Dear Bill (Gates): Fund This! ...Eradicate TB!

Much effort and money has been spent to fight Ebola of late. This is a scary, deadly virus that has, however, affected a remarkable few compared with the millions that die every year from such diseases as tuberculosis. Below is a short excerpt from an email I receive daily. Tuberculosis is an insidious disease that kills readily. It should be eradicated. It requires a concerted worldwide effort and billions of dollars to do so.

WHO: Nine million people developed TB in 2013.

CNN (10/23, Wilson) reports, “On Wednesday, the World Health Organization released its 2014 Global Tuberculosis Report, which shows that 9 million people developed tuberculosis in 2013 and 1.5 million died, making it one of the world’s deadliest communicable diseases.”

        TIME (10/23, Frizell) adds that, of the nine million cases, TB’s death toll was “1.5 million people in 2013, including 360,000 people who were HIV positive.”

        NBC News (10/23, Fox) reports that despite the high prevalence of the infectious disease, “companies and countries alike are actually cutting their investments in TB.” The WHO says “$8 billion is needed each year to find and treat patients and to invest in better drugs and work on a vaccine,” but each year there is a $2 billion shortfall in funding. Dr. Mario Raviglione, director of the global TB program at WHO, told reporters “the pharmaceutical industry is less interested in developing countries, where the potential gains are limited.”

        US News & World Report (10/23, Leonard), Reuters (10/23, Kelland), and Medscape (10/23, Brooks) also report on the story.

NO, Ebola is NOT a Biological Weapon

Stratfor publishes erudite fact-based information and this article is no exception. I have not seen any significant discussion about Ebola as a biological weapon, but hopefully this article (quoted below) will put that suggestion to rest.

Evaluating Ebola as a Biological Weapon

By Scott Stewart

Over the past few weeks, I've had people at speaking engagements ask me if I thought the Islamic State or some other militant group is using Ebola as a biological weapon, or if such a group could do so in the future. Such questions and concerns are not surprising given the intense media hype that surrounds the disease, even though only one person has died from Ebola out of the three confirmed cases in the United States. The media hype about the threat posed by the Islamic State to the United States and the West is almost as bad. Both subjects of all this hype were combined into a tidy package on Oct. 20, when the Washington Post published an editorial by columnist Mark Thiessen, in which he claimed it would be easy for a group such as the Islamic State to use Ebola in a terrorist attack. Despite Thiessen's claims, using Ebola as a biological warfare agent is much more difficult than might appear at first blush.
In the past, there have been several outbreaks of Ebola in Africa. Countries included Sudan, Uganda, the Republic of the Congo and the Democratic Republic of the Congo, and several comparatively small outbreaks occurred in Gabon as well. In most cases, people who handled or ate animals infected with the disease started the outbreaks. "Bushmeat," or portions of roasted meat from a variety of wild animals, is considered by many to be a delicacy in Africa, and in a continent where hunger is widespread, it is also a necessity for many hungry people. After several months of medical investigations, epidemiologists believe the current outbreak most likely began when a two-year-old child in Guinea touched or perhaps ate part of an infected animal such as a bat or monkey.

The source of the disease means it is highly unlikely that some malevolent actor intentionally caused the latest outbreak. Besides the fact that the current outbreak's cause has been identified as a natural one, even if a transnational militant group such as the Islamic State was able to somehow develop an Ebola weapon, it would have chosen to deploy the weapon against a far more desirable target than a small village in Guinea. We would have seen the militants use their weapon in a location such as New York, Paris or London, or against their local enemies in Syria and Iraq.

As far as intent goes, there is very little doubt that such a group would employ a biological weapon. As we noted last month when there was increased talk about the Islamic State possibly weaponizing plague for a biological attack, terrorist attacks are intended to have a psychological impact that outweighs the physical damage they cause. The Islamic State itself has a long history of conducting brutal actions to foster panic.

In 2006 and 2007, the Islamic State's predecessor, al Qaeda in Iraq, included large quantities of chlorine in vehicle bombs deployed against U.S. and Iraqi troops in an attempt to produce mass casualties. The explosives in the vehicle bombs killed more people than the chlorine did, and after several unsuccessful attempts, al Qaeda in Iraq gave up on its chlorine bombings because the results were not worth the effort. Al Qaeda in Iraq also included chemical artillery rounds in improvised explosive devices used in attacks against American troops in Iraq on several occasions. Again, these attacks failed to produce mass casualties. Finally, according to human rights organizations, the Islamic State appears to have recently used some artillery rounds containing mustard gas against its enemies in Syria; the group presumably recovered the rounds from a former Saddam-era chemical weapons facility in Iraq or from Syrian stockpiles.

The problem, then, lies not with the Islamic State's intent but instead with its capability to obtain and weaponize the Ebola virus. Creating a biological weapon is far more difficult than using a chemical such as chlorine or manufactured chemical munitions. Contrary to how the media frequently portrays them, biological weapons are not easy to obtain, they are not easy to deploy effectively and they do not always cause mass casualties.

The Difficulty of Weaponization

Ebola and terrorism are not new. Nor is the possibility of terrorist groups using the Ebola virus in an attack. As we have previously noted, the Japanese cult Aum Shinrikyo attempted to obtain the Ebola virus as part of its biological warfare program. The group sent a medical team to Africa under the pretext of being aid workers with the intent of obtaining samples of the virus. It failed in that mission, but even if it had succeeded, the group would have faced the challenge of getting the sample back to its biological warfare laboratory in Japan. The Ebola virus is relatively fragile. Its lifetime on dry surfaces outside of a host is only a couple of hours, and while some studies have shown that the virus can survive on surfaces for days when still in bodily fluids, this requires ideal conditions that would be difficult to replicate during transport. 

If the group had been able to get the virus back to its laboratory, it would have then faced the challenge of reproducing the Ebola virus with enough volume to be used in a large-scale biological warfare attack, similar to its failed attacks on Tokyo and other Japanese cities in which the group sprayed thousands of gallons of botulinum toxin and Anthrax spores. Reproducing the Ebola virus would present additional challenges because it is an extremely dangerous virus to work with. It has infected researchers, even when they were working in laboratories with advanced biosafety measures in place. Although Aum Shinrikyo had a large staff of trained scientists and a state-of-the-art biological weapons laboratory, it was still unable to effectively weaponize the virus.

