President Obama Addresses the Ebola Crisis

In this weekly address, President Obama addresses the Ebola crisis.  As we've come to expect from our Chief Executives, it's a perfectly crafted speech that addresses our major concerns. But the Population Health Blog doesn't think it goes far enough.  In its continuing quest to help Mr. Obama overcome his tanking approval ratings, the PHB changed a few words and modestly offers up a slightly edited version of the address.  It believe it speaks more forcefully to the issues at hand.....

PRESIDENT OBAMA: Hi everybody, this week, we remained focused on spinning a favorable White House narrative about Ebola. In Dallas, the natural history of the disease and basic isolation procedures limited spread of the disease to only two among the dozens of health care workers who had been in close contact with the first patient. Now, those two workers are two too many, which is why I've told the CDC that their calm and distant inertia is unacceptable.  As you know, that's my job.

The two nurses who contracted the disease in West Africa were thankfully released from the hospital. I was proud to welcome one of them to the Oval Office to give her a big hug and make sure plenty of photographs were taken.

And in Africa, the countries that did not wait for our help, Senegal and Nigeria, were declared free of Ebola.  Which is probably why New York City also decided to not wait on Washington DC. Local public health personnel there moved quickly to isolate the doctor who recently returned from West Africa. While we deployed one of our new CDC rapid response teams, I wonder what they'll learn from New York City's approach. Maybe a lot. And I’ve assured Governor Cuomo and Mayor de Blasio that they’ll have all the federal support they need as they go forward.  After all, I'm from big government and I'm here to help.

More broadly, this week we've continued to step up our use of words like "efforts" "outreach," "coordinate," and "integrate" across the country. New CDC outreach is helping hospitals coordinate and integrate training. The Defense Department’s new team of doctors, nurses and trainers will outreach, coordinate and integrate if called upon to help with coordination and integration and, you know, outreach and other efforts.

Now, rather than institute an unworkable travel ban, we now have a less unworkable travel measure that directs all travelers from the three affected countries in West Africa into five U.S. airports. Starting this week, these travelers will be required to report their temperatures and any symptoms on a daily basis—for 21 days until we’re mostly hopeful that they don’t have Ebola. Here at the White House, the lawyer I've appointed to coordinate and integrate the government's response will tell the doctors what to do and how to do it. And we have been examining the protocols for protecting our brave health care workers, and, guided by the science, we’ll continue to do everything we can to embarrass the Republican nutjobs who are also using Ebola for political gain.

In closing, I want to leave you with some basic facts. First, you cannot get Ebola easily through casual contact with someone. The only way you can get this disease is by coming into direct contact with the bodily fluids of someone with symptoms. But, if you do get it, your internal organs could liquefy. That’s why health workers must wear total body condoms. That's the science. Those are the facts.

Here’s the bottom line. We can beat this disease. But we at the White House have to stay on message by repeatedly saying that we have to work together at every level—federal, state and local. And we have to give the impression that we're leading a global response, because West Africa is in a world of hurt right now along with other global hot spots like Syria and Ukraine and Hong Kong and Russia.

And we have to be guided by the science—we have to be guided by the facts, not fear. Yesterday, New Yorkers showed us the way. Despite the mainstream media's alarmist reporting, they did what they do every day—jumping on buses, riding the subway, crowding into elevators, heading into work, gathering in parks, ignoring speeches like this and wondering why the Yankees aren't in the World Series.

That spirit—that determination to carry on—is part of what makes New York one of the great cities in the world. And that’s the spirit all of us can draw upon, as Americans, as we meet this challenge together.

Health Worker Nonchalance About Ebola?

The Ebola virus

Recent reports of two nurses becoming infected with Ebola begs the question of whether they were lax in following infection-control protocols. Even if that's true (and it may not be) the bigger mystery is healthcare community's apparent nonchalance. TV's talking heads are generally not alarmed. NBC medical correspondent Nancy Snyderman reportedly snuck out to get some take-out food. Experts at the CDC apparently okayed one mildly feverish nurse's request that she be allowed to travel.

What gives?

First off, how does Ebola spread?

 Ebola is "filovirus" (so named because it has a uniquely filamentous appearance) that, once introduced into the body, can attach to and invade numerous types of human cells. Getting into the human body occurs from the injection of infected blood (such as a inadvertent needle stick from a person with Ebola) or hand-borne "self-inoculation" of a patient's body fluids into the mucus membranes. That's typically the mouth, nose or eyes. 

"Self-inoculation" of a virus by rubbing the eyes or touching the nose/mouth has been a long-known means of spreading infection. Because humans unconsciously touch their facial mucous membranes frequently during the course of a day, eye goggles and facemasks are not only a barrier to airborne virus (such as regular cold viruses), but also act as a reminder to keep your fingers away from your face and eyes (which is more important with the Ebola virus, which is not airborne). 

After the inoculation and during the initial stages of invasion and replication, there aren't enough viral particles to pose a significant person-to-person transmission risk. It's only when the infection becomes overwhelming (which is heralded by a fever) that the virus makes its appearance in body fluids, including blood, tears, saliva, sweat, diarrhea and vomit. Healthcare workers cannot avoid handling the sick patient or their bedclothes, and that's when accidental needle sticks and unconscious touching of their face - i.e. mucus membranes - leads to transmission of the virus to a new victim.

What are healthcare workers' attitudes about infections?

Getting health care workers to pay attention to the inadvertent spread of infection in the course of patient care has been a topic of research for decades.  It's not like they don't know how viruses move from person to person.  Rather, failure to act on that knowledge is a result of poor adherence, insufficient resources, staffing problems, lack of culture change, no impetus to change, and issues related to staff and patient education.  Even with intense education, attitudes may shift by a only a few percentage points. It's not uncommon for up to a quarter of health care workers to not follow basic infection control protocols after a teaching intervention.

How well do health care workers educate lay-persons?

Even when patients are in contact isolation for other reasons, healthcare workers do a bad job of dealing with the concerns of family members or educating their patients about its importance. And it doesn't help that nurse "burnout" can be an independent risk factor for the inadvertent transmission of infection to patients.

While reports like this portray the importance of public education, it's fair to say that the gap between the "stay calm" Ebola expertise of organizations like the CDC and the growing alarm of the lay public is significant.

The Population Health Blog's take?

Healthcare providers have cared for patients with other serious infectious diseases, and their attitudes to dealing with Ebola are not new. While the PHB is unaware of the details of how the two nurses described above contracted the disease, it was just a matter of time until someone got infected. 

If more primary Ebola cases occur in the U.S., we can expect more healthcare workers to contract the disease. A nonchalance toward infectious disease has been a part of the medical landscape for decades.  While the risks associated with Ebola are higher (a purported mortality rate as high as 70%), this is another virus bumping into decades-long patterns of imperfect human behaviors.

While the public is extremely concerned about the specter of Ebola, expert infectious disease talking-heads are well-acquainted with the above data.  They are not surprised that nurses are coming down with Ebola.  Unfortunately, that unsurprised expertise combined with a legacy of poor lay-public education is coming across as incompetence. That's especially true when clinical judgment about a fever leads to a plane-load of passengers being exposed to a sick patient's body fluids. The public deserves better.