Senator William H. Frist, MD

As the CDC treats the nation’s first two Ebola cases there are a lot of questions and concerns about the disease in America—Could it become an epidemic here? How contagious is it? How is it caught?

Although my medical specialty is cardiothoracic surgery, I have spent a good deal of time working on global health issues in Africa and elsewhere, and I have been in close contact with the CDC over the past week. I thought it might be useful to highlight some of the features of Ebola that make it more—and less—dangerous.

As a viral disease, Ebola follows a fairly predictable timeline.

Incubation: the time between when a person is exposed to the virus, and when symptoms start. In Ebola, that incubation period can be between 2 and about 21 days. During that time, the patient does not feel sick and research suggests that they are not contagious. (see doi:  10.1016/j.phrp.2011.04.001) There’s been concern about infected travelers spreading Ebola to other parts of the world after traveling from West Africa. That is certainly possible with a long incubation period.

Onset of Symptoms: However, once an infected person starts to feel sick, they are quickly seriously ill. There is sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, impaired kidney and liver function.

Unlike a cold, when you could be spreading the virus and not really feel that unwell, Ebola patients know that they are sick. This is actually a good thing, because sick patients are easy to identify, isolate, and treat. Other diseases still need to be ruled out—malaria, typhoid fever, cholera—but it’s clear that the patient has a severe illness.

Transmission: Here is perhaps the scariest part. How do you get it? How did Dr. Brantly get it? How is the virus spreading between people?

Some diseases are infectious, but not contagious. Lyme Disease or Rocky Mountain Spotted Fever are transmitted from ticks to humans but cannot be spread from human to human.

Contagious diseases can be spread from person to person, but not all equally well. Chicken pox, small pox, and measles, for example, are airborne spread—meaning the virus spreads very well with each exhale. These diseases are highly contagious.

Ebola, on the other hand, is only spread through direct contact with the bodily fluids of infected patients—blood, semen, sweat, urine and other secretions. And then, that fluid needs an easy entry into the body: a shared needle, an open cut, an exposed mucous membrane. It could possibly be spread through a cough or a sneeze, but that would require a fairly large drop of mucous to be coughed into another person’s face and get into their mouth or nose or eye.

For healthcare workers in West Africa, this could be possible. With limited supplies, perhaps there is a tear in a glove, or there aren’t enough goggles to go around, or bedding is reused because there isn’t an adequate way to clean it.

If patients are being cared for at home—either because they are too far away from a medical facility, or there’s some cultural distrust of foreign aid workers—caregivers in close physical contact with sick loved ones would have no medical or cleaning supplies. There are also vast cultural issues that influence the virus’ spread, and I’ll touch on those soon.

But with supplies, knowledge, and fully-equipped medical centers, these circumstances would be much less likely to happen. For these reasons, the Centers for Disease Control (CDC) is not concerned about an outbreak in the United States.

The situation is certainly serious—and will continue to be very serious in West Africa. But although we don’t know everything about how this virus behaves and changes, we do have quite a bit of useful knowledge about how to keep it contained, and how to keep our healthcare workers at home and abroad safe.

Kelsey Tipton

During the time that has passed since my last report I have been focusing my attention on the Tennessee Radon project. As I mentioned before I really have become interested in this particular project. Through my contacts I have been able to acquire short term radon tests to distribute throughout the community. Thus far I have received scores on 15 of the 20 test kits I have sent out. A safe radon rating for your home under is 4 pCi/L, so far ever test I have gotten back has scored under “1” pCi/L which is great! It has been rewarding to be able to go into the community and pass out the short term radon test not only because I can get data to record, but also because I can talk with the participants and help them to understand the major affects radon can have on their health. I feel like I am truly making a difference in some of these peoples’ lives and helping them understand what could be happening in their home is an eye opening experience for most.

Now that we are more than halfway through with the field experience semester the projects I have been working on are nearing completion. The only projects left are wrapping up of the data collected with TN radon, TV lobby, and Smokeout Day (which is Nov. 15). Looking back and seeing how far I have come since day one of my internship is really unbelievable. At the start of my internship I thought it would drag on forever and that I would get nothing accomplished. Now I can say that I was completely wrong, I have worked on numerous projects that not only helped me to complete my curriculum but also helped the community in one way or another and I feel like time has flown by and that I need more.

The date of our final presentation, when we show all that we have worked on, is approaching fast, and I can not be more excited and nervous all at the same time. I can not wait to show my fellow classmates and mentors all that has been done during my internship, but also to show them what a need there is in rural healthcare and communities.

Senator William H. Frist, MD

As I hope you’ve heard, there is an outbreak of the Ebola virus in Western Africa right now, particularly in Liberia. Two American aid workers, Dr. Kent Brantly with Samaritan’s Purse and Nancy Writebol, a volunteer working with the faith group Service in Mission, were recently infected.

I’ve been discussing the situation with the Centers for Disease Control, and I wanted to write a little bit about the transmission and natural history of the virus.

Ebola is a type of viral hemorrhagic fever (VHF). Four families of viruses cause VHFs, and Ebola is from the family Filoviredae. Dengue fever, Yellow fever, Crimean Congo fever, Hantavirus and Lassa fever are other types of VHFs you may have heard of.

