Ebolavirus
2014 Outbreak
October 26, 2014 Update #4
Paul
Herscu, ND, DHANP, MPH
Herscu
Laboratory
DON’T PANIC! (Part 2)
We have a physician living in New York testing positive for Ebolavirus
Disease (EVD) after doing great, important, inspiring work in Africa. The fear this
brings up in New York makes me write sooner than later. In short, even in New
York, DON’T PANIC. It is incredibly
unlikely that you will ever meet anyone who had EVD or that you will catch it.
I have had requests, for a few months now, to discuss the homeopathic
management of Ebolavirus Disease. And what may seem odd is that while I have written
about treatments over the past decades,
discussing very specific remedies at different stages of epidemic diseases, I
have not done so this time around. You may wonder why? And since I know that folks
at the CDC read this, I thought I would elaborate and make further suggestions
here.
As homeopathic physicians, we learn how to treat disease. As part of
that study, we read a philosophy book titled the Organon of Medicine, written by Samuel Hahnemann, a physician
living a couple of hundred years ago. While the focus is on homeopathy, he
addressed several other facets of medicine, well ahead of his time, such as
proper care of the mentally ill 150 years ahead of his time, and proper testing
of medicines a hundred years ahead of his time. Some of this book dealt with the
concept of public health, which is my main point of bringing it into the
conversation.
Early in that book, the fourth point in fact, Hahnemann writes,
“He is likewise a
preserver of health if he knows the things that derange health, and cause disease, and how to remove them from
persons in health.”
While we care about the ‘deranging health’
aspect, as in what habit or lifestyle weakens us to become ill in the first
place, like bad food, lack of sleep, or drinking alcohol, we also deeply care
about the part in bold, which refers to, amongst other things, germs such as
Ebolavirus. In other words, we care about the susceptibility to the germ, which
is to one extent or another within our control (more on that at a later time) but
the germ as well. The bottom line is that we are not only supposed to treat
disease but we are supposed to prevent it in the first place. Put another way
and as example, would I prefer to be the fellow that treats someone who has an
infection after surgery or the guy that convinces the physicians to develop
habits that keep them from creating an infection in their patients? I would
very much prefer to prevent the illness in the first place. I think every
homeopath would, given common sense, really anyone would. What I would like to
do here is share with you why it is, in no particular order, that I think the
most important aspect for our community to voice at this time is the second
bold part of the sentence, “remove
them from persons in health.”
Quarantine:
Quarantine must be the most important aspect of public health here,
but it has to be a proper quarantine.
First, the word quarantine. That word is such a funny word really. The word has
its root from the Italian, ‘quaranta giorni’, which means ‘40 days’. When a ship came to port,
they had to wait in isolation 40 days before they were allowed to enter the
city as a way to make sure that they did not carry the black death epidemic, spread
by Yersinia
pestis, an epidemic that killed perhaps
200 million people in a very short time. (Actually, this seclusion was
originally 30 days, but then was extended to 40 days, an important point that we’ll
come to below.) When a disease is quick to develop, it is just common sense to keep
those that seem healthy but may have been exposed away from the general
population.
With Ebolavirus Disease we
find a similar timeline. There is a short period of time between exposure and the
development of symptoms and then becoming contagious. It seems as though 21
days of being clear is enough to say that someone is not going to develop EVD.
It would seem both common sense and most practical to seclude people until we
know they are not a threat to others, including their family. This concept has been
really slow on the uptake for a variety of reasons.
One sensitive reason often mentioned
is that since it is Africans that are having the epidemic, quarantining people
from those countries is tantamount to racism since the vast majority of the
population is black. However, what people who claim racism to be at the heart
of a quarantine process may not know is that many African countries surrounding
these countries with EVD, have already done this. According to International
SOS, here are some of the countries which have put travel restrictions in
place. This is not racism, this is common sense.
Cameroon banned travelers
from Nigeria, Guinea, Liberia and Sierra Leone.
