Ebola and Root Cause Anaysis


Last month the CDC reported that worst case scenario, 1.4  million people will contract Ebola by early next year (2015.)  Somewhere around 70% of those will infected die.  (I wish to volunteer because I know about containment and proper donning and doffing of protective equipment.  I can help.)

This month the first two cases transmitted to someone on US soil happened.

The news media reports Ebola as “something we’ve never experienced,” and therefore we do not know how to deal with it.

Ebola strikes quickly, is deadly, and no immunization is available.  Still, Ebola is not a mystery disease.  There are four Ebola viruses that infect humans.  It is named after the Ebola River where it was first discovered in 1976.  Although no one knows for sure, experts suspect that people first became infected by eating contaminated meat.  Dogs do carry the disease after eating flesh infected with Ebola.)

Sadly, the way the disease strikes makes it both fatal and self-limiting.  That is, the disease spreads by direct contact with bodily fluids and once a person is sick, they are very, very sick.


Ebola is not like a cold or flu:

  • It is not spread by air or water or food;
  • People who become sick are too sick to walk around infecting others.

Using Root Cause Analysis and asking the “Five Whys” prompts addressing a problem at its source.

  • Why did the nurses in Texas become infected? (the first to be infected on American soil.)  They came in contact with infected body fluids.
  • Why did they come in contact with infected fluids?  Because their PPE (Personal Protective Gear) was either inadequate or improperly used.)
  • Why did Ebola get to Texas?  A sufferer unknowingly contracted the disease in Liberia and flew here before symptoms set in.
  • Why did he get Ebola in Liberia?  Because the healthcare system is inadequate to isolate and treat the disease.  Too many people are contracting the disease for the the system to handle.
  • Why is Liberia’s healthcare system inadequate? Civil war, lack of education, poor communication, inadequate infrastructure.

Root Cause Analysis can seem like pointing a finger or finding someone to blame.  Far from blaming nurses, identifying faulty gowning procedures helps identify how to eliminate future infections.  The biggest risk is not pile-up of infected waste, or covering more area or putting on thicker layers. The biggest risk is self-contamination when the PPE is taken off. Although reports of waste piled to the ceiling is unsettling, if it is in a contained area, it does not in itself, pose a risk.  (By the way, I doubt the angle of repose would allow waste piled to the ceiling.  I know, math geek, here.)

A military effort to combat Ebola seems somewhat counter-intuitive.  However, Root Cause Analysis provides some insight.  The military is trained to put on and take off PPE designed to protect against biological and chemical warfare.  The military can provide infrastructure, communication, and protection for volunteer health care providers.

The Ebola epidemic gets compared to AIDS because it is spread through bodily fluids (blood, semen, saliva, feces, vomit, breast milk.)  However, a person with the  AIDS virus can be without symptoms and infect others for years before having any signs himself.  This is unlikely with Ebola because symptoms come quickly, usually within 8 days, and severely:

  • headache,
  • fever,
  • diarrhea,
  • vomiting,
  • Muscle pains,
  • Severe stomach cramps,
  • Unexplained bleeding (in about 17% of sufferers)

Death occurs within a week.  Ebola is nothing like AIDS.

The method to control a disease like Ebola is more like those used to isolate historically familiar diseases:  polio, diphtheria, small pox, and even the bubonic plague.  Although the modes of transmission are different, isolating the sick and those exposed prevents the spread of diseases.  Using aseptic techniques and universal precautions protects those who care for the sick.  Techniques and precautions must be used properly.

One more why:  Why so many, so quickly?

A disease can go along for quite some time before anyone considers it a crisis.  The math looks something like this considering one person infects just one other person and 8 days to show signs of infection:

1→2→ 4→    8→16→32→→→2048 people infected in

1→8→16→24→32→40→→→     96 days

Ebola got discovered in 1976.  That’s represented by the flat part of the graph below.

Along the horizontal line is the number of people infected.

Along the vertical (y) axis is time.  In the beginning, the infection rate is so slow, it hardly gets noticed.

(The CDC is only taking medical personnel volunteers to help.  When they are ready to take trained quality assurance personnel, I am ready.)