Is North Carolina's Ebola Quarantine Justified?

I'm puzzled by the announcement that asymptomatic individuals returning to the Charlotte area from Liberia are being quarantined for a period of 21 days because of concern they may be incubating Ebola.

Several important questions that I think need to be answered include:

• Is this a "voluntary" quarantine or is it mandated? What is the penalty for breaking it?
• Who is the governing authority? Mecklenberg County or the state of North Carolina?
• Where will these individuals be confined to? Their homes? A facility? 
• Since Ebola is not casually transmitted what is the evidence that such a quarantine would be effective?
• If this is to be taken as a precedent are all CDC officers deployed to West Africa to be quarantined upon return as well? 
• It's OK to fly, but not to freely move about Mecklenberg County?
• Why was this action never undertaken with travelers to prior Ebola outbreaks, Lassa Fever outbreaks, or to the Middle East (where the more contagious MERS circulates)?

Authorities say this quarantine order is being issued "out of an abundance of caution" but it does not excuse taking actions without an actual risk-based justification. To me, this quarantine delivers a mixed message to a public desperate for clarity on the actual transmission risk of Ebola. 

A True Doomsday Pathogen?

Today, while rounding on infectious disease patients, I came face to face with a deadly killer for which I had no treatment to offer.

It wasn't Ebola. 

This killer lurks within the US, can spread person to person with ease, and can cause whole hospital units to shut down.

Its name: XDR Acinetobacter.

Because many of the infections this pathogen causes occur in elderly chronically Ill nursing home patient, it doesn't grab headlines. It should for it is a harbinger of the future if antimicrobial resistance continues and current strategies in the treatment of infectious diseases, reliant almost exclusively on broad spectrum antimicrobials, are not rethought.

So while more flashy diseases may turn heads, the serial killer in the shadows continues its work.

Would You Like Some Mycobacteria with Your Tramp Stamp?

People often forget that one of the most crucial components of the immune system is the skin. Though it is less intricate and flashy as antibodies, complement, neutrophils, lymphocytes, and, one of my favorites, natural kill cells, the skin is an essential barrier that stymies many pathogens.

This fact is why Band-Aids are important. 

Anything that causes a breach in the skin--be it a laceration, an IV, or a puncture--is the equivalent of leaving the door open to pathogens. 

One ornate welcome mat recently in the news is the tattoo. Tattoos, when applied with dirty needles, have been associated with hepatitis C infections but a recent advisory was issued warning of the possibility of infection from certain bacterially-contaminated  tattoo inks. In particular, non-tuberculous mycobacterial infections are the main risk. It is thought that dilution of inks with tap water introduces bacterial contamination. Mycobacterial infections are particularly hard to diagnose and often require prolonged courses of treatment. 

I once heard the expression "peeing on the birthday cake" and it seems to be a particularly apt way to describe what the inconsiderate Mycobacteria are doing to people's tattoos. 

HIV, Ebola, & Wild Child Emerging Infectious Diseases

I was asked a really interesting question on a recent TV interview. I was asked about what lessons from HIV can be applied to Ebola. That I think about HIV a lot might seem strange given that it is now a completely treatable "chronic" infectious disease and not an explosive mysterious emerging infection. 

But, HIV had its wild-child phase and it is the arguably the most successful emerging infectious disease ever. 

HIV-1 spilled into humans from chimpanzees around the dawn of the 20th century, probably in Cameroon, and at first was likely a disease of bush-meat hunters and their close contacts who contracted the virus when butchering chimpanzees. Once industrialization connected these once remote areas to each other HIV-1 found a means to propagate amongst humans through sexual contact and the disease exploded. 

The disease trickled on, accruing victims without notice. I always think if infectious disease physicians would have noted this trickle of patients before it became a worldwide epidemic decades later, it could have been contained (to some degree). 

There's a story I've heard about a physician, Dr. Bila Kapita, recognizing the presence of the AIDS-defining illness Kaposi's Sarcoma in Kinshasa in 1975 and noting its presence in prior hospital records. I think this anecdote illustrates that if you look hard enough, you can find low-level "viral chatter" transpiring. 

Ebola is similar in many respects. These explosive outbreaks represent stuttered forays into the human population and burn out because the virus is not efficiently transmitted between humans. 

Studying these stuttered starts of emerging pathogens is what it means to be "tracking zebra".

Demystifying the ZMapp "Miracle" Cure for Ebola

Like everyone I am very excited about the prospect of Mapp Biopharmaceutical's innovative tobacco-based monoclonal antibody product, ZMapp, dministered to both individuals with Ebola who were subsequently transported to Atlanta. One of these patients is ambulatory and the other is able to eat--encouraging signs of recovery.

Monoclonal antibodies are a promising new technology used in host of illnesses and provide an elegant means to avert the use of antibiotics by using a rationally-designed targeted treatment. I spent a lot of thinking about monoclonal antibodies working as a team member on this project (in which we even interviewed Mapp's Larry Zeitlen). Currently, the only FDA-approved monoclonal antibodies for infectious diseases are for RSV and anthrax.

There have been reports labeling these drugs as a "miracle cure" with near instantaneous effects. I believe that people should be cautious, as NIAID director Dr. Anthony Fauci noted, about such interpretations for a number of reasons that include:

• The small number of humans (2) that have received the drug--were these two already going to recover without this medication and was ZMapp administered on the cusp of convalescence?
• The presence of confounding effects: Atleast one patient received convalescent sera prior to ZMapp, a treatment that likely has some efficacy on its own.
• The lack of published data from these patients on such biomarkers as viral load, liver function tests, blood clotting times, etc.

In short, much excitement is justified and this drug has proven to be highly efficacious in non-human primates. However, I think that more data is clearly needed to establish causation with respect to the course of illness in these two patients (and I am confident it will emerge as more individuals are administered this treatment). But I, for one, am cheering the use of monoclonal antibodies for the treatment of an infectious disease.