The death of Thomas Eric Duncan leaves vexing questions on whether prompt, aggressive treatment might have spared his life.
It’s also caused some doctors to suggest that his girlfriend, Louise Troh, and 47 others who came into contact with him receive preventive measures beyond monitoring to keep virus from spreading. The group is being checked twice daily until the 21-day incubation period ends Oct. 19.
“We’re all in the middle of a brand-new epidemic,” said Dr. Ashish Jha, a general internist and professor at Harvard University’s School of Public Health. “Now that the patient has unfortunately passed away, the least we can do is learn as much as possible.”
Medical experts warned health care workers to remain vigilant in detecting other cases that might emerge in Texas or the U.S.
Duncan, a Liberian visiting in Dallas, died Wednesday, just 14 days after he started running fever and 10 days after he was placed in an isolation unit at Texas Health Presbyterian of Dallas.
Emergency room workers initially failed to recognize his symptoms when he showed up for treatment Sept. 25. And it took nearly two days for his blood to be tested for the Ebola virus after he was admitted Sept. 28. Experimental treatments using antiviral medications weren’t started until four days later.
The delays could have affected his ability to fight the illness, said Dr. Joseph McCormick, regional dean of the University of Texas School of Public Health in Brownsville, who helped investigate the first recorded outbreak of Ebola in 1976.
“If you wait too long, the damage is already done,” he said.
Hospital officials have defended their handling of the case, saying Duncan received top-notch care in keeping with Centers for Disease Control and Prevention guidelines.
Local health officials also have defended their staffers, saying they followed protocols set up in the extensive preparation for a possible outbreak in Texas.
“There was no misstep by Dallas County Health and Human Services staff,” director Zachary Thompson said this week. “And I will defend that.”
The message seem to have gotten through in Frisco, where health care workers at an urgent care clinic promptly notified authorities Wednesday when a man showed up with stomach pains and said he’d been exposed to Duncan. He is now in an isolation room at Presbyterian.
Duncan’s death brings other worries, including how to safely handle his remains.
His burial must follow guidelines set by the CDC, which warns that Ebola can live on for some time in human remains. The hands-on burial practices in West Africa have contributed to the spread of the disease.
After careful preparation, Duncan’s body will be cremated, say state health officials. CDC guidelines allow remains infected with Ebola to be cremated or “buried promptly in a hermetically sealed casket.” His family agreed to cremation.
The intense heat of the cremation process kills any virus in the body, and his ashes will be returned to the family, state officials said. No protective gear is needed to handle the remains after cremation.
The CDC guidelines discourage an autopsy and prohibit embalming, and call for personal protective equipment to be worn during the preparation of the body.
Proper handling of medical waste left behind in the northeast Dallas apartment where Duncan stayed has posed problems for local officials. They eventually hired a private company to handle the cleanup. The people in the apartment unit where he stayed have since been moved to an undisclosed location, and all materials have been removed and are to be destroyed.
On Thursday, the same company that sanitized the apartment left Presbyterian Hospital after cleaning rooms there. It's unclear whether they were cleaning the isolation unit where Duncan died or the room where the Frisco patient is being treated.
Medical experts, meanwhile, should study Duncan’s case closely to understand the decisions made in his treatment, Jha said.
“We’ve got to learn how to be better the next time we have a patient,” he said. “I hope there are no more cases, but I think the chances we will have another one remain high.”
Jha said hospital officials should be open in sharing details of the case, particularly the use of antiviral medications and the apparent decision not to use transfusions of blood with Ebola antibodies. It is not known what role the family members may have played in making those decisions.
“Why the hospital decided to wait as long as it did on the antiviral or why they chose not to try the antibodies … it would be very helpful for them to articulate … those reasons.”
Antiviral medications and blood transfusions are experimental at best, but have been used on other Ebola patients who survived. There are no specific treatments known to kill the Ebola virus, which has been fatal in 60 percent of the cases worldwide in the current outbreak, which is centered in West Africa.
Duncan received brincidofovir, an antiviral medication that was being developed for smallpox. It has shown promise against Ebola in test tube experiments but has not been used in humans. At most, Duncan received two doses before he died.
An experimental medication, ZMapp, was used to treat the first two U.S. patients, but the supply has been exhausted. It could be months before additional supplies are available.
McCormick said the antiviral medication and the blood transfusions should be considered for those who came in contact with Duncan, if sufficient blood supplies are available.
“Next is just simple surveillance of the family members and close contacts, and getting them under treatment,” he said. “Certainly, they should have some antibodies around if they do become ill.”
Doctors familiar with how Ebola spreads also urged Dallas officials to look closer at the people who were exposed to Duncan but show no signs of the disease.
“We knew from previous outbreaks in Africa that some people carry the virus without developing symptoms or spreading it to others,” said Dr. Aileen M. Marty, a professor of infectious diseases at Florida International University. She recently spent a month in Nigeria helping to combat the Ebola outbreak there.
Health care workers across the state and nation remain on heightened alert for new cases in hopes of getting better results. The local monitoring will continue for at least 10 more days, until the initial incubation period ends. Any new cases that develop would start the clock again.
“We’ve always wondered, if you get into really good, high-quality care, does that reduce your risk of death from Ebola?” said McCormick. “Well, maybe not so much.”
dhunt@dallasnews.com;
sjacobson@dallasnews.com
WHAT WENT WRONG
Questions have been raised about possible missteps in the handling of Thomas Eric Duncan, the first person to die in the U.S. from Ebola. Among the concerns:
Slow detection
Duncan was initially sent home from a hospital emergency room even though critics say his symptoms and recent arrival from Liberia should have flagged him as a possible Ebola case. By the time he was admitted to a hospital isolation unit, additional people had come in contact with him.
Delay in blood testing
His blood was not sent to be tested for the Ebola virus for nearly two days after he was placed in the isolation unit. This may have delayed containment of people who had contact with him.
Slow containment and cleanup
Health officials left some of Duncan’s close contacts in the apartment where soiled linens and towels remained.
Failure to avoid contact with emergency workers
Ambulance workers and sheriff’s deputies are among those being monitored after coming into contact with Duncan. One of those deputies is now in isolation at a hospital after coming down with stomach pain Wednesday.
Lag in providing antiviral medications
Duncan did not receive antiviral medications until four days after the Ebola diagnosis was confirmed. The experimental treatment is believed to help curb the virus’ growth in the body if it is given early in treatment.
