Ebola and public health 101 - disease outcomes follows socio economic status

Professional medical personal were asked how it is the Americans treated for the Ebola infection in the US were being cured? The response was: "The honest answer is, we're not exactly sure."

Yet, what public health officials know, because of decades of disease tracking, is that a person's socio-economic status is correlated with health outcomes.  

In other words, Americans are much higher on the socio-economic scale than most Africans. Therefore, an American's chance of recovering from the Ebola virus, when treated in the US, is greater than a person who is an African, regardless of where they are treated.  Consequently, "the honest answer is".. the right answer. Indeed, public health 101 doesn't know precisely why socio-economic status helps determine health outcome, but evidence supports the correlation.

Holly Yan reports on CNN

For a disease that kills more than half of its victims abroad, Ebola in the United States is getting snuffed out at a remarkably fast rate.

When Dr. Kent Brantly became the first U.S. patient with Ebola in August, he was hospitalized for 19 days.

On Tuesday, when nurse Amber Vinson became the most recent American patient discharged, she was hospitalized for just 14 days.

Her colleague, Nina Pham, also went home after just 14 days.

"So the question is, why did our patient recover so quickly?" said Dr. Bruce Ribner of Emory University Hospital in Atlanta, where Vinson was treated."The honest answer is we're not exactly sure."

But he and other health experts have several hypotheses.

Younger patients recover faster

Vinson, 29, and Pham, 26, were among the youngest patients treated in the developed world.

"We know from a lot of data coming out Africa that younger patients do much better than patients who are older," Ribner said.

But unlike West Africa, where Ebola has killed close to 5,000 people, Americans have the advantage of better nutrition. If an infected patient getting proper care normally has a strong immune system -- and younger patients generally do -- the chance of survival goes up.

The virus was aggressively attacked

"The general dogma in our industry in July was that if patients got so ill that they required dialysis or ventilator support there was no purpose in doing those interventions because they would invariably die," Ribner said.

"I think we have changed the algorithm for how aggressive we can be in caring for patients with Ebola virus."

Of the nine Ebola patients treated at U.S. hospitals, eight have survived. And all of those released have something in common -- they were treated at one of the country's four hospitals that have been preparing for years to treat a highly infectious disease like Ebola.

The sole fatality in the United States -- Thomas Eric Duncan -- was not treated at one of those facilities. (Julie's note: What's worse, the basic rules about infectious disease triage weren't implemented at Texas Health Presbyterian, in Dallas Texas, when Mr. Duncan first presented, ie, identify, isolate and inform - others.)

Speed matters

This may seem obvious. But sometimes it's the basics -- namely, the ability to pump ample fluids through patients with severe diarrhea and vomiting -- that can mean the difference between life and death.

"The most important care of patients with Ebola is to manage their fluids and electrolytes, to make sure that they don't get dehydrated," said Dr. Tom Frieden, director of the Centers for Disease Control and Prevention. "And that requires some meticulous attention to detail and aggressive rehydration in many cases."

When he first arrived at Texas Health Presbyterian Dallas Hospital, Duncan was sent home with antibiotics. He wasn't admitted for another three days.

Brantly, Nancy Writebol and Dr. Rick Sacra became symptomatic while they were still in Liberia -- and they had to be flown here, spurring a slight delay in treatment.

Most others were quickly tested and quarantined as soon as a low-grade fever was detected.

Transfusions may have helped

Most of the American patients received blood or plasma transfusions from other survivors. The plasma contains antibodies that could fight the virus in others.

Brantly donated plasma to at least three patients -- Pham, Sacra and NBC freelance cameraman Ashoka Mukpo. All three survived.

"It's very fortunate that the three patients I've been able to donate to, they and I share the same blood type," Brantly told CNN's Anderson Cooper.

There was some controversy about why Brantly didn't give plasma to Duncan, who eventually died. But health officials said the two did not have the same blood type.

Dr. Craig Spencer, the only Ebola patient still being treated at a U.S. hospital, recently received a transfusion from Writebol, one of the first American survivors.

Experimental drugs may have helped, too (Julie's note - this is probably the least of the reasons for the improved outcomes of US patients because the drugs used were truly experimental.)

Duncan received experimental medicine six days after admission to the hospital. It was a far longer wait than four other Ebola patients treated in the United States. Those patients got experimental medicine immediately.

