlessly in their headline whether YOU were on a flight with Duncan. Even more incredibly, stocks in US airlines were dumped yesterday in response to the news of Duncan’s flights:

Investors were also selling stocks following news that the first case of Ebola had been diagnosed in the U.S. Investors dumped airline stocks and bought a handful of drug companies working on experimental Ebola treatments.

The story of just how Duncan became infected is a sad one. On September 15 (recall that he left Liberia on the 19th and arrived in Dallas the 20th), Duncan helped neighbors take their 19-year-old daughter to the hospital. Sadly, the hospital was already overwhelmed with patients and she was turned away, only to die early the next morning after returning:

In a pattern often seen here in Monrovia, the Liberian capital, the family of the woman, Marthalene Williams, 19, took her by taxi to a hospital with Mr. Duncan’s help on Sept. 15 after failing to get an ambulance, said her parents, Emmanuel and Amie Williams. She was convulsing and seven months pregnant, they said.

Turned away from a hospital for lack of space in its Ebola treatment ward, the family said it took Ms. Williams back home in the evening, and that she died hours later, around 3 a.m.

Mr. Duncan, who was a family friend and also a tenant in a house owned by the Williams family, rode in the taxi in the front passenger seat while Ms. Williams, her father and her brother, Sonny Boy, shared the back seat, her parents said. Mr. Duncan then helped carry Ms. Williams, who was no longer able to walk, back to the family home that evening, neighbors said.

The hospital in Dallas where Duncan is being treated has received a lot of criticism because he first went there on September 26 but was sent home when only exhibiting a low grade fever:

When Mr. Duncan first arrived at the hospital last Friday, six days after he had arrived in America, he told a nurse that he had come from West Africa. Public health officials have been urging doctors and nurses to be on the alert for Ebola in anyone who has been in Guinea, Liberia or Sierra Leone. But information about Mr. Duncan’s travel was not “fully communicated” to the full medical team, said Dr. Mark Lester, executive vice president of Texas Health Resources, the parent organization that oversees Texas Health Presbyterian Hospital.

As a result, that information was not used in the clinical diagnosis and Mr. Duncan was sent home, with the diagnostic team believing he simply had a low-grade fever from a viral infection, Dr. Lester said.

Those with whom Duncan had contact from the time of the onset of his symptoms until he returned the hospital on September 30 28 (corrected; September 30 was when tests confirmed Ebola after he returned to the hospital on September 28) in much worse condition and was then isolated are being monitored for signs that they may be infected:

Officials said Wednesday that they believed Mr. Duncan came into contact with 12 to 18 people when he was experiencing active symptoms and when the disease was contagious, and that the daily monitoring of those people had not yet shown them to be infected.

The incubation period (the time between exposure to the disease and the onset of symptoms in an infected person) for Ebola varies from 2 to 21 days. Recall that Duncan was exposed on September 15 and visited the hospital for the first time on September 26, so his incubation period was around eleven days. We are now around six days into the time since Duncan first visited the hospital, so those with whom he came into contact will need to be monitored for for another two weeks or so until at least 21 days have passed since their last contact with Duncan.

While there is some chance that one or more of those with whom Duncan had contact while he was contagious will become infected, as long as everyone who was in contact with him during that critical period is under observation now, there is virtually no chance of the disease spreading outside that small group of people. And you can rest assured that nobody from any of the flights Duncan was on will come down with disease from exposure to him.

CDC Modeling Demonstrates Importance of Intervention in Ebola Outbreak

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Helpful graphic from WHO illustrating precautions to prevent infection while traveling. Click on image to see a larger version.

Helpful graphic from WHO illustrating precautions to prevent infection while traveling. Click on image to see a larger version.

As the Ebola outbreak in West Africa continues to grow, fresh attention was focused on it yesterday when the CDC announced that in a mathematical model they developed of the outbreak, failing to intervene in spread of the virus could lead to as many as 1.4 million people infected by late January. Somewhat lost in the response to the “wow factor” of a projection of over a million people being infected is that the model also very powerfully demonstrates how the viral outbreak can be contained simply through moderate adoption of the most basic aspects of an infection control program.

First, to review from my previous Ebola post, Ebola is only transmitted when bodily fluids of infected or dead individuals come into contact with broken skin or mucous membranes.

The key to preventing spread of the virus is for those who care for infected patients, whether they are health care workers at a hospital or family members in the home, is preventing contact with fluids from the patient. CDC has prepared an informative guidance document for how health care workers can control the spread of Ebola in their facilities. The key steps are to provide protective clothing to cleaning staff, use an effective disinfectant, avoid re-use of materials with pourous surfaces and dispose (as regulated medical waste) of all textiles, linens, pillows and mattresses that may be contaminated.

