Ebola part 3: FOR THE LOVE OF GOD DON'T PANIC!

[Aemon Stark]

Like I said, I agree with you. And yes, that's more or less the answer I was looking for. There's enough evidence that low grade fever or elevated temperature or whatever you want to call it, is one of the early symptoms, and absent any other symptoms like diarrhea or vomiting, probably means that there's a low risk of transmission. I would classify both 100.4F and 99.5F in the low risk of transmission category. My only point, and it's clear that there are people who disagree, is that it doesn't make sense to claim that there is zero risk at 99.5F while maintaining that there is a risk at 100.4F.

Sorry, what data are you basing your risk assessment on?

[Swordfish]

No, I wasn't creating a straw man, just making an observation.

ha. An observation of an argument that no one has made. but whatever. It's not even important.

Second, yes, trust CDC.

Ok. So since the nurse did just that, then you have no issue with her boarding the plane? Or... What, exactly? i mean, we wouldn't want her to start a panic by ignoring their advice, now would we? What if that became public!!!

:cheers:

It would be utter mass panic without them and they are acting in the best interest of the country. Just remember, it was always expected that we would have cases here. You also need to consider the role of hospitals in this. CDC can't do it all. The other factor is that it's all well and good to analyze from the safety of a keyboard, but we are dealing with something that's never been dealt with in this country before. AIDS comes closest to the media scrutiny and criticism we're seeing now.

Well.. Yes. That's exactly my point, and has been all along.

Because we've never dealt with it before, there are bound to be mistakes. Apparently a lot of them.

Hence a lot of peoples concern (not panic) about the disease.

I really don't see what's so complicated about that.

Additionally, when you have public officials saying there's almost no risk of certain things, and then those things happen, or that 'we have protocols for this so there's no reason to worry', and then there's a new infection or mistake being made every day, you have a major credibility problem on your hands.

[Mudguard]

Sorry, what data are you basing your risk assessment on?

There's little data to be had for this disease to begin with, and what we do have isn't that clear. A lot of the risk assessment is based on common sense. Is there a rational explanation for assigning a substantially different level of risk to a person with a temp of 100.4 and a person with a temp of 100.3F? We are really beating a dead horse here, and TerraPrime laid out the reasoning.

But if you want some hard data, here's an excerpt from one paper:

Clinical Manifestations and Case Fatality Rate

Table 1 provides information on demographic characteristics and symptom frequency in patients with confirmed or probable EVD with a definitive outcome in Guinea, Liberia, Nigeria, and Sierra Leone. The most common symptoms reported between symptom onset and case detection included fever (87.1%), fatigue (76.4%), loss of appetite (64.5%), vomiting (67.6%), diarrhea (65.6%), headache (53.4%), and abdominal pain (44.3%). Specific hemorrhagic symptoms were rarely reported (in <1% to 5.7% of patients). “Unexplained bleeding,” however, was reported in 18.0% of cases. These patterns are similar in each country (see Supplementary Appendix 1).

So in about 13% of the cases, a fever wasn't reported in patients with confirmed or probable ebola. Sure, there are many possible explanations that can try to explain why fever wasn't always reported, but you can't say with any surety that all the potential sources of error account for the 13%.

Can you provide any data that proves that there's a significant difference in risk between 100.4 and 99.5 or 100.3F?

ETA: added a link to the full paper which was published in the New England Journal of Medicine this August very recently.

[Aemon Stark]

There's little data to be had for this disease to begin with, and what we do have isn't that clear. A lot of the risk assessment is based on common sense. Is there a rational explanation for assigning a substantially different level of risk to a person with a temp of 100.4 and a person with a temp of 100.3F? We are really beating a dead horse here, and TerraPrime laid out the reasoning.

But if you want some hard data, here's an excerpt from one paper:

So in about 13% of the cases, a fever wasn't reported in patients with confirmed or probable ebola. Sure, there are many possible explanations that can try to explain why fever wasn't always reported, but you can't say with any surety that all the potential sources of error account for the 13%.

Can you provide any data that proves that there's a significant difference in risk between 100.4 and 99.5 or 100.3F?

ETA: added a link to the full paper which was published in the New England Journal of Medicine this August very recently.

