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Déjà vu all over again...

The phrase "It's like déjà vu all over again." Is attributed to the great Yogi Berra who never seemed at a lack for one-liners. It is a fitting title for this blog as I think back to the 2014-2016 Ebola outbreak.

During that outbreak, 11 people with Ebola were treated in the United States, nine of whom had contracted it in western Africa, most as health care workers. Two died – a Liberian visiting the United States and a doctor who had treated Ebola patients in Sierra Leone. Two American nurses contracted the disease while treating the Liberian patient, but both recovered.

We all remember the news coverage as we watched the Thomas Duncan tragedy unfold. Thomas Eric Duncan was a Liberian citizen who became the first Ebola patient diagnosed in the United States on September 30, 2014 while visiting family in Dallas.

There have been many Ebola outbreaks since the first known outbreak in 1976, all in sub-Saharan (west, east and central) Africa. By far the deadliest outbreak occurred in 2014-2016 when more than 11,000 people died (most in west African Guinea, Liberia and Sierra Leone). More than 2,000 people died during the second largest outbreak to date, from 2018 to 2020, in the Democratic Republic of Congo.

Currently Ebola is not considered a threat outside of certain countries in sub-Saharan Africa. Very few people with Ebola have been outside of that area. The 2014 -2016 outbreak left us with a lot of lessons-learned and led to an increased awareness of the disease and its symptoms. Protocols, resources and training for health care providers and health care facilities have been developed, as part of the National Emerging Special Pathogens Training and Education Center, to support safe care for patients in the U.S. and to help prevent the spread of Ebola.

Of course, COVID-19 woke us up for a bit as well, enhancing some of the awareness and increased protocols but has it been enough or are we still being reactive instead of proactive?

I recollect quite clearly when the Ebola outbreak began that while hospitals were receiving information almost daily regarding best practices, very little trickled down to the world of EMS and its personnel who were suddenly on the frontline of something emerging and strange. As COVID began its reign in America, the same was observed; information slowly trickled down to frontline workers but it was also watered down by the time it reached them.

As I write this, the US Centers for Disease Control and Prevention (CDC) is sending personnel to Africa to help stop outbreaks of Marburg virus disease and is urging travelers to certain countries to take precautions. The CDC is also taking steps to keep infections from spreading to the United States.

Equatorial Guinea and Tanzania are facing their first known outbreaks of Marburg virus, a viral fever with uncontrolled bleeding that's a close cousin to Ebola. This week, the CDC urged travelers to both countries to avoid contact with sick people and to watch for symptoms for three weeks after leaving the area. Please note: this is the same steps the CDC took at the beginning of the Ebola outbreak as they assured us that Ebola would not reach the United States!

In the United States, the agency will post notices in international airports where most travelers arrive, warning them to watch for symptoms of the virus for 21 days and to seek care immediately if they become ill. They will also get a text reminder to watch for symptoms.

Is this for real? Again?

There is no mention or obvious intent of the CDC (or anyone else for that matter) creating materials and trainings for EMS at a local level despite the fact that these will be the folks that pick up the first Marburg case in America.

According to news releases, the CDC is “standing up” a “center-led” emergency response but this will not be as “all-encompassing” as when they set up their Emergency Operation Center like they did for COVID.

So if we can, let’s see the scenario clearly.

One single person travels the to the United States. Perhaps they even read the poster at the airport when they land (although I doubt it). They continue to the home of relatives. Let’s assume it is a couple with two children.

Three weeks later, our visitor starts to show symptoms which include fever, chills, muscle pain, rash, sore throat, diarrhea, weakness. It is definitely the flu, right? An ambulance is called manned by two young EMT’s wearing masks (Perhaps. COVID is over, remember?) and gloves.

At the hospital, our flu patient is attended to by two nurses and a Doctor.

The next day, our host family starts to show symptoms which they ignore because it is the flu. After another day or two, the symptoms get worse, but it is too late. Dad has been going to work at the office where there are 42 employees, 68% of whom are married with children. Mom has been to the grocery store twice since their visitor arrived, interacting and being surrounded by a minimum of 100 people each time. She also works part-time at a Florist shop downtown with 5 other employees and an average of 60 customers per day.

The children, ages 6 and 12 go to two different schools. One has 200 students and one school has 312 students.

Wanna do the math?

Wanna be an EMT?

Not me.

If the exposure stops at the families of the children in the schools and the immediate families of those at the office, emergency room and the Florist shop, we have an exposure of over 2800 people. If we assume only 15% call an ambulance and the rest take themselves to the doctor’s office, we have 420 ambulance transports being performed by EMT’s that have not been given any information regarding Marburg, its symptoms or best practices if it is suspected.

Equatorial Guinea, on the coast in West Africa, declared an outbreak of Marburg virus disease in mid-February with cases spread across multiple provinces. As of March 22, Equatorial Guinea had 13 confirmed cases, including nine people who have died and one who has recovered. Nine CDC staffers are on the ground there. They have established a field laboratory and are assisting with testing, case identification and contact tracing.

