A man felt sick, went to a hospital emergency room, didn’t tell ER personnel that he had recently arrived from Liberia, and was treated and released. He returned three days later with advanced symptoms of an infectious disease, which ultimately led to his death.
When this happened last fall in Dallas, it led to national alarm over Ebola after Thomas Eric Duncan died. But while it happened again over the past week in New Jersey, after a 55-year-old Essex County man died from Lassa fever, public-health officials emphasize that people shouldn’t be alarmed, since there are key differences between the diseases.
“Given what we know about how Lassa virus spreads to people, we think the risk to the public is extremely low,” said Dr. Tina Tan, the state epidemiologist, in a statement.
Lassa fever is much less deadly than Ebola -- while as many as 70 percent of Ebola patients can die from the disease if left untreated, only about 1 percent of Lassa fever patients die, and it’s less likely to be spread from person to person. New Jersey infectious-disease doctors say state residents shouldn’t be alarmed, since there’s never been a person-to-person transmission of Lassa fever in the United States, and that practicing good hygiene is the best defense against it and other diseases.
The man, who hasn’t been publicly identified by state or federal health officials, flew from Liberia through Morocco, arriving on May 17 at JFK International Airport in Queens. He didn’t have a fever at the Liberia airport, didn’t show symptoms during the flights, and didn’t run a high temperature when he arrived in New York, according to the U.S. Centers for Disease Control and Prevention.
On May 18, he went to a hospital in New Jersey, which hasn’t been publicly identified, with symptoms of a sore throat, fever, and tiredness. According to the hospital, he was asked that day about his travel history and he didn’t indicate travel to West Africa. He was sent home the same day and returned on May 21 when his symptoms worsened. He was taken to a treatment center, also not named by state or federal officials, which was prepared to treat viral fevers that cause hemorrhages.
Samples submitted to CDC tested positive for Lassa fever early on Sunday, while tests for Ebola and other viral hemorrhagic fevers were negative. The patient died in isolation on Sunday evening.
Lassa fever is common in West Africa but rare in the U.S., with only six cases since 1969, although there was a death from the disease in New Jersey in 2004. In West Africa, it’s generally spread by rodents and transmitted to people through contact with rodent urine or droppings, although there are rare cases of transmission through blood or bodily fluids, through mucous membrane or through sex. The virus isn’t transmitted through casual contact, and patients aren’t believed to be infectious before they have symptoms. There are roughly 5,000 deaths related to Lassa fever in West Africa annually, of 100,000 to 300,000 cases.
CDC is working with public-health officials to generate a list of people who had contact with the New Jersey patient. State officials said that “despite the unlikelihood of person-to-person transmission, the Department of Health is working with hospital officials to identify all close contacts,” including healthcare workers, family members, and anyone who may have come in contact with the patient, “out of an abundance of caution. They will be monitored for symptoms.”
CDC spokesman Benjamin Haynes said in an email that the agency is working with the hospital and the state health department “to fully understand the events of May 18 to May 24 as they unfolded.” He added that according to the hospital, the man had a fever of 103.1 degrees, which was reduced to readings of 99.9 and 101 through a fever-reducing medication and he was discharged with antibiotics.
In response to a question about the apparent similarities between the Essex County man and Duncan, Haynes wrote:
“In an age of international air travel, infectious diseases that do not make an infected person immediately too sick to travel will challenge health systems of all nations. Rapid diagnosis of an illness is best for the patient, the treating healthcare, facility and the community.”
He added that many illnesses start with early symptoms of fatigue and fever, and that medical providers often must begin to treat patients based on vague signs and symptoms and a patient history, before lab tests can rule out or confirm specific illnesses.
State Department of Health spokeswoman Donna Leusner said that the department would review the circumstances that led to the death, “in order to continue to improve our response for the future.” She added that the state is continually looking to improve, such as when it asked all hospitals to drill for a potential Ebola case last fall. Leusner noted that the state and local health officials monitored nearly 200 contacts with the Lassa fever patient in 2004, including healthcare workers and family members, without the disease being transmitted to anyone.
Dr. Tanaya Bhowmick, an assistant infectious-disease professor at Rutgers Robert Wood Johnson Medical School in New Brunswick, said medical personnel might have been unlikely to release a patient with a fever if they knew he’d recently been in Liberia.
“It’s not something that the public should be panicked about, by any means,” since Lassa fever is so difficult to transmit, Bhowmick said. She directs a program to prevent resistance to antimicrobial treatments at Robert Wood Johnson University Hospital in New Brunswick.
Bhowmick noted that there’s been a heightened awareness of severe viral diseases among hospital workers since the Ebola outbreak.
“There are still signs up (saying that) if you have a fever and you traveled recently please let your healthcare provider know,” Bhowmick said. “If he was asked and he denied it, he’s putting himself in danger in addition to the people who are taking care of him. We can’t screen for everyone coming from anywhere in the world.”
Dr. Richard Porwancher, another infectious-disease specialist, noted that there is an effective medicine to treat Lassa fever, named ribavirin. “Nothing’s a 100 percent, but it’s been used successfully,” said Porwancher, a Medical Society of New Jersey member who practices at St. Francis Medical Center in Trenton, Robert Wood Johnson University Hospital Hamilton, and University Hospital of Princeton at Plainsboro.
Porwancher said it would be premature to judge who was responsible for what happened to the Essex County man until the CDC knows more. “I would be very careful about pointing fingers quite yet until they finish,” said Porwancher, who’s also a clinical associate professor at Rutgers Robert Wood Johnson Medical School.
Dr. Elliot Frank, president of the Infectious Diseases Society of New Jersey, said it's disturbing when patients don’t identify that they have traveled to a high-risk area.
“Both sides have a responsibility here -- we as medical professionals to make sure we ask the right questions,” said Frank, chairman of the Department of Medicine at Jersey Shore University Medical Center in Neptune. “Patients have a responsibility to be honest and disclose” where they’ve been.
Patients need to understand that doctors won’t use their travel or medical history as a means to “shun them or deny them care.” Frank added that every hospital in the state could handle patients with “virtually any infectious disease,” and transfer them to another hospital if it’s appropriate.
Emergency-room doctors must always be vigilant for severe viral diseases, noted Dr. Meika Roberson, chief medical officer and emergency medicine chief at CarePoint Health’s Hoboken University Medical Center.
But she said hospital emergency departments have been even more alert after they practiced disaster-preparedness drills after the Ebola outbreak.
“Policies just don’t do quite as much as a hands-on drill,” she said.
Roberson also encouraged patients to be frank about their histories.
“Healthcare is a two-way street. The physicians and the nurses have to know what to ask,” and patients have to be forthcoming, said Roberson.
She added a word of caution that applies to both severe outbreaks and everyday good health: wash your hands frequently, cover your mouth when coughing, and use tissues.
“Do that, and that will keep everybody else healthy,” she said.