Wednesday, October 22, 2014

Ebola: Lessons from Dallas and Facts about Ebola

By James L. Holly, MD
CEO, Southeast Texas Medical Associates

The problem with information about Ebola is that simple answers are not helpful in public health and personal safety for avoiding contracting an Ebola infection. A statement by U.S. Sen. Rand Paul may true, but if it is not the whole truth, it is not helpful in to the public. The senator said, “If someone has Ebola at a cocktail party, they’re contagious, and you can catch it from them.” On the face of it, this statement is true, but it is not the whole truth about the spread of Ebola.

First, to address Ebola contagiousness, you must distinguish between contagious patients and asymptomatic patients — those who have the virus but at very low viral load, are not spreading their body fluids with sneezing or coughing, and are not manifestly sick — who are not contagious in the ordinary use of the term. It is probable, if you received a blood transfusion from this asymptomatic person with a low viral load that you would develop Ebola, but it is also probable that the casual exposure of being in the same room with this asymptomatic person would not result in your becoming infected.

While we cannot make dogmatic statements without random-controlled or double-blind studies, which are not possible due to the seriousness of the Ebola infection, we can draw inferences from the “natural experiment” that took place in Dallas. Every human death is a tragedy, but every human death does not result from culpable action or inaction on the part of a health care worker or professional. When Thomas Eric Duncan manifested Ebola and when he subsequently died, his family and other contacts were quarantined appropriately.

The good news is that no one that who casual contact with Mr. Duncan has contracted Ebola. Those who were in the emergency room when Mr. Duncan presented, those who took care of him in the emergency room, and now even Mr. Duncan’s family have completed the quarantine period without having contracted an Ebola infection. While they have not completed the 21-day observation period, no one who was on the airplane with the nurse from Dallas has developed an Ebola infection.
Being in the same room with an asymptomatic person who has Ebola is not desired and is not to be recommended, but it also is not as dangerous as some would like to say.

Fact

Ebola is a dreadful and dangerous disease. Even with the best of care, many with the infection will die. Ebola can be spread by contact with bodily fluids of an infected person, but even that must include contact with a mucous membrane or a break in the skin. Also, the infectivity of Ebola is not 100 percent. If a person with Ebola coughs on you, and if any fluids from that cough fall on intact skin, and if you wash that skin with soap and water, the probability of your contracting Ebola is very low. You will not contract Ebola simply by being in a social setting with someone who is in the early, asymptomatic stage of an Ebola infection.

Real Life Experiences

At one time there was a great fear of HIV infectivity. HIV is a much different disease from Ebola, and we are at a much different point in the history of the treatment of HIV disease. There was a time, however, when many people made statements about the infectivity of HIV like Rand Paul’s statement about the infectivity of Ebola. They were wrong, also. Children who had HIV infection were refused admission to school; people would not shake hands with those who were HIV positive. We shortly learned that casual contact with an HIV-positive person was not dangerous.

Many years ago, a physician friend called me in a panic. He had punctured himself with a needle that had been used with a patient who was HIV positive. I encouraged him to clean the wound carefully with an antimicrobial soap and copious amounts of water, and I assured him that the probability of contracting HIV from a single needle stick was very low. Twenty-five years later, he is still HIV negative. This does not mean we should be casual about needle sticks, but it does support our contention that everyone who has a needle stick will not contract HIV.

Some years ago, my wife and I had a dear friend who was HIV positive. He developed HIV-AIDS and became very ill. This was before there were good treatments for HIV. Carolyn and I were with our friend when he was actively dying at home. She held his left hand, and I held his right hand as we comforted him. When he breathed his last breath, I looked down and saw that the cuticle of the thumb of his right hand was bleeding and that the blood was dropping on my hand. Without panic, I went to the bathroom and scrubbed my hand with soap and water. I was confident that I would not contract HIV, and I did not.

The Power of Skin

I would not recommend intentional contract with blood from an HIV positive person, but I would affirm that one of the best barriers to viral illnesses is intact skin. Whether it is the highly contagious, airborne Influenza virus, or the less contagious but much more dangerous Ebola virus, skin is the first and best barrier to infection. The problem comes when a person has had exposure to a viral illness that resulted in viral contact on the hands, and then the person touches his or her eye, nose, or mouth. This by-passes the skin barrier and carries the virus straight to a mucous membrane and from there into the body.

This reminds us that the most important viral-infection prevention is frequent, vigorous washing of the hands with an antimicrobial soap and copious amounts of water. It also reminds us that if we can diminish or eliminate the spread of aerosol virally infected particles from a cough or sneeze, we can decrease the spread of viral infections. We can do that by covering our mouth and/or nose when we sneeze or cough and then by washing the body part used for that purpose immediately. If you are young enough and can bend that far, coughing or sneezing into the bend of the elbow is the best tool. This technique is not adequate protection from Ebola, but it is a first-aid means of addressing all viral infections until isolation can be achieved.

Conclusion

If a person does not have an Ebola infection, he or she cannot spread an Ebola infection. I recently heard a public health official include this in a list of high-risk situations: “if you have contact with someone who had contact with an Ebola-infected person.” The reality is if you have contact with someone who had contact with an Ebola infected person, if your contact did not have Ebola, you have nothing to worry about. And, while we Baptists would not be at a cocktail party, even if you are but no one is sick, coughing, or sneezing, you have very little, if anything, to worry about.

Dr. Holly is a Beaumont family physician, CEO of Southeast Texas Medical Associates. He is adjunct professor at The University of Texas Health Science Center and clinical associate professor Texas A&M Health Science Center.

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