The challenges Aum Shinrikyo's biological weapons program faced would be multiplied for the Islamic State. Aum Shinrikyo operatives were given a great deal of operational freedom until their plans were discovered after the 1995 sarin attacks on the Tokyo subway. (The group's previous biological weapons attacks were so unsuccessful that nobody knew they had been carried out until after its members were arrested and its chemical and biological weapons factories were raided.) Unlike the Japanese cult, the Islamic State's every move is under heavy scrutiny by most of the world's intelligence and security agencies. This means jihadist operatives would have far more difficulty assembling the personnel and equipment needed to construct a biological weapons laboratory. Since randomly encountering an infected Ebola patient would be unreliable, the group would have to travel to a country impacted by the outbreak. This would be a difficult task for the group to complete without drawing attention to itself. Furthermore, once group members reached the infected countries, they would have to enter quarantined areas of medical facilities, retrieve the samples and then escape the country unnoticed, since they could not count on randomly encountering an infected Ebola patient.

Even if Islamic State operatives were somehow able to accomplish all of this -- without killing themselves in the process -- Ebola is not an ideal biological warfare vector. The virus is hard to pass from person to person. In fact, on average, its basic reproductive rate (the average amount of people that are infected by an Ebola patient) is only between one and two people. There are far more infectious diseases such as measles, which has a basic reproductive rate of 12-18, or smallpox, which has a basic reproductive rate of five to seven. Even HIV, which is only passed via sexual contact or intravenous blood transmission, has a basic reproductive rate of two to five. 

Ebola's Weakness as a Weapon

The Ebola disease is also somewhat slow to take effect, and infected individuals do not become symptomatic and contagious for an average of 8-10 days. The disease's full incubation period can last anywhere from two to 21 days. As a comparison, influenza, which can be transmitted as quickly as three days after being contracted, can be spread before symptoms begin showing. This means that an Ebola attack would take longer to spread and would be easier to contain because infected people would be easier to identify.

Besides the fact that Ebola can only be passed through the bodily fluids of a person showing symptoms at the time, the virus in those bodily fluids must also somehow bypass the protection of a person's skin. The infectious fluid must enter the body through a cut or abrasion, or come into contact with the mucus membranes in the eyes, nose or mouth. This is different from more contagious viruses like measles and smallpox, which are airborne viruses and do not require any direct contact or transfer of bodily fluids. Additionally, the Ebola virus is quite fragile and sensitive to light, heat and low-humidity environments, and bleach and other common disinfectants can kill it. This means it is difficult to spread the virus by contaminating surfaces with it. The only way to infect a large amount of people with Ebola would be to spray them with a fluid containing the virus, something that would be difficult to do and easily detectable.

Thiessen's piece suggested that the Islamic State might implement an attack strategy of infecting suicide operatives with Ebola and then having them blow themselves up in a crowded place, spraying people with infected bodily fluids. One problem with this scenario is that it would be extremely difficult to get an infected operative from the group's laboratory to the United States without being detected. As we have discussed elsewhere, jihadist groups have struggled to get operatives to the West to conduct conventional terrorist attacks using guns and bombs, a constraint that would also affect their ability to deploy a biological weapon.

Even if a hostile group did mange to get an operative in place, it would still face several important obstacles. By the time Ebola patients are highly contagious, they are normally very ill and bedridden with high fever, fatigue, vomiting and diarrhea, meaning they are not strong enough to walk into a crowded area. The heat and shock of the suicide device's explosion would likely kill most of the virus. Anyone close enough to be exposed to the virus would also likely be injured by the blast and taken to a hospital, where they would then be quarantined and treated for the virus.

Biological weapons look great in the movies, but they are difficult and expensive to develop in real life. That is why we have rarely seen them used in terrorist attacks. As we have noted for a decade now, jihadists can kill far more people with far less expense and effort by utilizing traditional terrorist tactics, which makes the threat of a successful attack using the Ebola virus extremely unlikely.

Read more:  Evaluating Ebola as a Biological Weapon | Stratfor 
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Ebola: Facts, Not Hyperbole (Thank You Johns Hopkins!)

Johns Hopkins, my undergraduate alma mater, has always held a special place in my heart and mind. It is one of the greatest institutions of "higher" learning and the people who attend and work there are exposed to a ridiculous wealth of knowledge. Now, as usual, Johns Hopkins has put together a special forum to discuss and explain Ebola from all angles, including the history, epidemiology, current and past outbreaks, and treatment solutions. Please take some time to review the videos they published on YouTube. In particular, Dr Trish Perl's talk (Part 2) is highly informative and educational. She puts into perspective the other past outbreaks of the Ebola and similar viruses.











Ebola: USA Laser-Focused on Containment

Although there were missteps related to the delayed diagnosis of the first Dallas Ebola patient, Mr Duncan, and subsequent infections occurred in two nurses which might have been prevented with better protocols, these issues appear to have been remedied. I am very encouraged by the recent decisions to transfer infected individuals to appropriately equipped and readied hospitals. I think that is an excellent move. It is a sign that the nation's efforts are coming up to speed. Hopefully therefore, this thing will be contained and eliminated in short order. Might we see more infections occur in the USA? Perhaps. But awareness and vigilance, not panic and fear, are of key importance moving forward.

Please visit my site and click on the "Ebola" tab for more educational resources. 

From the AMA daily email: 

Frieden testifies at congressional hearing on Ebola.

The CBS Evening News (10/16, story 3, 2:30, Axelrod) reported, “Federal health officials were on Capitol Hill today. They came under fire for the handling of the Ebola situation.” CBS Congressional Correspondent Nancy Cordes added, “Under oath the CDC director went head to head with Republicans, who want a ban on travelers from West Africa.” Tom Frieden, CDC Director argued against such a ban, saying, “If passengers are now allowed to come directly, there is a high likelihood that they will find another way to get here, and we won’t be able to track them.” Cordes added that Dr. Daniel Varga, the head of Texas Presbyterian Hospital in Dallas, “testified by videophone.” Dr. Varga said, “Unfortunately in our initial treatment of” Thomas Eric Duncan, “despite our best intentions and a highly skilled medical team, we made mistakes. We did not correctly diagnose his symptoms as those of Ebola. and we are deeply sorry.”