Experts, however, say the jury's out on the effectiveness of these drugs.

Protective wear reduces exposure

The relatively swift recoveries of Vinson and Pham might also be attributed to their personal protective equipment (PPE) they were wearing when they treated Duncan.

While some nurses at the Texas hospital reportedly complained about PPE that left their necks exposed, at least Vinson was suited up.

"She was wearing personal protective equipment during the care of her patient in Dallas, and therefore it is quite likely that the amount of virus she was exposed to was substantially less than what we see in patients who get infected in less developed countries," Ribner said.

"And we also know that the higher the viral load that you get infected with, the more severe your disease is likely to be."

Excellent 60 Minutes Segment on Ebola from the nurses who cared

"And we held his hand and talked to him and comforted him because his family couldn't be there."

(I was particularly  appreciative of how these nurses revealed the intensity  of the personal care they provided to the deceased Ebola patient Mr. Duncan.)

Thank you to the heroic nurses who did all they could to save the life of Ebola patient Mr. Duncan, at Texas Presbyterian in Dallas Texas.  This 60 Minutes segment, with interview led by Scott Pelley, demonstrates the unlimited compassion and competence of the heroic nurses who valiantly tried to save Mr. Duncan's life but, sadly, the virus was already too advanced for him to recover.  

Nurses who cared for Ebola patient Mr. Duncan at Texas Presbyterian in Dallas Texas

Treating Ebola: Inside the first U.S. diagnosis

The medical staff who treated Thomas Eric Duncan, the first Ebola patient diagnosed in the U.S., tell the inside story to Scott Pelley.

The following is a script of "Treating Ebola" which aired on Oct. 26, 2014. Scott Pelley is the correspondent. Patricia Shevlin and Gabrielle Schonder, producers.

You've heard a lot about the Dallas hospital that treated Thomas Eric Duncan, the first Ebola patient diagnosed in America. But you've never heard what actually happened from the people who fought for his life at the risk of their own. You're about to meet four nurses who treated Duncan from the time he came into the emergency room, to the moment that he died. The staff had been blindsided by a biomedical emergency that burst into their ER like a wildfire. Contrary to reports that the hospital bungled the response, the story the nurses tell sounds more like a heroic effort to stop an outbreak. 

On September 28, Duncan was rushed by ambulance to Texas Health Presbyterian Hospital. He was isolated in a separate section of the ER and nurse Sidia Rose, starting the night shift, was briefed on the special precautions required for what they now suspected was a case of Ebola.

Sidia Rose: I went over and met with a nurse who gave me a report. She also went over the protective gear that we would be wearing that night. She gave, you know, finished briefing me on what was going to happen, and I literally burst out in tears.

Scott Pelley: Why?

Sidia Rose: It's very scary. I know about Ebola, and the only reason I do, it's because I've been just researching it on my own. Since January, I kept hearing the word popping up in the news. And I just wanted to find out about it.

Richard Townsend: When our supervisor said that we had a potential Ebola case, I don't want to call it calamitous but there was a lot of concern, people became very vocal, understandably it's the boogie man virus.

Emergency room nurses Richard Townsend and Krista Schaefer made sure that Rose was suited up properly. As per the hospital's protocol, she worked with Duncan alone, with Townsend watching over her.
"I got myself together. I'd done what I needed to get myself prepared mentally, emotionally, and physically, and went in there and did what I was supposed to."

Scott Pelley: When you went to approach Mr. Duncan for the first time, what did you do? How did you prepare for that?

Sidia Rose: I gathered myself together. I put on my protective wear and I went in and introduced myself to him and you know just let him know that I would be the nurse helping him tonight.

Scott Pelley: What were you telling yourself?

Sidia Rose: I was very frightened. I was. But and I just dried my tears, rolled down my sleeves, so to speak, and went on about my night.

Scott Pelley: But why do you go in there? Why don't you say, "You know, this one's not for me"?

Sidia Rose: As a nurse, I understand the risk that I take every day I come to work and he's no different than any other patient that I've provided care for. So, I wasn't going to say, "No, I'm not going to care for him."

Scott Pelley: But you were risking your life to take care of this patient.

