[blueash]

Ok, I know there are already Ebola threads and I could post there. The New England Journal of Medicine is the top medical journal in the world. This is so well written, so evidence based, so reasonable that it deserves its own thread. I hope that the partial use of the material does not violate copyright rules as I have included a full citation. This link also will allow interested persons to read the entire editorial

Editorial Ebola and Quarantine

Jeffrey M. Drazen, M.D., Rupa Kanapathipillai, M.B., B.S., M.P.H., D.T.M.&H., Edward W. Campion, M.D., Eric J. Rubin, M.D., Ph.D., Scott M. Hammer, M.D., Stephen Morrissey, Ph.D., and Lindsey R. Baden, M.D.

October 27, 2014DOI: 10.1056/NEJMe1413139

"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. The governors' action is like driving a carpet tack with a sledgehammer: it gets the job done but overall is more destructive than beneficial.

Health care professionals treating patients with this illness have learned that transmission arises from contact with bodily fluids of a person who is symptomatic — that is, has a fever, vomiting, diarrhea, and malaise. 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. 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. Furthermore, we now know that fever precedes the contagious stage, allowing workers who are unknowingly infected to identify themselves before they become a threat to their community. This understanding is based on more than clinical observation: the sensitive blood polymerase-chain-reaction (PCR) test for Ebola is often negative on the day when fever or other symptoms begin and only becomes reliably positive 2 to 3 days after symptom onset. This point is supported by the fact that of the nurses caring for Thomas Eric Duncan, the man who died from Ebola virus disease in Texas in October, only those who cared for him at the end of his life, when the number of virions he was shedding was likely to be very high, became infected. Notably, Duncan's family members who were living in the same household for days as he was at the start of his illness did not become infected.

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. Médecins sans Frontières, the World Health Organization, the U.S. Agency for International Development (USAID), and many other organizations say we need tens of thousands of additional volunteers to control the epidemic. We are far short of that goal, so the need for workers on the ground is great. These responsible, skilled health care workers who are risking their lives to help others are also helping by stemming the epidemic at its source. If we add barriers making it harder for volunteers to return to their community, we are hurting ourselves."

[graciegirl]

This journal to me speaks ex cathedra. It doesn't get any more valid than this. I always trust it. It is made up of the greatest minds in medical science in my opinion.

But...this also shows my obsessive behavior. I am still skeptical and will be skeptical until a valid cure is found and a vaccine.

It just shows how dumb I am.

[l2ridehd]

It says almost the same information about the common cold. Which is transmitted the exact same way. Only big difference is the cold virus will live on a shopping cart handle for up to 72 hours or 3 days. The Ebola virus up to 50 days. A cold is transmitted by body fluids. You sneeze, blow your nose, get the germs on your hands, shake hands, that person rubs their eye, transmission. Same with Ebola. Probably it is harder to transmit than a cold, but not really proven.

The only big difference is a person with a cold tends to try and carry on as usual and therefor impacts more people. A person with Ebola is to sick to carry on as usual.

Yes I trust what this journal says, but as many experts will also say, we still don't know a whole lot about Ebola as it has not been prevalent where medicine is well studied. As an example they have just determined that one strain can be transmitted as an airborne virus which was previously claimed was not possible.

So for me the jury is still out.

[billethkid]

Some of us still remember the yellow card the health department would come out and staple to the front door of the house where someone with measels lived......big QUARANTINE....letters. Somehow we all managed to abide by and live through the ordeal.

For today and ebola I will follow the 21 day incubation cycle....see ya in three weeks!!!

The quarantine did not seem to be a big deal to people involved until the recent rogue nurse camera in the face daily episode

[gomoho]

Originally Posted by billethkid

The quarantine did not seem to be a big deal to people involved until the recent rogue nurse camera in the face daily episode

Interesting point - I am curious how many others have been quarantined we haven't heard about. I am familiar with one other, only because he was on
the news, but was quietly trying to have it lifted. He said all hope is now lost for him due to the nurse.

Does anyone know of other cases?

[redwitch]

Originally Posted by billethkid

The quarantine did not seem to be a big deal to people involved until the recent rogue nurse camera in the face daily episode

Not true. Another nurse abided with the quarantine but publicly decried the policy and is threatening a lawsuit.