Cape
Verde denied entry to non-resident foreigners coming from countries with
‘intense Ebola transmission' including Sierra Leone, Guinea and Liberia and banned
travelers who have been to those countries in the previous 30 days.
Chad closed its land
border with Nigeria at Lake Chad, and banned entry of travelers originating or
transiting through Guinea, Liberia, Nigeria or Sierra Leone. Airlines serving
the country reportedly rerouted flights.
Equatorial
Guinea has denied entry to travelers whose journeys originated in countries affected
by Ebola.
Gabon has restricted
the issuance of entry visas to travelers from Guinea, Liberia, Sierra Leone and
Nigeria on an individual basis.
Gambia suspended entry of persons who have
visited Guinea, Liberia, Sierra Leone or Nigeria in the 21 days prior to
travel.
Kenya closed the Suam
border crossing (Trans-Nzoia county) with Uganda due to reports of an
Ebola-related death in Bukwo district (Uganda). Earlier, Kenya suspended entry
of passengers traveling from and through Guinea, Liberia and Sierra Leone,
excluding health professionals supporting efforts to contain the outbreak and
Kenyan citizens.
Mauritius banned entry to
all travelers who have visited Nigeria, Sierra Leone, Guinea, Liberia, Senegal
and Congo (DRC) in the last two months.
Namibia's foreign
ministry announced that foreigners travelling from countries affected by Ebola
would be prohibited from entering the country.
Rwanda banned entry to
travelers who have visited Guinea, Liberia or Sierra Leone in the 22 days prior
to travel.
Senegal closed its land
border with Guinea, while the country's sea and air borders have also been
closed to vessels and aircraft from Guinea, Liberia and Sierra Leone.
Seychelles
suspended
entry to travelers who have visited Sierra Leone, Liberia, Guinea-Bissau,
Guinea, Nigeria or Congo (DRC) 28 days prior to their journey, with the
exception of Seychellois citizens.
South
Africa restricted entry for all non-citizens traveling from Guinea, Liberia
and Sierra Leone.
South
Sudan has placed a ban on travelers coming from Guinea, Sierra Leone,
Liberia or Congo (DRC), or those who have traveled to those countries in the
preceding 21 days.
One very common comment is
that quarantine will not work, as the borders are too long and too porous and
people will just pass through. But in fact that is not going to be the case,
the disease itself makes travel less possible. When you consider the majority of cases which spread
outside the initial countries, it has been from individuals going to the countries in
question, becoming infected and bringing it back to other countries. While it
may not be palatable, quarantining people and regions is the best way to limit
spread. Look at the surrounding countries that have effectively stopped the
spread by closing borders and quarantining the ill. It works but must be done
properly, and in conjunction with quick identification, surveillance and
treatment.
The most cost effective and
scientific way to do this is to stop the people who are in those countries from
traveling outside the countries for 21 days. Quarantine them for 21 days as a
pause in their travel, while they are still in-country, and once they are past the
21st day then let them leave a holding area to travel to their destinations.
Really, this is similar to the boats being held at harbor for 40 days. It is
more convenient, cheaper, and less likely to spread the disease to do this
while they are still in country than to let them travel outside the country.
At this moment
the USA made an alteration to travel for anyone who began their travel in Liberia,
Sierra Leone or Guinea that they can only enter the country through a half
dozen airports, but the possibility is that they will be fine when they get
there only to become ill later on. There needs to be a total ban on travel
until after they clear a 21-day cycle. This is the quickest way to stop the
spread. In lieu of that option, people are going to modify this to say that
this is only going to be the case if you are dealing with an Ebolavirus Disease
patient, but actually since you may not be aware of that you might mislead
those at the boarder control, test normal and then move past those controls. For
sure this process will slow down the spread, but why not stop it completely by
keeping those wanting to travel in a forced 21-day quarantine while still in
the country where they may have been exposed to the Ebolavirus.
