1. Ebola is a highly contagious viral disease.
2. Ebola spreads via transfer by bodily fluids.
3. Sweat is one of the bodily fluids that contain the Ebola RNA
virus.
4. The specific mechanism of spreading via bodily fluids is
unclear.
5. The current outbreak in West Africa is the first time Ebola
has broken out in a higher density area.
6. The rate of spread in a higher density area appears to be
greater and lacks the natural self containment of previous outbreaks which were geographically quarantined.
7. The specific mechanism of infection of US based individuals
is uncertain other than having had some form of proximity to an Ebola infected
patient. In almost all cases the actual mechanism of transfer is unknown.
8. Ebola RNA titers in the blood and urine last about 20 days
after initial symptoms. The Ebola RNA
titers are still quite high and measurable in sweat after 40 days from start
of symptoms.
9. New York subways are high contact transportation systems
having hand rails and the like which are a source for sweat transfer.
10. If sweat is a carrier of Ebola RNA, and if an infected
patient uses the subway in New York, then there is a likely probability of a
transfer of RNA and interaction by third parties with that RNA.
11. To minimize such a potentially lethal exposure the only
solution is a quarantine of exposed individuals in some appropriate manner.
Now in a recent NEJM piece the authors write:
The governors of a number of states, including New York and New Jersey,
recently imposed 21-day quarantines on health care workers returning to
the United States from regions of the world where they may have cared
for patients with Ebola virus disease. We understand their motivation
for this policy — to protect the citizens of their states from
contracting this often-fatal illness. This approach, however, is not
scientifically based, is unfair and unwise, and will impede essential
efforts to stop these awful outbreaks of Ebola disease at their source,
which is the only satisfactory goal.
If one follows the "scientific facts" or observables then conclusion seems correct. Admittedly placing anyone in a tent in some lot in Newark is cruel and unusual punishment but after all it was Newark,
If it is unscientifically based then one wonders where the above logic fails based upon facts.
Now the NY Times has stated:
For example, it we have but 10,000 virions per ml at day 40 and we have a patient then exposing others to that concentration, is that ethically acceptable? Since the minimal viral load is not known, do we best err on the side of public safety?
Now the NY Times has stated:
However,
some public health professionals say that the governors are letting
politics guide their decision making in a way that could prove
dangerous. “The
governors’ action is like driving a carpet tack with a sledgehammer: it
gets the job done but overall is more destructive than beneficial,”
according to the editorial in the journal. The article lays out the science behind the spread of the disease, as it is currently understood. “We
have very strong reason to believe that transmission occurs when the
viral load in bodily fluids is high, on the order of millions of virions
per microliter,” according to the editorial. “This recognition has led
to the dictum that an asymptomatic person is not contagious; field
experience in West Africa has shown that conclusion to be valid.
Therefore, an asymptomatic health care worker returning from treating
patients with Ebola, even if he or she were infected, would not be
contagious.”
Let us return to the NEJM Ebola data from Germany as we show below.
Now this starts at day 10, and the concentration is virions per ml in log base 10. Thus in sweat at day 40 we have 10,000 virions per ml or only 10 per micro l. But likewise we have at day 10 in serum about 100,000 per micro liter, or an order of magnitude below the above contagion level. However we also know that such a patient is contagious. Thus we really do not have adequate data. At least in the public domain.
Also the authors of the NEJM editorial have no references to facts, The NEJM editorial states:
A cynic would say that all these “facts” are derived from observation
and that it pays to be 100% safe and to isolate anyone with a remote
chance of carrying the virus. What harm can that approach do besides
inconveniencing a few health care workers? We strongly disagree.
Hundreds of years of experience show that to stop an epidemic of this
type requires controlling it at its source.
One need not be a cynic. One need to be certain they have the duty of care to the public and absent any definitive evidence that care must be extreme, not based on conjecture. Even the German case is a one of data point. Why, for example, do we not now have a set of such data for all the Ebola cases in the US? Then we start to deal with data.
Oftentimes Medicine is a "what and how" profession. Namely diagnose and then use the standard treatment. It is becoming a "why" profession as well, and the ability to answer the way depends on data, and there now is a significant set of it available and it should become a key element of the conversation.
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