[billethkid]

the entire family of patient zero were quarantined and they did their 21 days without a whimper.

[CFrance]

Originally Posted by billethkid

the entire family of patient zero were quarantined and they did their 21 days without a whimper.

I think that was different. First of all, duncan was extremely ill with Ebola. The quarantine some states are mandating is for people who are not already sick and have no symptoms.

Secondly, wasn't Duncan's family's quarantine either agreed to by them or legally mandated?

I'm going with the New England Journal. We need healthcare workers to go over there and stop this at the source. I think the media has stirred this up a frenzy.

[Rags123]

Just to complicate things a bit....

"STANFORD, Calif. (AP) -- Top medical experts studying the spread of Ebola say the public should expect more cases to emerge in the United States by year's end as infected people arrive here from West Africa, including American doctors and nurses returning from the hot zone and people fleeing from the deadly disease.

But how many cases?

No one knows for sure how many infections will emerge in the U.S. or anywhere else, but scientists have made educated guesses based on data models that weigh hundreds of variables, including daily new infections in West Africa, airline traffic worldwide and transmission possibilities.

This week, several top infectious disease experts ran simulations for The Associated Press that predicted as few as one or two additional infections by the end of 2014 to a worst-case scenario of 130."

Hoping for the low end of the scale for sure.....we only have TWO months left in 2014 which is what I find a bit alarming.


""I don't think there's going to be a huge outbreak here, no," said Dr. David Relman, a professor of infectious disease, microbiology and immunology at Stanford University's medical school. "However, as best we can tell right now, it is quite possible that every major city will see at least a handful of cases."

News from The Associated Press

[sunnyatlast]

The original post is an opinion piece by the editorial board of NEJM.

An opinion piece by editorial staff is not an original article publishing research findings that are scientifically proven.

It's almost funny when the sycophant proponents of the nurse and other anti-quarantine followers here keep saying "a quarantine must be decided by science, not emotion, fear, irrationality or opinion"……but here in this thread, we are being told we're fools if we don't agree and decide based an OPINION piece!

THIS is an original article based in SCIENCE and scientific method, not opinion:

The Lancet

Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 west African outbreak

Isaac I Bogoch MD a b, Maria I Creatore PhD c, Martin S Cetron MD d, John S Brownstein PhD e f, Nicki Pesik MD g, Jennifer Miniota MSc c, Theresa Tam MD h, Wei Hu MSA c, Adriano Nicolucci MSA c, Saad Ahmed BSc i, James W Yoon MISt c, Isha Berry c, Prof Simon Hay DSc j k, Aranka Anema PhD f l, Andrew J Tatem PhD j m n, Derek MacFadden MD a, Matthew German MSc c, Dr Kamran Khan MD

Summary

Background
The WHO declared the 2014 west African Ebola epidemic a public health emergency of international concern in view of its potential for further international spread. Decision makers worldwide are in need of empirical data to inform and implement emergency response measures. Our aim was to assess the potential for Ebola virus to spread across international borders via commercial air travel and assess the relative efficiency of exit versus entry screening of travellers at commercial airports.

Methods
We analysed International Air Transport Association data for worldwide flight schedules between Sept 1, 2014, and Dec 31, 2014, and historic traveller flight itinerary data from 2013 to describe expected global population movements via commercial air travel out of Guinea, Liberia, and Sierra Leone. Coupled with Ebola virus surveillance data, we modelled the expected number of internationally exported Ebola virus infections, the potential effect of air travel restrictions, and the efficiency of airport-based traveller screening at international ports of entry and exit. We deemed individuals initiating travel from any domestic or international airport within these three countries to have possible exposure to Ebola virus. We deemed all other travellers to have no significant risk of exposure to Ebola virus.

Findings
Based on epidemic conditions and international flight restrictions to and from Guinea, Liberia, and Sierra Leone as of Sept 1, 2014 (reductions in passenger seats by 51% for Liberia, 66% for Guinea, and 85% for Sierra Leone), our model projects 2·8 travellers infected with Ebola virus departing the above three countries via commercial flights, on average, every month. 91 547 (64%) of all air travellers departing Guinea, Liberia, and Sierra Leone had expected destinations in low-income and lower-middle-income countries. Screening international travellers departing three airports would enable health assessments of all travellers at highest risk of exposure to Ebola virus infection.