What is sad for
me is that we have done this sort of quarantine with animals already for many
decades, but find it hard to do so now with people. If you wish to bring a
horse into the USA from countries
with screwworm, the horse gets quarantined for 7 days, and if from countries
with African horse sickness they get quarantined for 60 days. In other words,
we want to keep a healthy ‘looking’ horse who may be harboring a disease
quarantined so as not to make the rest ill because we care about the other horses.
If the situation worsens, then for sure
this kind of quarantine will be created, but why not do it now. Instead of
spending so many millions in developed countries we can put that money to much
better use keeping the disease from leaving those countries where it is and
using the tremendous money saved to help the health infrastructure within the
affected countries.
Airborne
Panic and Confusion:
One of the most
important reasons quarantine in one fashion or another is going to work, and is
already working, is that the virus is NOT airborne. But I want to address this
very specifically. I know that people are hearing that Ebolavirus may indeed be
airborne, we have heard this in the media, from our politicians and at times,
from the CDC. But thankfully, it is not.
If it were, there would be millions dead. I do want to address why it is that
there have been mistakes in understanding about the virus.
First a one
sentence primer. When we say airborne
we mean a germ that can infect you from say one room to the other, or from one side
of a room to another. Information from one study which is often quoted but
seldom read is about pigs infected with Ebolavirus then infecting monkeys. The
pigs were housed very near monkeys who did not have EVD and without contact,
the monkeys developed EVD. The study was designed to test primarily one thing, which
was, is it possible for pigs (one species) to pass EV to monkeys (a different
species) and the answer they found was yes they can. However, as was described,
pigs, unlike humans, develop EVD in the lungs. They breathe out and sneeze out
a constant barrage of droplets and it is likely those droplets, instead of
landing directly on the ground, landed on the nearby monkeys instead, allowing the
monkeys to become infected. Here, droplets carrying the virus are the equivalent
to a sick man vomiting blood unto another man. Yes, for the briefest second the
vomit was in the air, but that does not make it airborne. It is not airborne
transmission, and if the one man was standing on the other side of the room,
the vomit would not reach him. It is the same here with the droplets from the
pigs landing on the monkeys in cages inches away. The story is a bit more
complicated but you get the point. They did not test monkeys in a separate room
from pigs to see if they could be infected via airborne transmission since that
was not the actual purpose of the experiment. So, bottom line. Water droplets,
like vomit or diarrhea or semen may carry the virus, and if you touch the
droplet you may get infected. But that is a different definition of airborne.
To put it slightly differently, we have never demonstrated the ability to pass EV
from individual person to individual person via air alone. What one can see
though is how the media and non-scientists may have gotten it wrong. An easy
mistake. Here is the paper.
(if clicking on
this link does not work, try copying/pasting directly into your browser)
The numbers
though speak to this as well. Think about it this way. If it were airborne, and
if the disease were really as lethal and as morbid as it is, then each person
would be infecting so many more people. Look at the map. It would have been
impossible for Senegal to have one test positive and have 67 close contacts
test negative. That is not what you see with airborne lethal viruses. Having
Ebolavirus become airborne is one of my worst nightmares. But if and when that
happens it is not going to be subtle. We will all know it quickly and
dramatically. I will make my point again below. For now, it still looks like
the main reason so many are ill is because of the poor healthcare structure
within those countries, and lack of funds and trained care to isolate, treat,
and change behaviors. It is an economic question, not a germ question.
OK
here comes a little wrinkle the numbers:
Here is a bit of
a confusing point, but one that I hope makes sense. Up until this epidemic, we
did not have many EVD patients within any one outbreak and even in total. What
we thought we knew was based on small samples, and since there are different
forms of EV which may act somewhat differently from each other, each outbreak manifests
slightly differently. Now that we have a great deal more data, one of the
‘hard’ numbers seems to be wrong. When you look at the data on all the people
to now, what we find is that each outbreak had a different length of time from
exposure to when the person became symptomatic. Below is a chart from the paper
I cite that makes the point. It seems that during this epidemic, one may become
symptomatic after the standard 21 days that everyone is quoting. Look at the
chart.