I don't understand what you're asking. You need to familiarize yourself with concepts like sensitivity and specificity. A symptom is considered x% "sensitive" for a disease if x% of confirmed cases exhibit said symptom. So what your data suggests is that the sensitivity of fever in Ebola virus disease is 87%. That's actually pretty high.

On the other hand, sensitivity refers to the percentage of people without a disease who do NOT have a certain symptom. Unfortunately, lots of people have fevers (actual fevers) for many reasons other than Ebola virus disease, which is what's meant when we call fever a "non-specific" symptom.

What this means that a suspect Ebola case requires not only clinical symptoms (the more the better) but also an exposure history. The combination of symptoms and exposure greatly increases the probability of confirmed Ebola virus disease.

In the case we're discussing, we have a potential exposure history but no confirmed symptoms. In that situation, further monitoring is appropriate. Whether a temp of 37.5 should have been considered as a reason not to embark on a flight is debatable. After all, some 13% of confirmed Ebola virus disease cases won't even present with fever.

[Mudguard]

I don't understand what you're asking. You need to familiarize yourself with concepts like sensitivity and specificity. A symptom is considered x% "sensitive" for a disease if x% of confirmed cases exhibit said symptom. So what your data suggests is that the sensitivity of fever in Ebola virus disease is 87%. That's actually pretty high.

On the other hand, sensitivity refers to the percentage of people without a disease who do NOT have a certain symptom. Unfortunately, lots of people have fevers (actual fevers) for many reasons other than Ebola virus disease, which is what's meant when we call fever a "non-specific" symptom.

What this means that a suspect Ebola case requires not only clinical symptoms (the more the better) but also an exposure history. The combination of symptoms and exposure greatly increases the probability of confirmed Ebola virus disease.

In the case we're discussing, we have a potential exposure history but no confirmed symptoms. In that situation, further monitoring is appropriate. Whether a temp of 37.5 should have been considered as a reason not to embark on a flight is debatable. After all, some 13% of confirmed Ebola virus disease cases won't even present with fever.

Here's a more straightforward article from Harvard Medical School:

The 98.6° F “normal” benchmark for body temperature comes to us from Dr. Carl Wunderlich, a 19th-century German physician who collected and analyzed over a million armpit temperatures for 25,000 patients. Some of Wunderlich’s observations have stood up over time, but his definition of normal has been debunked, says the April issue of the Harvard Health Letter. A study published years ago in the Journal of the American Medical Association found the average normal temperature for adults to be 98.2°, not 98.6°, and replaced the 100.4° fever mark with fever thresholds based on the time of day.

Now, researchers at Winthrop University Hospital in Mineola, N.Y., have found support for another temperature truism doctors have long recognized: Older people have lower temperatures. In a study of 150 older people with an average age of about 81, they found that the average temperature never reached 98.6°. These findings suggest that even when older people are ill, their body temperature may not reach levels that people recognize as fever. On the other hand, body temperatures that are too low (about 95°) can also be a sign of illness.

The bottom line is that individual variations in body temperature should be taken into account, reports theHarvard Health Letter. Ideally, you and your doctor should have enough temperature measurements at various times of day to establish a baseline for you. Short of this, recognize that 98.6° isn’t the benchmark that we’ve long believed it to be.

So, people can be ill without ever reaching a temperature of 100.4F. Not sure what's hard to understand about people being potentially infectious (admittedly at low risk) while being ill and having a temperature below 100.4F.

If you have data that contradicts this, I'd love to see it.

[Aemon Stark]

I just fucking said that 13% of people with confirmed Ebola virus disease don't have any fever. So, if you actually read my reply, you'd know that I agree with that.

And, thanks, but I'm also well aware of atypical disease presentations in the elderly. Almost like I learned that on geriatrics rotations (and earlier lectures) in medical school, to say nothing of the dozens of octogenarian pneumonia patients I've admitted as a resident.

[Mudguard]

I just fucking said that 13% of people with confirmed Ebola virus disease don't have any fever. So, if you actually read my reply, you'd know that I agree with that.

And, thanks, but I'm also well aware of atypical disease presentations in the elderly. Almost like I learned that on geriatrics rotations (and earlier lectures) in medical school, to say nothing of the dozens of octogenarian pneumonia patients I've admitted as a resident.

My apologies, but I can't follow where your point of disagreement (I'm assuming there is one somewhere) is then.

