by Tia Will
This is a three-part article. I have been asked to write an article on Ebola I have included some factual information about the disease, a description of our local precautions for the management of Ebola and my perspective on other impacts of “ Ebola preparedness” as they affect our community now and in the future.
Ebola infection is a disease caused by a specific type of virus. There are five known strains of this virus, which occur in various regions of Africa and are not known to occur naturally in other geographic areas. The strains have different favored hosts and different degrees of lethality to humans. These viruses are known to exist in fruit bats and primates and the killing and preparation of these animals for food is believed to be the principle means for initial human infection. This virus is not transmissible by mosquitoes or other insects. It is not transmissible by indirect human contact.
In human-to-human contact, the transmissibility (the ease of passing the virus from one person to the next) of the virus is quite low. Catching the virus from another individual requires that live virus, present in bodily fluids of the carrier must enter the body of the uninfected individual through either a mucous membrane such as the eyes, nose or mouth, or a break in the skin such as on the hands or face. Another very important point about the transmissibility of the virus is that it cannot be transmitted by asymptomatic persons. No symptoms, no transmissibility. This brings us to the basis for an effective containment strategy.
I will start with the system I know best, Kaiser Permanente. Within this health care delivery system we are blessed with the facilities, expertise, and funding to be able to take on this problem internally with consultation from local health authorities and the Centers for Disease Control (CDC).
Our approach is based on four principles and actions. Identify, isolate, protect, and escalate. In Davis, our response protocol is outlined below.
- Identify: All patients contacting our system for care will be asked at the point of initial contact be it a call center, the reception desk of a medical office building, or at point of entry to a hospital, two screening questions. The first is have you recently travelled to West Africa? The second is, do you have any of the symptoms associated with Ebola (check list read off and recorded by the initially contacted employee).
- Isolate: If the screening questions elicit a positive response, the individual will be asked to remain where they are, separate from other patients
- Protect: One designated, and fully trained member of our assessment team (3 doctors – 2 internists and one pediatrician) will suit up, escort the patient to a pre designated isolation room and perform a thorough history and examination. If the patient is identified as at risk they will move immediately through an escalation protocol.
- Escalate: The escalation protocol (which is continuously being updated to comply with NHS guidelines as more information is obtained) is currently as follows:
- A call is made from the isolation room initiating notification of security, nursing administration, our local Infectious Disease experts, the county infectious disease designee, the state infectious disease designee and the NHS.
- If there is a need for urgent care, that will be initiated by the individual provider already in protective gear on the spot. If the case is questionable and no immediate care is needed, infectious disease consultants will make the decision of whether the individual is a candidate for transport to our designated isolation unit located in our South Sacramento Hospital, which has the needed isolation and containment capability.
The Yolo County Department of Health Services protocols for dealing with Ebola are summarized on the following memorandum of October 21, 2014, which states in part:
The risk of an Ebola in the United States remains very low. There are no Ebola cases in Yolo County. The Yolo County Department of Health Services has been preparing, and will continue to prepare, for the unlikely chance that a person sick with Ebola comes to a Yolo County hospital.
The Yolo County Department of Health Services is in regular and frequent communication with local hospitals to share information about Ebola. These communications provide guidance from the Centers for Disease Control (CDC) and the California Department of Public Health (CDPH) about how to identify possible cases and prevent the spread of Ebola.
Hospital staff throughout Yolo County and the United States is routinely trained to put protections in place when dealing with contagious patients. Protections include gloves, waterproof gowns, facemasks and eye protection. These measures are very effective in preventing the spread of infection. The Department of Health Services continues to make recommendations to local hospital staff and emergency responders for proper personal protection equipment.
Full information including a flow sheet for county protocols is available on the Yolo County Department of Health Service web site.
All of these special preparations come at significant cost. Notification and fact sheets have been sent either electronically or by mail to all of our members. So far all Kaiser doctors have spent at least one hour in mandatory Ebola preparedness information sessions. Other local health providers have initiated similar plans.
Those in leadership roles have all spent at least one to three more hours in more detailed training. The first responders have spent still more time being trained in the safe use of their specialized personal protective equipment. And this does not include the many hours spent by upper level administrators including doctors, nursing staff, leadership of ancillary services such as EVS and security on Ebola preparedness planning, The cost of maintenance of the isolation rooms at each facility and the isolation / confinement ward at South Sacramento, we are looking at many hundreds of thousands of dollars spent in preparation for an extremely unlikely event. Similar preparations are occurring in other health care systems with similar costs.
There have been to date nine cases of Ebola ever diagnosed or treated in the United States. All have been directly linked to recent travel from, or care of an individual from, the known endemic area. None of them have been in Yolo County. None have been in California.
So let’s compare this with some with some other infectious diseases in California.
In the flu season of 2013-2014 there were reported to the CDHP, 7 fatal influenza cases in children, and 196 severe or lethal cases in adults under age 65. Ninety percent of flu related deaths are in people over age 65. Influenza is a much more common, potentially lethal, and highly human-to-human transmissible disease than is Ebola.
West Nile Virus is another concern in California. Although not transmissible human- to-human, it is a disease strongly related to human activities in terms of our individual and agricultural water management practices. Since the beginning of 2014, 604 human cases have been reported in California. There are active efforts to minimize the risk of West Nile Virus through the city of Davis working in conjunction with the Sacramento–Yolo Mosquito and Vector Control District.
Ebola, influenza, and West Nile viruses along with a large number of other infectious diseases or those strongly related to human behaviors are in competition for our attention and resources. We have a choice. We can assess the relative risk and allocate our resources effectively focusing on those problems most likely to affect large numbers of individuals in our community or we can respond emotionally and irrationally to headline-precipitated fears. The latter may course may result in feelings of safety based on the belief that “every effort” is being made and “no expense is being spared” to keep us safe.
Or we could make sound, risk and evidence based assessments of our needs knowing that we can never limit risk to zero. We could place our time, energy, efforts and dollars into those measures demonstrated to provide protection in our setting. We could focus on such tried and true primary prevention tactics as immunization, sick leave or other compensation or aide to enable children and workers to stay home when ill. We could provide education on means to protect one’s self, one’s children and other members of the community from transmissible diseases coupled with an ethic that rewards voluntary self-isolation behaviors rather than penalizing them. Money could be spent on development of vaccines and antivirals rather than on excessive numbers of isolation units and personal protective gear unlikely to ever be used.
Each choice we make for our protection and risk reduction carries with it both readily visible and unseen costs. Each allocation of resources means that those resources are not available for other pressing needs. It is my personal opinion that all needs should be taken into account when making any decision about where to allocate our limited resources. I welcome your questions and comments about my perspective.
* Due to the rapidly evolving situation and changing recommendations regarding best practices as more information is gathered, the precautions being enacted are current as of the time of this writing based on information from 10/24/14 and may have changed by the time you read this. If there is enough interest, I will be happy to update as I receive more information.
Tia:
I’m wondering if you were actually helping Ebola patients in Africa if you would fly back to Davis and immediately “Go for a run through the UCD Campus, go to the farmers market, and take a taxi to a bowling alley ” (like the NY MD that has Ebola did)?
I think it is great what doctors without borders do (a good friend’s sister keeps going back to Africa despite getting robbed and shot at over the years) but it seems to me (a non MD) that it might have been a good idea for the NY MD to lie low for a few days to see if he had any Ebola symptoms.
Yes SOD, would anyone want to be on an airplane, shared the same arm rest or used the same cramped restroom as that doctor? We should have an embargo on all flights to the Ebola stricken countries. Even other African nations have embargos or restrictions on flights to these countries.
South of Davis
I think that this is a very good question and worth a serious answer. I do not believe that running through the UCD campus, going to Farmer’s Market, or going bowling or taking a cab are dangerous activities for a person returning from West Africa as long as they are carefully self monitoring as this doc apparently was. The reason that I say this is a biologically known property of Ebola. Unlike many viruses which are transmissible prior to the patient having symptoms that they recognize ( such as herpes, or some strains of the flu which may have symptoms so mild that the individual is not aware that they are ill) Ebola spreads in a very predictable fashion. If the individual has no symptoms, the virus cannot spread to another person through casual contact. It requires contact with a bodily fluid containing the virus. I would find it irresponsible if he had done any of this activities if he had a fever. But he didn’t. He was monitoring his temperature and called at the slightest elevation ( 100.3 is considered low grade temperature elevation, and except for his known exposure would not be cause for alarm). Ebola only becomes dangerous to other individuals when it reaches the stage of viral shedding in the form of vomiting, diarrhea and bleeding. So in this case, the doctor was not being reckless in his actions.
Having said that, I am an extremely cautious sort. If it were me, I would have put myself on strict self quarantine for 21 days knowing that what I was doing had no scientific basis but was solely based on my unfounded concern that I might pose an infinitesimal risk to some one else.
Once again, no symptoms, no possibility of transmission.
The CDC let a Dallas nurse who had been exposed to the ebola patient Duncan fly on a commercial airline even though she contacted them and said she had a fever and it has been determined that she now has Ebola. How much confidence that that give everyone about the CDC?
You know who we should have confidence in? Donald Trump, that guys knows what he is talking about.
I guess you’re referring to Trump’s tweet that Obama should resign over the Ebola mess. Trump is as much of a fool as Obama, I don’t have much confidence in either.
That being said, Michelle, being that you have children would you be okay with them flying on an aircraft with someone who had treated an Ebola patient and was running a fever? Would you be okay with your children using the same small cramped aircraft restroom after them?
“How much confidence that that give everyone about the CDC?”
I do not believe that one judgement error on the part of one individual should be enough to condemn an entire agency.
Joe Biden’s aide Ron Klain who has no medical background is the new Ebola Czar. Now that guy knows what he’s talking about.
Statistically speaking my kids would be more likely to die from the plane crashing, or in a car accident on the way airport, then contracting Ebola.
I get this a scary disease, I just think we should base decision on rational facts then irrational fears, but clearly that is not how things operate.
I see you dodged the question?
It is easy to create “fear” scenarios. It’s more productive to statically determine how likely they are to happen. Would I be comfortable flying on a plane with someone who has been exposed to the Ebola virus and has symptoms, of coarse not. I also wouldn’t want to fly in a plane that has something wrong with the engine, or a pilot that didn’t get enough sleep the night before.
Pandering to people’s fear, to make money, or win votes, the way our politicians, and news media outlets do is shameless and destructive. It seems to make them money and win them votes, so sadly it appears this tactic works.
Pandering to fear? You just said you wouldn’t want to fly on a plane that had someone aboard who had Ebola. So obviously you fear it too. Are you pandering to fear?
Tia–as I understand it, transmission has been demonstrated to occur thru contact with bodily fluids after the infected person becomes symptomatic. However, the converse has not been conclusively demonstrated; i.e. that transmission cannot occur prior to exhibiting symptoms. There is a risk that presymptomatic patients may have a low level of virus shedding, such that is some low–but not zero–risk that they are transmissive (this scenario has not been conclusively ruled out; I don’t think there is enough info, to put probability bounds on this yet). Furthermore, not all Ebola patients exhibit high fever, even though their blood titer levels of Ebola are high; and thus presumably they may be a transmission vector without being symptomatic. The risk is likely low; but low is much different from zero.
I’ve also read from research abstracts that the virus can survive (within bodily fluids; blood or mucus droplets) on surfaces for several days or more at room temperature; longer at cooler temperatures (winter is coming). Such bodily fluids do not necessarily dry quickly (as for example water droplets do in nonsaturated air); coagulated proteins and cellular debris within the mucus/blood droplet can trap aqueous liquids (from evaporation), within which the virus can remain active (its my understanding the viral structure denatures and becomes irreversibly inactivated if it is not immersed in water). Furthermore drying slows greatly on humid rainy winter days; of course many rainy days have humidity of 100% or even be super-saturated, and small aqueous aerosol droplets might not have much of their water evaporate; particularly in view of the lower free energy of water in a hydrophilic disrupted cellular matrix/protein mixture.
In my view this survival of virus in bodily fluids distant from the host body (mucus and blood from sneezes, coughs, runny nose, etc.) on surfaces is something that warrants great caution and further research to more clearly define the risks. Would you want a late pre-symptomatic Ebola carrier (one, for example, who might start exhibiting noticeable symptoms later on in the evening that day) sitting next to you or talking to you to cough or sneeze at you? Would you feel comfortable using the ice-cream spoon they just ate from to take a spoonful of ice cream yourself? At this point it appears that the risk (with current known variants of the Ebola virus; which however mutates very rapidly) is small; but small is much different from zero.