Humans are not a natural vector for the Ebola virus, so outbreaks occur after a human comes in contact with an infected animal such as a monkey, pigs or especially bats. Human-to-human spread then occurs through contact with bodily fluids such as urine, secretions, blood, stool or contaminated medical equipment.

Ebola is not technically contracted by respiratory contact with an infected individual, but aresolization of secretions—for example, a coughing patient—can cause spread of the virus. Therefore, barrier precautions like gloves and gowns as well as airborne precautions like masks and goggles (to prevent absorption through the cornea of respiratory droplets) are necessary to prevent transmission. For healthcare workers, infection is almost exclusively the result of a tear or other weakness in their protective barriers.

VHF viruses are dangerous because they are highly contagious, have a high rate of infectivity with low doses of exposure and high rates of complications and death. Therefore, it is important to recognize the signs and symptoms to quickly isolate potentially infected individuals. First, the individual’s travel history is important if not already in an endemic area. Second the timing is helpful to raise suspicion. The incubation period is a few days to weeks. The illness begins with fever and muscle soreness, low blood pressure, red eyes and a rash (specifically, petechial hemorrhages).  The constellation of these symptoms with potential exposure is enough to warrant immediate quarantine.

The virus then attacks blood vessels all over the body and increases vessel permeability resulting in fluid loss and bleeding. The fluid and blood loss causes shock and disorders of the clotting system resulting in hemorrhage from mucous membranes as well as in internal organs such as the gastrointestinal tract and lungs. While there are experimental drugs under research and being used in Liberia today, the only known available treatment at this time is supportive care.  Supportive care includes fluids, blood products, blood pressure and respiratory support and possibly comfort measures.

The key to survival of Ebola is immediate and sufficient isolation of infected individuals and treatment with aggressive supportive care in an intensive care setting. Once patients have stabilized they are no longer infectious and can be taken out of quarantine. The virus is so rapidly fatal that naturally occurring outbreaks can be contained if patients are quickly isolated and effective barrier and airborne precautions implemented.

There are some experimental drugs for Ebola, but none have completed clinical trials and some have only been tested in lab animals. Many are arguing that the most advanced of these treatments be made available to the sick, even though they haven’t been fully tested yet. One such serum was administered to Ms. Writebol. Dr. Brantly has had a blood transfusion from a boy who survived the virus, in hopes that some antibodies to the virus may be transferred.

Much of the outbreak problem in West Africa can be attributed to lack of knowledge about the virus to recognize and immediately quarantine the sick, as well as the cramped facilities where the healthcare workers were operating. West Africa has never seen Ebola before, and most healthcare facilities are not properly equipped to handling the kind of quarantine needed.

The Centers for Disease Control is currently working to send in personnel and supply support to help contain the virus. Dr. Friedan, the director of the CDC, has little fear of spread to the U.S. due to quarantine posts at all points of entry. He also predicts it may take up to six months to completely contain the virus in Liberia, but he’s confident of eventual success.

Join me in praying for all of the infected individuals and the healthcare workers on the ground and abroad that are making efforts to help contain the outbreak.

Joseph Schlesinger

We arrived safely in Nairobi and stayed at the Mennonite Guest House.  The next morning we ate breakfast with missionaries from all over the world in different stages of their calling around Africa.  Kijabe’s reputation is well known and they wished as well as we were picked up and driven to Kijabe via a road that had terrible slums juxtaposed with sweeping views of the Rift Valley. 

We toured the hospital and got settled in our lodging for the month and got sign-out from the ICU as one of us was on-call the first night.  It took adjusting to drugs and equipment that were foreign to us.  All of the patients did well overnight leading into our first day in the operating rooms, or “theatres,” as they are called.

The staff comprises one MD anesthesiologist and in our case, two anesthesia residents, missionary and local surgeons, surgery residents, KRNA (the Kenyan version of a CRNA), and anesthesia students.  Patients present with late-stage disease, terrible trauma, and for obstetric emergencies without previous prenatal care.  One could take care of a neonate with a tracheoesophageal fistula followed by a patient after a road traffic accident followed by a C-section.  The steep learning curve of anesthesia is addressed with intense didactics combined with a sick and varied patient population.  The KRNAs and students do a great job.  However, there is not insignificant morbidity.

I had the pleasure to oversee a few operating rooms, help the KRNAs and students perfect there neuraxial anesthesia techniques, discuss pharmacology and physiology, and teach them approaches to regional anesthesia that they have not seen before.  The way they gather around and pay attention exhibiting their willingness to learn is refreshing.

After the first day, we brought two heavy suitcases of medical supplies to the anesthesia workroom as most of the equipment is donated.  It caused me to step back and realize the amount of equipment we use in America and how we take many things for granted at our institution.

Everyone at Kijabe has been extremely welcoming and the missionary spirit of providing excellent medical care in the midst of educating the local medical staff is encouraging for the future.  All of this paired with the beautiful land, delicious food and chai, and local wildlife seen on our weekend hikes prepare us for a busy week next week in the operating theatre.