Because practices such as these are routinely implemented in US health facilities when patients with high risk infectious diseases are being treated, there is little to no chance of Ebola spreading within the US. As noted in the previous Ebola post, the extreme poverty of the health care systems in the affected countries in Africa is what has allowed the disease to spread, as health care facilities there simply cannot afford the materials they need for implementing safe practices.

Here is the output of the model for Ebola spread in Liberia and Sierra Leone if infection control is not implemented beyond the current level. As noted in the NYTimes article linked above, the current estimate is that 18% of patients in Liberia and 40% of patients in Sierra Leone are treated in facilities that prevent spread of the virus. The model predicts both the number of infected patients in the two countries and the number of beds devoted to care of those patients (“corrected” means that the estimate for number of infected individuals is corrected for the assumption that 2.5 times more patients are infected than have been officially reported):
no intervention

As noted above and widely cited in the press yesterday, if the virus outbreak is left unchecked, the model predicts a cumulative total 1.4 million infected patients in the two countries by January 20 (many of whom are dead by then) and a need for up to 100,000 beds for treatment of these patients.

The good news that is buried in the CDC model is that stopping the virus outbreak does not require implementation of virus control measures for treatment of every infected patient. In the graphs below, we see the output from the model under the assumption that viral control practices start to be implemented now and expand to a level of 70% of infected patients (25% of them in hospitals and 45% in home treatment) being treated under safe practices by December:
intervention

Note that the cumulative number of cases levels off between 25,000 and 30,000 and the total number of beds needed peaks at around 13,000  1300 before dropping rapidly.

This model demonstrates very clearly that the highest priority for stopping the Ebola outbreak should be rapid and widespread implementation of basic infection control practices. Spreading this information into homes where patients are being treated is key. Convincing families of the importance of removing infected clothing and bedding seems likely to be the pivotal aspect of the public information campaign. Help from the West will be essential in providing the huge amount of disposable protective clothing and the necessary cleaning and disinfecting supplies. Replacement clothing, linens, mattresses and pillows should be provided as many of the affected families will be hard-pressed to replace these items under the already difficult conditions of an infected family member.

Further good news is that these projections were based on conditions in August and there is reason to believe that the situation may already be getting better. From the Times, again:

The caseload projections are based on data from August, but Dr. Thomas R. Frieden, the C.D.C. director, said the situation appeared to have improved since then because more aid had begun to reach the region.

“My gut feeling is, the actions we’re taking now are going to make that worst-case scenario not come to pass,” Dr. Frieden said in a telephone interview. “But it’s important to understand that it could happen.”

Let’s hope that Dr. Frieden is correct.

CIA, Pakistan Taliban Bring Fighters to Syria…and a Global Polio Emergency

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Recall that last fall, Barack Obama spent some time altering the public record on when CIA-trained death squads first entered Syria to move the date from just before the Ghouta sarin attack to just after (while also trying to shrink the size of those first groups). But the US was a month behind Pakistan’s Taliban, who also sent fighters to Syria, ostensibly on the same side as us this time, to fight pro-Assad forces. But while these efforts on the same side in Syria are having little success as Assad remains in power and might even be gaining the upper hand, the work of the CIA and Taliban on opposite sides in Pakistan has produced a devastating result, with the World Health Organization announcing yesterday that it has declared a Public Health Emergency of International Concern over the spread of polio to countries where it previously had been eradicated:

After discussion and deliberation on the information provided, and in the context of the global polio eradication initiative, the Committee advised that the international spread of polio to date in 2014 constitutes an ‘extraordinary event’ and a public health risk to other States for which a coordinated international response is essential. The current situation stands in stark contrast to the near-cessation of international spread of wild poliovirus from January 2012 through the 2013 low transmission season for this disease (i.e. January to April). If unchecked, this situation could result in failure to eradicate globally one of the world’s most serious vaccine preventable diseases. It was the unanimous view of the Committee that the conditions for a Public Health Emergency of International Concern (PHEIC) have been met.

Although fundamentalist Islamic groups have long accused vaccination campaigns, and especially polio vaccinations, of being efforts by the West to sterilize Muslims, the very high profile case of Dr. Shakeel Afridi carrying out a hepatitis vaccination ruse on on behalf of the CIA in an effort to obtain blood samples from Osama bin Laden’s compound in Abbottabad provided a refreshed incentive for attacks on vaccine programs.