A more humble attitude toward our knowledge of Ebola is taken by infectious disease expert Dr. Osterholm (link below), in contrast to the rather patronizing platitudes and ungrounded assurances offered by our politicians, CDC spokesman, and other public health spokesman (for whom the record shows political considerations clearly trump the delivery of accurate information to the public, and also trump the protection of the US population).
Dr. Michael Osterholm, Director of CIDRAP, University of Minnesota:
https://www.youtube.com/watch?v=NAKBtPWGO10
tribe USA
I have read Dr. Osterholm’s statements on this. While what you are saying about the ability of Ebola to live outside the human body in pooled fluids is true and it is also true that it has not been proven that one cannot obtain Ebola in these ways, this is only because it is always impossible to prove a negative. So of course we cannot prove that it is impossible or that the risk is zero. However, what is being ignored is that there has never been a case of non direct human-to-human transmission documented dating back to 1979. This has never occurred. Not in the current outbreak and not in any of the outbreaks. So could it happen? Maybe. But it never has. But if never has . We do not, and with limited resources, cannot live our lives based on a goal of zero risk. If we were living our lives based on zero risk, none of us would get into our cars today since deaths in automobile accidents are far more common than Ebola. None of us would eat out since the risk of E.coli infection is far, far higher than our risk of Ebola. I would not go to my job since my risk of HIV from a needle stick is many, many times higher than my risk of Ebola. If we make zero risk our goal, our society would grind to a very abrupt halt.
So, to take no precautions would be absurd. To take draconian precautions is also absurd. So where is the prudent path? I believe that for health care workers, the prudent path would be self monitoring for symptoms at home. Now you might say “well one nurse already got on a flight on the advice of a representative of the CDC “and you would be correct. However, this was not a nurse specially trained in the management of Ebola patients and she was not a nurse returning from West Africa. What has changed since that nurse got on the plane is a vastly heightened awareness of what effective self monitoring means, implementation of special precautions throughout our health care systems, and the fact that the medical personnel returning from West Africa have already proven their willingness to risk their own lives to save the lives of others. By their own actions, these are not thoughtless, uncaring individuals.
Just as I believe that our veterans of foreign wars deserve our respect and care when they return home, I believe that these health care workers deserve far better than an isolation tent outside a hospital with a portable toilet when they return from lifesaving missions. The inability to prove zero risk should not preclude them from returning to the comfort of their own homes for self monitoring of this difficult ( not impossible) to transmit virus.
Tia: re your Oct. 27 5:37 am response “However, what is being ignored is that there has never been a case of non direct human-to-human transmission documented dating back to 1979. This has never occurred. Not in the current outbreak and not in any of the outbreaks. So could it happen? Maybe. But it never has.”
It seems to me this statement needs further qualification. In the current situation in Africa, particularly Liberia, it is likely that many (if not most) cases have not been conclusively traced to direct bodily contact mode of transmission, the situation there is too chaotic to trace transmission for all patients. Thus there are likely a large proportion (if not most) of cases for which the route of transmission is unknown. I’m sure you are aware of the case of the two locked primate cages at opposite sides of the same room, where there is a very strong suggestion of a non-direct route of Ebola transmission between the two cages.
The root of the problem is we don’t know how low ‘low’ is with regard to frequency of non-direct modes of transmission; 1:100 is much different from 1 in a trillion. Though 1:100 are still low odds, due to the enormous societal cost of a spreading deadly disease 1:100 odds would seem to warrant very strong safeguards; erring on the side of caution. For example, lets suppose the odds of Ebola infecting several thousand people or more in the USA, as a result of insufficient safeguards against non-direct transmission, are likely no higher than 1:100; however infection of a few thousand people could cost the USA economy around $1 trillion (healthcare costs would be a small fraction of this amount; most of the economic hit would be avoidance strategies by the population); so $1 trillion divided by 100 justifies a $10 billion dollar effort to strongly safeguard against a spreading of Ebola by non-direct transmission.
Hopefully future research can determine a reliable number (or better bounds) on the frequency of non-direct transmission, hopefully is is less than 1 in a million, in which case we can spend only $1 trillion/1 million = $1 million dollars to safeguard against spreading by non-direct transmission!
Tia: Re ” I believe that these health care workers deserve far better than an isolation tent outside a hospital with a portable toilet when they return from lifesaving missions.”
I agree with you here. Once again, the politicians bungled things and implemented the quarantine before they were adequately prepared. The health care workers and military personnel coming back from west africa should be put up, on the tab of the government (federal would be better than state) in accomodations similiar to a nice hotel room or even suite, in respect and reward for their service and personal risk incurred, and they should be paid handsomely for the time spent in quarantine. This will likely be expensive; I as a taxpayer am willing to pay my share.
Tia, it is my understanding that the NBC cameraman who contracted the disease did not have direct human to human contact with an Ebola patient. It is believed that he contracted it by cleaning the interior of a vehicle that had transported a dying Ebola patient. The CDC has also issued an updated statement indicating that Ebola can spread via droplets up to a distance of 3 feet. It would seem that our understanding of transmission is evolving.
http://www.cdc.gov/vhf/ebola/pdf/infections-spread-by-air-or-droplets.pdf
Not just the cameraman either, many of the doctors and nurses that now have Ebola can’t pinpoint the incident in which they felt they could’ve caught the disease. You know they were being very cautious but they still contracted the virus.
Thanks Tia. Very informative and I appreciated the contrast in stats between the 3 diseases you mention. As a Kaiser patient I am especially pleased to hear the pro-activity of my health plan and I received electronic info as well tho not as detailed.
I am unsure however what your conclusions are for allocating resources. You state that a few times toward the end. Are you questioning the resources that have been put in place for Ebola identification, isolation and escalation because of the possible yield for us locally ? They seem reasonable and the identification step not burdensome.
I tend to agree with SOD that in hindsight, self ‘quarantine’ not mixing with others when high risk healthcare worker returns from treating Ebola pts is wise.
Again thanks!
Hi Soda
“Are you questioning the resources that have been put in place for Ebola identification, isolation and escalation because of the possible yield for us locally ? They seem reasonable and the identification step not burdensome.”
I do not blame anyone in the administration of any of the health care plans for their decision to allocate resources to Ebola. However, I do believe that the magnitude and cost of the response is disproportionate to the risk that we are incurring. And I do believe that our perceived risk is being driven by fear rather than a reasoned risk assessment.
While it is true that the identification step is not burdensome, it is also true that all the remainder of the steps are both burdensome, very expensive, and take time and resources from other needs. Let’s just use the example of the time of one doctor. Let’s take an internist designated as a first evaluator. This doctor will typically see 4 patients an hour and handle an average of 5 messages, fill 5 prescription requests in that hour. Now, we take this doctor out of clinic duties for four hours for training and practice in the correct use of protective gear and the items that must be covered on their initial history and physical exam of a suspected patient. So now for training for an extremely low probability event, we have 16 patients who have not been seen and 40 electronic or phone requests that have not been taken care of.
So far it doesn’t sound so bad. But now, multiply that by the 3 doctors involved just at our small Davis clinic and you have 48 patients not seen and 120 additional care requests not handled. Now look at that in terms of the Kaiser Sacramento region. We have 7 Medical Office buildings in the area from Davis to Folsom on the east. If each facility is using the 3 doctor strategy ( unlikely since we are the smallest clinic) we now have used 84 hours of physician time with the combined loss of patient care ( 336 patients and 840 messages not handled )and that is for initial training only. As of Friday, none of these doctors had triaged a single suspect patient. So far we have only accounted for physician time, not the potential spread of the much more highly infectious disease ( flu ) as we move into the flu season and at least some of these folks go untreated, or the costs to support these physicians in terms of ancillary staff who also must all be trained, and the expensive suits required for all of these providers ( both doctors, nurses, and EVS workers). I also have not mentioned the much higher costs involved in training all of our ER staff and Infectious Disease doctors and nurses, our labor and delivery and intensive care unit staffs, and all the EVS hospital workers. And, all of these preparations are being undertaken for a circumstance whose probability of occurrence is very, very low.
Now think of these costs as occurring in every health system in the area and you will just begin to scratch the surface of the true cost not of the presence of Ebola, but of the fear of Ebola.
Agree, but Kaiser’s planning would have been helpful in the TX situation, no?
I was back East last week, having CNN bombarding the airwaves with the ‘fear’ so I do agree with that!
Are MDs required to be the ones trained or could some other HC professionals be in the mix, to decrease cost and still provide expected survelliance?
“Are MDs required to be the ones trained or could some other HC professionals be in the mix, to decrease cost and still provide expected survelliance?”
Sorry that I missed this question. In theory, providers other than MDs could be trained to do the initial history and physical evaluation. Unfortunately, there are not enough of them to cover all shifts at all facilities and it is not in most of their contracts to work after hours as our docs will have to do to cover all of the needed shifts. They are also not trained in the specialized areas of Infectious Disease which will need coverage at the designated hospitals in the event of an identified case. They could of course be requested to help pick up the slack in terms of covering the designated doctors messages and phone calls just as all of the clinic doctors will be asked to do for their colleagues.
Tia–from the research abstract reading I’ve done; not enough certainty can be attached to possible low-level modes of transmission to accurately quantify or bracket the risks involved. It is certainly true that if the infection were to take off in the USA to the point where several thousand people or more got infected, it would overwhelm our healthcare system (I think even major hospitals do not have adequate isolation facilities for more than a few patients), and impact the entire USA economy. This risk is likely low or very low; but the costs are extremely or even catastrophically high; so you multiply the low or very low risk by the extremely high cost; and you wind up with the odds favoring spending plenty on 2nd, 3rd, even 4th-order protective measures; and hope that these protective measures seem to be for naught.
tribe USA
“you wind up with the odds favoring spending plenty on 2nd, 3rd, even 4th-order protective measures; and hope that these protective measures seem to be for naught.”
I would agree with you if money were all that were at stake. It is not. What is also at stake are the number of lives that will be lost ( but not be attributed to) our diversion of resources from other prevalent illnesses. Our health care system does not have an unlimited amount of money. But more importantly, we have a shortage of primary care providers. The more of these human resources that are diverted to the prevention of the “near zero probability event” the fewer you have to take care of the likely events.
Resources diverted from the calls about whether or not to come in to the office for treatment of symptoms that might or might not be the flu resulting in the patient just deciding to “walk in” thereby spreading the freely transmissible flu from person to person in the waiting room. Resources diverted from flu clinics. Resources diverted from our intensive care units. Resources diverted from our Labor and Delivery and Emergency Rooms. Primary care is already stretched extremely thin throughout the country. What we do not, and will not ever see, are the lives that will be lost while we scramble to prevent the unthinkable, but near zero probability event that makes such very dramatic headlines.
My favorite line regarding Ebola fear is:
“More Americans have been married to Kim Kardashian than have died from Ebola.”
(Unfortunately it may be untrue soon, but it makes a point. )
In case you don’t know why the disease has the name Ebola, The Economist recently told the story:
Rich
Thanks for today’s interesting anecdote. I knew it was named for the river, but did not know the back story.
Barack Palin
I cannot answer for Michelle, but I can answer for me. I would be completely comfortable with someone who had treated an Ebola patient and did not have a fever being on the same airplane with my children. I would not be ok with a such an individual with a fever. Again, this was a mistake by two individuals. The nurse, who should not have flown ( and presumably suspected it or she would not have called ) and the individual who erroneously advised her that it was ok to fly. It was not President Obama or “the CDC”. This is attributional error pure and simple and the fact that there are individuals deliberately using this to push their own political agenda is distracting from the true problem and frankly disgusting.
In addition the the Ebola virus an epidemic I would really like to see an end to is the pandering and fear mongering that politicians participate in, especially right before an election.
The Obama Administration (and Bush / McCain / Romney would have been no better) looked around and were thinking … hmmm… who could we appoint for this? An expert in epidemiology? Somebody with experience in coordinating the logistics of an emergency response? A useless public relations shill? Or an even more useless lawyer crony with connections to that epic success Solyndra?
Yeah, that last one sounds about right. We’ll go with that.
Yes Clem, that appointment has people shaking their heads. Political shill is right, someone who they knew they could control the message through.
The huge press effort and creation of “fear” and “hype” about Ebola may or may not be a diversion, and at least Tia offers good information. But, I’d certainly like to see some discussion at the City Council and by first responders (police, fire, rescue, etc. ) about just how prepared we are for a crude oil train disaster from a simple spill to derailment to an explosion and fire. At the very least, the public needs to know what the preparations are and in the event that some kind of evacuation is needed at any place along the RR line in Yolo County, including Davis, what route or routes people should take and especially to avoid showdowns or gridlock as people try to get out of the way of whatever they need to get out of the way for….
