By Richard Knox
Ebola in Boston? It’s not as far-fetched as you might think.
If the disease does pop up here, it will be a big deal — but probably not as nightmarish as you might imagine.
First of all, virtually no public health or infectious disease specialists think an imported case of Ebola could touch off an outbreak.
That's because the virus is not spread through the air (except perhaps by certain medical procedures which generate sprays of virus-containing droplets). People can catch it only if they’re exposed to bodily fluids of obviously sick Ebola victims.
No airport screening program could detect such silent infections.
Moreover, U.S. medical personnel have the training and equipment to prevent its spread, and public health experts know how to identify and isolate contagious patients and track down close contacts who might have been exposed.
Still, against the increasingly dire backdrop of West Africa’s epidemic, Boston’s 20 hospitals, two dozen community health centers, public health officials and others have been preparing since August for the possibility that Ebola could appear here.
“My husband calls it the Ebolacoaster,” says Dr. Sharon Wright, director of infection control at the Beth Israel Deaconess Medical Center, speaking of the intense back-to-back “what-if” planning sessions.
The risk of an imported case of Ebola, Wright says in an interview, “is probably more than I would have thought a few weeks ago.”
A Silent Infection
Boston's not alone. Health centers across the country are sorting out Ebola preparedness plans at a feverish pace. “Ebola doesn’t pose a health risk to the U.S. public, but we’re taking precautions at home,” Dr.Thomas Frieden, director of the Centers for Disease Control and Prevention, told reporters on a conference call Tuesday.
One complication specific to the Ebola virus is that it can take up to three weeks after someone is infected before symptoms appear.
“So, it’s entirely plausible that someone gets on a plane in West Africa and arrives here from other points of entry from the U.S. or abroad,” says Dr. Larry Madoff, director of epidemiology and immunization at the Massachusetts Department of Public Health. “They can be perfectly healthy while they’re traveling and come down with the disease once here.”
No airport screening program could detect such silent infections.
Earlier this month one research team put the risk of an imported Ebola case in North America at somewhere between 1 and 18 percent by the end of September, based on analysis of air traffic from West Africa to the rest of the world.
The risk has undoubtedly declined since then as commercial flights to and from Ebola-affected countries have been curtailed by an estimated 70 percent.
“That just delays the international spread,” says Alessandro Vespignani of Northeastern University, a co-author of the analysis. “It might not happen in September or October. But perhaps in November. We have to expect the importation of cases as the number of cases in West Africa grows quickly.”
And those numbers are soaring exponentially. A CDC analysis published Tuesday predicts as many as 1.4 million cases of Ebola in Liberia and Sierra Leone by Jan. 20, 2015, if a crash campaign to control the epidemic doesn’t get at least 70 percent of victims into effective treatment in the next month or two. Currently only about 18 percent of Liberian victims are believed to be getting care that minimizes the chance of spread, and about 40 percent of Sierra Leone victims.
Boston’s role in the medical relief campaign could expose this area to a higher risk of Ebola importation. Medical volunteers, such as those organized by Boston-based Partners in Health, are traveling to and from affected countries at an increasing rate.
“As we see more people go over, the possibility that people coming back might develop Ebola gets higher,” Wright says.
“It is still a low-likelihood event. If the recommended precautions are followed, there should not be any exposures and therefore no illnesses in health care workers,” Wright says. “However, the personal protective equipment is hot and uncomfortable, and sometimes hard to remove, so there is the chance that people may make mistakes.”
A Focus On Health Workers and College Kids
Dr. Anita Barry of the Boston Public Health Commission says medical volunteers may get exposed to the virus without realizing it. “If we see Ebola, I think it’s going to be most likely in health care workers who have gone to volunteer over there,” she says in an interview. “That’s one group we have to pay attention to.”
At least health care workers “know how to monitor their symptoms,” Northeastern’s Vespignani notes, and would most likely quarantine themselves if signs of Ebola infection appeared.
But Ebola might appear in Boston through other routes. Local colleges and universities have students and faculty with connections to West Africa. And the area has communities of West African immigrants. If someone from these groups inadvertently brought the virus here, the infection might be wrongly perceived as a simple cold or flu.
So community health centers and university clinics are being warned to look out for anyone with a history of travel to West Africa and symptoms such as high fever, severe headache, muscle pain, weakness, diarrhea, vomiting, abdominal pain and unexplained bleeding or bruising.
Boston EMTs are undergoing training to transport any suspected Ebola patient without getting exposed themselves. And if someone balks at being taken to the hospital, Barry of the Public Health Commission says, “I can give them authorization” to transport involuntarily.
Boston hospitals are also making plans in the event they have to care for patients with Ebola.
“We would close part of a wing — four or five beds,” says Beth Israel's Sharon Wright. “You’re setting up a mini-containment area. There’s a lot of stuff that has to come to the area – gowns, personal protective equipment, and a lot of trash generated when all that comes off."
Another reason to isolate such patients, Wright says: "I can only imagine the concern from other patients and family members if they found out they were on a floor with a possible Ebola patient."
It could take three to five days to determine if a suspected case is indeed Ebola, she says. Massachusetts doesn’t have a laboratory where the virus can be diagnosed, so blood and tissue samples would have to be sent to labs in either Albany or Atlanta.
Meanwhile, elaborate precautions would be needed to ensure that neither personnel nor equipment got contaminated. Ebola is considered a BL-4 pathogen – a virus that should only be handled in a laboratory rated as Biosafety Level 4, the maximum containment level. No hospital in the area runs that type of lab.
“There’s a lot of concern about how to handle a BL-4 pathogen in a hospital lab that’s typically a BL-2,” Madoff says. "Hospitals are considering setting up mini-labs near the suspected Ebola patient’s room so samples could be processed by specially trained technicians under protective hoods."
And all these precautions would be conspicuous, to say the least, and likely trigger a panic.
“Our general stance is if there’s no public threat, we don’t see a reason to disclose” a suspected case, Barry says. But she acknowledges that this news would probably leak. “And then you’ve got yourself in a heck of a mess, because people would think you’re not being truthful.”