Tuesday, October 28, 2014

Ebolavirus 2014 Outbreak - #4

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 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.

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