We need to know what kind of emergency notification is in place: sirens, automated phone calls, notice on TV programs, etc. , and we need to now what kind of response there will be.
Instead of taking this as seriously as Ebolo or Innovation Parks, so far nothing has been communicated to the public even though at City Council meetings on this subject the public has for the this.
SODA
“Kaiser’s planning would have been helpful in the TX situation, no?”
Yes, the triage strategy would have been helpful. But, from what I have read about that case, the triage was actually done. It was the isolation and escalation phase that failed. My understanding is that the initial intake nurse did ask the appropriate questions, and filled out the information on a form that was then overlooked by the subsequent providers. This is a failure of communication and escalation.
I think my article would have been better had I stated what I think would be equally effective at much less cost. I believe that it is a tremendous waste of resources to have every health care system run its own Ebola containment procedure. This is one place where I feel that collaboration would definitely be more cost effective than our stubborn adherence to our current competitive model. What I would propose is that in terms of management of infectious disease of high lethality,we should adopt a collaborative model that might work as follows:
We would designate one ( and only one ) “center of excellence’ in the region for the management of Ebola. In our case, lets say it would be UCD Medical Center. If a suspected Ebola case were to present to any medical office in the entire region, the individual would be placed in an isolation room and the UCD team would be contacted immediately and they would be in direct contact with all of the appropriate authorities. They would then either handle the situation by phone if appropriate or in person if needed to make the decision. Ebola progresses in the individual over a matter of days, not hours, so there would be time to dispatch a specialized team to do the initial evaluation and appropriately disinfect the isolation room. Doctors, nurses, EVS and everyone else at the office of initial presentation could be going about their usual duties. The designated facility would be contracted with one, and only one provider of transportation so that the specified transfer team, rather than every provider of emergency transport would receive special training.
If cases of Ebola were to occur, this system could be expanded as needed rather than every health care system gearing up for the extremely unlikely event of a single case of Ebola as we are now doing. There is precedence for such an approach. For many years, health care systems have cooperated in this way to provide highly specialized care not available at every hospital. Just one example is that of trauma centers. These are regional facilities that offer highly specialized services. Not every hospital can just decide it is going to be a trauma center and gain approval and this is how it should be. Likewise, not every hospital offers Labor and Delivery services since we recognize that these highly specialized service are best concentrated in centers that have the necessary personal, knowledge and equipment on a regular basis.
What seems to be a driving factor behind the Ebola response is fear, not a reasoned approached with reliance on proven techniques. We have the ability to be prepared for the very unlikely event of a case of Ebola by reliance on enhancement of our existing strategies, preventing errors in communication and judgement. I do not believe that it is necessary, or wise for every Medical Office Building and or hospital to make the individual expenditures when a regional response team could do so more effectively and for much less cost, not only in terms of money, but also in other medical needs not met. The money is quantifiable, the diversion of resources and its human costs are not.
So true. Works for MRAP too. Life has risks, probably the riskiest activity in Davis is getting in our cars and driving yet people just do it.
But we are talking about the forcing of unnecessary risk for what reasons?
Worldview?
Symbolism?
Stubbornness?
It is one thing to weigh the cost of risk mitigation and make a calculated decision based on the numbers, but to do so for political reasons is unacceptable.
The place to attack Ebola is on the ground in Africa. We need aid workers and health experts to go there and work to contain the epidemic. Those who are overseeing that effort are very concerned that unnecessary and draconian quarantines will reduce the supply of volunteers for that effort. Doctors Without Borders is not a political enterprise. Per their U.S. director:
It is the calls for quarantines that appear to be political in nature, not the decisions against them.
Ebola has a REAL 50% survival rate in countries with good healthcare. For those that survive, they are likely to have ongoing chronic problems and a shortened lifespan.
Risk aversion is justified. Especially when the only argument against it is dealing with some temporary hurt feelings. Healthcare workers quarantined… well yes, welcome to your profession that pays very well because you have to endure certain inconveniences. And it is only temporary.
There is a line that this thing can easily cross where all of us will be looking back asking why we did not take more extreme measures to contain it when we had the chance. Then we would really understand the human cost for preventing hurt feelings.
But I agree that we should be working to win this battle at the source.
America to the rescue again! But yet we are not the exceptional country, right?
Thankfully Obamacare has not yet gutted our leading drug development industry.
It is Médecins Sans Frontières to the rescue. And any number of NGO’s, including American ones. America is not exceptional in regard to this disease.
Risk aversion that is without basis is not justified.
There is not “temporary hurt feelings.” There is the real risk of reduced numbers of these incredibly heroic health care volunteers stepping forward to travel to Africa. I will take the word of those who are fighting this disease about that issue, rather than your slender hypothesis.
How much are the doctors in Médecins Sans Frontières paid?
So I guess the Democrat Governor from New York Andrew Cuomo’s call for quarantines were political in nature.
Yes, they were. Certainly they were without scientific basis.
I thought having a quarantine was standard protocol for viruses like TB and ebola?
I don’t consider those diseases comparable, but I’ll let Tia explain the differences.
Once again, our leaders/representatives create a strawman argument that they then knock down.
I don’t know anyone who suggests the returning healthcare workers need be treated like criminals or prisoners. Can you conceive of of situation where they are not? I can–it is actually possible to conceive of a realistic implementable quarantine arrangement that is not draconian (see next paragraph).
Returning healthcare workers and military should be quarantined in accommodations comparable to that of a nice hotel room or even a suite, with full amenities. They should be compensated handsomely for their time in quarantine (doublepay for healthcare workers; combat pay for military). This will be expensive., and needs to be on the dime of the government (federal should take the responsibility; state by default as feds dither). I am willing to pay my share as a contributing taxpayer. With such assurance of good treatment and good pay during quarantine, the impact on the recruitment of medical volunteers would not likely be large.
Don, I think you are naive to suppose these healthcare spokesmouths do not experience considerable political pressure; part of the selection process in choosing these particular individuals is for their political skills.
Medicins Sans Frontières is quite vigilant about avoiding political entanglements to the greatest extent possible.
Your quarantine strategy would be very generous. I’m sure Congress will leap to fund it. But the health care officials who are devising the response don’t feel this disease warrants those measures. They have developed a protocol based on several levels of exposure. Evidently the military has adopted a simpler approach based on their institutional capabilities. We don’t know what their basis is for assessing risk, since they don’t divulge that.
I’ve waited until Tia had an opportunity to expound and expand on her excellent and welcome article. As public health officials have told you, it’s hard to catch Ebola in a developed country. Known methods can and do work to prevent the disease.
Ebola is scary, but remote. Here, in the USA, we have real, immediate, problems that, if ignored, will be equally devastating. We are ranked 26th, out of the wealthiest 29 countries for child well being, by Unicef. We have among the highest infant mortality rates. We have one of the lowest child immunization rates and lowest average birth weights. Although our children were among the most likely to exercise, they were also the most overweight. All more imminent threats than Ebola, all more accessible and treatable. So:
Children learn by example, so make sure you stay in shape and and eat right by cooking healthful meals, with your kids!
“Don’t drink and drive.” Drunk drivers accounted for over 10,000 deaths last year including many teens and babies.
Unload and lock-up that gun. At last count, more than 32,000 lives will be lost at the end of a gun barrel. Seven chidren or teens will be killed by firearms, today, in the USA.(but your second amendment rights are in danger, right)
Support and demand better mental health care. A lesson so sadly brought home to Davis. Diagnosing and treating depression early is critical. Six kids will take their own lives, in the USA, today.
Get a flu shot. The flu kills almost 50,000 Americans every year. And immunize your children. (I don’t care if a B-movie actress tells Oprah that it causes autism, it doesn’t and you shouldn’t take medical advice from Jenny McCarthy.)
Davis is an international magnet, drawing people from countries where hunger and poverty are the norm and so, are breeding grounds for pestilence. You are wise to make yourselves aware of the real dangers. Please do not ignore the ones lurking right here, that are far more likely to afflict each of us.
;>)/
Biddlin
Thanks so much for your additions. My live in “editor” advised me to not stray too far away from my topic of Ebola, but all of these concerns and many more would be on my list of issues that we should be tackling with all the fervor that is now being directed at Ebola.
Yeah, but they don’t sell commercial time the same way fear of ebola does….
Barack Palin
“someone who they knew they could control the message”
I know next to nothing about Mr. Klain and so my comment in not either for or against him and his appropriateness of lack thereof for this position. However, I think that this sentence of yours may sum up the argument for, rather than the argument against him. In my opinion, we are at greater risk from fear at the present time than we are from Ebola. If he indeed is successful in organizing a unified message that is calming and reassuring in the same sense as the message conveyed by the Medical Commissioner of New York City Dr. Travis Bassett then he will have done a major service to the country. I say that we wait and see before passing judgement on the effect of this appointment.
Tia Will, since you’re writing more articles and taking on the role as the DavisVanguard Ebola expert I think you at least should get to know who the new Obama appointed Ebola Czar is. Here is a little video that will bring you up to speed:
https://screen.yahoo.com/snl/ebola-czar-cold-open-070817045.html
Thank you, Tia, for a learned primer on the topic. You have put a popular topic in perspective.
I have a question about the so-called “Medical Professionals” going over to West Africa: Shots? Vaccines? In the Military we had shots like crazy, but if you deployed overseas, you got another round depending on where you went. Is this for civilians too?
Miwok
I can only speak for Doctors without Borders as a medical relief agency. Their policy, since vaccination is one of their key missions is to vaccinate all who will be providing care in their field organizations. I suspect but do not know, that the same is true for their administrative and office workers.
The problem in the case of West Africa is that to date, there is no effective vaccine for Ebola. As you might imagine this is now a subject of very active research, but we aren’t there yet.
The messages we hear endlessly not to be afraid are all very well and good.
I would add to that list; do not be afraid to be prudently cautious. It would seem that many are afraid of appearing prudently cautious, for fear that such caution may earn them the label of a mindless hysterical paranoiac. Do not be afraid of social pressures against the (gauche) excercise of calm, measured prudent caution.
tribeUSA
“It would seem that many are afraid of appearing prudently cautious”
I am not sure to whom you are referring. I have not heard anyone not urging being “prudently cautious”. I have heard many voices urging fear avoidance and a calm, reasoned, evidence based approach. This is exactly how we teach our doctors and nurses to respond to medical crises.
Fear is paralyzing and actually increases the risk of poor outcomes. We are taught as surgeons when faced with a life or death emergency, to first, take our own pulse. Fear disables and increases the risk of a poor outcome by increasing the risk of error. Reasonable prudence in self protection and the protection of others is the best way to achieve the best outcome possible. Hysteria does not equal prudence. I have heard many arguing for the latter, none for the former.
Message from the Chief Medical Officer UC Davis Health System
10/14/2014
Dear Colleagues:
This morning in the Emergency Department, our team identified a possible Ebola patient. Because it was a potential case, a set of special protocols and procedures, which are based on guidance from the federal Centers for Disease Control (CDC), were immediately initiated. Fortunately, it was a false alarm. But the event helped us recognize some of the protocols that worked well and some that need more refinement and practice. We are continuously monitoring the CDC for the latest updates to ensure the very best practices.
We have been meeting almost daily with a large Ebola planning group that includes representatives from every key department in the hospital. We are mapping out, with exacting detail, a process that will provide care for patients and ensure protection for everyone, especially our nursing teams.
Our top priority is to keep everyone safe.
Today’s event was a good learning experience. For example, while we are using CPU-approved personal protection equipment (PPE), we are exploring alternative PPE gear that could provide additional levels of protection for staff. We also will be conducting spot drills and practices for care team members and support staff.
Keep in mind, every hospital in the nation is facing the same situation. We are all working hard to be fully prepared for a possible case_
Our preparation includes the imminent formation of a dedicated, inpatient Ebola care team, composed entirely of volunteers. We are assembling the team because of the unique nature of patients with Ebola. Team members will undergo intensive training to ensure that all infection-control protocols and procedures are fully understood and followed. We believe that this approach is not only prudent, but required to ensure the safety and confidence of both patients and staff.
This is a challenging time. Please contact your supervisor at any time to share whatever questions or suggestions you have about this difficult situation, Your input is invaluable as we further refine our practices and procedures.
I am proud of how dedicated you are to our patients, and to each other.