Interpretation
Decision makers must carefully balance the potential harms from travel restrictions imposed on countries that have Ebola virus activity against any potential reductions in risk from Ebola virus importations. Exit screening of travellers at airports in Guinea, Liberia, and Sierra Leone would be the most efficient frontier at which to assess the health status of travellers at risk of Ebola virus exposure, however, this intervention might require international support to implement effectively.

Funding: Canadian Institutes of Health Research.

Introduction……..

Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 west African outbreak : The Lancet

[graciegirl]

OCTOBER 16,2014
Ebola Virus Disease in West Africa — The First 9 Months of the Epidemic and Forward Projections

WHO Ebola Response Team
N Engl J Med 2014; 371:1481-1495October 16, 2014DOI: 10.1056/NEJMoa1411100
Comments open through October 22, 2014
Share:








AbstractArticleReferencesCiting Articles (2) Comments (14)
Background

On March 23, 2014, the World Health Organization (WHO) was notified of an outbreak of Ebola virus disease (EVD) in Guinea. On August 8, the WHO declared the epidemic to be a “public health emergency of international concern.”
Full Text of Background...


Methods

By September 14, 2014, a total of 4507 probable and confirmed cases, including 2296 deaths from EVD (Zaire species) had been reported from five countries in West Africa — Guinea, Liberia, Nigeria, Senegal, and Sierra Leone. We analyzed a detailed subset of data on 3343 confirmed and 667 probable Ebola cases collected in Guinea, Liberia, Nigeria, and Sierra Leone as of September 14.
Full Text of Methods...


Results

The majority of patients are 15 to 44 years of age (49.9% male), and we estimate that the case fatality rate is 70.8% (95% confidence interval [CI], 69 to 73) among persons with known clinical outcome of infection. The course of infection, including signs and symptoms, incubation period (11.4 days), and serial interval (15.3 days), is similar to that reported in previous outbreaks of EVD. On the basis of the initial periods of exponential growth, the estimated basic reproduction numbers (R0 ) are 1.71 (95% CI, 1.44 to 2.01) for Guinea, 1.83 (95% CI, 1.72 to 1.94) for Liberia, and 2.02 (95% CI, 1.79 to 2.26) for Sierra Leone. The estimated current reproduction numbers (R) are 1.81 (95% CI, 1.60 to 2.03) for Guinea, 1.51 (95% CI, 1.41 to 1.60) for Liberia, and 1.38 (95% CI, 1.27 to 1.51) for Sierra Leone; the corresponding doubling times are 15.7 days (95% CI, 12.9 to 20.3) for Guinea, 23.6 days (95% CI, 20.2 to 28.2) for Liberia, and 30.2 days (95% CI, 23.6 to 42.3) for Sierra Leone. Assuming no change in the control measures for this epidemic, by November 2, 2014, the cumulative reported numbers of confirmed and probable cases are predicted to be 5740 in Guinea, 9890 in Liberia, and 5000 in Sierra Leone, exceeding 20,000 in total.
Full Text of Results...


Conclusions

These data indicate that without drastic improvements in control measures, the numbers of cases of and deaths from EVD are expected to continue increasing from hundreds to thousands per week in the coming months.
Full Text of Discussion...


Read the Full Article...
__________________
I have to be myself, everyone else is taken.

[rubicon]

I respect the New England Journal of Medicine. However I believe their intent in writing this article was out of concern that many health care workers would refuse to volunteer if they believed a 2 day quarantine was needed.

I keep reading tt Ebola mutates on a continuum and that it can live on a cold surface for up to 50 days. further that the 21 day quarantine may not be enough.

On a personal basis I am tired of hearing some authorities describing people as emotional hysterical etc. Its insulting and its a method of manipulation.
I doubt know any sane person that would embrace someone they believed was infected with a deadly disease. Its human nature...I love but I'll show you after 21 days

This is one of the deadly diseases on earth and to date it has no cure. It continually mutates and medical people are being infected.