Tanzania, on the coast in East Africa, declared an outbreak of Marburg virus disease on March 21, with cases reported in two villages in the Kagera region. As of March 22, Tanzania has had eight confirmed cases, including five deaths. The CDC has a permanent office in Tanzania that is assisting with the outbreak. It is sending additional staff to support those efforts.

Marburg virus is a rare and deadly virus that causes (as I said) fever, chills, muscle pain, rash, sore throat, diarrhea, weakness or unexplained bleeding or bruising. It is spread through contact with body fluids and contaminated surfaces. People can also catch it from infected animals. It is fatal in about half of cases who get it.

In its early stages, the infection is difficult to distinguish from other illnesses, so a history of travel to either of those countries will be essential to helping clinicians spot it.

Marburg virus is the causative agent of Marburg virus disease (MVD), a disease with a case fatality ratio of up to 88%, but can be much lower with good patient care.

So why am I up in arms about this? We are not good at learning from the past, especially our OWN past. Another reason is because I love the EMT’s in our country and I have grown weary of them being treated like the red-headed stepchildren of the response world and being given information based on reactionary measures and being kept in some weird universe of “need-to-know”. At this point, if we are sending CDC personnel to other countries, then the CDC should already have sent out materials and made even short online trainings available to EMT’s at the local level. There seems to be something about the word “FRONTLINE” that the CDC still is not understanding. America’s EMT’s are not expendable bomb robots we just send in to retrieve patients.

Marburg and Ebola viruses are both members of the Filoviridae family (filovirus). Though caused by different viruses, the two diseases are clinically similar. Both diseases are rare and have the capacity to cause outbreaks with extremely high fatality rates.

Two large outbreaks that occurred simultaneously in Marburg and Frankfurt in Germany, and in Belgrade, Serbia, in 1967, led to the initial recognition of the disease. The outbreak was associated with laboratory work using African green monkeys (Cercopithecus aethiops) imported from Uganda. Subsequently, outbreaks and sporadic cases have been reported in Angola, the Democratic Republic of the Congo, Kenya, South Africa (in a person with recent travel history to Zimbabwe) and Uganda.

Now, somebody out there is going to send me a letter telling me that we should not be worried and that I am trying to cause a panic. Both not true. I am blogging fact here. We should recall statements made by professionals like Dr. Alexander van Tulleken of Fordham University who was given a lot of air time in 2014 stating “This is not an epidemic; it’s not the kind of disease that can sweep through New York City”.

Really? I just told you about that first outbreak in Frankfort Germany, home to 753,000 residents. The truth is, despite warnings and the CDC sending people overseas at the beginning of COVID, we failed miserably despite considerable advantages. Immense resources, biomedical geniuses and boundless expertise.

Do we need a thousand cases? Nope. We need one. Marburg spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids. And this is all information EMT’s deserve to have.

Historically, health-care workers have frequently been infected while treating patients with suspected or confirmed MVD. This has occurred through close contact with patients when infection control precautions are not strictly practiced. Thank God it looks like the flu on early onset, right?

So, if you are an EMT or know one, let’s bypass the CDC for a moment as they are busy elsewhere. The incubation period for Marburg (interval from infection to onset of symptoms) varies from 2 to 21 days.

Illness caused by Marburg virus begins abruptly, with high fever, severe headache and severe malaise. Muscle aches and pains are a common feature. Severe watery diarrhea, abdominal pain and cramping, nausea and vomiting can begin on the third day. Diarrhea can persist for a week. The appearance of patients at this phase has been described as showing “ghost-like” drawn features, deep-set eyes, expressionless faces, and extreme lethargy.

By the way, three members of my family have had these symptoms in the last month and it was indeed the flu.

In the 1967 European outbreak, non-itchy rash was a feature noted in most patients between 2 and 7 days after onset of symptoms.

Many patients develop severe hemorrhagic manifestations between 5 and 7 days, and fatal cases usually have some form of bleeding, often from multiple areas. Fresh blood in vomit and feces is often accompanied by bleeding from the nose, gums, and vagina. During the severe phase of illness, patients have sustained high fevers. Involvement of the central nervous system can result in confusion, irritability, and aggression. Orchitis (inflammation of one or both testicles) has been reported occasionally in the late phase of disease (15 days).

In fatal cases, death occurs most often between 8 and 9 days after symptom onset, usually preceded by severe blood loss and shock.

Hopefully this is helpful. Do I think we should panic? No, but I think we should be a lot smarter than we are since the 2014-2016 Ebola outbreak and our recent experience with COVID. I personally won’t be going to Africa anytime soon, but that does not mean someone else is going tomorrow and returning next week.

C’mon people. I can Google how to change the starter in my car and how to prevent my hot water from burning out. We can’t provide some better information for our frontline workers?

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