Ebola in Dallas

I wanted to have a place to aggregate facts. While obviously I am more worried than with my previous information aggregation post, I am trying to retain my calm by collecting and sharing facts. Times, when listed, are when I learned about those stories, not when they were reported. Also, they're in my time zone: Central US.
So here we go.

• 2014-10-15
  Nina Pham (the first health care worker to contract Ebola from Duncan) is no longer the only person in history to contract Ebola on US soil. Late last night, another worker tested positive. Meanwhile, Ms. Pham's boyfriend is also in quarantine. So here's what this says to me: R0 in Dallas is 2, in line with the average for Ebola. Malthus must be smiling from his grave.[1]
• 2014-10-12
  Just as we were breath a sigh of relief on Michael Monnig's behalf, a health care worker who treated Duncan has tested positive for Ebola. R0 has officially gone from 0 to 1, and the contact circle has to have expanded significantly. How many people did this health care worker treat after becoming infectious? Hopefully the answer is "zero." Interesting bit from the article:

  The worker became infected despite wearing full protective gear while treating Duncan, who later died from the disease, during his second visit to the hospital.

  [1] Can we pretty pretty please shut off travel from West Africa now, or at least require everybody leaving to go through quarantine? If we get this thing in Dallas under control, but another outbreak starts somewhere else, then what good will have been accomplished?
• 2014-10-09
  Michael Monnig tested negative (sorry - no link. This was widely reported.) R0 is still 0 in Dallas, thankfully. Hopefully it continues to stay that way. 21 days from when Duncan was hospitalized is October 19. Unfortunately, due to the poor implementation of containment protocols (several days elapsed before cleaning Duncan's vomit, several days elapsed before sterilizing the apartment, with people inside, etc., that isn't the day when we can really say that nobody will catch it from Duncan's pre-hospitalization period. I'd peg that date right around Halloween.
  There is also the risk of transmission during disposal of Duncan's body and cleaning the isolation ward where he was treated. So let's say it takes 3 days to dispose of the body; that would imply the clock for workers involved in that process starts 10/11, and runs out on November 1.
  In all, this implies that whenever there is a bona-fide case, we can expect five weeks to elapse before we know whether that case was successfully contained. Possibly more time, now that I think about it. Had Duncan survived, he would continue to be contagious for 7 additional weeks, at least via semen.
• 2014-10-08 8:49 pm
  Dallas County Sheriff Deputy Michael Monnig went to an urgent care clinic in Frisco, Texas with his wife on Wednesday
  A witness at the clinic described him as 'hunched over and flushed'
  The deputy was inside the apartment where Ebola patient Thomas Duncan fell ill - the officer wasn't wearing protective clothing
  The CDC said the person is not one of the 48 contacts being monitored
  The CareNow clinic was placed in lock-down
  Sgt Monnig's family said today the CDC had told them that their loved one was not at risk and they were just taking precautions
  

  The day after going into the apartment, Monnig and his fellow officers were told to bag up the clothes they'd been wearing. Their police cars were also taken out of commission.
  'That starts putting question marks in your mind,' Monnig told WFAA in an October 3 report. 'You know when you go home and then the next day you start hearing that equipment is being quarantined or asked to be bagged up, that you had on or were driving.
  'Then your question is, "well, what about me?" And so those were the questions that were raised.'
  Now the question is: Why wasn't Monnig warned before entering the home completely without protection?
  [1]

• 2014-10-08 3:50 pm
  Unnamed Dallas County Sheriff's deputy walks in to a walk-in clinic and says he was in Duncan's apartment without protective gear and thinks he has Ebola. Earlier today, Duncan passed away. (I found out much earlier, but forgot to update this page...) [1]
• 2014-10-05 7:42 am
  Duncan in critical condition. A day or so ago he was in "serious but stable" condition. Looks like his gambit may not have paid off. Here's hoping his family has not contracted it, and that no animals carted off with any of his vomit. [1]
• 2014-10-03 8:20 pm
  My brother summarized this article fairly well:

  Girlfriend and children of Patient DumbFuck now showing symptoms. CDC dropping the ball on their quarantine and care. Why is a news source in the UK the first to report this?