As you can see the Zaire outbreak really took a nosedive at around the 21-day mark, in bold. However, when you look at the current epidemic some occurrences seems possible past that day. It is an interesting paper that we should all read. The bottom line of the paper is that we have to balance the potential of spread with the costs of isolating people. What is the right number of days to quarantine someone after exposure? (Remember how during the Black Death, before it was a quarantine 40 days, it was a “trentine,” 30 days of isolation.) Looking at the above chart of people who really got EVD this year, it becomes clear that 21 days is not the actual, last potential day of becoming ill. However, it also shows that the likelihood of developing the symptoms 35 days out is, though possible, highly unlikely. This leaves me with a further suggestion, as below.
As you can see the Zaire outbreak really took a nosedive at around the 21-day mark, in bold. However, when you look at the current epidemic some occurrences seems possible past that day. It is an interesting paper that we should all read. The bottom line of the paper is that we have to balance the potential of spread with the costs of isolating people. What is the right number of days to quarantine someone after exposure? (Remember how during the Black Death, before it was a quarantine 40 days, it was a “trentine,” 30 days of isolation.) Looking at the above chart of people who really got EVD this year, it becomes clear that 21 days is not the actual, last potential day of becoming ill. However, it also shows that the likelihood of developing the symptoms 35 days out is, though possible, highly unlikely. This leaves me with a further suggestion, as below.
Until then, I
believe that 21-day number will stick as the health notice. It would be a
public relation nightmare to change the date at this point. It would cause too
much confusion for the healthcare workers and for the public. Much better is to
stick to the 21 days. That number of days will capture most of the infected
patients, and for those that it does not, they will be identified and treated
and more or less fly under the radar. If the curve changes dramatically and it
becomes more public knowledge, we will address it at that time, but until then,
the 21 days will stay as is.
My
suggestion:
How about this
as a possibility regarding the quarantine question? No one leaves the
three primary countries unless they first remain in an internationally run
quarantine area in those countries for a period of time. From the graph above, 10
days will identify most of the people who are infected. That does not seem like
a long time to wait, and that could be the mandatory number of days for
everyone who is leaving the country and does not think they were around anyone
who had EVD. After that, those not ill or testing positive in any way are
allowed to travel but are kept track of. For those that were in actual contact
with EVD patients, a mandatory 21 days will identify virtually the rest of the
people. If you want to be especially cautious 40 days would have to be the
number but that seems too burdensome to the situation at hand. One of the main
problems we have now is the lack of volunteers to go into those countries.
Adding burdens makes recruiting even harder. It is a balance of risks and
needs. Personally, I believe this protocol should include all people in-country
including healthcare workers who came to help. Meaning that MSF should
institute this immediately for their volunteers who are leaving an assignment. Everyone
is quarantined, while still in Africa, for a period of days.
The alternative to
in-country quarantine is a forced quarantine of the same persons, but this time
in the developed world. As I write this, New York and New Jersey are
instituting mandatory quarantine but in the person’s home, which is likely to
be 21 days long. Here, the solution is similar with the only additional people
at some sort of risk are those who fly with the individual. This too is likely
to work to slow the spread, though not as fool-proof as keeping them
in-country, though definitely a good step forward.
With the great
amount of money saved not having to treat people in the developed world, that
money can be used in the individual developing countries where EVD is in
epidemic. In those countries, there are whole regions that have no EVD. The
affected areas within countries should be quarantined in a similar fashion.
This will allow us to use the saved funds to provide monitoring, identifying,
treating, and modifying practices in the effected areas.
In one way or
another this is the direction the world will have to shift to sooner or later.
