Stay calm...

The first case of Ebola in the United States was announced today, with a patient in Dallas who traveled to the US from Liberia. The resultant hysteria and xenophobia prompts this reminder. There is NO need to panic.

Ebola is NOT transmitted before a patient develops symptoms. Ebola is transmitted by contact with infectious secretions from body fluids or blood. It has NOT shown airborne transmission.

Viral airborne vs. droplet transmission - courtesy Ian MacKay.

In the US, Ebola does not pose the same magnitude of risk as it does in Africa. There was profound poverty in the affected areas of West Africa and a very limited infrastructure even before the epidemic hit. Liberia had just one doctor for nearly 100,000 inhabitants before the outbreak. Since then, there have been 211 deaths among some 375 infected health care workers in Africa (35 in Guinea, 89 in Liberia, 5 in Nigeria, and 82 in Sierra Leone), according to WHO. Roads, electricity and basic supplies are also in extremely short supply.

While our infrastructure is crumbling, with a number of roads and bridges in disrepair and increasing poverty and hunger, it is orders of magnitude different than in Africa or many other countries. In Liberia, 80+% live below their country’s poverty line; 93% live on less than $2/day per the World Bank, as is true of many other African and Southeast Asian countries.

The US has a history of a good public health infrastructure. As Dr. Thomas Frieden, director of the CDC, noted in today’s press conference about the Dallas, TX case, the skills required to control Ebola in the US are basic, standard public health skills—not something new, exotic, technically difficult, or never before tried. It requires bread-and-butter, old-fashioned contact tracing of people exposed to a contagious patient, observation, and isolation.

Garbed for Superbug Isolation Patient

And while specialized containment facilities have been used so far in the US, basic isolation is something we do everyday in hospitals. Here, for example, is a photo of me garbed to enter an isolation room for a patient with CRE (carbapenem-resistant Enterobacter). Not Ebola, but an increasingly common, often fatal bacteria most commonly acquired in hospitals, and associated with a 40-50% death rate. I wish more people would get excited about CRE or other highly resistant bacteria (superbugs). Nosocomial (hospital-acquired) infections are far more likely to kill you in the US than Ebola is…

Also of note is that there have been several previous cases of hemorrhagic fevers related to Ebola—Lassa and Marburg—imported to the US with NO secondary transmission.

Some have called for canceling flights and closing borders. This is not only histrionic, but would be ineffective. The CDC predicts that by the end of January, 2015, western Africa could have as many as 1.4 million cases. With global travel, there is no way to prevent someone asymptomatic but brewing the disease from entering the country, especially as the incubation period can go up to 21 days. And quarantines have been shown to backfire and worsen epidemics.

Relative risks

Let’s put this Ebola case in perspective. In the US, you are far more likely to be killed by an irresponsible gun owner than Ebola. Just in the year after Newtown, there were more than 12,000 deaths from guns. There have been 16,647 gun injuries since Jan 2014.

Anti-vaxxers have killed more people in this country than Ebola ever will. Influenza kills 36,000 people every year and sends about 200,000 to the hospital. You get flu from coughs and sneezes—it is more easily transmitted than Ebola.

Measles: There were 592 cases as of 8/1 in US. Per 1000 infections,1-2 children will die and one will be injured for life from encephalitis. Before vaccinations against measles started in 1963, about 3-4 million people got measles each year in the United States. Of those people, 400 to 500 died, 48,000 were hospitalized, and 1,000 developed chronic disability from measles encephalitis.

You can transmit measles to innocent, unprotected kids who are too young to be vaccinated or who have contraindications (e.g., are on chemotherapy) and kill them—just by a cough or sneeze. Patients with measles are infectious for 4 days before they develop a rash, as well as for days after. “Measles is so contagious that if one person has it, 90% of the people close to that person who are not immune will also become infected with the measles virus.” The saddest cases I have ever seen were children dying from vaccine preventable diseases.

In contrast Ebola is not infectious until symptomatic, and then requires close contact for transmission.*

(*Note to those who oppose vaccinations: I don’t care if you kill yourselves with your choices. I seriously object to your hurting or killing innocent kids with your choice. Vaccines do not cause autism.)

HPV: 79 million Americans—more people than live in California, Texas, and Illinois combined—are currently infected with human papillomavirus, which can cause cancers of the cervix, head & neck…and is now vaccine preventable.

Food-borne infections affect 1/6 (48 million) Americans annually, send 128,000 to the hospital, and kill 3,000.

While not transmitted person-to-person, malaria kills more than 600,000 people every year, or about 68 people per hour.

The other thing with Ebola—our risk of dying from it, even if infected, is far less than occurs in Africa. This is because we have better nutrition and health in general, are not coinfected with parasites or HIV, and have better supportive care. As I mentioned in my last post, Ebola-the World's Katrina, our mortality in sepsis trials dropped from ~50% to 10-15%, solely be improvements in supportive care, such as being more aggressive with monitoring and fluid replacement. Part of the extremely high mortality in Africa is the inability to provide even basic intravenous fluid replacement. And as Erin Hohlfeder aptly tweeted today,

Disparities in health expenditures

Infection Control

What we need to do with Ebola is the same as for any other infectious disease—“universal precautions.” We need to place close attention to hygiene and disinfection, and continue careful isolation of patients ill with infections in hospitals. This is effective, when done properly…One of my concerns however, from working in a variety of hospitals across the country, is that hospitals are increasingly taking short-cuts with infection control. I have voiced this concern previously regarding the control of superbugs—many hospitals are increasingly short-staffed, and nurses, in particular, are responsible for more patients than they used to be. Better hospitals have good isolation equipment and ongoing infection control training. They provide adequate personal protective equipment (PPE) and dedicate supplies like blood pressure cuffs and stethoscopes to specific isolation rooms. Others are penny wise and pound foolish, refusing to provide dedicated isolation equipment or thorough training, citing cost concerns.

I call on the CDC and State Health Departments to focus some of their attention away from bioterrorism preparedness and Ebola, to remedial infection control 101. That is the way they can help protect the country from any infectious diseases threat.

Dr. Frieden: “Bottom line, I have no doubt that we will control this importation or case so that it does not spread widely in this country...It is certainly possible that someone who had contact with this individual could develop Ebola, but there is no doubt in my mind it will stop here.” I agree—if all hospitals beef up their infection control training and practices.

In the meantime, instead of fueling xenophobia and conspiracy theories, if people want to help control this epidemic, a good start would be by relaying accurate information and donating to one of these great groups working to stem the outbreak in Africa:


Doctors Without Borders, from my perspective the most selfless and effective group

From Ian MacKay's assessment on his blog:

  • Médecins Sans Frontières (MSF)

    They are meticulous, fastidious and well trained so they don't needlessly risk themselves. They are on the front lines everywhere. They have been all over this outbreak from early one. They warned us.

  • Direct Relief

    They can (and have) mobilize the PPE I want delivered. They have contacts with others in industry. They are a nexus for getting this done.

  • International Federation of Red Cross and Red Crescent Societies. They are one the ground helping keep locals informed about Ebola virus

  • United Nations International Children's Emergency Fund (UNICEF)

    Always finding way to help children. There is a growing orphaned population in West Africa.

  • United Nations Foundation Ebola Response Fund

    The UN created this fund as way to allow individuals, corporations and civil society organizations to directly support UN entities in their efforts to respond to the Ebola virus disease outbreak.

I also trust the recommendations of ONE and Kelly Hills.

Please don't just fuel panic and hate. Help in any way you can, by sharing accurate information or donating your money or skills.


Ian Mackay, for use of his graphs

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