Statistically, when it comes to more Ebola cases arriving in North America, the question is not if, but when.
The CDC estimates that by January of 2015, there will be up to 1.4-million cases of Ebola in Western Africa. With over 100,000 residents here that hail from the affected countries of Liberia, Sierra Leone, and Guinea, travel between our geographies is common, and often only one airport connection away. Ebola has an incubation period of up to 21 days before symptoms appear, meaning that those who are infected will often feel completely well, and therefore safe to travel here to visit friends and relatives. Thus, many patients, similar to what occurred in the case of Thomas Duncan in Dallas, will only manifest illness well after their arrival on our shores. With over a million people likely to be infected within the next three months, and with so many of those remaining asymptomatic for weeks after their infection, it is almost statistically inevitable that we will have multiple, repeated cases of infected patients making their way here, unaware of their illness until it is too late.
Current airport and hospital screening is essentially useless
Current screening at our airports and hospitals relies on identification of two traits: a fever and a documented history of travel to affected countries. Fever is easily masked by medications such as acetaminophen and ibuprofen, and while it is difficult for visitors to lie about their travel history at airports, doing so at a hospital is easy and common. I can personally attest to the fact that patients infected with deadly viruses lie about their travel history, having been exposed to SARS in 2003 by a patient of mine that lied about his travel to an affected location, and thus misled me into believing he suffered only from a common flu.
Given that Thomas Duncan, who passed away from Ebola in Dallas, lied about his Ebola exposure before travel to the United States, it appears that similar dishonesty will be common in this outbreak as well. For these reasons, in addition to Ebola's long incubation period, our current screening techniques will miss a very significant percentage of infected travellers, and achieve little more than public reassurance.
Our experiences to date show that the average hospital is not adequately prepared to safely treat the illness, and that health care workers are at risk
Since the start of this outbreak, we have had two transmissions occur in hospitals outside of Africa to health care workers, one in Spain and one in Dallas, both due to staff who apparently breached safety protocols. However, donning and removing the full body protective gear required to safely care for an Ebola patient is an elaborate process, and one that the average health care worker receives minimal training in. I, myself, while familiar with the gear used, have never had any hands-on training as to the proper way to use such equipment for this virus. As a frontline Emergency Room physician, given that I am one of the most likely health care workers to encounter this illness firsthand, this terrifies me. Were an Ebola patient to arrive at my hospital tomorrow, I do not feel confident in my ability to put on, use, and take off protective gear in a manner that is foolproof.
In its earliest days, Ebola is indistinguishable from the flu
In Ebola's later stages, it is distinctive from other flu-like illnesses by its severity of symptoms, its high mortality rate (greater than 70 per cent), and its classic hemorrhagic manifestations, with patients often bleeding from their mouths, noses, and internal organs. However, at the onset of disease, the symptoms of Ebola are completely non-specific and flu-like: usually fever, muscle aches, headache, sore throat, vomiting and diarrhea. These are symptoms I see on a regular basis in my ER throughout the year. So should we ever have a widespread outbreak, with travel history becoming unnecessary for exposure, it will be near impossible for frontline physicians such as myself to distinguish patients with early Ebola from patients with the common flu. Such a situation would make the safe practice of frontline medicine near impossible, something I fear to imagine the consequences of.
So, what next?
While I still believe there is no cause for a general panic over Ebola, I feel that the approach being taken at present by our public health authorities is overconfident, dogmatic, and inflexible, with an unwillingness to consider that current containment measures may not be adequate. As a front line health care worker, I feel that my own safety is already at risk, and I can only hope that not very many more of us in my profession have to become ill in order for our governments to recognize that, in the setting of one of the largest disease outbreaks in modern history, plans limited to questionnaires and thermometers at airports may be far from sufficient to protect us.
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