The main point here is that prevention, via this effective tool, limits spread,
saves resources and allows resources to be spent where they are needed to
address those who are ill and to build infrastructure in the developing world
and populate that structure with trained medical care that is also needed.
One suggestion
that may mollify emotions is to pay those in quarantine their daily wage. To be
sure, most of the health care workers moving into these countries do so for the
greater good, displaying altruism that is born out of religious or
philosophical good will towards their fellow humans, displaying the best of
what our species has to offer. They put themselves in harm’s way, they give of
their work generously. However, it may be that when they want to come home they
are done with that part and want to reintegrate. Asking them to hold off and go
into quarantine seems like it may be too much to ask. Not that they are doing
it for this reason, but paying them their daily wages during that time may help
mollify those emotions. Likewise, paying people in the developing countries to
stay in quarantine, their daily wages, may do the same. Yes it will cost money,
but much, much less than having to later track down and quarantine 100’s in the
USA and shutting down airports and traffic, etc. Paying them may take part of
the sting out of the quarantine.
OK. Back to me
being a homeopath. Why have I been harping on all of us to get our politicians
to do the right thing and fund appropriately? We are in a race here. If we do
not change the rates of infection and do not limit spread, and thus allow
others in other countries to develop EVD, then next year promises the
following. Everyone gets a new vaccination for EVD. A brand new vaccine, for a
disease most of you had never heard of. All vaccines have a plus/minus side to
them. So while we get this vaccine to prevent EVD some will develop some
unexpected adverse events that may impact their health. This happens with every
vaccine, as we all know, but we, as a society, have decided that the risks of
no vaccination outweigh the risks of vaccination for each of the illnesses.
With Ebolavirus
Disease, if it spreads worldwide, then we all get vaccinated, and it will be
mandatory. Very similar to smallpox. In fact we would have traded bugs but
entered a similar playing field. However, if it becomes truly endemic but only
in a small region, then I imagine that would become mandatory for those living
in the region and those visiting that region. No vaccination record, no entry
back to other countries. And if by chance it goes away very quickly, then it
probably becomes an optional vaccine that you might want to have. Remember
people have lived in Uganda and DRC forever with only a few people getting
sick, without vaccinations.
So what is the
future we want? After this vaccine there are about another 150 viruses still on
the list as bad as EVD. Are we going to be getting vaccinated for all of those?
Surely, if a vaccine is available then it should be offered to whoever wants
it, needs it, if the situation warrants. I would expect healthcare workers to
get vaccinated originally. My point is that this situation is ‘warranted’
because we are letting this epidemic drag on much longer than it need be.
In part, I feel
badly that the homeopathic community has mostly either remained mute on the
subject, or is instead thinking that what we need to do is offer suggestions of
which remedies should be given. I understand as homeopaths our focus is
typically on treating the individual, however the issue before us is not about
any one patient. The issue before us is a public health one. In fact as I write
this, there are homeopaths in Africa treating EVD, but in no way is that as
important as preventing the spread of this disease and bringing this epidemic
to a quick end, which we all want.
To put it in
context. Every year, including this year, somewhere between a quarter of a
million to half a million people are going to die from influenza around the
world. This year, it may be 30,000-50,000 dead in the USA alone. Last year
during the flu season more than 100 pediatric deaths occurred in the USA, from
flu related causes. During this EVD epidemic, we will see less than 50 people
with EVD in the USA. Think about it. Everyone reading this post will know
someone who contracts influenza, and some of those will fare poorly. But you
contracting EVD, well, is not likely. Pitch in. If you can, and have the skill
set, consider volunteering. If you can’t consider having your town become a
sister city to a town in the impacted countries, provide supplies. How about we
stop the EVD epidemic. By implementing the suggestions put forward here and in
previous posts, to isolate the virus to a few countries as quickly as possible,
for the good of the people in those great nations and for ours.
In health,
Paul Herscu, ND, DHANP, MPH