Through Warning, preparedness and the lessons learned from today’s experience, we can safely handle whatever comes our way, just like we always do
Sincerely,
J. Douglas Kirk, M.D.
Chief Medical Officer
UC Davis Medical Center
From: Jaroslaw Waszczuk [mailto:jjw1980@live.com]
Sent: Sunday, October 19, 2014 2:56 AM
To: ann.rice@ucdmc.ucdavis.edu
Cc: vincent.johnson@ucdmc.ucdavis.edu; jdkirk@ucdavis.edu; julie.freischlag@ucdmc.ucdavis.edu; Thomas.Nesbitt@ucdmc.ucdavis.edu; timothy.maurice@ucdmc.ucdavis.edu; James.Goodnight@ucdmc.ucdavis.edu; micheal.minear@ucdmc.ucdavis.edu; heather.young@ucdmc.ucdavis.edu; Chong.Porter@ucdmc.ucdavis.edu; Mike.Minear@ucdmc.ucdavis.edu
Subject: EBOLA FALSE ALARM IN THE UC DAVIS MEDICAL CENTER , SACRAMENTO CALIFORNIA- OPEN LETTER TO UC DAVIS MEDICAL CENTER CHIEF OPERATING OFFICER MS. ANN MADDEN RICE
Dear CEO Rice,
From the UCDMC Chief Medical Officer, J. Douglas Kirk, MD, FACEP, e-mail letter dated October 14, 2014, I learned that on the same day, the UCDMC Emergency Department team had identified a possible Ebola patient. Furthermore, Mr. Kirk’s letters stated that it was “fortunate“ that “it was a false alarm” without more specificity, but my understanding is that a suspected Ebola patient has been sent home and will not come back with full-blown symptoms, as happened in Texas Presbyterian Hospital.
The letter also states, “Our preparation includes the imminent formation of a dedicated, inpatient Ebola care team, composed entirely of volunteers. We are assembling the team because of the unique nature of patients with Ebola. Team members will undergo intensive training to ensure that all infection-control protocols and procedures are fully understood and followed. We believe that this approach is not only prudent, but required to ensure the safety and confidence of both patients and staff.”
I don’t understand the above part of this letter or, more specifically, why the Ebola care team would be composed entirely of volunteers. First, I am surprised that UCDMC has no trained team ready to handle the situation if any outbreak takes place. Second, who are the volunteers? Are they professional doctors and nurses, or are they whoever would volunteer to be trained and take risks? As an employee of UC Davis Medical Center for 13 years, I understand that UCDMC is the 50th best ranked medical facility in the United States and is not being operated by volunteers, but by professionals who will take care of such a situation according to their duty and positions’ assignments, not according to “I want to do it” or “I don’t want to do it.”
Volunteer means “I volunteer, and I quit volunteering whenever I want to, and I may want to quit after the intensive training I receive.” Who is going to replace these intensively trained volunteers if they decide to quit? Could Mr. Kirk provide an explanation in this second letter? Volunteers could go to Liberia or Sierra Leone, but it should be not an issue in a facility like UC Davis Medical Center to take care of Ebola patients. It looks like UC Davis Medical Center is completely unprepared to handle a potential Ebola outbreak.
At the end of his letter, the Chief Medical Officer responsible for handling the potential Ebola outbreak wrote, “This is a challenging time. Please contact your supervisor at any time to share whatever questions or suggestions you have about this difficult situation, Your input is invaluable as we further refine our practices and procedures.”
Through Warning, preparedness and the lessons learned from today’s experience, we can safely handle whatever comes our way, just like we always do.
The above statement is not assurance for anybody that the situation would be handled properly and professionally by UCDMC professionals but is vague and ambiguous whining about a serious and potentially grave situation.
In regard to the supervisors mentioned above in Mr. Kirk’s statement, I would like to give an example about the UCDMC Plant Operation and Maintenance Department supervisor’s abilities to act in similar but the lesser evil than Ebola situation.
In 2010 there was quite an issue with Influenza H1N1 outbreaks in the country, and UCDMC administration issued orders for all employees to mandatory flu vaccination or wearing masks. In response to a Department Head’s memo, my two supervisors Dorin Daniluc and Patrick Putney openly coerced several shop employees to boycott H1N1 vaccination. The coerced shop employees were driving and walking around campus and in the hospital in the gas masks designed for handling confined space jobs and chemicals. As I remember, many patients and hospital staff got concerned about seeing maintenance personnel in gas masks. Department Head Charles Witcher completely ignored his two subordinate supervisors’ behavior.
When I made a short video about two supervisors boycotting what they should support and encourage, then-new HR Labor Relations Manager Travis Lindsey attempted to use this video as a cause for termination of my employment in May 2012. It happened just before unsuccessful provocation on May 31, 2012, orchestrated by your special assembled team which attempted to end my employment with UCDMC in Trauma Unit #11 or in UCDMC morgue. (See attached video and Travis Lindsey e-mail.) The question is what would have happened if a supervisor like Dorin Daniluc or Patrick Putney or a manager like Charles Witcher would do if the situation became more serious with Ebola. Could you depend on the managers and supervisors like them who, instead of taking care of UCDMC business, have their own businesses and run their own businesses on the University’s time? If something more serious happened, I could bet you that you wouldn’t see them in the workplace and that departments would be left without any direction as to what to do. They are good merchants to sell ducks, sheep, goats and other animals in the shop, stealing company time and attacking those who are good employees and don’t like their style of serving the University.
Please read the fragments from the two letters of recognition an HVAC Shop technician received and what happened to him in the aftermath and what Witcher, Daniluc and Putney have done to him. (All letters of recognition attached.)
“I just want to thank Dereck Cole for fixing the temperature problem in my office and in my laboratory at the MIND wet labs. I have been here for 8 years and endured a terribly cold office and lab with multiple visits related to the problem. I cannot say how many facilities people have been here with no results – all of whom usually took one temperature reading and said they thought it was fine.
Best wishes
Frank Sharp MD
Professor of Neurology”
I am a scientist in Research III (building 95). I have worked in this building since 2008. In that time, I had given up hope of ever being comfortable or maybe even safe in here In the short time that Dereck has been working here, he has solved many of the issues that have been plaguing us for years. I can finally not FREEZE to death everyday or eat under dripping ceiling tiles where floods have happened over and over. He is such a welcome sight and a great guy. Everyone here is so thankful to have him around.
Please tell Dereck thank you from everybody on the second floor of Research III. He is an awesome worker and we really appreciate him. Please, please keep him here!
Rebekah Tsai, MS
SRAIII Mack Lab
I have no need to remind you of what Putney, Witcher, Daniluc and Lindsey have done to another good worker, Kenny Diede, who reported a twice-convicted child pornography felon illegally accessing University computers and most recently what Witcher, along with another shop supervisor and Travis Lindsey did to another good worker from the paint shop, Frank Gonzales, during his mother’s funeral.
How are you going to rely, in a serious situation like an Ebola outbreak, on a manager like Witcher and supervisors like Daniluc and Putney and their director Mike Boyd, who has been neglecting UCDMC hospital equipment for eight or ten years, making people suffer? Director Boyd is not different than previous Facilities Director Robert Taylor, who gave the present job to Witcher and awarded completely unqualified Daniluc with a supervisor position in exchange for Daniluc’s service in his private residence.
Look at Taylor’s 2007 e-mail that was sent to hundreds of people, including Dorin Daniluc, about his happiness and joy that The Joint Commission (Formerly The Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) is gone.
The email clearly shows Director Taylor’s arrogance and disregard for The Joint Commission’s presence in the UC Davis Medical Center. You imagine having Taylor in charge of facilities during an Ebola outbreak when his mind was set in Antarctica and the Falkland Islands, like Witcher in his sailboat.
Taylor left for Boyd problems outlined in the letters of recognition Dereck Cole received, and Boyd did nothing but give a green light for Witcher and Putney to viciously and despicably attack Dereck Cole in an attempt to provoke him for physical confrontation in the hospital cafeteria and fire him from the job for his great service.
The year 2007 was the year when I was abruptly removed by Taylor and Witcher from the Central Plant because my coworker William Buckans reported a serious safety and environmental hazard (discharging machine oil to the city storm drain and river). Mr. Buckans also reported Central Plant manager notorious porn activities on the company computer and on company time., I helped him with his complaints.
In 2011 the situation was repeated by Witcher and Boyd after my coworker Kenny Diede reported a child pornography felon accessing illegally a UC computer in the shop, and I was removed from the premises in September 2011 under false pretenses and I was fired in December 2012. It is unknown yet whether porn and child porn activities among supervisory personnel at UCDMC is a deeper problem than I thought, and any employee’s complaint against supervisors’ misconduct raises red flags that it could lead to porn activities, safety problems, unrepaired equipment for years and other problems disclosure which for now are covered with thick layers of “dirt” in UC Davis Medical Center.
In addition to the above, I sent you a response to your alarming email dated September 25, 2011 (one month ago), about a power outage which caused disruption to our operating room, emergency department and clinics. Although the hospital quickly restored power and all facilities and services returned to normal function, I recognize that questions and concerns remain. In my response, I wrote to you that
“The Central Plant was placed into service in ‘99; load shedding was not tested. The hospital administrators declined the test to prevent disrupting hospital operations and the serious problems endangering UCDMC patients’ lives still exist, as outlined in your alarming e-mail. This problem needs to be fixed. Rescheduling maintenance or testing could trigger an interruption of critical utilities between 9 p.m. and 6 a.m. But dilution of the problem is not a solution. You have held the position of CEO in UCDMC for at least 10 years and have been aware of the problem for long time. In December 2013, UC Davis Medical Center experienced similar problem when the Central Plant was operated at full load and lost SMUD power. The GTG could not shed the load and tripped the breakers.”
How are you going deal with a similar power outage situation and disruption of emergency department and clinics during the potential Ebola outbreak with the UCDMC Hospital full of patients? Are you going to run Honda’s portable generators and light the candles with the help of Daniluc and Putney to control panic among patients and staff or beg for your illiterate professionals in power generation and distribution like Witcher and Boyd?
Good luck.
Respectfully Submitted on October 19, 2014 Lodi , California
Sincerely,
Jaroslaw Waszczuk
2216 Katzakian Way
Lodi, CA 9524
Cell: 209-663-2977
Fax : 209-247-1089
Message from CEO Ann Madden Rice
UC Davis Health System 10/24/2014 01:06 PM
Please respond to public.affairs
Dear Colleagues,
Although you might not know it from the news media’s coverage of it, Ebola is very difficult to contract, and the likelihood that UC Davis Medical Center will receive a patient with Ebola is very low.
Regardless, for the past few weeks, we have been intensely engaged in preparing and planning for the possible arrival of a patient with Ebola. Today, there will be an announcement that the UC Office of the President has informed the California Department of Public Health (COPH) that all five UC medical centers are positioned to provide inpatient care for Californians who have confirmed cases of Ebola, if necessary. The CDPH has committed to helping the medical centers obtain the necessary personal protective equipment (PPE), should we have sourcing challenges.
Full details about UCOP’s arrangement with the COPH will be posted on The Insider.
At UC Davis Medical Center, a wide-ranging group has been working tirelessly to prepare us for the potential arrival of a patient with Ebola. We have assembled a group of volunteers who will serve as a dedicated, inpatient Ebola care team. In response to our call for volunteers, we received responses from more than twice the number of employees that we were seeking. This tremendous response exemplifies the selfless, can-do spirit of UC Davis, and l cannot express how proud and grateful I am.
Our Ebola task force, composed of personnel from all departments that would be involved in the handling of an Ebola patient, continues to meet daily. It is continually refining protocols and adjusting practices as we learn more each day. Although we are using guidelines from the federal Centers for Disease Control (CDC) as a foundation, our refinements, in many ways, make us far better prepared than other hospitals.
Our preparations have included a recent, four-hour presentation on Ebola preparedness, which included a demonstration on donning and removing PPE. The presentation was streamed live, and a video of it is available here: http://tinvuri.com/Ebola-UC-DAVIS.
I realize that tension and anxiety are high among some of our staff. That is understandable, as guidelines for handling potential Ebola patients remain fluid. However, we are monitoring developments intently, and will continue to adjust our practices as the CDC revises its recommendations, and as we learn lessons on our own. As part of our commitment to ensuring
the safety of our staff, we will keep you informed about developments as they evolve.
I appreciate all of your hard work and dedication as we work to ensure that UC Davis Medical Center remains at the highest level of readiness possible.
Sincerely,
Ann Madden Rice
CEO. UC Davis Medical Center
Military troops effectively put in quarantine for 21 days on departure from Liberia. The military thinks they need to quarantine, but Obama doesn’t want commercial passengers from Liberia and other ebola stricken countries to have to go through the same screening.
http://www.cnn.com/2014/10/27/politics/soldiers-monitored-ebola/index.html
because the military is the most enlightened organization when it comes to such things?
i’m with those who think this is overblown. there are far worse health threats that have not induced this type of hysteria.
Far worse health threats? Like what?