        Bloomberg News (10/17, Wayne, Hunter) reports that “in written testimony submitted before he appeared before a panel of the House Energy and Commerce Committee,” Frieden said, “We remain confident that Ebola is not a significant public health threat to the United States.” He added, “We know Ebola can be stopped with rapid diagnosis, appropriate triage and meticulous infection-control practices in American hospitals.”

        Meanwhile, in a 1,200-word story titled “Transfer Of Ebola Patients Reflects A Tacit Shift In Strategy,” the Los Angeles Times (10/17, Levey) reports, “The federal government effectively began to restrict the care of Ebola patients to hospitals with special bio-containment units” yesterday, “and the Obama administration labored to reassure jittery Americans and increasingly skeptical lawmakers that public health authorities can prevent a widespread Ebola outbreak” in the US. This “tacit shift in policy came amid growing concerns about mistakes at Texas Health Presbyterian Hospital in Dallas, where two nurses who treated Thomas Eric Duncan of Liberia have since come down with the disease.” One of those “nurses is being treated at Emory University Hospital in Atlanta,” while “the other” will be treated at “a specialized treatment center at the National Institutes of Health.”

        Obama considers appointing an “Ebola czar.” In an 1,100-word article titled “White House takes drop everything approach to respond to public health crisis,” the New York Times (10/17, Shear, Subscription Publication) reports, “President Obama remained at the White House on Thursday to focus on the government’s response to Ebola, canceling a second day of election-season travel as the administration concentrated on what is already turning into a political as well as a public health crisis.” According to the Times, “Aides said there was no sudden shift in the president’s thinking and described his new, more aggressive public posture on Ebola as the natural response to a ‘dynamic situation.’”

        According to the Washington Post (10/17, Eilperin), the President’s effort to show he is focused on the Ebola outbreak “has done little reassure a jittery America public that the danger is contained or to stanch the political fallout, some of it from lawmakers in his own party.” The Post says the White House “is now engulfed in a crisis that has resurrected questions about the president’s governing style.” White House senior adviser Dan Pfeiffer is quoted as saying, “We need to try to calm people because many people are fanning the flames here now in a way that’s deeply irresponsible, but we also understand that there is real concern, and we’re trying to be sensitive to that.”

        In an 1,800-word front-page story, the New York Times (10/17, A1, Healy, Tavernise, Goodnough, Subscription Publication) reports, “President Obama raised the possibility on Thursday that he might appoint an ‘Ebola czar’ to manage the government’s response to the deadly virus as anxiety grew over the air travel of an infected nurse.”

        The AP (10/16, Kuhnhenn) reports that the President “said his team of Ebola advisers is doing ‘an outstanding job.’” But, he said, “It may make sense for us to have one person ... so that after this initial surge of activity we can have a more regular process just to make sure we are crossing all the Ts and dotting all the Is.”

        Calls for travel ban mount. The AP (10/17, Werner, Daly) reports that on Thursday, “House Republicans demanded a travel ban...calling it the only sure way to protect Americans,” but, according to the AP, the White House continues to insist that a ban is “not under consideration” and “could actually make things worse.” Although some Democrats are among those urging the implementation of travel restrictions, most reports cast the debate in partisan terms.

        On CNN’s AC 360 (10/16), Anderson Cooper reported that President Obama had just announced that he “didn’t rule out appointing a so-called ‘Ebola czar’ if need be, and also talked about growing calls to restrict travel from West Africa.” President Obama was shown saying, “I don’t have a philosophical objection necessarily to a travel ban if that is the thing that is going to keep the American people safe. The problem is, is that in all the discussions I’ve had thus far with experts in the field, experts in infectious disease, is that a travel ban is less effective than the measures that we are currently instituting.”

        The Washington Times (10/17, Wolfgang) notes that CDC officials “argue that if a ban is instituted, travelers who have visited affected countries — primarily Sierra Leone, Guinea and Liberia — may lie about where they’ve been in order to get into the US,” which “would complicate efforts to track the virus and determine who may have been infected.”

        Visit the AMA Ebola Resource Center (10/16) for expert resources for physicians and the public

A Rare Vascular Cause of Left Arm Pain and Numbness In A 30 Year-Old

A 30 year-old woman with three weeks of numbness and tingling in her left arm underwent an arterial ultrasound that showed recent thrombosis/occlusion of the radial and ulnar arteries. She described blanching of her raised hand, which occurred while washing her hair. Interestingly, she also had a longer-standing history of several years of neck pain and left arm pain, numbness and tingling.

A vascular surgeon then performed surgery (open embolectomy) to remove the blood clots in her arteries and restore blood flow to her hand. A CT scan of the neck and upper chest was also obtained which showed a cervical rib, an aneurysm of the left subclavian artery, and a false joint (or pseudarthrosis) of the C7 rib where it meets with the 1st thoracic rib.

The course of events and clinical and anatomic findings may seem straightforward as I’ve described them. But the long-standing symptoms may have contributed to the length of time that the underlying anatomic abnormalities went undiagnosed by creating a difficulty for the physicians who had previously seen her. They had evaluated her for musculoskeletal or nerve-related abnormalities. Those diagnostic evaluations were unsuccessful in yielding the true nature of her ailment until the arterial ultrasound was performed and interpreted by this vascular radiologist. She will still need definitive therapy, constituting surgical resection of the abnormal rib to remove the extrinsic compression on the subclavian artery and eliminate the potential for further vascular problems.

3-D CT rendering of a left C7 cervical rib

3-D CT rendering of a left C7 cervical rib

Cervical rib depicted as anatomical cartoons, also demonstrating the relationships to adjacent nerves and the subclavian artery, which are displaced anteriorly.

Cervical rib depicted as anatomical cartoons, also demonstrating the relationships to adjacent nerves and the subclavian artery, which are displaced anteriorly.

From Wikipedia:

“A cervical rib is a rare congenital abnormality where a rib arises from the seventh cervical vertebra. A cervical rib is estimated to occur in 0.5% of the population, 66% are bilateral, and are twice as common in females as in males.

Most cases of cervical ribs are not clinically relevant and do not have symptoms; cervical ribs are generally discovered incidentally. However, they may cause problems such as brachial plexopathy or thoracic outlet syndrome, because of pressure on the nerves or subclavian artery, respectively.