Marcy pointed out the stupidity of Leon Panetta’s confirmation that Afridi worked with the CIA in the ruse the day before Panetta’s 60 Minutes segment ran:

Not only does this presumably put more pressure on Pakistan to convict Afridi of treason (he remains in custody), but it exacerbates the problem of having used a vaccination campaign as cover in the first place, confirming on the record that similar campaigns in poor countries might be no more than a CIA front.

I presume someone in the White House gave Panetta permission to go blab this on 60 Minutes; I assume he’s in no more legal jeopardy than Dick Cheney was when he insta-declassified Valerie Plame’s identity.

But shit like this discredits every single claim national security experts make about the need for secrecy. I mean, how are CIA officers ever going to recruit any more assets when the assets know that the CIA director may, at some time in the future that’s politically convenient, go on 60 Minutes and confirm the relationship?

Afridi was eventually sentenced to 30 years imprisonment, not on treason but on other dubious charges and in a shopped venue. And the fallout in Pakistan’s tribal areas from US confirmation of the vaccination ruse was exactly as might be expected: multiple deadly attacks on polio vaccine workers and many new cases of paralyzed children.

While the polio virus circulating in Syria doesn’t appear to have come directly with the Taliban fighters sent from Pakistan, it is indeed a strain from Pakistan’s tribal areas that is in Syria now:

Thirteen cases of wild poliovirus type 1 (WPV1) have been confirmed in the Syrian Arab Republic. Genetic sequencing indicates that the isolated viruses are most closely linked to virus detected in environmental samples in Egypt in December 2012 (which in turn had been linked to wild poliovirus circulating in Pakistan).

WHO is recommending drastic measures, primarily calling for all travelers from Pakistan, Cameroon and Syria to be vaccinated for polio, preferably at least four weeks prior to international travel, but at least at departure if it hasn’t been done earlier. WHO is also calling for increased efforts in vaccinations in countries (Afghanistan, Equatorial Guinea, Ethiopia, Iraq, Israel, Somalia and Nigeria) where the virus is known to be present but from which transmission has not been seen.

So the fears from two years ago on the impact of the CIA’s actions on polio eradication are now met. But keep in mind that it’s not just vaccine programs that were put at risk by this incredibly stupid move. A large alliance of humanitarian groups complained directly to the CIA that all humanitarian groups were put at risk by the move, since the CIA ruse was carried out under cover of a humanitarian organization. Will John Brennan be able to heed this advice?

More Fallout From Hakimullah Mehsud Drone Killing: Polio Vaccines Halted in Waziristan

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Yesterday, we got the tremendous news that after having lead the world in the number of polio cases as recently as 2009, the World Health Organization announced that there have been zero polio cases in India for three consecutive years. In today’s Express Tribune, we see a discussion of whether and how Pakistan can now rise to the challenge of polio eradication. In the article, we learn that the US drone killing of Pakistan Taliban leader Hakimullah Mehsud not only disrupted the developing plans for peace talks between the Taliban and Pakistan’s government, but it also affected polio vaccinations in North and South Waziristan:

According to the State Minister for National Health Services, Regulations and Coordination Saira Afzal Tarrar, NWA and South Waziristan did not receive any immunisation in months, contrary to former North Waziristan Agency (NWA) surgeon Jan Mir Khan, who was part of recent polio efforts. “After the drone strike that killed Hakimullah, it all stopped. Not just the peace talks, but also our efforts,” she says.

The terrible impact of the CIA’s vaccination ruse employing Dr. Shakeel Afridi in the search for Osama bin Laden has been extensively documented here, but this is the first time I have seen a suggestion that backlash to a drone strike directly resulted in polio vaccines being denied to children. Tarrar is not ready to give up, however, and believes that Pakistan and the Taliban will eventually come to an agreement that will allow vaccinations to resume:

Saira Tarrar also emphasised that the people of the area need to be part of the solution. “Parents are now sick of the ban; this pressurises the Taliban.”

“There is an accessibility problem in Fata, but by 2014, we will get a bargain and get some access.” And access is key, as far as Elias Durray, the head of Polio Eradication at the World Health Organization in Pakistan is concerned. “Immunisation prevents circulation. The virus won’t vanish on its own.”

Let us hope that Pakistan can achieve full vaccine coverage and have polio disappear as quickly in Pakistan as it did in India. Of course, this will require the US actually letting peace negotiations between the Taliban and Pakistan come to fruition, so success is far from guaranteed.