In all fairness, some things went very well during America's first experience with Ebola virus infection. The state and county health departments in Texas effectively collaborated with the Centers for Disease Control and Prevention (CDC) to ensure that all of Thomas Duncan's community contacts in Dallas were isolated; this helped ensure there would be no outbreak in the city. In this sense, they did a great job.
However, vulnerability was also exposed among our nation's acute-care and community hospitals. Duncan tragically died, and two ICU nurses who cared for him were exposed and infected with Ebola. There were uncertainties about which contacts needed isolation and whether they should have been prevented from traveling. This in turn revealed limitations in our public health system to restrict a highly mobile US population.
New US Ebola Czar Ron Klain will need to carefully weigh what worked and what needs improvement. And to do that, it will be helpful to return to first scientific principles.
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We can actually predict the course of epidemics. It requires understanding of two things: How the disease agent is transmitted, and what happens after it infects a person or animal. Ebola is no different; we can assess what went right and what went wrong these last few weeks by better understanding its medical virology. Doing so also provides key lessons learned in the event of more Ebola patients entering the United States.
In the first one to two weeks following initial infection, a person harboring the Ebola virus has no symptoms. However, this period is followed by the onset of fever and what is often called a "flu-like" illness. During this early phase an infected individual still has a very low amount of virus in her body, and the risk of transmission is extremely low. This explains both why airline passengers are seldom at risk for acquiring Ebola from a recently exposed or infected individual, and why after isolating Duncan's contacts and then placing them in quarantine, we did not see an Ebola virus outbreak in Dallas.
It's okay for a non-physician to serve as the White House Ebola Czar, who needs to first and foremost have extraordinary management and organizational capabilities, and be able to integrate many different sectors.
But then the grace period ends. The real problem with Ebola infection arises when a patient becomes sick enough to require hospitalization. The Ebola virus produces a protein that deceives the body's defenses, which fail to fully recognize the presence of the virus. As a consequence, an infected person cannot respond adequately to the virus in order to produce sufficient quantities of a protein known as interferon, which is the body's first line of defense against most viruses. The end result is that the Ebola virus replicates massively.
By the time a patient is sick in an ICU bed, her body is teeming with billions and billions of virus particles — I sometimes refer to a person severely ill with Ebola as a "bag of virus." This helps us understand why ICU nurses and doctors are at high risk of acquiring Ebola. According to CDC Director Tom Frieden, things may have been made even worse in Duncan's case because he required invasive procedures that may have helped to disseminate additional virus particles into the environment, and possibly also prolong the period when the virus could proliferate even further.
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So what are the lessons learned? Taking care of sick Ebola patients is an extremely complicated endeavor. Practically speaking, this means that while any hospital in the United States should be able to safely identify, isolate, and diagnose an Ebola patient, there are only a handful of American facilities that should venture to take care of sick patients in an intensive care setting. Right now, only four such facilities are available: Emory University Hospital in Atlanta, the University of Nebraska Medical Center in Omaha, the US National Institutes of Health (NIH) Clinical Center outside Washington, DC, and St. Patrick Hospital and Health Sciences Center in Missoula, Montana, located near NIH's Rocky Mountain Laboratories. Yesterday, Texas Governor Rick Perry announced that two more will be established in the state.
Once a hospital isolates and diagnoses a suspected Ebola patient, the hospital must transfer the patient safely and quickly to one of these specialized facilities; this would maximize the safety of both the patient and the nurses, doctors, and other healthcare providers. Unless a large epidemic occurs — I don't believe one will — it is unfair and unrealistic to ask most acute-care and community hospitals to manage and treat complicated Ebola patients.
Another advantage to focusing on specialized treatment facilities? They have experience with obtaining and administering new investigational and experimental drugs not yet licensed by the FDA. Currently, available Ebola drugs include two new antivirals — brincidofovir and favipiravir — and either plasma or serum from recovered Ebola patients; alternatively, a specialized immune globulin can be prepared from recovered patients. Such potentially life-saving pharmaceuticals work best if they are given early in the patient's illness when the amount of virus in his body has not yet reached maximal levels.
Beyond the necessity of specialized treatment hospitals, the US needs a coordinated and integrated national crisis response. We have seen how disruptive even a single Ebola patient can be to not only the public health infrastructure but also to transportation, law enforcement, environmental control, and even the economy.
This is why it's okay for a non-physician to serve as the White House Ebola Czar, who needs to first and foremost have extraordinary management and organizational capabilities, and be able to integrate many different sectors, and one who can successfully integrate many different sectors.
That said, the country also needs a physician in a leadership position who can communicate regularly with the public during a health crisis. This task has long been an important role for the US Surgeon General, and the country has paid the price for not having a permanent one in place who is empowered with a measure of independence by the White House and who can free up the CDC Director to focus more on fighting disease. Confirming a surgeon general needs to be a priority.
Peter Hotez, MD, PhD is Dean of the National School of Tropical Medicine and Texas Children's Hospital Endowed Chair in Tropical Pediatrics at Baylor College of Medicine in Houston. He is also President of the Sabin Vaccine Institute and a Baker Fellow in Disease and Poverty at Rice University. Follow him on Twitter: @PeterHotez
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