A cervical rib represents a persistent ossification of the C7 lateral costal element. During early development, this ossified costal element typically becomes re-absorbed. Failure of this process results in a variably elongated transverse process or complete rib that can be anteriorly fused with the T1 first rib below.

The presence of a cervical rib can cause a form of thoracic outlet syndrome due to compression of the lower trunk of the subclavian artery. These structures become encroached upon by the cervical rib and scalene muscles. Aneurysm formation can occur, followed by distal embolization if not earlier identified and treated.

Compression of the brachial plexus may be identified by weakness of the muscles around the muscles in the hand, near the base of the thumb. Compression of the subclavian artery is often diagnosed by finding a positive Adson's sign on examination, where the radial pulse in the arm is lost during abduction and external rotation of the shoulder. A positive Adson's sign is non-specific for the presence of a cervical rib, however, as many individuals without a cervical rib will have a positive test.”

The importance of the above vignette and discussion is that some abnormalities are difficult to identify. Often, the appropriate specialists, in this case a vascular/interventional radiologist, are needed to identify the underlying abnormalities, and a vascular surgeon and a cardiothoracic surgeon are needed to treat them. With a coordinated team approach to health care, the highest quality of care can be delivered and patients will have the best chance at prompt diagnoses and treatments.



Don't Let Fear And Panic Win

When fear and panic take over, intelligent, thoughtful logic is needed.

Ebola is a scary entity. Many of the individuals who become infected have, to date, died. It is true. And there is as yet no vaccine. Effective cure is not yet fully developed.

People are clamoring to close the U.S. borders to people travelling from West Africa.

But Charles Kenny, a senior fellow at the Center for Global Development and the author of "The Upside of Down: Why the Rise of the Rest is Great for the West," has exactly the intelligent, logical thoughts for us.

He states:

"In an average year, more than 23,000 deaths in America are associated with influenza. But this toll isn't enough for us to shut the borders in an attempt to keep influenza at bay. The idea that we could completely seal off the U.S. from the rest of the world is laughable - at best we might delay a disease from arriving by a few days or weeks. When it comes to the flu, we're not even willing to take considerably more targeted and effective measures, such as banning kids from school if they haven't received the vaccine or providing shots for free at pharmacies."

Measured, intelligent thought always makes more sense than panic-stricken flailing. Supporting the countries where the incidences of infection are greatest makes the most sense. We must offer our support and assistance as they try to fend off this disease. And the average American citizen would do well to keep cool under pressure, knowing that Ebola is a remote risk to most of us and that much more common infections, such as influenza and measles, are far more important for us to remain vigilant against.

Be safe. Stay healthy.

Essential Ebola Information - Courtesy of APIC

Essential knowledge about Ebola

Disease background
Ebola hemorrhagic fever, or just Ebola for short, is a severe disease often leading to death in humans and non-human primates (such as monkeys, gorillas, and chimpanzees). Five different Ebola virus species have been identified, and four of these cause disease in humans. The first Ebola species was discovered in 1976 near the Ebola River in what is now the Democratic Republic of Congo. Since then, sporadic outbreaks have occurred in Africa. Researchers believe the virus is carried in bats, but the exact source is unknown.

Ebola has been in the news over the last few months as the largest outbreak in history has developed in Western Africa. Several American healthcare workers who have worked with patients in Africa have become sick and been brought back to the United States for treatment. On September 30, 2014 the first case of Ebola was diagnosed in the United States in a patient who had recently traveled from Africa.

Signs and symptoms
A person infected with Ebola is not contagious until symptoms appear. Symptoms usually begin eight to 10 days after a person has been exposed to an ill Ebola patient. However, symptoms may begin anywhere from two to 21 days after the exposure.

Typical signs and symptoms of Ebola infection are:

  • Fever (greater than 101.5oF)
  • Severe headache
  • Muscle pain
  • Vomiting
  • Diarrhea
  • Stomach pain
  • Unexplained bleeding or bruising

How is the virus spread?
The virus can enter the body through broken skin or unprotected mucous membranes of the eyes, nose, or mouth. When a person is sick with Ebola there are several ways the virus can be spread to others.

  • Direct contact with the blood or body fluids (feces, saliva, urine, vomit, and semen) of the sick person.
  • Contact with objects (needles and syringes) that have been used and contain blood or body fluids of the infected person.

Ebola is not spread through the air or by water or food in the U.S.

Currently, there are no specific vaccines or medicines (such as antiviral drugs) that have been proven to work against the Ebola virus. Sick patients are treated by providing relief to their symptoms as they appear. Typical treatment can involve providing intravenous (IV) fluids and monitoring body electrolytes, maintaining oxygen status and blood pressure, and treating other infections as they happen.

Is there danger of Ebola spreading in the U.S.?
Please keep in mind the likelihood of contracting Ebola is considered extremely low unless there is direct exposure to the body fluids of an infected person. Ebola in not spread through casual contact; therefore, the risk of an outbreak in the U.S. is very low. The further spread of Ebola can be stopped through finding cases, isolating ill people, contacting people exposed to ill persons, and further isolating contacts if they develop symptoms. The U.S. public health and medical systems have had prior experience with sporadic cases of diseases such as Ebola. In the past decade, the United States had five imported cases of Viral Hemorrhagic Fever disease similar to Ebola. None resulted in transmission in the United States.

Advice for travelers
Centers for Disease Control and Prevention (CDC) has issued a travel notice for Ebola affected countries, which means travelers should avoid non-essential travel to Guinea, Liberia, and Sierra Leone. For current travel advisories please visit

  • If you are returning from a country where the outbreak is occurring:
    • After you return, monitor your health for 21 days.
    • Seek medical care immediately if you develop the signs and symptoms of Ebola infection.
    • Tell your doctor about your recent travel and symptoms before you go to the office or emergency room. Advance notice will help your doctor care for you and protect other people who may be in the facility or office.
  • If you are traveling to an area where the outbreak in occurring:
    • Wash your hands frequently or use an alcohol-based sanitizer.
    • Avoid contact with blood and body fluids of any person, particularly someone who is sick.
    • Do not handle items that may have come in contact with an infected person’s blood or body fluids.
    • Do not touch the body of someone who has died from Ebola.
    • Do not touch bats and nonhuman primates or their blood and fluids and do not touch or eat raw meat prepared from these animals.
    • Avoid hospitals where Ebola patients are being treated. The U.S. Embassy or consulate is often able to provide advice on facilities.
    • Seek medical care immediately if you develop symptoms of Ebola virus.
      • Limit your contact with other people until and when you go to the doctor.
      • Do not travel anywhere else besides a healthcare facility.