Sidia Rose: Oh, I know that. And that's why I, as frightened as I was, I didn't allow fear to paralyze me. I got myself together. I'd done what I needed to get myself prepared mentally, emotionally, and physically, and went in there and did what I was supposed to.

Though Duncan's test results wouldn't be known for two days, she was certain she was witnessing Ebola.

Nurse Sidia Rose: The first time when I went in and he vomited, I was standing in front of him, he was sitting on the commode, and there was just so much it went over the bag, it was on the walls, on the floors. I had two pairs of gloves on and shoe covers. And I had my face shield on. I didn't have two masks on at the time, I had just one. No, we didn't have any head covers. But I wiped down the walls, wiped down the floor with some bleach wipes.

Nurse Richard Townsend: He was having so much diarrhea and vomiting that he, you know, she was constantly having to give him the little bags that we have for people to vomit into.

Nurse Richard Townsend: All of that was hazardous waste and it had to be bagged and then double bagged and then put into a separate container that could then be disposed of later. Because anything that has any of his bodily fluids on it has the potential to be lethal to somebody else.

"And that's when he said to me his family had suffered a loss. That he had buried his daughter who had died in childbirth."

Eric Duncan was 42 years old, from Liberia, which is ground zero for this outbreak. Half of all the cases in the world are in Liberia. He flew to Dallas to visit family, became sick a few days later, and then made his first visit to the Dallas hospital.

It was the night of September 25 when Duncan first came into this emergency room. According to the hospital records, he had a temperature of 100.1. Over the course of the four hours or so that he was here, his temperature spiked to 103, but then it dropped back down. Again, according to the hospital records, he told the staff that he had come from Africa, but did not specify West Africa or Liberia. About three o'clock in the morning, with his symptoms not very severe, the staff decided to send him home with antibiotics.

But three days later he was back in the ER gravely ill and about as contagious as he would ever be. The virus is not transmitted though the air but physical contact with a single viral particle can cause infection. The hospital notified state health authorities immediately. And they wanted Nurse Sidia Rose to ask several urgent questions of Duncan.

Nurse Sidia Rose: I explained to him, "We are under the impression that you may have been exposed to Ebola. And I said, "Where are you from?" And he told me Liberia.

Nurse Sidia Rose: And I asked, "Have you been in contact with anyone who's been sick?

Scott Pelley: He said?

Nurse Sidia Rose: No. He said no.

State and federal health officials wanted to know if Duncan had been with anyone who had died in Liberia.

Nurse Sidia Rose: And that's when he said to me his family had suffered a loss. That he had buried his daughter who had died in childbirth.

But nurse Rose says Duncan told her it wasn't Ebola that killed his daughter. Rose told us that she reported this to the Texas Department of Health, but then Duncan denied his own story when he spoke to those officials.

Scott Pelley: What information was it that he denied to the health officials?

Sidia Rose: About his travels, about him burying his pregnant daughter who had died in childbirth. He denied that. He said that's not true.

Scott Pelley: So he wasn't honest with them.

Nurse Sidia Rose: Yeah.

"And we held his hand and talked to him and comforted him because his family couldn't be there."

This is nurse Richard Townsend, who dressed in the protective gear that was recommended by the CDC at the time, just as Sidia Rose did.

Scott Pelley: Was any of your skin exposed?

Sidia Rose: At that time it was just a gown that I was wearing, so yeah. Not my hands, not my legs, my face, I had my face shield on, the mask with the face shield.

Scott Pelley: So your neck was exposed?

Nurse 

Sidia Rose: Yes.

Scott Pelley: So the CDC protocols that you would've looked up the day he came into the emergency department was in your estimation deficient?

All: Yes.

On September 29, Duncan was carried from the emergency department to intensive care. Nurse Nina Pham, who was involved in the transfer, would become the first person to catch the virus in the United States.

It took 48 hours to get Duncan's positive test results. And by then the hospital, on its own, had equipped the staff with suits that allowed no skin to be exposed. It would be another three weeks before the CDC made this its new standard. Then the hospital moved out all of the patients in medical intensive care and reconfigured the 24-bed unit for just one patient. It was a strange scene for ICU nurse John Mulligan.

Nurse John Mulligan: By the time I came in, they had already received the Tyveks, the pappers. So we had the full hazmat gear that people are used to seeing.

Scott Pelley: Is this the full suit?