Barack Palin
The military enforces many things on its members that we would find completely unacceptable for the general population. I cannot honestly say, as a former medical member of the military, that I would advocate using the military as the gold standard for medical management of our entire population.
The military tends to view its personnel as assets that it is unwilling to expose to what it deems as unnecessary risk.
Too bad the CDC and the Obama administration do not view the general American population the same way.
It seems to be a real contradiction. (See my larger post below with unanswered questions.)
Nothing is overblown . As today we 10,141 reported Ebola cases and number is not down but going up . 4,922 peopled died from this deadly disease.
According to CDS:
No FDA-approved vaccine or medicine (e.g., antiviral drug) is available for Ebola.
Symptoms of Ebola are treated as they appear.
Experimental vaccines and treatments for Ebola are under development, but they have not yet been fully tested for safety or effectiveness.
Question is what would happen if Ebola virus mutates and turn into Ebol or some other even more deadly and incurable evil ? Over 10 thousand reported cases is a great risk that it would spread without having vaccine to stop it .
“the case of the two locked primate cages at opposite sides of the same room, where there is a very strong suggestion of a non-direct route of Ebola transmission between the two cages.”
As you suggested, I am well aware of this case and have two comments about it.
1. It is suspected, not proven non-direct route of Ebola transmission.
2. It is in non-human primates.
For me, given the evidence against non-direct human to human transmission, this is very thin speculation on which to hinge multi-billion dollar responses to a potential, not proven threat.
Again your monetary analysis includes only the calculation for the potential management of Ebola and does not address the monetary cost, and loss of life, from the other diseases that are having resources diverted to the fear of ( rather than the reality of ) Ebola. But let’s suppose that you are correct and that these billions should be spent on protection against Ebola. These billions should then be being spent on stopping the spread in West Africa, not on “Ebola proofing” every hospital and medical office building in the US.
“Nothing is overblown . As today we 10,141 reported Ebola cases and number is not down but going up . 4,922 peopled died from this deadly disease.”
While I agree that concern over Ebola is not over blown, I do believe that we are misdirecting our efforts. Instead of focusing on making every American hospital and medical office building Ebola safe, we should ( in my opinion) be utilizing those resources to address the threat where it is actually occurring, namely in West Africa.
To use a crude analogy, if a house is on fire in Davis, would we be better off directing our limited water supply to the house itself and the adjacent properties or would we be better off hosing down the houses in Woodland ? Local containment would be much more useful even if a few sparks had drifted north.
I also wanted to address the issue of the use of “volunteers”. While I am not affiliated directly with UCDMC, I can address how this term is used in the Kaiser system making the assumption that it may be used similarly at UCDMC. A “volunteer” is not someone of lesser degree of training or expertise. The “volunteer” must have full qualifications for the position or procedures for which the are volunteering. What it does imply is either that there is some hazard, some inconvenience, or some potential objection to the procedure that one is being asked to engage in. There is ample precedent for this in the medical community. For example, medical personnel who for religious reasons object to the termination of pregnancy are not forced to participate in these procedures. Likewise, we would not force a Jehovah’s witness to hang blood or a Catholic who believes that all sexual acts should be open to the possibility of conception to place IUDs. Those who are willing to participate are considered to be doing so “voluntarily”.
From more than 25 years in the Kaiser system, I can state that the result of development of these specialized teams of “volunteers” is better outcomes for the patients. This is because over time, with more experience with a particular set of skills, the volunteer team becomes much more adept at performance of these limited set of procedures thus providing better patient care than if many different people are involved and do the procedures rarely. This is true whether the procedure is a particular type of operation, or a highly specialized radiologic procedure or whether it is strict adherence of an infectious disease isolation protocol. Dedicated teams whether or not they carry the designation “volunteer” provide better care with less risk to both patient and provider.
West Africa needs 40 thousand medical staff volunteers to contain outbreak . We could only pray not to get more cases in the US cities which are in a lot worse financial shape than California’s cities and town . Is no cure for and people are flying back and for .
tribeUSA
“ in accomodations similiar to a nice hotel room or even suite,”
How would you see housing returning health care workers in a nice hotel room or even suite as being any safer than having them remain in their own homes ? If anything, I would see this as a riskier strategy as it requires the indirect exposure of more people ( housekeepers, linen launderers, meal servers, etc) that would not be needed in their own homes. So if your concern is the unproven risk of indirect exposure, self isolation in the individual’s own home would seem the least risky solution to me.
Tia,
yes of course these must be special accomodations that are specially staffed and managed according to special procedures–I don’t know why you and other healthcare spokespeople continue to throw up strawman scenarios that you then knock down. I will let you see if you can conceive of a way to provide special accomodations with specially trained personnel to reduce potential transmission, I am well aware you have the intelligence (P.S. It is not rocket-science level difficult). Of course such special facilities and trained staff/protocols and procedures will be expensive to implement; but in my view a worthwhile investment. I don’t see why management/operation of such a facility need be widely different than old-time quarantine facilities, which were quite effective; I am merely advocating a major step up in the quality (for the quarantined person) of the facility.
“I don’t see why management/operation of such a facility need be widely different than old-time quarantine facilities”
What I am wondering is why you feel that the added expense of such a facility would be necessary when the individual could be equally if not more safely quarantined in their own home. If you are afraid that they would not honor the quarantine, you could post a single guard. Again, I am curious about how you believe that a quarantine facility would be a safer location.
Basically comes down to more assurance of containment at a facility
(1) Remove the risk to family/friends who might live there or visit(?or just boot out your family/pets?) , and frankly, the concern, justified or not, of neighbors (particularly if in apartment complex) about unfortunate and doubtless unfounded regard as Mr. or Ms. Ebola next door.
(2) Obtaining provisions (food, other supplies); though I would concede they could be delivered by other means; and left on doorstep.
(3) Better monitoring by centralized staff arrangements at quarantine, fewer staff needed and no travel time between quarantinees.
(4) On the off chance you develop symptoms, more secure (and quicker if ambulance housed at quarantine facility) delivery to hospital from quarantine facility, and home has zero risk of contamination (germs in the frig/freezer?) by you if you are at quarantine facility.
(5) Sadly, the record to date of health care personnel, nurses and doctors, in prudent self-quarantine or at least restricting their public movements, has been dismal. I do not bring this up as a negative comment on healthcare workers in particular, but just an example of the fallibility of human nature; particularly those who are highly social may have a hard time fighting off temptation to take a quick jaunt about the neighborhood and face-to-face chat with a good friend. Heck, 1/3 of americans do not exert a healthy discipline in controlling how much food they shove down their gullets, including many good and intelligent people (I myself usually am able to exert good self-control in this regard, but it is not easy; and sometimes my stomach-brain takes the lead when presented with the opportunity for ice-cream or cake).
One guard 24/7 really means 3 shifts of guards (plus weekend shifts), plus deliveries of food and incidentals; I suspect quarantine arrangements could be made for a comparable or cheaper price per detainee (hmmm.., the guard is out front for awhile now; I think I’ll sneak out the back window, just for a little bit: I’m going stir-crazy and lonely in here!). What about sprucing up some disused army barracks or other military facilities, so that there are several such facilities spruced up with accomodations comparable to that of a nice hotel? Such military installations are typically fenced, so that detainees could amble about (in shifts, depending on risk levels they may want to avoid close contact with each other) outside for a distance with the temptation to walk off the facility removed by the presence of the fence.
Thank you, Tia, for your very informative article and posts. I agree that we should not react with fear, and that we should focus and spend funds wisely. But I am puzzled why we don’t quarantine medical professionals, citizens and staffers who return to the country. This just seems like common sense – an ounce of prevention beats a pound of cure. I do have a few issues of interest.
1. There is obviously still a dispute within our administration, as medical workers will be self quarantined (?), but military personnel will be quarantined in Italy for 21 days. This is occurring right now. I’d think a doctor would have much more exposure than a solider building a treatment facility.
2. The doctor in New York followed all of our elaborate protocol. He wore the hazard suit, worked in short periods, was observed by a 3rd person as he was sprayed down with a solution (chlorine), his suit was not punctured, there was no exchange of bodily fluids, etc., and yet he still came down with Ebola. It seems contrary to the declaration that Ebola is “tough to catch”.
3. Over 200 doctors have contracted Ebola in Africa, which also seems to counter the idea that it is tough to catch.
4. The New York doctor who is infected, came into the US and passed our new-and-improved testing procedures. Doesn’t this prove that it is difficult to detect, and supports the concept of quarantine? It seems like we are exposing ourselves to great risk if even a few infected individuals into the country. We saw with stark reality what the problems one infected person could create in a metropolitan city like New York, riding the subway, riding cabs, spending time at a bowling alley. Couldn’t one or two obtuse or ill-informed or dishonest individuals wreck havoc on our medical system?
5. Is it true that 15% of infected individuals don’t run a fever, thereby being more difficult to diagnose?
6. I have heard that it is an RNA-based virus, which can more easily mutate. Is this relevant.
7. There are new reports that President Obama may bring non-citizens infected with Ebola, to be treated within the United States. If so, do you think this is a wise decision?
I am thankful and admire the work our health care volunteers are conducting, but was under the belief that one of the main concepts of epidemiology was to isolate a deadly virus. You isolate it, you contain it, and they often burn out.
Apparently both Dr. Spencer and nurse Amber Vinson were symptomatic for about 1 week (with fatigue, malaise and headache) prior to developing a fever. It would seem that, at least in these two cases, fever was a symptom that manifested late in the course of the illness.
So does that imply that testing for the virus is not perfect or simple?
It implies that relying solely on fever as an indication of infection with Ebola can be very inaccurate. It is my understanding that the actual blood testing for the virus is quite accurate.
Elizabeth
I am sorry to be so late in getting back to answering questions today. I agree with you that knowledge is evolving about the transmissibility of Ebola. However, I do not believe that the example you gave of cleaning up after the moribund patient is suggestive of a different means of transmission. What does seem to be known is that the patient near death and newly dead are the most likely to transmit. This is why so many persons who are diagnosed have a history of either taking care of the near death individual of cleansing the corpse. The current instruction about management of the isolation rooms is that all items in them are considered to be contaminated until disinfected with chlorine so I do not think that anyone is being remiss in that regard.
I agree that it is harder to know how the others who did not have obvious breaches in their gear actually were infected, but as a surgeon I know that I received a number of small abrasions, cuts and near misses from needles over the years that I did not even realize were there until hours afterwards, which makes me think that I might have sustained many more than I realized. Just as I think it is important to keep an open mind about other not yet demonstrated means of transmissibility, I also think that it is important to not be seduced by the what if scenarios and the fears that they engender.
Elizabeth
The issue of blood testing appears to be an area in which our understanding is is still evolving. While it is true that blood testing is quite accurate once there is a large viral load, since the virus first seems to like to replicate in the liver and spleen, blood testing too early in the course may “miss” seeing the virus because the particle load per drop of blood is just too low to detect even using PCR.
Have you seen any statistics on the number of false negatives and false positives ?
I have not yet seen this information. I would anticipate that the number of false positives would be vanishing low, and the number of false positives would be quite high based if the mechanism of early replication is indeed as stated above.
“…blood testing is quite accurate once there is a large viral load”
That is my understanding as well. It is also my understanding that in the early course of the illness the rate of false negatives is quite high although I have not seen the numbers on this.
The case of the NBC cameraman highlights the indirect mode of transmission via contaminated surfaces, proving that transmission of the virus does not require direct person to person contact as previously believed. In fact, it has been known for several years that the Zaire Ebola virus can survive for very long periods of time on surfaces, in some cases almost 50 days.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2672.2010.04778.x/pdf
SOD–good post. I’m nonplussed that United States healthcare spokesmouths tend to so dismissive of simple precautions, and throw up strawman scenarios (see some of my posts above) that they then knock down, as if this conclusively settles the issue. Worse, they tend to paint those with such concerns, many of of which are quite legitimate, as the product of uneducated, ignorant, and paranoid minds, in an apparent attempt to quell any dissent–there is no official acknowledgement of the actual situation regarding our knowledge of Ebola, which is that there are indeed major unknowns in transmission mechanisms and associated frequencies; as well as in other aspects of Ebola (e.g. asymptomatic carriers with moderate or higher blood Ebola titers, the possibility that shedding of virus might, in some people, slightly precede clear symptoms such as fever, etc.)
Since you are now making health science assertions, can you please tell us your credentials?
Bachelors degrees in Math and Physics
Masters degrees In Biochemistry & Molecular Biology, and BioChemical Engineering
PhD in Hydrology (a science which also addresses modes of transport/fate of diseease organisms, including viruses, in surface and subsurface waters.