Additional resources


WHO—Ebola virus disease

APIC—Clean your hands often

Access a printer-friendly copy of this alert




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Ebola - Get Informed. Stay Cool

Evaluating Patients for Possible Ebola Virus Disease: Recommendations for Healthcare Personnel and Health Officials

This is an official


Distributed via the CDC Health Alert Network
October 2, 2014, 20:00 ET (8:00 PM ET)


The first case of Ebola Virus Disease (Ebola) diagnosed in the United States was reported to CDC by Dallas County Health and Human Services on September 28, 2014, and laboratory-confirmed by CDC and the Texas Laboratory Response Network (LRN) laboratory on September 30. The patient departed Monrovia, Liberia, on September 19, and arrived in Dallas, Texas, on September 20. The patient was asymptomatic during travel and upon his arrival in the United States; he fell ill on September 24 and sought medical care at Texas Health Presbyterian Hospital of Dallas on September 26. He was treated and released. On September 28, he returned to the same hospital, and was admitted for treatment.

The purpose of this HAN Advisory is to remind healthcare personnel and health officials to:

(1) increase their vigilance in inquiring about a history of travel to West Africa in the 21 days before illness onset for any patient presenting with fever or other symptoms consistent with Ebola;

(2) isolate patients who report a travel history to an Ebola-affected country (currently Liberia, Sierra Leone, and Guinea) and who are exhibiting Ebola symptoms in a private room with a private bathroom and implement standard, contact, and droplet precautions (gowns, facemask, eye protection, and gloves); and

(3) immediately notify the local/state health department.

Please disseminate this information to infectious disease specialists, intensive care physicians, primary care physicians, and infection control specialists, as well as to emergency departments, urgent care centers, and microbiology laboratories.


The first known case of Ebola with illness onset and laboratory confirmation in the United States occurred in Dallas, Texas, on September 2014, in a traveler from Liberia. The West African countries of Liberia, Sierra Leone, and Guinea are experiencing the largest Ebola epidemic in history. From March 24, 2014, through September 23, 2014, there have been 6,574 total cases (3,626 were laboratory-confirmed) and 3,091 total deaths reported in Africa. Ebola is a rare and deadly disease caused by infection with one of four viruses (Ebolavirus genus) that cause disease in humans. Ebola infection is associated with fever of greater than 38.6°C or 101.5°F, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage. Ebola is spread through direct contact (through broken skin or mucous membranes) with blood or body fluids (including but not limited to urine, saliva, feces, vomit, sweat, breast milk, and semen) of a person who is sick with Ebola or contact with objects (such as needles and syringes) that have been contaminated with these fluids. Ebola is not spread through the air or water. The main source for spread is human-to-human transmission. Avoiding contact with infected persons (as well as potentially infected corpses) and their blood and body fluids is of paramount importance. Persons are not contagious before they are symptomatic. The incubation period (the time from exposure until onset of symptoms) is typically 8-10 days, but can range from 2-21 days. Additional information is available at


Early recognition is critical to controlling the spread of Ebola virus. Consequently, healthcare personnel should elicit the patient’s travel history and consider the possibility of Ebola in patients who present with fever, myalgia, severe headache, abdominal pain, vomiting, diarrhea, or unexplained bleeding or bruising. Should the patient report a history of recent travel to one of the affected West African countries (Liberia, Sierra Leone, and Guinea) and exhibit such symptoms, immediate action should be taken. The Ebola algorithm for the evaluation of a returned traveler and the checklist for evaluation of a patient being evaluated for Ebola are available at

Patients in whom a diagnosis of Ebola is being considered should be isolated in a single room (with a private bathroom), and healthcare personnel should follow standard, contact, and droplet precautions, including the use of appropriate personal protective equipment (PPE). Infection control personnel and the local health department should be immediately contacted for consultation.

The following guidance documents provide additional information about clinical presentation and clinical course of Ebola virus disease, infection control, and patient management:

• Guidelines for clinicians in U.S. healthcare settings are available at

• Guidelines for infection prevention control for hospitalized patients with known or suspected Ebola in U.S. hospitals are available at

• Guidelines for safe management of patients with Ebola in U.S. hospitals are at

The case definitions for persons under investigation (PUI) for Ebola, probable cases, and confirmed cases as well as classification of exposure risk levels are at

Persons at highest risk of developing infection are:

• those who have had direct contact with the blood and body fluids of an individual diagnosed with Ebola – this includes any person who provided care for an Ebola patient, such as a healthcare provider or family member not adhering to recommended infection control precautions (i.e., not wearing recommended PPE

• those who have had close physical contact with an individual diagnosed with Ebola

• those who lived with or visited the Ebola-diagnosed patient while he or she was ill.

Persons who have been exposed, but who are asymptomatic, should be instructed to monitor their health for the development of fever or symptoms for 21 days after the last exposure. Guidelines for monitoring and movement of persons who have been exposed to Ebola are available at

Diagnostic tests are available for detection of Ebola at LRN laboratories as well as CDC. Consultation with CDC is required before shipping specimens to CDC. Information about diagnostic testing for Ebola can be found at

Healthcare personnel in the United States should immediately contact their state or local health department regarding any person being evaluated for Ebola if the medical evaluation suggests that diagnostic testing may be indicated. If there is a high index of suspicion, U.S. health departments should immediately report any probable cases or persons under investigation (PUI) ( to CDC’s Emergency Operations Center at 770-488-7100.

Killing Cancer...By Genetic Targeting

Gene therapies to combat cancers are becoming a reality. It may take a few more years before such therapies are widespread but it is happening. To me, this is one of the most exciting developments to occur in healthcare in recent years. Stay tuned.

From the AMA Daily email: 

Study: Lung cancer medicine reduced tumor size in patients with gene defect.