  [1]
• 2014-10-03 8:07 pm
  Jesus. Sanitation workers are getting zero training. [1]
• 2014-10-03 4:06 pm
  Duncan's former boss in Liberia says that Duncan knew he was exposed and came to US specifically to seek treatment. His gambit may very well have condemned his family and hundreds of others to death. [1]
• 2014-10-02 9:33 am
  Number of people being screened grows to 80. I would think that taking this guy at his word, that he was not symptomatic when he boarded the flight, is not sufficiently conservative, considering the stakes. The list ought to include anybody who was traveling through Brussels, DC, or Dallas on 9/20. If I were on any flights on that day, I would be very concerned right now. TX health officials apparently have a broader list of 100 people.

  ... health officials have also formally ordered four of Mr. Duncan's close family members to stay home and not receive any visitors until at least Oct. 19. The family members could face criminal charges if they don't abide by the order.

  I think that's prudent. People who know me might wonder how I square that with my libertarian bent. It's fairly simple: people who have reason to believe they present a risk to others should not expose others to that risk - doing so would be an act of aggression, and thus violate the nonaggression principal. I don't particularly like the lack of due process, however. [1]
• 2014-10-02 8:26 am
  Interesting commentary from my friend tmi3rd. Basically, if Duncan survives, expect a bunch of folks from West Africa to try to come here for treatment. [1]
• 2014-10-02 7:36 am
  I spent some time yesterday saying that Ebola in W. Africa had an R0 around 1.2. Turns out my memory did not serve me well; it's actually 1.5 in Guinnea, 1.6 in Liberia, and 2.5 in Sierra Leone. Why the difference between nations? A number of things, as I understand it. First, R0 is a measure of how much a virus is actually transmitting, not of its potential to transmit. So if you have control over the epidemic, then R0 will be less than 1, and the epidemic will end. If you don't, then R0 will be greater or equal to 1, and the epidemic is spreading. You can think of R0 as an exponential factor. [1]
• 2014-10-02 7:16 am
  

  There is considerable misunderstanding concerning the potential for aerosol transmission of filoviruses. The data on formal aerosol experiments leave no doubt that Ebola and Marburg viruses are stable and infectious in small-particle aerosols, and experience of transmission between experimental animals in the laboratory supports this [49, 56–63]. Indeed, during the 1989–1990 epizootic of the Reston subtype of Ebola, there was circumstantial evidence of airborne spread of the virus, and supporting observations included suggestive epidemiology in patterns of spread within rooms and between rooms in the quarantine facility, high concentrations of virus in nasal and oropharyngeal secretions, and ultrastructural visualization of abundant virus particles in alveoli [17, 50]. However, this is far from saying that Ebola viruses are transmitted in the clinical setting by small-particle aerosols generated from an index patient [64]. Indeed patients without any direct exposure to a known EHF case were carefully sought but uncommonly found [65]. The conclusion is that if this mode of spread occurred, it was very minor. [1]

  In other words, there is some evidence that a different strain, Ebola Reston, has been communicated in an airborne manner, among apes. Ebola Reston was the subject of a chapter or two in The Hot Zone. A facility where apes were being studied, in Reston, Virginia, had to be quarantined, all of the apes destroyed, and the building chlorinated. No humans were infected in that incident. There has still never been a documented case where humans have caught Ebola via an airborne route, as far as I know.
• 2014-10-02 6:30 am
  Same article as last night - I was in a rush and didn't read the whole thing. More info from there:
  • Witness who described the vomit/screaming during the ambulance-load is a Bosnain immigrant named Mesud Osmanovic.
  • Stocks had reactions one might expect: everything tanked except for those of companies with Ebola treatments in the pipeline
  • Dallas school super Mike Miles claims the school-aged children were not showing symptoms and therefore presented little risk of spreading the virus. This ignores, IMHO, the fact that Duncan took a full week to show symptoms.
  • "Texas officials said health workers who took care of the patient had so far tested negative for the virus and there were no other suspected cases in the state." This contradicts USA today and WFAA (Dallas ABC Affiliate) reports that there was a second suspected case. Perhaps that 2nd case tested negative?
  • Buried at the bottom of the article is perhaps the most important bit of information, Duncan's travel itinerary:

    A Liberian official said the man traveled through Brussels to the United States. United Airlines said in a statement that the man took one of its flights from Brussels to Washington Dulles Airport, where he changed planes to travel to Dallas-Fort Worth.

    If he really was not symptomatic until 9/24, then that itinerary isn't horribly concerning. If he was already trying to fight through things, hoping for better treatment in the US than he could get in Africa, then that itinerary means he had 3 separate airplanes and 2 layovers where he was spreading EBOV prior to making it to Dallas. Even if he was not symptomatic, as reported, I think it ought to be clear that air travel from West Africa needs to be shut down immediately.
  [1] [2] [3]
• 2014-10-01 8:21 pm
  Duncan puked on the ground outside his apartments while trying to get into the ambulance. His whole family was reportedly screaming. [1]
• 2014-10-01 2:38 pm
  
  • Patient name is Thomas Eric Duncan.
  • On 9/15, Duncan helped his carry his landlord's daughter to the hospital for care. This is thought to be how he was exposed.
  • Duncan is believed to have had contact w/ 12-18 people, including 5 school-aged children from 4 different schools.
  • Schools are to undergo a "thorough cleaning" (bleaching? not clear), but remain open.
  • The 18 people are going to be monitored daily for 21 days.
  The implication of the events of 9/15, as I see it, is that Duncan knew he'd been exposed, and boarded a plane anyway. [1]
• 2014-10-01 10:19 am
  Dr Jesse L Goodman says several people were exposed and it's likely many more will be infected. I'm amazed that somebody saying something like this is given any press time in the "don't panic" press atmosphere. [1]
• So much for R0 remaining 0... A second person is being "monitored." [1]
• What is R0? [1]
• The ambulance used has been decontaminated, presumably by spraying with bleach, and the EMS workers have been quarantined. This was reported to have been done as of 9/30, 2 days after patient zero was transported to the hospital. Sure hope everybody else who rode in that ambulance has been contacted. I've seen no reports as to whether that is the case.
  [1] [2]
• Patient Zero's timeline:
  

  9/20 - Arrives from Liberia without symptoms

  9/24 - Symptoms begin

  9/26 - Seeks care

  9/28 - Hospitalized

  href='https://twitter.com/GioBenitez/status/517069057666084864'>[1]

  Some observations: Patient Zero apparently sat around thinking it was just a cold for 2 full days before seeking care. Whoever he sought care with on 9/26 dropped the ball by either not asking if he'd been to West Africa recently, or by disregarding that vital piece of information. Patient Zero then spent another 2 full days becoming more virulent before he was finally hospitalized.
  I have seen no reports as to whether the original caregivers have been quarantined or are just under observation. I have likewise not seen any reports as to whether the facility where he sought care on 9/26 is being or has been decontaminated.
• Ebola is spread by direct contact with bodily fluids and is not airborne. This is often presented as a fact which should be comforting. Consider this list of bodily fluids, though:

  Body fluids- as obvious as this may seem- include (but are not limited to) blood, sweat, tears, vomit, urine, feces, semen, vaginal secretions, and the like. [1]

  The implication is that sitting on a vinyl cab or bus seat after an infected person contaminates it with sweat (or worse) may be more dangerous than you might think.

  The threat to motorcycle drivers and their passengers is obvious but flatbed trucks are not necessarily any safer. “The back of the truck has to be cleaned out between patients,” says William Fischer, a physician who helped to fight the Ebola epidemic in Guinea this past spring and is now back in the U.S. But getting the needed resources to clean the vehicle or cleaning it well enough can sometimes be a problem. [2]