Worked with modes and rates of transport of viruses in both aqueous and aerosol form while employed in the Biotech Industry, presented results at international conferences, one publication (most of the research was proprietary), and helped develop filtration systems for aqueous phase and aerosolized viruses.
My posts have addressed very basic aspects of viral transmission that are not being adequately addressed in public statements by public health spokespeople. If you don’t have the background/knowledge to address my arguments on their own merits, without a pin of MD label attached to the person making the statements, you need not feel obligated to take them seriously.
So you disagree with these statements about the means of transmission? http://www.cdc.gov/vhf/ebola/transmission/index.html
… and here are the current recommendations, based on five risk categories: http://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html
In the last 24 hours the CDC updated their guidelines about transmission to include droplet spread up to a distance of 3 feet.
http://www.cdc.gov/vhf/ebola/pdf/infections-spread-by-air-or-droplets.pdf
Don–re: your Oct 28 8:26 post; I have no reason to doubt the validity of the statements in the first paragraph of quoted text, it is relatively simple to confirm positive results for transmission.
However, the statement “Ebola is not spread through the air or by water, or in general, by food.” definitely needs to be qualified with insertion of the words ‘definitively known to’ between the words ‘not’ and ‘spread’. As Tia points out in one of her posts, it is nearly impossible to prove a negative; i.e. definitively, completely and absolutely rule out any particular mode of transmission. Thus the quoted statement is, in fact, not accurate as it is worded; nobody can claim with absolutely certainty the virus can’t be transmitted by any of the stated routes. However, evidence and experiments can be performed to evaluate and actually bracket numerical probabilities for each of the individual hypothesized routes of transmission. From what I have read about the Ebola virus, there is insufficient evidence, experimental or epidemiological, to form reliable numerical bounds on such (likely low-level) transmission probabilities. There is enough evidence to state that the likelihood of significant transmission by such routes is low; the big question that has not been answered is, how low is ‘low’? For example, it is likely that odds of transmission by non-bodily contact may be no higher than 1:100; the problem is that if the virus beats the 1:100 odds, the consequences are enormous in terms of societal impacts (you buy fire insurance for your home, don’t you?); furthermore this particular class of retrovirus has a very high mutation rate and is known to evolve rapidly as it passes thru multiple hosts; such that levels of transmission by different routes may shift over time.
Basically, further research needs to be performed; the statement “Ebola is not spread through the air or by water, or in general, by food.” is not definitively known to be accurate, as worded (neither is it definitively known to be inaccurate) –awaiting more experimental and epidemiological evidence!
“Obama OK with different quarantine policies for military, health workers”
Really, so because their service isn’t voluntary they have to be quarantined when others who were in the same Ebola stricken areas don’t? Tell me how that makes any difference, you’re either a threat to spread the disease or you aren’t. Being civilian or military has nothing to do with it. Obama’s statement was really ignorant.
http://www.erietvnews.com/story/27146616/obama-ok-with-different-quarantine-policies-for-military-health-workers
Some hypothesize that the military leaders put their foot down, and said no, we can’t tolerate the risk, we have to be prepared and 100% safe.
We have our military building structures over there, I wonder why those jobs aren’t given to the locals, who could use the jobs, money, and experience.
I think that this is a good point. However, I think that this had already been taken into account by the hoods provided as part of the PPE recommended for anyone in direct contact with an infected individual. I would also point out that this does not represent a departure from the concept of contact with bodily fluid as the means of transmission since that generally includes saliva say from a cough, or mucous from a sneeze. They also did not specify semen although one would also want to avoid that.
I agree that this new CDC statement should not affect the current guidelines for PPE which already protect against droplet spread. What it might affect is the notion of allowing exposed individuals on airplanes, cruise ships, subways etc. during the incubation period, which the WHO now says can be up to 42 days rather than 21.
http://www.who.int/mediacentre/news/ebola/14-october-2014/en/
Exactly EB. I’ve read that the Ebola virus can last days on surfaces. I used to work for an airline and I’ve seen how the planes are cleaned. Most of the time the cleaning crews only had minutes because of quick turns. The lavatories and seats just get a quick garbage pickup and not much of a wipe down if any.
BP
“The lavatories and seats just get a quick garbage pickup and not much of a wipe down if any.”
It would seem to me that the most effective response in this case would be to change the protocol for cleaning planes flying out of West Africa to one of wiping down all the lavatory surfaces with chlorine solution rather than anticipating that we will be able to stop everyone with Ebola from flying.
If all of our medical office buildings and offices can ask screening questions prior to taking any object from a registering patient, then surely the airlines can elect to clean their lavatories.
Tia Will, the planes would have to be thoroughly cleaned and disinfected everywhere, not just on planes leaving West Africa. They would also have to be disinfected at every airport in the world because who knows where to infected passengers took a connecting flight to. Airlines operate on quick turn times, they don’t make money when a plane is sitting on the ground getting cleaned and disinfected. Not just the lavatories would have to be thoroughly cleaned, but also every armrest and seat back. Not going to happen, an embargo needs to be put in place. Tia Will, we need to get out in front of this instead of offering up patches as you have suggested.
EB
“What it might affect is the notion of allowing exposed individuals on airplanes, cruise ships, subways etc. during the incubation period, which the WHO now says can be up to 42 days rather than 21.”
On this we are in agreement. However, as usual the devil is in the details. We are trusting that people will honestly and accurately self identify as having been exposed and thus at risk. Just from the ongoing change in lengths of time and conditions of spread we can see that the situation is one of ongoing change day to day as more information is acquired.
We have several associated risks. We can provide humane recommendations ( such as home isolation) and expect good cooperation from those who are at risk ( such as the returning health care workers) or we can impose draconian measures and risk the possibility that someone will lie about their exposure and risk to avoid those measures. Because of the demonstrated lesser lethality of Ebola here in the US, I would vote in favor of the voluntary approach at this time, considering the outcomes to date.
As always, in this rapidly evolving situation, my opinion is subject to change. With my tendency to favor collaborative behavior over enforced behaviors, I would never have guessed that I would have favored mandatory quarantine and no fly rules.However, that is exactly what I would have called for had I been able to influence the situation in West Africa.
Sadly, it has been members of our own profession, Drs. Snyderman and Spencer, who have demonstrated the most irresponsible behavior when it comes to voluntary home isolation, eroding the confidence of the public and of politicians that this can be a viable option for exposed individuals. For those individuals who are willing to strictly comply with voluntary home isolation, I agree that this would seem to be the least restrictive option. Unfortunately, a couple of bad apples may have spoiled it for everyone.
Maybe some missed this, and the lies told by the New York doctor have now come to light. So we see that doctors are human. We also see that the 3rd health care worker is chaffing at the home detention / self monitoring. Not good.
What are your thoughts on the Presidents plans to bring infected non-citizens to the United States for treatment?
TBD
I believe that your question about quarantine is a very good one. If I had been response coordinator, I would have handled this differently. I don’t know that it would have been any better however, I will give it my best “in a perfect world” shot, and you guys can tell me what you think.
Based on what we know about Ebola as of this evening, this would have been my strategy:
1. I would have started the huge ramp of military and volunteer medical worker response back in August. Yes, this also would have been overkill which I have argued against here, but the difference is that the best strategy for stopping an infectious disease is to isolate its victims as near the site of initial infection as possible. I believe that the US response and the response of the rest of the world was at least initially, too little, too late. But that may be nothing more than 20-20 hindsight.
2. My preferred policy would have been to have no limitations on flights of supplies and personnel into the area, but a strict policy of 21 day quarantine prior to an individual being flown back to the US. The means by which I would have implemented this would have been to assign teams in which volunteers spent a designated amount of time in direct patient care as soon as possible after arriving and then a second span of duty in which they performed administrative or supply and support jobs for 21 days away from patient contact while awaiting the end of their observation period. A two month minimum volunteer time would cover 5 weeks of medical service + a 21 day observation period prior to returning home. If this time restriction did limit the number of volunteers as was postulated, I would suggest overcoming this with very generous “hardship” stipends in addition to the pay offered by Doctors without Borders.
3. I am in agreement with bringing those who are infected back to the US for treatment. So far it has been demonstrated with the affected health care workers that once the correct diagnosis is made, they can be transferred and treated safely and effectively.
I would be interested in your thoughts.
Thank you, I almost thought I was living in a parallel universe. I’m not a doctor. But if I have the flu, or Hong Kong Flu, or XYZ Deadly virus, I don’t invite myself to a neighbors house, plop down, and have a 3-hour dinner. I restrict my travels, I don’t have visitors into the house (generally), and I keep others safe. So 1. and 2. sound logical.
Number 3, I’m unsure. Why don’t we keep them at their present location, and help them there? Especially given that the virus reportedly can live on a park bench or wherever for 50 days? The risk seems far too high, especially since we don’t know how the doctor contracted it, if it is so hard to pass, and we are super careful.
State Department plans to bring foreign Ebola patients to U.S.
“The State Department has quietly made plans to bring Ebola-infected doctors and medical aides to the U.S. for treatment, according to an internal department document that argued the only way to get other countries to send medical teams to West Africa is to promise that the U.S. will be the world’s medical backstop.”
Read more: http://www.washingtontimes.com/news/2014/oct/28/state-department-plans-to-bring-foreign-ebola-pati/#ixzz3HW7LqjIa Follow us: @washtimes on Twitter
TBD
I understand and respect people’s concerns about the risks of Ebola. However, I would also like to point out that much of the fear seems to be driven by the way in which Ebola has spread ( in West Africa), and its approximately 70% lethality (in West Africa). Not how it has behaved here in the United States.
So if we look at what has happened here, we have had to date I believe 16 cases of Ebola diagnosed and/or treated in the United States. We have had only one death and that was of an individual in whom there was an apparent delay of diagnosis.
What are the differences that I see in the two situations:
1. We have a universally agreed upon understanding of the disease. We do not hide our ill family members taking them in to hospitals only when they are dying because we fear that health care workers are selling body parts or killing people with chlorine. We do not bathe the corpses of our family members and bury them ourselves. We do not have the dead and dying lying on our streets. With only one exception in Texas, all of the patient’s in the United States have been identified prior to the highly infectious stage.
2.We have medical offices and hospitals and a communication system that allows for a very rapid response to changing conditions. The systems that I had described in my article had been in place for around a week at the time I wrote my article. At a meeting for review of our processes at one of our Sacramento medical offices, I became aware of just how universal and immediately accepted these practices are, a receptionist reported that the second thing she does after greeting the patient ( before she takes the card or any paperwork) is to “run my script”. When I asked what she meant, she said “You know, the Ebola questions.” All the front office folks agreed.
3. Once identified we have the lab capability to determine within the hour exactly what fluids and electrolytes need to be replaced if and when individual patient gets to the stage of vomiting and diarrhea.
While I firmly believe that quarantine is an essential step in the control of this very dangerous disease, I believe that the most effective mandatory containment is that which occurs in West Africa. I believe that self monitoring at home is adequate for those who are returning health care workers who are keenly aware of the risks and responsibilities associated with the care of those with Ebola.
So given the difference in the lethality and transmission of Ebola as demonstrated in West Africa, versus its lethality and transmission here in the United States, I believe that the best course of action is to bring those who have voluntarily risked their own lives here for the best possible treatment. I also believe that all Western countries that have essentially the same robust medical capabilities as the United States and in some cases much better organized medical systems should share in this responsibility.
Tia, you wrote: “I believe that self monitoring at home is adequate for those who are returning health care workers who are keenly aware of the risks and responsibilities associated with the care of those with Ebola.”
Two weeks ago I would have given this serious consideration. But now we have at least two doctors on the record as not self monitoring at home, one lying through his teeth, and a third worker who seems more worried about her civil rights than our health.
You may know that Dr. Nancy Snyderman, a TV doctor who went to West Africa, claimed she was at home, self monitoring. we then found out she took a limo with friends to go get Chinese food.
Worse is the case of the infected doctor in New York. The story has now come out that he lied to the health care workers and police about his whereabouts when he came back home. He said he was in his flat, “self monitoring”. Only when the authorities looked at his credit cards and metro pass, did they find out that he was bopping all over town. He then confessed to his travels around New York City.
TBD
“I thought having a quarantine was standard protocol for viruses like TB and ebola?”
Don is correct that TB and Ebola are quite different diseases. Tuberculosis is caused by a bacteria, not a virus. Prior to effective antibiotics it was indeed most effectively controlled by stopping its spread through isolation of affected individuals during its active phases. Since it is bacteria it can usually ( with the exception of multiple antibiotic resistant strains ) be treated readily with antibiotics. After “x” amount of time on effective treatment ( no infectious disease expert here) people can safely rejoin the community prior to completion of their full course.