"Bloomberg News (9/28, Ostrow) reports Pfizer Inc.’s Xalkori (crizotinib) for advanced lung cancer reduced tumors in patients suffering from a rare genetic mutation, citing a study “that may provide the first targeted treatment for these patients.” The medicine shrunk the size of tumors in 36 of 50 patients in the study “while halting tumor growth in another nine, according to company-funded research released today at the European Society for Medical Oncology meeting in Madrid and online in the New England Journal of Medicine.” The company notes that around 15,000 people, “or 1 percent of the estimated 1.5 million annual new cases of non-small-cell lung cancer, have an abnormality to the ROS1 gene.”

        MedPage Today (9/28) reports that “ROS1 rearrangement defines a second molecular subgroup of NSCLC for which crizotinib is highly active,” Shaw and colleagues noted in the article published in the New England Journal of Medicine.

        Reuters (9/28, Berkrot) also covers the news."

Cancer Sucks. But Don't Let Fear Rule.

When faced with an illness, a natural reaction can be an overwhelming fear of imminent death. For this reason, it is imperative that you clearly understand the ramifications of what you are up against. 

The tendency to over-treat is widespread. Doctors and patients alike, as a broad generalization, tend to feel that the best answer to a problem is to ferret it out with the most powerful weapons available.  

But that sort of aggressiveness comes with a price. Aggressive medical therapy carries the potential for side effects, a potential with any drug regimen. Aggressive surgery carries the obvious potential for physical deformity as well as immediate and subsequent complications. Even the smallest abdominal surgery can still predispose a person to subsequent bowel obstructions.

To be clear, I am absolutely not advocating that you forego appropriate, necessary treatments for an illness. I am merely pointing out the need for clear understanding of the risks and benefits of any regimen. 

Dont let fear overwhelm you. Get informed so you can maximize your chances of getting back to health. 

What prompts my post today? The following excerpt from the AMA Daily Email: 

Bilateral mastectomy may not increase survival chances for most women with breast cancer.

The AP (9/3, Tanner) reports that research published in the Journal of the American Medical Association suggests that “removing both breasts to treat cancer affecting only one side doesn’t boost survival chances for most women, compared with surgery that removes just the tumor.”

        Bloomberg News (9/3, Cortez) reports that “the surgery...carried a survival rate of 81 percent over 10 years in about 200,000 women studied.” According to Bloomberg News, “That compares with 83 percent for patients who underwent a lumpectomy...followed by radiation.”

        TIME (9/3, Sifferlin) reports that the investigators “found that double mastectomies for early-stage breast cancer increased significantly from 1998 to 2011.” The data also indicated that “double mastectomies increased the most among women who were under age 40 when they were diagnosed.”

        The San Francisco Chronicle (9/3, Colliver) reports that while “physicians and researchers aren’t exactly sure why more women are having double mastectomies...they say that anxiety about getting a second cancer, improvements in reconstruction surgeries and concern about breast symmetry may play a role.”

        The Pittsburgh Post-Gazette (9/3, Carpenter) points out that the majority of patients “choosing double mastectomies are white, have private insurance and receive treatment at a National Cancer Institute-designated cancer center, the researchers found.” The NPR (9/3, Shute) “Shots” blog and HealthDay (9/3, Doheny) also cover the story.

Remove IVC Filters When Not Needed

For years I have been pointing out to friends and colleagues that certain IVC filters can and should be removed because they migrate ever so slightly and could cause damage to surrounding structures. 

A news article states: "“Heidi is a poster child for this” problem, said Scott O. Trerotola, chief of interventional radiology at Penn, who treated her. “There is relatively little recognition [of it] among anyone except interventional radiologists.”" 

Some filters migrate ever so slightly with the normal pulsations that occur due to the pumping of the heart, breathing, movement, etc. These filters have thin legs that can begin protrude, as a result of the slow migration, and potentially cause problems. While these migrations are not rare, clinically apparent problems are, fortunately, still quite uncommon. Nevertheless, it is prudent to remove such a "foreign body," as we call a device that is otherwise not native to a human being.

If you or a loved one has an IVC filter, please make sure you discuss with your doctor whether it can or should be removed. And if your doctor is unfamiliar with a good interventional radiologist in town...find one and ask him! Or ask me.

Keep Scope of Practice Limited - Patients Depend On Us

There has been much discussion and some movement on the issue of expansion of the "scope of practice" of nurse practitioners. While nurse practitioners are important to the health care team, simply giving full independence on the level of trained physicians may not result in improved patient care.

Non-physician caretakers, such as nurse practitioners, are a crucial component of our healthcare system. They are hard-working, dedicated, patient-centered individuals who are more than likely the first person a patient encounters. Together, the nurse practitioner and physician care for patients. The nurse practitioner typically obtains the information and creates a coherent list of a patient's presenting complaint, history and physical exam findings. Nurse practitioners work collaboratively with physicians for their patients, communicating information and findings, arming the physicians with the necessary information to allow him/her to put together accurate diagnoses. Such collaboration saves time for everyone involved. The physician considers the gathered information and generates a clinical picture from the various pieces, thereby making a diagnosis. That is not to say that a few nurse practitioners may exceed the clinical expertise of a few physicians. But physicians have a long head start due to their years of training and education. The clinical acumen that physicians acquire cannot be underestimated, nor discounted. 

To better understand the levels of training of various caretakers, including physicians and nurse practitioners, click here for a graphic depiction, originally published by the Florida Medical Association. Importantly, the very different types of training and lengths of education make physicians and nurse practitioners well-suited to work collaboratively. The vast importance of the medical school years, coupled with years of residency and standardized, extremely rigorous and challenging medical board exams has to be acknowledged and understood in this context. 

But what is also important to note is that the physician is the person who is primarily responsible, from a legal standpoint, for the patient's care. Expansion of the scope of practice of nurse practitioners, allowing them to practice independently, must also carry the same liability as physicians currently carry.

The Florida House (@MyFLHouse) recently agreed to expand the scope of practice of nurse pratitioners but, fortunately, the Florida Senate (@FLSenateGOP) did not. This mixed result has many people thinking that it is only a matter of time before the scope of practice expansion bill passes, allowing nurse practitioners to practice independently, without physician oversight and guidance.

Fortunately, there is an alternative plan that deserves much consideration. The Florida Medical Association has published the Five Pillars of Expanded Access, which addresses the shortage of physicians and access to care issues. It calls for increased collaboration between physician assistants, nurse practitioners and physicians. And it aims to regulate and codify telemedicine, an important developing component of health care in the 21st century. It is worth understanding this plan as the preferred alternative to unnecessarily expanding the scope of practice of nurse practitioners.