Your reply started like this:

I don't understand what you're asking. You need to familiarize yourself with concepts like sensitivity and specificity. A symptom is considered x% "sensitive" for a disease if x% of confirmed cases exhibit said symptom. So what your data suggests is that the sensitivity of fever in Ebola virus disease is 87%. That's actually pretty high.

My question that you didn't understand was this:

Can you provide any data that proves that there's a significant difference in risk between 100.4 and 99.5 or 100.3F?

And you wanted some data for my risk assessment.

So to make sure I follow you, what are your specific disagreements with my position and what data are you looking for?

[The Fallen]

What is your contention, that the threshold should be lowered to 99.5?

[Shryke]

What is your contention, that the threshold should be lowered to 99.5?

That we should be more afraid and that the CDC is terrible seems to be the overall thrust.

[WrathOfTinyKittens]

So, wise board, I am here at ground zero in Dallas. Exactly how much "not panicking" should I do? Because I have to agree that this is following the script of a zombie story pretty closely at this point.

Dumb question: exactly how dangerous is Ebola? Is it a death sentence? I know it can't be "cured" but can it be effectively controlled in an infected individual until he/she is able to get better?

[The Fallen]

That we should be more afraid and that the CDC is terrible seems to be the overall thrust.

I never get the hysterics. Even if the situation has deteriorated to epidemic level hysteria is the last thing we need.

At this point, three cases in a population of over 300 million is not cause for us walking around in hazmat suits.

[Fez]

So, wise board, I am here at ground zero in Dallas. Exactly how much "not panicking" should I do? Because I have to agree that this is following the script of a zombie story pretty closely at this point.

Dumb question: exactly how dangerous is Ebola? Is it a death sentence? I know it can't be "cured" but can it be effectively controlled in an infected individual until he/she is able to get better?

Historical mortality rate is 51%, mortality rate this time seems to be 70% (not that this necessarily means its gotten worse, there was an outbreak in Congo a few years back with a 90% mortality). All there really is to do is to keep patients hydrated and comfortable. There's no evidence stuff like blood transfusions or the various antibiotics work, but it doesn't seem like they hurt at least. And its known within a couple weeks if a patient will survive or not, the virus' course moves very fast (although if you do survive, and you're a man, don't have sex for about two months; apparently the virus remains in semen for up to seven weeks after its gone from other fluids).

Unless you have close personnel contact with healthcare workers at that Dallas hospital, or have such contact with those who do, I don't think the fact that you're in Dallas means you should be any more concerned than the rest of us. Which is to say, you should be concerned; but don't think that its about to sweep through the streets of Dallas. I'd say the warning sign that things are legitimately spiraling out of control is if we start seeing a lot of third generation infections, where the healthcare workers are spreading Ebola to other people. Since we haven't seen any yet, I think its okay to just be pissed off at how incompetent and hubristic everyone involved seemed to be.

[Aemon Stark]

I think this video is pertinent:

http://youtu.be/p4m-lNi61Rk

(bad quality sadly)

[daskool]

So, wise board, I am here at ground zero in Dallas. Exactly how much "not panicking" should I do? Because I have to agree that this is following the script of a zombie story pretty closely at this point.

Dumb question: exactly how dangerous is Ebola? Is it a death sentence? I know it can't be "cured" but can it be effectively controlled in an infected individual until he/she is able to get better?

Don't know, the numbers coming out of Africa, overall number of infections and mortality rates, are known to be complete bullshit. If a patient is put on inotropes and a ventilator and closely monitored in an ICU then it might be less than 50% mortality. Unfortunately if there's a major outbreak in the U.S. that option will not be available to the vast majority.

[davos]

I still am confident that the chances are remote that Ebola will spread significantly in this country. The fact that, to date, none of Mr Duncan's family members who were in close contact with him for some days after he developed symptoms (he was apparently quite ill by the time of the second trip to the hospital) strongly supports the assertion that Ebola is actually difficult to catch except under specific conditions (contact with bodily fluids from a patient in the latter stages of the disease). The fact Ebola patients have been successfully treated in both Nebraska and Atlanta without apparent transmission to health care workers suggests that it is indeed possible to treat Ebola if not safely, as working with this organism can never be truly safe) with a minimum of risk.