Ebola is a virus and as such there are no effective antibiotics although there may soon be some effective antivirals and possibly immunization.
Tia and Don–how about putting our money where are mouths are? I’m willing to make a 1:100 odds bet with you or others on this forum whom I can trust not to Welsh. If by around this time next year (Halloween might be an appropriate date), the research community does still not have any indications that Ebola is spread except thru close bodily contact (with symptomatic Ebola patients), I pay you $10. If, on the other hand, the research community concludes there is some significant (or higher level) evidence for a non-bodily contact mode or modes of transmission, you pay me $1,000.
Are you willing to bet on these odds? It should be an easy $10, right? When I pay up, you can go out with your friends for coffee and mock the neanderthals who had been concerned about Ebola spreading (by the way when I was younger I had a tinge of red in my straw-colored hair, and thus can proudly count the robust and mighty neanderthals among my ancestors; passed on thru the bloodline of my father, a retired thoracic surgeon who had much redder hair than I when young).
On the off chance that I win, however, I will indeed hold you to the bet and demand the $1,000. If you do not pay up pretty fast, I will hound you mercilessly and relentlessly until you do (presumably you are honorable and I won’t need to let loose my inner hound, or invoke the spirit of my mighty neanderthal ancestors!)
I concede I’m likely to lose the bet. If so, I can also breath a sigh of relief as I pay you your $10.
So what about it? Are you willing to back up your words with the almighty dollar?
Welsh is not the same as welch
Residents of Wales are very thrifty, but that doesn’t mean they do not pay their debts.
Oxford English Dictionary
The OED says of the verb welsh or welch:
Their first quotation meaning to renege on a betting debt is from an 1860 Racing Time
Ah, the wonders of google.
I prefer the spelling welsh to welch–it reminds us of the etymology of the word, it’s origins, history, and roots in culture. Kind of like the word ‘gyp’ in reference to gypsies; many other such examples. The colorful world of yesteryear!
“If by around this time next year (Halloween might be an appropriate date), the research community does still not have any indications that Ebola is spread except thru close bodily contact (with symptomatic Ebola patients)”
I went back and read your post more carefully and believe that I am not being clear about my position.
In my posts, I have said several times that this is an evolving situation, that we do not understand Ebola completely, and that as more information is obtained, the precautions that we need to take may also change.
As of the time of my writing, the best evidence that we have is that Ebola cannot be contracted by casual contact with an asymptomatic carrier of Ebola. This is because our form of “casual contact” does not include such acts as hugging or kissing strangers or casual acquaintances. So in fairness to those who have posted the idea of alternative means of transmission I think a full consideration of each is warranted.
1. The individual believed to have contracted Ebola while cleaning out the ambulance that carried the person in the very late stages of Ebola.
No one is discounting the possibility of transmission by pooled bodily fluids once the individual has entered the high shedding phase of the disease. In our isolation rooms, everything that enters or leaves the room is considered to be contaminated. This is to the point where the responding clinicians have been instructed to leave their personal possessions such as cell phones or tablets outside the room. But this is believed to be specific to the symptomatic patient. This would be supported by the very point that Elizabeth has made about the amount of viral load necessary to even detect the virus in the blood.
I would like to clarify this point. The transmissibility of a virus ( or bacteria) depends ( in part ) upon the amount of the virus present. If it is present in very small numbers, the hosts defense mechanisms will t successfully defend against the organism. If it is present in very large numbers, it is more likely to overcome the previously uninfected persons defense mechanisms. This is true in the common “cold sore” which is most likely to be passes when one has a visible sore on the lip and much less likely to be passed when no sore is visible, even thought the virus is still present. From the pattern of cases of Ebola, this would also appear to be true for Ebola.
2. The health care workers who cannot identify how they got Ebola.
Lack of knowledge of a breach of PPE or an open area of skin does not equal the absence of such. As a surgeon, I have sustained many small breaks in the skin of my hands that I did not see until hours if not days after a surgery, and then could not have conclusively said how I got that tiny, now almost healed over ding in my skin. Likewise, after taking off my PPE after surgeries is was not unusual for me to have a small amount of blood visible under a fingernail even if neither myself nor the nurse watching had seen any breach in my glove. A common phrase heard in the scrub area after a delivery or surgery is “You missed a spot of blood, right there, by your eye”. Surgical PPE and that worn by L&D staff is, in the post HIV world, is very similar to that worn by the initial Ebola responders. I do not think that it should be assumed that they had to have acquired Ebola by some other means because they cannot identify when it happened.
3. The case of the primates in separate cages.
I think it much more likely that there may have been some breach in the protocols for cleaning the cages, or supplying food and water than that the Ebola transmitted through the air of the room. Without knowing the exact protocols used and where the inevitable sources of error might be to determine the probabilities here. As such, I see this as an interesting unknown, and a cause for further investigation, not a cause for alarm or expenditure on vast amounts of resources that could be used on known threats to our public health.
4. Someone had asked the question “would I be comfortable sharing an ice cream with someone with Ebola”.
The answer is no. But then, I would be more comfortable not sharing food with casual contacts at all. Viruses and bacteria that are deadly are already amongst us in the form of Norovirus of which we see sporadic outbreaks with fatalities and of some strains of E.coli of which we also see sporadic lethal outbreaks. The number of known transmissions of Ebola by such means in this country ( or any country ) is zero. I believe that what is happening is that people are seeing the devastation that this disease has caused in West Africa and projecting it onto what might happen in this country. This is inappropriate since our information systems and medical infrastructure are simply not comparable to those of West Africa. I believe that this is an error in risk assessment. As such I believe that it leads to errors in fund allocations for “preparedness”.
While I do not down play the risks associated with Ebola, I also do not downplay the risks associated with the flu ( or any of a host of other contagious diseases that we presently encounter in large numbers). My feeling is that we should not, in response to fear, ignore the army that is already on my doorstep in order to prepare for the one threatening from across the world. What the headlines and nightly news do not highlight is what other efforts are now losing funding, and costing lives in order not to find a cure or vaccine for Ebola, but rather to provide training, PPE, empty isolation rooms and other measures for that which is extremely unlikely to occur here.
tribeUSA, I fully agree with betting what is of value to me.
The almighty dollar is not what matters to me. But I am very willing to bet. Straight across hour for hour. You win on your bet and I volunteer 10 additional hours of tutoring, which is what I am currently doing as my principle volunteer activity outside health care ( or hours tabling for health issues at Farmer’s Market if you want it confirmed localy ), if I win the bet you have proposed, then you donate 10 additional hours to some health or social well being project to be agreed upon.
If my salary is indeed as much higher than yours as some folks on this blog like to assume, then I would be putting up the higher temporal and monetary value.
Deal ?
Tia–Ah, I’m disappointed in your lack of confidence in your position.
The entire point of the 1:100 terms was that this reflected the upper end of odds against another significant route of transmission. I think we can agree that odds as high as 1:100 are significant (do you not buy fire insurance)? Therefor if you consider the risk of alternative routes of transmission to be insignificant, are you not willing to accept 1:100 odds? Surely you don’t consider the odds to be higher than this?
If you want to consider your time as more valuable than mine, that is entirely your perogative, but it is also my perogative not to accept this contention.
tribeUSA
“If you want to consider your time as more valuable than mine”
I don’t. I consider everyone’s time to be equal.
You have misinterpreted my comment, or perhaps not seen previous comments of mine on my perception of the importance of money vs. time. I have advocated repeatedly for the unit of exchange in our society to be our time since that is the only thing that is of the same value for all of us.
The reason that I wrote, ” as some folks on this blog would like to assume”, is that our society has decided to arbitrarily value some people’s time as of more value than others. I fundamentally disagree with this position and thus am willing to bet with what is of most value to me, my time. If you, on the other hand, value money more highly, as your post would imply, then it would have been you who established the differential. Since I have no idea who you are , I have no idea which of us earns or has more money. You could be a neurosurgeon ( making twice what I make), or you could have inherited millions for all I know. It was not a lack of faith in my position, but my fundamental belief in the equality of the value of our time that led to my alternative proposal. But if you don’t want to bet according to my counter offer, that is fine too.
Tia-yes, we are definitely misunderstanding each other in a couple places–by the way I largely agree with you about time as a medium of exchange; however contribution also has to factor in somewhere, perhaps some sort of measure that accounts for both time and contribution independently as predominant factors.
But the main point I’d like to clear up isn’t money vs time; the main point is clarifying our understanding of or agreement on the odds. I am positing a particular numerical (not financial) value on the term ‘insignificant risk’ in relation to alternative modes of transmission; perhaps we can each agree that the risk begins to become ‘significant’ when that risk exceeds 1:100 (the home fire insurance analogy; actually the average odds on any particular house burning down are less than 1:1000 in a town like Davis; yet presumably most homeowners are insured). So a contention that risk is insignificant can perhaps be qualified to mean it has less than a 1:100 chance of occurring. So my bet that the alternative modes of transmission might be shown (with some significant degree of confidence) to occur has only a 1% chance of being accurate. Your bet that no significant evidence for this will turn up has a 99% chance of being accurate. Therefor since I am about 100 times more likely to be incorrect than you are, the betting terms are appropriately 100:1.
We already know of 2 modes of transmission other than direct person to person contact:
1. we have indirect transmission via contaminated surfaces – this is reportedly how the NBC cameraman became infected. It is known that the Ebola virus can survive for days, in some cases almost 50 days, on surfaces.
2. via droplet spread (coughs, sneezes) which the CDC claims is only up to a distance of 3 feet although it is known that, depending on the size of the droplets, the distance traveled can be anywhere from 15 feet up to hundreds of feet. This mode of transmission was acknowledged just this week by the CDC.
How far away is that passenger sitting next to you on the plane? Don’t worry though, some people on here want to rationalise that threat by saying the car ride to the airport or the plane crashing has a greater chance of happening.
Our CDC has now quietly admitted that ebola can be spread by droplets / and / or a sneeze.
http://nypost.com/2014/10/29/cdc-admits-droplets-from-a-sneeze-could-spread-ebola/
From: Jaroslaw Waszczuk [mailto:jjw1980@live.com]
Sent: Wednesday, October 29, 2014 1:43 AM
To: ann.rice@ucdmc.ucdavis.edu; chancellor@ucdavis.edu; ann.rice@ucdmc.ucdavis.edu; chancellor@ucdavis.edu; ann.rice@ucdmc.ucdavis.edu; chancellor@ucdavis.edu
Cc: vincent.johnson@ucdmc.ucdavis.edu; jdkirk@ucdavis.edu; Thomas.Nesbitt@ucdmc.ucdavis.edu; timothy.maurice@ucdmc.ucdavis.edu; James.Goodnight@ucdmc.ucdavis.edu; micheal.minear@ucdmc.ucdavis.edu; heather.young@ucdmc.ucdavis.edu; Chong.Porter@ucdmc.ucdavis.edu; Ralph J Hexter; regentsoffice@ucop.edu; vincent.johnson@ucdmc.ucdavis.edu; jdkirk@ucdavis.edu; Thomas.Nesbitt@ucdmc.ucdavis.edu; timothy.maurice@ucdmc.ucdavis.edu; James.Goodnight@ucdmc.ucdavis.edu; micheal.minear@ucdmc.ucdavis.edu; heather.young@ucdmc.ucdavis.edu; Chong.Porter@ucdmc.ucdavis.edu; Ralph J Hexter; regentsoffice@ucop.edu; vincent.johnson@ucdmc.ucdavis.edu; jdkirk@ucdavis.edu; Thomas.Nesbitt@ucdmc.ucdavis.edu; timothy.maurice@ucdmc.ucdavis.edu; James.Goodnight@ucdmc.ucdavis.edu; micheal.minear@ucdmc.ucdavis.edu; heather.young@ucdmc.ucdavis.edu; Chong.Porter@ucdmc.ucdavis.edu; Ralph J Hexter; regentsoffice@ucop.edu
Subject: WORSE THEN EBOLA VIRUS -RESPONSE TO OCTOBER 24, 2014 MESSAGE FROM UC DAVIS MEDICAL CENTER (UCDMC) CEO ANN MADDEN RICE -OPEN LETTER
WORSE THEN EBOLA VIRUS
RESPONSE TO OCTOBER 24, 2014 MESSAGE FROM
UC DAVIS MEDICAL CENTER (UCDMC) CEO ANN MADDEN RICE
Ms. Rice,
I found your October 24, 2014 Ebola message more appealing than UCDMC Chief Medical Officer Mr. J. Douglas Kirk’s M.D October 14th, 2014 message about the Ebola false alarm in UCDMC.