If you understand this issue as I do, and you live in Florida, please call your Representative and let them know that the solution to the physician shortage is not independently practicing non-physician caretakers. The solution to access to care issues is the Five Pillars plan promoted by the FMA. Please call your state Senator and thank them for not passing the bill and also impress upon them the importance of maintaining a firm stance against the expansion of the scope of practice of nurse practitioners. Ask them to keep the valuable and long-standing cooperative structure in place, allowing nurse practitioners and physicians to continue to work together for the safety and health of all patients.

Patients depend on their caretakers to give them the best care possible. The highest level of expertise must remain clearly spelled out in the laws so that people everywhere can continue to have confidence in the medical profession. 


Chew Longer. Lose Weight!

One of the simplest things to remember is chew your food thoroughly. So many people wolf down their meals like there's no tomorrow. The simplest thing to remember is the longer you chew, the sooner your brain will indicate the "full feeling." 

From the AMA daily email:

Devices, apps help people eat more slowly by chewing longer.

On the front of its Personal Journal section, the Wall Street Journal (8/12, D1, Reddy, Subscription Publication) reports on new medical devices and applications designed to help people eat more slowly by chewing longer. Chewing food thoroughly appears to make people feel fuller sooner, and some studies indicate that people who chew their food the most may consume fewer calories. One group of researchers is using funding from the National Institutes of Health to design a study which will test the efficacy of a diet in which participants will be restricted to just 100 bites of food on a daily basis.

FDA Approves First Colon cancer Screening Lab Test

My hope is that a simple screening test soon replaces colonoscopy or CT colonography, eliminating the discomfort, preparation and small risk of perforation.

As reported by the AMA daily email: 

Bloomberg News (8/12, Edney) reports the FDA gave approval to Exact Sciences Corp. to sell “the first noninvasive DNA screening test for colorectal cancer that patients can use at home.” The article notes that the FDA “cleared Cologuard, which screens stool samples for the presence of red blood cells and DNA mutations that may indicate the presence of cancer.” The article notes that in a study, Cologuard “detected 92 percent of cancers and 42 percent of advanced precancerous growths, significantly more than an older test that looks only for blood in the stool.”

        The AP (8/12, Perrone) notes that the new test, however, “was not superior on all counts.” The AP notes that Cologuard “was less accurate than older blood tests at correctly ruling out cancer, reporting more growths when none were actually present.”

        The news was also covered by the Wall Street Journal (8/12, Walker, Subscription Publication), the St. Paul (MN) Pioneer Press (8/12), the Wisconsin State Journal (8/12), Medscape (8/12, Nelson) and HealthDay (8/12).

Caretakers are Products of Years of Training AND Experience

DON'T just take a drug because your doctor prescribes it.

Ask WHY?

We doctors are products of the knowledge we gain through training AND years of experience. Nurse practitioners and physician assistants have vastly different training pathways and typically much different experiences compared to licensed, board-certified physicians. This point cannot be under-emphasized (although it is certainly being under-appreciated of late).

Personally, I also subscribe to the tenet "If it ain't broken don't fix it." So many people nowadays are swayed by unfortunate social standards that prompt them to cut and change and alter otherwise intact parts of their bodies simply to achieve a more desirable aesthetic. As an interventional radiologist, I often see the complications of some of those adventures. 

Just something to consider.

As to the excerpt below, get informed so you know what the risks and benefits are.

As reported by the AMA: 

Pfizer faces mounting number of lawsuits over Lipitor side effects.

The Wall Street Journal (8/8) reports on the growing number of lawsuits filed against Pfizer by women who claim the company failed to warn the public about the side effects of type 2 diabetes or memory loss from the use of its cholesterol medication Lipitor (atorvastatin calcium). Over the past five months lawsuits by women in the US who allege Lipitor caused them to develop type-2 diabetes soared to almost 1,000 from 56.

Powdered Caffeine is Dangerous! Do Not Use!

Please educate everyone, especially teenagers who might not realize the dangers associated with this powerful drug! Powdered caffeine is causing deaths. Only 1 teaspoon is equivalent to 25 cups of coffee! 

As reported in my daily AMA email: 

Use of powdered caffeine may result in death.

"NBC Nightly News (8/3, story 7, 2:40, Holt) reported on the “troubling trend involving caffeine, including the growing use a pure powdered form” which is marketed as a dietary supplement to increase “alertness and athletic performance.” NBC News correspondent John Yang explained that just one teaspoon of the unregulated substance “is the equivalent of 25 cups of coffee.” Taking it can result in “irregular heartbeat, muscle spasms and kidney failure.”

        The NPR (8/1, Hobson) “Shots” blog reported that in the aftermath of an overdose last May, the “Food and Drug Administration issued a warning about powdered caffeine, saying it’s impossible to accurately measure it with your standard kitchen equipment.” An excess of caffeine powder “can speed the heart and cause seizures and death, the FDA says.”"

"The Pill Linked to Breast Cancer Risk"...OR NOT! Whatever Happened to Responsible Journalism?!

The recently published article, entitled "The Pill linked to breast cancer risk for younger women," is an example of the typical irresponsible journalism rampant in today's media publications. The title is inflammatory and unnecessarily raises fears where there is already enough fear. To make matters worse, the conclusion of the article is that birth control pills remain safe for thousands of women and no change in behavior is recommended on the basis of the study. So why write the article? The title is obviously a pathetic ploy to get more people to read it. Beyond that, I see no redeeming qualities.

Excerpts as follows:

"But birth control pills have evolved over the decades since their introduction and the hormone doses they contain have dropped steadily, so many studies are based on data for formulations that are no longer used, Beaber and her colleagues point out in the journal Cancer Research."

""Use of formulations with high dose estrogen, ethynodiol diacetate (synthetic progestin), and specific triphasic oral contraceptives in the past year was associated with an increased breast cancer risk in our study, while other formulations, including low dose estrogen oral contraceptives, did not appear to be associated with an elevated risk," Beaber told Reuters Health."

"“Weak associations, consistent with noise and not signal, were the overall finding,” Dr. David A. Grimes told Reuters Health by phone.