I agree when they say stop it at its source but my definition is to keep it all in West Africa.. But they won't because they believe they can't as they will not get the required workers to fight this disease. I agree but I also believe it signals how serious an issue this is and how quickly it can get out of control

[billethkid]

Originally Posted by rubicon

I respect the New England Journal of Medicine. However I believe their intent in writing this article was out of concern that many health care workers would refuse to volunteer if they believed a 2 day quarantine was needed.

I keep reading tt Ebola mutates on a continuum and that it can live on a cold surface for up to 50 days. further that the 21 day quarantine may not be enough.

On a personal basis I am tired of hearing some authorities describing people as emotional hysterical etc. Its insulting and its a method of manipulation.
I doubt know any sane person that would embrace someone they believed was infected with a deadly disease. Its human nature...I love but I'll show you after 21 days

This is one of the deadly diseases on earth and to date it has no cure. It continually mutates and medical people are being infected.

I agree when they say stop it at its source but my definition is to keep it all in West Africa.. But they won't because they believe they can't as they will not get the required workers to fight this disease. I agree but I also believe it signals how serious an issue this is and how quickly it can get out of control

Given the living conditions in those areas where the disease is out of control, and the fact not much will change (like no running water) the disease will not end at it's source.....based on what we know today anyway.

The most likely transmitters to other countries will be the care givers that travel back and forth between the infected areas and their home countries. Also other travelers to the infected regions that come in contact with any infected/infectuous persons.

I still maintain as long as there is a recognized 24 day incubation period, like it or not, the 21 day quarantine is the best solution based on current knowledge. The popular approach of I am not sick and feel good and have no symptoms within the 21 day period is totally and completely irresponsible in my opinion. Just like any of the others who have become infected here in the USA to date.....none were exhibiting any symptoms while traveling or when they first get here.

I totally do not get why it is acceptable to some, including the courts (apparently), knowing what we know now....that it is OK to have free reign and as long as not CURRENTLY exhibiting symptoms anytime before the 22 day!!!!

I suppose when and if there are more cases as seem to be predicted it will be treated as a disease with no inconveniences (for some).

Some Americans just don't understand prevention....and are not inspired to act until it becomes a crises....

I hope I turn out to be wrong and all the optomists and lets wait and see folks get lucky!!!

[Indydealmaker]

Even if Ebola is not contagious prior to the infected party becoming symptomatic, I am in favor of the most conservative practice of a quarantine for those returning from Ebola areas because:

I do not TRUST anyone to place the common good over selfish desires. Not any more!

Ignored in all of these discussions are the possibilities of deliberate transmission of Ebola by fanatics and religious radicals. A 21-day quarantine would catch ALL of these. Trusting will catch zero.

[blueash]

Originally Posted by sunnyatlast

The original post is an opinion piece by the editorial board of NEJM.

An opinion piece by editorial staff is not an original article publishing research findings that are scientifically proven.

It's almost funny when the sycophant proponents of the nurse and other anti-quarantine followers here keep saying "a quarantine must be decided by science, not emotion, fear, irrationality or opinion"……but here in this thread, we are being told we're fools if we don't agree and decide based an OPINION piece!

THIS is an original article based in SCIENCE and scientific method, not opinion:

The Lancet

Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 west African outbreak

Summary

Background
Decision makers worldwide are in need of empirical data to inform and implement emergency response measures. Our aim was to assess the potential for Ebola virus to spread across international borders via commercial air travel and assess the relative efficiency of exit versus entry screening of travellers at commercial airports.

Methods
We analysed International Air Transport Association data for worldwide flight schedules between Sept 1, 2014, and Dec 31, 2014, and historic traveller flight itinerary data from 2013 to describe expected global population movements via commercial air travel out of Guinea, Liberia, and Sierra Leone. Coupled with Ebola virus surveillance data, we modelled the expected number of internationally exported Ebola virus infections, the potential effect of air travel restrictions, and the efficiency of airport-based traveller screening at international ports of entry and exit. We deemed individuals initiating travel from any domestic or international airport within these three countries to have possible exposure to Ebola virus. We deemed all other travellers to have no significant risk of exposure to Ebola virus.