Nurse John Mulligan: This is the full suit, yes. There were always two of us in the room at all times. And we were designated two people to be in there. I've been in health care for nearly 20 years and I've never emptied as much trash as just from the waste of his constant diarrhea that he was having was remarkable. And we had these longer surgical type gloves on. They were taped to the Tyvek suit, full headgear with a circulator with a HEPA filter that would plug into the back. And the first time I got out of that suit, it literally looked like someone had pushed me into a swimming pool. I was drenched.

They were working 16 to 18 hour days, spending two hours at a time in Duncan's room.

Nurse John Mulligan: And we held his hand and talked to him and comforted him because his family couldn't be there.

Scott Pelley: You held his hand through the spacesuit?

Nurse John Mulligan: I did. He was glad someone wasn't afraid to take care of him. And we weren't.
"We asked for volunteers. Everyone volunteered."

Nurse Richard Townsend: I have nothing but respect and admiration for everyone that was involved in his care you know everyone has someone in their lives that they love and they care about. I have a five-year-old and a three-year-old and my wife is pregnant. And the mortality rate for pregnant women with Ebola is, it's essentially 100 percent.

Scott Pelley: But Richard, why don't you go to the administration and say, "You know, I'm sorry. But my wife is pregnant."

Nurse Richard Townsend: People were allowed to request not to be tasked with his care.

Nurse Krista Schaefer: We asked for volunteers. Everyone volunteered.

Scott Pelley: Everyone was a volunteer, everyone that was there wanted to be there?

Krista Schaefer: Every person, housekeeping, respiratory, physicians, nurses.

But despite all the volunteers Duncan grew worse. An experimental drug wasn't helping.

John Mulligan: Early Saturday morning he had become very critically ill and was placed on a respirator.

Scott Pelley: He was intubated.

Nurse John Mulligan: He was intubated.

Scott Pelley: Tube down his throat?

Nurse Mulligan: Tube down his throat. He had a dialysis catheter placed because he was not making any urine, but he needed to. He was heavily sedated and he had tears running down his eyes, rolling down his face, not just normal watering from a sedated person. This was in the form of tears. And I grabbed a tissue and I wiped his eyes and I said, "You're going to be okay. You just get the rest that you need. Let us do the rest for you." And it wasn't 15 minutes later I couldn't find a pulse. And I lost him. And it was the worst day of my life. This man that we cared for, that fought just as hard with us, lost his fight. And his family couldn't be there. And we were the last three people to see him alive. And I was the last one to leave the room. And I held him in my arms. He was alone.
"I would have nightmares, and still do, of my co-workers being infected and not being able to get to a hospital and treatment and dying."

Scott Pelley: Sidia, you spent perhaps the most time talking with Mr. Duncan and I wonder what you think people should know about him.

Nurse Sidia Rose: He was very kind and very appreciative. Even something as simple as me just giving him cold washcloth to cool his face down because his fever wasn't breaking, even that he was grateful for. He told me thanks.

Within days of Duncan's death, nurse Nina Pham was admitted to the hospital with Ebola.

Scott Pelley: When Nina became sick, that must've sent a lightning bolt through the staff because now it's one of you.

John Mulligan: I thought someone was playing a cruel joke until I finally looked at my phone and saw the missed text messages and the voicemails and turned the news on and went, "Oh my goodness."

Then four days later, nurse Amber Vinson fell ill. Both nurses have since recovered; this is Nina Pham leaving a hospital on Friday. But many on the staff still wonder whether they could be next.

Scott Pelley: Are any of you, all of you, still self-monitoring for signs of infection?

Nurse Sidia Rose: I am.

Scott Pelley: You are? You're still within the 21-day window?

Nurse Sidia Rose: For Mr. Duncan I'm passed my 21-day period. But for Nina Pham I'm still being monitored. I've been asymptomatic. My temperature has been rock solid.

Those who contract the virus are not infectious until they actually become sick. Members of the medical staff must take their temperature now twice a day and show the reading to a state health official. But, in at least one other way, the effect of fighting this virus could linger.

Nurse John Mulligan: I would have nightmares, and still do, of my co-workers being infected and not being able to get to a hospital and treatment and dying. And so it's like any traumatic event, this too shall pass. It's just going to take a little time.