Grimes is a clinical professor in the department of Obstetrics and Gynecology at UNC School of Medicine in Wilmington, North Carolina."

The new results are not important for women or doctors, Grimes said. Other, better studies have found no increase in breast cancer risk with birth control, which is essential for women’s health, he said."

Physician-Patient Relationship Is Obsolete

Well, of course I'm not serious about the title! I'm merely pointing out the obvious lunacy associated with a recent court decision that Florida physicians are not permitted to imquire (merely ASK?!!!) about firearms or discuss firearm safety with their patients. 

How unbelievably intrusive must your physician be (sarcasm alert) to want to inquire into whether you have guns, like guns, want to shoot guns, and whether you might possibly keep them safely locked up when not in use!  

We physicians understand the importance of privacy. With HIPAA rules, and associated large fines, ever hanging over our heads, no physician wishes to knowingly violate the sanctity of the physician-patient relationship.

In that same vein, don't you think it is reasonable for a physician to want to discuss aspects of a person's life that may affect their health?  seems acceptable to me, but I'm sure I may hear equal and opposite reactions to such a query.

Here are some excerpts of the reports of the AMA reaction (from the daily AMA email): 

AMA critical of ruling upholding Florida law restricting physicians from discussing gun risks with patients.

Politico (7/30, Villacorta) reported in a brief piece in “Politico Pulse” that the AMA is not “pleased” with a recent “court ruling upholding a...Florida law that restricts” physicians from discussing the risks of firearms with patients. AMA President Robert Wah said, “This law poses real harm to patients as it interferes with physicians’ ability to deliver safe care, and hinders patients’ access to the most relevant information available.”

        MedPage Today (7/30, Wallan) reported, “The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the” AMA “all issued statements condemning the legislation and the...ruling.”

        In the New York Times (7/30, Subscription Publication) “The Upshot” blog, Aaron E. Carroll, a professor of pediatrics at Indiana University School of Medicine, wrote that physicians “who ask about guns aren’t doing so because they’re nosy.” Carroll writes, “If the courts decide that people have the right never to be asked sensitive questions, they’re interfering with the relationship between” physician “and patient,” and “they’re deciding that some health risks are worth minimizing and others are not.”


Renal Cryoablation Delivers Excellent Long-term Results

...And Could Become Standard of Care for Cancers <3cm.


Galil Medical, a company that has developed the technology to enable interventional radiologists to perform the procedure, recently promoted an article that I excerpt as follows from their brochure:


In a 2014 article describing their prospective study, Christos S. Georgiades and Ron Rodriguez summarized the results following cryoablation of 261 renal tumors.

Outcomes at 5 years:

  • Overall survival: 98.7%
  • Recurrence free survival: 97%
  • Cancer specific survival: 100%

Low rate of clinically significant complications:

  • CTCAE Grade ≥ 3:  6%


To say that these results are exciting would be an understatement. I and my partner have been performing renal cryoablations for approximately ten years. We have developed a high degree of comfort with the available devices.

The ideal kidney cancer projects posteriorly (towards the back) and is smaller than 3cm. While larger cancers can be treated with this freezing technique, recurrence rates rise as cancer size increases above 4cm. The procedure also becomes technically more challenging and the procedure time becomes longer the larger the cancer size.

We have seen very few recurrences in our patient population. In addition, these procedures are extremely well-tolerated. We routinely treat people who are well into their 80s, and/or who are not able to undergo traditional surgical resection.

In our experience, patients who undergo this treatment do extremely well, with the great majority being sent home the same day, after several hours of observation to ensure no immediate complications arise.

This procedure is typically performed under moderate or deep sedation, meaning that we enlist the services of the anesthesia team. They administer heavier sedation than the usual interventional procedure, in order to keep patients as comfortable and still as possible so that we physicians can perform the procedure with no risk of patient movement compromising safety.

In summary, as I am typically asked, I would certainly want my loved ones to undergo this procedure if they were unfortunately diagnosed with a kidney cancer that was anatomically appropriate. In the right hands, as with most things, the procedure is effective, fast, safe, and definitive.

#iloveinterventionalradiology !



ACA Is Working, Sort Of. Now Fix It.

U.S. uninsured rate falls to 15%. Millions of people have found insurance through the Affordable Care Act and I think it is becoming clear that such a program, while flawed in many ways, has begun to help us down the road to improve healthcare in this country. While insuring these millions of people will presumably cost taxpayers more in the short run, perhaps overall health care expenditures may decrease through better care.

What I hope now is that Congressional leaders realize that fixing the existing laws makes much more sense than continuing to flail around, helplessly arguing for full repeal, something that doesn't look even remotely possible. Exhort your leaders to fix ACA now.

Excerpts as follows from the AMA:

Survey: US uninsured rate fell to 15% under ACA.

A late-breaking report garnered coverage across several major national websites Thursday morning. The New York Times (7/10, Sanger-Katz, Subscription Publication) “Upshot” blog highlights the new survey, out of the Commonwealth Fund, which shows that not only did many people sign up for health insurance under the Affordable Care Act, but those that did so are “pretty happy with their purchases.” In total, the study found “that about 15 percent of adults younger than 65 now lack health insurance, down from 20 percent before the Affordable Care Act rolled out in January.” Moreover, “73 percent of people who bought health plans and 87 percent of those who signed up for Medicaid said they were somewhat or very satisfied with their new health insurance.”

        McClatchy (7/10, Pugh, Subscription Publication) reports that the survey determined that “some 9.5 million Americans gained health coverage during the recent marketplace enrollment period.” And, “young adults ages 19-34, whose participation in the Affordable Care Act’s coverage initiative was crucial but always uncertain, saw some of the largest coverage gains.” Overall, “their uninsured rate fell from 28 percent to 18 percent.”

        CNBC (7/10, Mangan) reports that the survey reveals that “young adults, Latinos and the poor” have emerged as “Obamacare’s big winners.” These groups, the article explained, “long had the toughest time affording health insurance,” yet have seen “larger drops in their uninsured rates after the launch of Obamacare than any other group.”

        In its coverage, the Huffington Post (7/10, Young) points out the discrepancy in the figures between states that expanded Medicaid and those that did not. Indeed, in states that opted out, “more than one-third of their lowest-income residents remain uninsured, a rate virtually unchanged from last year, even as millions gained coverage elsewhere.”