Findings
Based on epidemic conditions and international flight restrictions to and from Guinea, Liberia, and Sierra Leone as of Sept 1, 2014 (reductions in passenger seats by 51% for Liberia, 66% for Guinea, and 85% for Sierra Leone), our model projects 2.8 travellers infected with Ebola virus departing the above three countries via commercial flights, on average, every month. 91 547 (64%) of all air travellers departing Guinea, Liberia, and Sierra Leone had expected destinations in low-income and lower-middle-income countries. Screening international travellers departing three airports would enable health assessments of all travellers at highest risk of exposure to Ebola virus infection.

Interpretation
Decision makers must carefully balance the potential harms from travel restrictions imposed on countries that have Ebola virus activity against any potential reductions in risk from Ebola virus importations. Exit screening of travellers at airports in Guinea, Liberia, and Sierra Leone would be the most efficient frontier at which to assess the health status of travellers at risk of Ebola virus exposure, however, this intervention might require international support to implement effectively.

Introduction……..

Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 west African outbreak : The Lancet

I have taken the opportunity to change some of the phrases in bold font. I guess I am the sycophant to whom you refer. (Are you sure you know what that word means?)

The Lancet is a world class journal. Its articles are peer reviewed and carry significant weight in forming evidence based medical care. In this article which you heavily praise as scientific the authors have provided a mathematical analysis of risk of ebola spread. The goal of the article is to attempt to offer an opinion of the relative merits of different screening at airports. Their estimate of risk of spread is totally based on there being no screening of air travelers. The authors caution that all of their numbers are based on past data and that those assumptions may or may not be accurate.

"these numbers must be considered in the context of potential travel restrictions, the intensity of Ebola virus activity in affected countries, and the underlying assumptions of our model"

So given all that, what did the Lancet article have to say about the options for travel from these 3 countries. Screen 1. at departure airport, 2. At direct arrival airport, 3. At non-direct arrival airport

1.They carefully discuss the relative utility of screening at the exit airport in Africa. Keep in mind that their assumption in producing risk estimates is that there in NO AIRPORT SCREENING in Africa. In fact since the writing of the article every of the airports in the discussion has instituted screening using WHO guidelines. So this critical assumption is wrong. Nonetheless, the authors recommend departure screening as the best thing to do (and now it is being done)

"Our analyses show that exit screening at international points of departure would offer greater efficiency, and might be simpler to operationalise, than entry screening all flights arriving directly from affected countries"

2. Direct arrival airport (not done in their analysis of risk)
"the short flight durations out of affected countries, compared with the much longer incubation period of Ebola virus, indicates that if exit screening from affected countries were implemented effectively, the incremental gains from additional entry screening would be negligible"

3. Multi-segment arrival screening (not done in their analysis)
" screening travellers on multisegment flights to their final destination would probably have minimum benefits to unaffected countries but could incur important opportunity costs"

They offer an opinion which they clarify is not even addressed in their study about what might be a good approach:

"Although not directly assessed in this study, educational and communication strategies could be used to further reduce the risk of international spread of Ebola virus or to rapidly identify new imported cases. These strategies could include advice for individuals before travelling, with emphasis on international aid workers and foreign-born diaspora populations returning home to visit friends and relatives in affected areas. In some cases, international aid workers have agreed to a self-imposed 21-day monitoring period post-return from affected countries"

This is the only part of the Lancet article that is germane to the nurse. They offer that some aid workers have agreed to a 21 days monitoring period. I do believe that the nurse fully agreed to that and only objected to a far more intense quarantine in a tent in New Jersey or on house arrest with a cop outside her door in Maine.

It is nice to see that this article in Lancet is in accord with the NEJM editorial. In fact if you understood how NEJM editorials were produced you would be aware they are evidence based using the most up to date relevant scientific literature. They are an attempt to inform policy both within the medical community and in the world at large as to what the data, the science, points to as the best way forward. It is in effect the conclusion after consideration of many many studies on the topic. And like everything in science, it may be wrong. But each article itself is an "opinion" on interpretation of its own data and constrained by its own assumptions. Science does not claim infallibility but IMO policy should be based on what evidence is available. The editors of the NEJM you can be sure were very aware of this Lancet article and included its contribution in their formulation