Freelance writer Leigh Cowart, in her article, entitled “Nature’s Most Perfect Machine,” described Ebola as nightmare fuel, a biological doomsday device conspiring with our bodies to murder us in uniquely gruesome fashion (http://penguinrandomhouse.ca/hazlitt/longreads/natures-mostperfect-killing-machine).
From your statement, I understood that on October 24, 2014 UCDMC has no personal protective equipment and if the false Ebola alarm announced by the UCDMC Chief Medical Officer on October 14, 2014 had not been false, it would have turned deadly for UCDMC Hospital staff and other UCDMC patients. Furthermore you stated in your letter that UC’s Office of the President has informed the California Department of Public Health (COPH) that all five UC medical centers are positioned to provide inpatient care for Californians with confirmed cases of Ebola, if necessary. The CDPH has committed to helping the medical centers obtain the necessary personal protective equipment (PPE), should we have sourcing challenges. This is quite a confusing statement: UC medical centers were positioned to take care of Ebola patients without yet having personal protective equipment? I don’t know who wrote this letter for you, but it is a total mess regardless of whether UCDMC will have any Ebola patients or not. The mess which you disclosed in your letter was confirmed by RoseAnn DeMoro, executive director of the California Nurses Association and National Nurses United, who said that California hospitals have failed to provide adequate training or equipment to nurses, a claim hospitals disputed.
“None of the hospitals in California are prepared,” DeMoro said after meeting with Brown. “We cannot name a hospital that we feel comfortable with for patients in the state of California to attempt to have the appropriate response in an Ebola situation.” Speaking at a news conference outside Brown’s offices at the Capitol, DeMoro said, “The deficiencies in the systems in California are outrageous.” I am not sure why hospitals dispute DeMoro’s claim if UCDMC CEO Ann Madden Rice said different. The other issue is whether UC campuses and medical centers have students, faculties and staff from West Africa or locals which are traveling back and for to the places of Ebola outbreak.
I had no intention of writing anything in response to your message. However, on the same day I received your message about UCDMC preparedness for Ebola patients, I also received a letter from UCDMC Labor Relations Consultant Mr. Shawn Hadnot about a complaint filed by UCDMC Paint Shop worker Frank Gonzales, to whom I am providing representation. There would be nothing wrong with HR Labor Relation letter if Mr. Hadnot did not write down the letter the following statement “Furthermore, the requested resolution related to the alleged treatment at the workplace shall be referred to PO&M management and will not be subject in this review process.”
I am not going to even repeat what kind of treatment Mr. Gonzales has received from PO&M management since October 2013 and the complaints which were filed against PO&M Management. They are being handled by Mr. Shawn Hadnot and his Manager Travis Lindsey, thus the above-mentioned statement is nothing else but an example of the treatment complaining employees receive from your and Chancellor Katehi’s administration.
I looked at your Ebola message and Hadnot’s letter and came to a conclusion that Katehi’s and Rice’ administration was and is a lot better prepared to fight and attack labor than take care of deadly diseases. You, with your over-one-million-dollar salaries per year and fat bank accounts, probably don’t care about Ebola’s patients anyway or hospital staff and patients. You could quit today and take off without any harm to your wealth.
During this occasional response about the Ebola, I would like to also refresh your memory that three years ago on October 17, 2011, UC Davis Vice Chancellor for Research Harris Levine informed the U.S. Food and Drug Administration that the University of California Davis Institutional Review Board (IRB) completed its investigation about illegal experiments on UCDMC patients which involved opening the skull of and deliberately infecting the brains of cancer patients with the bacterium Enterobacter aerogenes, without FDA or Institutional Review Board (IRB) approval, and without compelling scientific evidence in support of the immunological hypothesis that a brain infection in glioblastoma patients could improve outcomes. It happened with your knowledge, under your and Claire Pomeroy’s executive power which brought two mercenary neurosurgeons to UC Davis Medical Center in the spirit of Auschwitz and Dr. Joseph Mengele’s ghost.
Looking at the very long list of lawsuits filed in County of Sacramento Superior Court against UCDMC, more than 95% of which are for medical malpractices, it makes me wonder whether these malpractices are the result of omission or mistakes or caused by deliberate illegal experiments by UCDMC staff, causing patients suffering who did not know they were subjects of unlawful procedures and experiments (list of lawsuits enclosed). Now you could only imagine how many UCDMC patients have been hurt or died because of UCDMC “experimental” procedures but never were subjects of lawsuits or complaints to federal law and regulatory agencies.
In my complaint filed with OSTEOPATHIC MEDICAL BOARD OF CALIFORNIA in June 2013, I wrote:
“In 2005, UCDMC Medial Director of Employee Health Services in Dr. Neil Speth almost killed me by forcing me to take a spirometry test against my will and, as a result of this incident of malpractice, I landed unconscious in the UCDMC Emergency Room. At the relevant time, I informed Dr. Speth about my pre-existing medical condition, which did not permit me to participate in spirometry tests. I intended to take legal action against Dr. Speth, but a few months later I had open-heart surgery and dropped the idea of taking him to court. I am not sure about what kind of assignment the “HR Death Squad” gave to Dr. Speth for May 31, 2012. By this complaint, I am trying to find out whether Dr. Speth had been assigned to confirm that I stopped breathing in the Trauma Unit after Lt. James Barbour’s response to the HR department’s planned, manufactured emergency situation that would end my employment with UC Davis Medical Center.
In my three appeals against the termination decision that I filed in accordance with the University of California’s policies, I gave this assembled UCDMC HR team a special nickname—”The UC Davis Medical Center Death Squad”—and I am hoping that the State of California’s various law enforcement agencies with whom I am filing complaints will investigate the UCDMC Death Squad’s activities and will disassemble this team, which is dangerous not only to employees of the UC Davis Medical Center but whose actions as white-collar criminals who only desire to preserve their positions and power are unthinkable and unconscionable for any normal person.
The Osteopathic Medical Board of California Executive Director Angie M. Burton referred me to the District Attorney’s Office. I did not follow up with it, because the investigation was assigned to UC Office of the President where it was pending for next 18 months and ended without resolution in September 2014 (Copy of a complaint attached).
In 2009, I was lying down on the bed in the UCDMC ER with closed eyes and during the shift change, a doctor asked another doctor or nurse: “Who is lying on that bed” than I had heard.
“Some Pollack ate too much cabbage, and he is complaining about the pressure and pain across his chest.”
I didn’t say anything and that statement made me laugh. Apparently, somebody knew Polish menu or cuisine, which includes cabbage, sauerkraut. I love people with a good sense of humor. However, today I am not quite sure whether it was good sense of humor or such treatment of patients in UCDMC ER is part of UC Davis’s climate outlined in 2013 Rankin & Associates survey and described below.
Another example I know of faulty UCDMC medical procedure is my former coworker, whose lungs were damaged due to malpractice, and who had to sleep for six months in sitting position.
Furthermore, three years ago in November 2011, the UC Davis Chancellor was described by freelance writers as “Chemical Katehi” after ordering a gas attack on peacefully protesting students in UC Davis campus. “Chemical Katehi brought to UC Davis the ghost of Greek Fascist Military Junta which in November 1973 attacked peacefully protesting students in Athens Polytechnic killing two dozen protesters and wounded over one thousand students. In November 1973 and on the days of the bloody massacre, Linda Katehi was a student in Athens Polytechnic.
It is unknown whether Katehi was on one of the protesters against fascist junta or whether she was Junta’s informer pointing who to arrests among protesters. Katehi in an interview with a Greek-American reporter was very vague about her involvement in the protest of 1973, which one year later brought the fascist military junta down. Considering that “Chemical Katehi” witnessed a bloody massacre of her fellow students and 38 years later ordered an attack on students in UC Davis Campus then I have no doubt that “Chemical Katehi’s “Bible” is Mein Kampf.
If you add into that that in November of 2011, Katehi requested a confidential report on me following the guide which profiled Europeans in civil unrests and that on May 31, 2012 an ill-minded but unsuccessful attempt was crafted to provoke me and end my employment in UCDMC Trauma Unit #111, and then my coworker was approached by UCDMC Chief Compliance Officer deputy Gina Guillame-Holleman to sign an affidavit or statement for the “UC Davis Most Unwanted” warrants with my photo on it, the picture of “Chemical Katehi” and UCDMC CEO Ann Madden Rice quite clearly shows real facade the present UC Davis Regime.
After Nazi War criminal Adolf Eichmann’s trial and execution in1962, Nazi hunter Simon Wiesenthal said: “The world now understands the concept of ‘desk murderer.’ We know that one doesn’t need to be fanatical, sadistic, or mentally ill to murder millions; that it is enough to be a loyal follower eager to do one’s duty.”
I could elaborate a lot more about UC Davis’ regime, but I will end this letter asking you to review my employee evaluations for the last two years of my employment with UCDMC and look again at two attached photos. One photo shows me in 1981 sitting next to an anticommunist movement leader who changed history in Europe and became the first President of free Poland, liberated from Soviet Union domination after 50 years of slavery. The second photo shows you with UCDMC Central Plant Manager Steve McGrath who carries two suicides on his back. One who tragically took her life was his wife. The second person who committed suicide was UCDMC Central Plant worker Todd Georlich in December 2010, after being bullied and harassed in Central Plant. As I know, Todd Georlich was Steve McGrath’s friend; and with his help Todd get a job in the Central Plant. I found it very odd that two people close to McGrath took their own lives . The irony of the photo of you and Steve McGrath is background of this photo is the University of California Whistle Blowing Policy Poster, which informing employees about protection from retaliation.
In conclusion, I don’t hesitate to say that you and “Chemical Katehi” and your henchmen are a lot worse and more dangerous for society than the deadly Ebola virus. You have destroyed many lives, including mine, and still do so. You are a cancer who should be eliminated by new President of University of California Hon. Janet Napolitano without further delay.
I am awaiting UC Response to my complaint I filed against you and your henchmen in court. Then you and “Chemical Katehi” will be reminded again who you are. Look at the photo of the backyard in home I had. You and “Chemical Katehi” took this from me just few years before my retirement and after 30 years of my hard work in this country. This is very personal, Ms. Rice.
Sincerely,
Jaroslaw Waszczuk
Lodi, CA- September 28, 2014
CC. UC President, Hon. Janet Napolitano, US and State of California legislators, UC Regents, UC employees.
Enclosure
Message from CEO Ann Madden Rice
UC Davis Health System 10/24/2014 01:06 PM
Please respond to public.affairs
Dear Colleagues,
Although you might not know it from the news media’s coverage of it, Ebola is very difficult to contract, and the likelihood that UC Davis Medical Center will receive a patient with Ebola is very low.
Regardless, for the past few weeks, we have been intensely engaged in preparing and planning for the possible arrival of a patient with Ebola. Today, there will be an announcement that the UC Office of the President has informed the California Department of Public Health (COPH) that all five UC medical centers are positioned to provide inpatient care for Californians who have confirmed cases of Ebola, if necessary. The CDPH has committed to helping the medical centers obtain the necessary personal protective equipment (PPE), should we have sourcing challenges.
Full details about UCOP’s arrangement with the COPH will be posted on The Insider.
At UC Davis Medical Center, a wide-ranging group has been working tirelessly to prepare us for the potential arrival of a patient with Ebola. We have assembled a group of volunteers who will serve as a dedicated, inpatient Ebola care team. In response to our call for volunteers, we received responses from more than twice the number of employees that we were seeking. This tremendous response exemplifies the selfless, can-do spirit of UC Davis, and l cannot express how proud and grateful I am.
Our Ebola task force, composed of personnel from all departments that would be involved in the handling of an Ebola patient, continues to meet daily. It is continually refining protocols and adjusting practices as we learn more each day. Although we are using guidelines from the federal Centers for Disease Control (CDC) as a foundation, our refinements, in many ways, make us far
better prepared than other hospitals.
Our preparations have included a recent, four-hour presentation on Ebola preparedness, which included a demonstration on donning and removing PPE. The presentation was streamed live.and a video of it is available here: http://tinvuri.com/Ebola-UC-DAVIS.
I realize that tension and anxiety are high among some of our staff. That is understandable, as guidelines for handling potential Ebola patients remain fluid. However, we are monitoring developments intently, and will continue to adjust our practices as the CDC revises its recommendations, and as we learn lessons on our own. As part of our commitment to ensuring
the safety of our staff, we will keep you informed about developments as they evolve.
I appreciate all of your hard work and dedication as we work to ensure that UC Davis Medical Center remains at the highest level of readiness possible.
Sincerely,
Ann Madden Rice
CEO. UC Davis Medical Center