Tuesday, November 4, 2014

The Ebola “Shake”

As the Ebola epidemic shows no signs of dissipating, it is probably time to change some common greeting customs. The standard greetings depending on location, culture, and state of intoxication include handshakes, hugs, kissing both cheeks, chest “bumps”, high five, low five, and multiple variations on above.
               With skin-to-skin contact, spread of the virus is possible but unlikely, as the infected contact is thought to require high illness severity accompanied by a high viral load.  To avoid transmission, but continue the formalities of social greeting, the suggestion has been made to switch to the lightly closed fist “hand-bump.”

               There are two variations of this:

1.      The covered hand (where you pull your clothing over your fist and then make contact.)

2.      The uncovered hand where you feign actual contact, gesture, miss, and retain the psycho/social effect.

The Japanese culture with traditional bowing has already solved this dilemma. Not sure that this will translate to a more macho western culture.

               There has been much controversy in the news media about the proper way of avoiding the spread of Ebola worldwide. The options of travel bans, closing air traffic, quarantine, and testing stimulate expert opinion. These expert opinions are extremely varied and seem to be based on political orientation to avoid panic and medical need according to the CDC based on medical evidence according to epidemiological techniques. At the present, there are shifting recommendations on a daily basis.  The 24-hour news cycle, political correctness, and true lack of knowledge makes it look like there is no black or white answers.

               In large part, these shifts reflect an imperfect science regarding the transmission of this virus.  The ease with which it spreads in some situations (e.g. to healthcare workers) is offset by a variable period of contagion (thought—but not guaranteed-to maximize at 21 days), an ill-defined onset of viral shedding (headache? myalgias? rhinorrhea? low-grade fever?), a degree of permeability to protective gear that is almost uncanny, as well as an unknown capacity to mutate and circumvent measures being established.

               Moreover, effective treatment is now generally agreed to depend on one dimension:  supportive care with adequate hydration and electrolytes.  It is almost cholera-like, and electrolyte depletion is now thought to be the final common pathway to death.  Quite likely, when the analytics are complete, they will show that most of the deaths in W. Africa could have been prevented with simple IV hydration.  Not to mention that much of the transmission there could have been averted by common-sense burial practices*, along with mitigation of unnecessary fear.  Yet, in those countries, at the height of the disease, those infected (including many healthcare workers) were sent to the back (rooms, tents, fields) and left alone, where they, of course, died.  Treatments such as convalescent serum, plasma, ZMapp were, in all successful cases, given along with good supportive care, and full hydration. Hence, it was, to any cogent medical mind, the hydration and support that made the difference.  Since cases are now being shown to recover just with fluids, the other “treatments” were clearly superfluous.

               The probable truth is that there are no straightforward solutions to the problem of stopping transmission.  They become, and are becoming more and more, epidemiologic and political decisions.  The common sense approach of attacking and isolating the problem at the source through quarantine and support sounds the best but may not be the whole answer.

               The Ebola epidemic will ultimately probably be controlled or burn-out itself and life will go on. In a prior blog (Life Imitates Art) it was stated that is really hard to get things right without the necessary experience. The fact that multiple communities and countries are trying different things will allow the analysts to come up with a “game plan” in the future for the next uncontrolled world-wide pandemic.  We should consider the present infection as a “test” of our preparedness and make the appropriate adjustments.

*In one well-known case, when it was thought the outbreak was just about under control, the body of a woman who died from Ebola was taken from the hospital under gunpoint by relatives.  Her remains were taken to their home, and the practice of full contact mourning caused a resurgent outbreak in the area.

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