That being said, the multiple errors made by in handling the disease have increased the potential for an outbreak of an outbreak of significance from near zero to extraordinarily unlikely. A number of mistakes have been made that added together have created unnecessary risk. Obviously, most of the blame can be laid at the feet of the Dallas hospital and public health officials in Dallas. The CDC has made errors that I would have have expected of it. While the anger directed at them is part of the panic and fear that has infected the nation in a rate Ebola could not dream of achieving, there are legitimate criticisms of how it has handled the situation. Most likely, these problems have their roots in funding cuts. Overall the CDC has been doing a difficult job well, and I suspect that once this current situation is tied up, the CDC will have shown itself as the quality organization that it is. Disease control is a very difficult thing and they are generally very good at it. It should have taken steps to prevent those exposed Mr Duncan from flying and it should have been more involved in his care from the beginning.

Still, we have strong reason that the general public can be successfully protected from Ebola Virus. I am not unconcerned anymore, but my concern remains very muted. My focus remains on Africa, where we have a building disaster of significant proportions.

[Relic]

Breaking story - someone working for Fox News has common sense!
http://m.huffpost.com/us/entry/5992510?ncid=fcbklnkushpmg00000063

"You should have no concerns about Ebola at all. None. I promise," stated Smith. He went on to tell viewers, "Do not listen to the hysterical voices on the radio and the television or read the fear-provoking words online. The people who say and write hysterical things are being very irresponsible."

He explained: "We do not have an outbreak of Ebola in the United States. Nowhere. We do have two healthcare workers who contracted the disease from a dying man. They are isolated. There is no information to suggest that the virus has spread to anyone in the general population in America. Not one person in the general population in the United States."

The Fox News host emphasized that political gamesmanship is skewing media coverage. "With midterm elections coming, the party in charge needs to appear to be effectively leading. The party out of power needs to show that there is a lack of leadership," said Smith.

Smith stressed, "I report to you with certainty this afternoon that being afraid at all is the wrong thing to do." He called media-stoked Ebola panic "counterproductive", saying that it "lacks basis in fact or reason."

He acknowledged that Ebola is a serious problem in West Africa, as well as for the victims and their families in Texas, but he pleaded with media outlets to stop fear-mongering about Ebola in the U.S.

Spot on.

[Solmyr]

Breaking story - someone working for Fox News has common sense!

http://m.huffpost.com/us/entry/5992510?ncid=fcbklnkushpmg00000063

Spot on.

Wut?! You've just put in question everything I thought I knew of the US, its political parties and their respectively controlled media...

[Shryke]

Wut?! You've just put in question everything I thought I knew of the US, its political parties and their respectively controlled media...

You must just not be familiar with Shep Smith. He does his own thing every now and then on Fox News, bucking against the networks agenda. It doesn't really effect anything at all.

[daskool]

http://nypost.com/2014/10/16/alarm-after-vomiting-passenger-dies-on-flight-from-nigeria-to-jfk/

A plane from Nigeria landed at JFK Airport Thursday with a male passenger aboard who had died during the flight after a fit of vomiting — and CDC officials conducted a “cursory” exam before announcing there was no Ebola and turning the corpse over to Port Authority cops to remove, Rep. Peter King said on Thursday.

I can't tell you how reassuring it is to know that the CDC can tell an Ebola case by simply eye balling a dead body. The body of someone who'd flown in from West Africa and vomited his guts up before kicking the bucket.

[Mudguard]

What is your contention, that the threshold should be lowered to 99.5?

I've repeated my contention over and over already. That there is no magic temperature where a patient goes from not infectious to infectious. As a practical matter for screening purposes, you have to settle on a number, but it's not a number that is set based on degree of infectiousness. It's just a somewhat arbitrary way to classify people as showing fever and not showing fever.

As a demonstration of the arbitrariness and the fact that the threshold does move, some of the CDC's recent temperature guidelines specify the threshold at 101.5. And this.

Symptoms of Ebola include

• Fever (greater than 38.6°C or 101.5°F)

According to this, you don't have a symptom of ebola, from a fever perspective, if your temp is below 101.5F. So if you have a temp of 100.4F, no symptom, right? Why is everyone talking about 100.4F? Apparently, the CDC has changed the threshold. So why did the magical threshold change?