Facing the Ebola of Their Time: Montezuma, Napoleon, Justinian, and Pericles

In a recent interview, I was asked what was the worst case Ebola scenario I could imagine. Here's what I didn't say: Ebola becoming airborne or Ebola spreading in the US.

What did I say? I said that if Liberia and Sierra Leone are unable to control Ebola they might face the collapse of their states, creating a dead zone ripe for organized criminals, terrorist organizations, slavery, and other unsavory practices to take hold. 

I don't believe this will happen given that the pace of control measures is rapidly accelerating. However, contemplation of this scenario concretizes just how a natural infectious disease epidemic might intersect with national security--a fascinating topic. 

Infectious diseases, in certain contexts, have the power to collapse societies--just ask Montezuma (smallpox) or Napoleon (typhus), or Justinian (plague), or Pericles (the Athenian "plague").

Allergic to Taking a Travel History

Of all the ongoing revelations regarding the first domestically diagnosed case of Ebola in the US, the one that I find most problematic is the fact that the patient initially presented to the hospital, made his travel history known, and was discharged.

It has been reported that the nursing records indicated the travel history but this information was not communicated to others on the care team.

This is a real error.

As an infectious disease physician, travel history is something I always emphasize and not just for Ebola. MERS, chikungunya, dengue, and malaria are all other diseases in which the travel history can be key to the diagnosis. Even for those within the US, travel history is crucial. Diseases like hantavirus, plague, Rocky Mountain Spotted Fever, histoplasmosis, and coccioidiomycosis (and now dengue) have a geographic element to their domestic epidemiology.

No doubt this patient's drug allergies (or their absence) were plastered all over his chart and tethered to his wrist. Travel history is the lynchpin of our defense against emerging infectious diseases and it merits the same level of importance.

The Ebola Gazette

A quick run down of some important developments with the Dallas Ebola case:

• Apparently, the patient's travel history was known at his first presentation but not communicated to the rest of his care team--a major flaw. I am sure the patient's allergies were easily communicated so why not his travel history?
• EMS workers are part of the circle of contacts and their ambulance will be cleaned appropriately
• There is some concern over one particular contact of the source patient

In other news, enterovirus patient deaths have been reported in Rhode Island. 

Ebola Does Dallas

So it looks like the inevitable--based on the sheer size of the outbreak and travel patterns-- happened, an infected non-healthcare worker from Liberia was diagnosed with Ebola in Dallas. While the details are sketchy at this point this case illustrates the extreme importance of asking a travel history in patients who may have been in Ebola-stricken areas. This patient departed Liberia on September 19 arrived in the US on September 20 and was not experiencing symptoms--and thus not contagious--until a few days later, on September 24. Interestingly, the patient first presented for care on September 26 but was not admitted to the hospital on September 28. 

This case, like any Ebola case, can be treated in an ordinary hospital and need not require a containment facility (as the four evacuated patients have been placed in). I, for one, hope that this case is taken care of in the "ordinary" setting of Texas Presbyterian Hospital to illustrate how non-contagious Ebola patients are when cared for using appropriate personal protective equipment.

Another thing to remember is that the US has adeptly handled imported cases of Lassa Fever and, Ebola family member, Marburg multiple times in the past. To quote CDC Director, Dr. Tom Frieden: "There is no doubt in my mind that we'll stop it here."

Ebola will not find the US as hospitable a place as Debbie did Dallas.

Scorpion Grants My Wish: An Infectious Disease Episode

Last week I hoped Scorpion, the new CBS show about a team of geniuses that assists the Department of Homeland Security, would focus on an infectious diseases as well as other problems. Well, this week they granted my wish and they were immersed in responding to a pathogen, related to the common cold virus, synthesized specifically to infect the California governor's daughter and a few others.

What the Scorpion team was facing was a biohacker who employed synthetic biology for a sinister purpose. Synthetic biology, the realm of biology that deals with the creation of novel genetic sequences, holds tremendous promise for curing disease, specifically targeting therapy as part of personalized medicine, and revolutionizing biotechnology. 

However, just like almost every trade, there are dual-use concerns with the rise of synthetic biology, the biohacker movement, and DIY biology. I share some of these concerns but have an overriding fundamental belief that all these developments are essentially good and representative a major advice for mankind. 

While the show requiring some suspension of disbelief--an antidote was made in two hours--it is good to see these issues penetrating into popular culture.