Friday, October 24, 2014

Bowling Alone


The big news tonight is that the governators of New York and New Jersey decided to institute quarantine for everyone returning from West Africa after having contact with Ebola patients. This decision was driven by political considerations, including the costs (in time and money) expended due to the decision to do extensive contact tracing around Dr. Craig Spencer’s movements in New York City since 7 am on Tuesday, October 21.

Nothing that has happened during this tragic Ebola epidemic has called into question this simple fact: Ebola is not transmitted in the absence of symptoms. Nor is it transmitted to casual or household contacts during early infection. Consider Mr. Duncan, sent home from the hospital with fever, spending the early days of his Ebola illness with almost 20 close contacts (mostly family members), until he was finally taken back to the hospital after vomiting “wildly” in an apartment complex parking lot. Let’s count the community and family transmission events: ……..ZERO. 

Careful monitoring of symptoms and signs (fever) is sufficient for early detection of symptomatic Ebola infection and prevention of community transmission. Movement restrictions, including strict home quarantine, provide no additional benefit. The adverse consequences of misguided quarantine of caregivers are clear, however: fewer providers willing to assist in the outbreak area, and fewer providers willing to volunteer to join Ebola care teams in US hospitals, complicating preparedness efforts. If Ebola providers returning from West Africa are quarantined, how can we not also quarantine US healthcare workers who provide care for Ebola patients? How will such providers commute to work, if they depend upon public transportation? Conversely, how will we convince anyone to participate in care, if they cannot return home to family for the duration of caregiving (+ 21 days)?

Don’t take it from me, though. Listen instead to an infectious diseases doc who’s been fighting the outbreak in Sierra Leone:
Dan Kelly, 33, an infectious disease doctor and a founder of Wellbody Alliance, a nonprofit organization working in Sierra Leone, criticized the governors’ response as knee-jerk. 
“I think we are just digging the grave deeper,” he said in a telephone interview from Freetown, the capital. “Come on, that’s exactly the move to push people away from going to Sierra Leone and other affected areas. It’s going to escalate the epidemic and not help solve the crisis."
He added: “If we’re going to get in front of it, we need health care workers from abroad. They cannot feel shunned or discriminated against.”

Thursday, October 23, 2014

Morebola

The news tonight about Dr. Craig Spencer, an MSF volunteer who recently returned from caring for Ebola patients in Guinea, is sobering for several reasons. There are many details to come, but I thought I’d post a few quick initial thoughts (or reminders) about how this tragic development should, or shouldn’t, change the way we think about the Ebola virus outbreak:

This outbreak is occurring in West Africa. Not in the US. West Africa. The level of hysteria in the US is directly proportional to the number of Ebola patients on US soil, but we should never forget, even for a minute, that the outbreak continues to rage in Liberia, Sierra Leone, and Guinea (where Dr. Spencer acquired the infection). This widely cited Lancet modeling study suggests that 2-8 Ebola infected individuals will board planes monthly during their incubation period. Thus the best way to combat Ebola in the US is to mobilize resources for West Africa.

In the US, those at risk for Ebola are healthcare workers who have cared for Ebola patients (whether here or in West Africa). Not mall-goers, bowlers, subway riders, or those who might have been in an airport terminal on the same day as an asymptomatic Ebola patient. The greatest transmission risk is borne by those who provide direct care for Ebola patients during severe illness, when viral shedding is very high. 

There may be no way to reduce Ebola transmission risk to zero in healthcare settings, given the current state of Personal Protective Equipment technology. Dr. Spencer reported no breaches in the MSF protocols, which are widely recognized as the most stringent (and effective) in use. Healthcare workers have always accepted some risk in provision of healthcare, and Ebola reminds us that the risks can be grave, and that healthcare workers willing to bear these risks are heroic.

This case may make it far more difficult to assemble care teams for suspected or confirmed Ebola patients. Not just because we have yet to determine how Nina Pham, Amber Vinson, Craig Spencer, and several other caregivers were infected, but because this case could result in more stringent protocols regarding self-monitoring and movement restriction (quarantine) for those willing to care for Ebola patients. Healthcare workers who learn they may be required to restrict their movement during the entire time they care for patients (and 21 days thereafter) may be less likely to step forward. 

All eyes now will be on Bellevue. If Dr. Spencer receives all of his care at Bellevue rather than being transferred to one of our four federally-funded and designated biocontainment facilities, the hypothesis that any well-prepared hospital can safely care for an Ebola patient will again be tested.

Photo credits: Facebook; Bryan Smith

Wednesday, October 22, 2014

Paul Farmer's take on the Ebola Epidemic

Click here for an excellent commentary on the Ebola epidemic by Dr. Paul Farmer in the London Review of Books. I was particulary struck by this paragraph:
I’ve been asked more than once what the formula for effective action against Ebola might be. It’s often those reluctant to invest in a comprehensive model of prevention and care for the poor who ask for ready-made solutions. What’s the ‘model’ or the ‘minimum basic package’? What are the ‘metrics’ to evaluate ‘cost-effectiveness’? The desire for simple solutions and for proof of a high ‘return on investment’ will be encountered by anyone aiming to deliver comprehensive services (which will necessarily include both prevention and care, all too often pitted against each other) to the poor. Anyone whose metrics or proof are judged wanting is likely to receive a cool reception, even though the Ebola crisis should serve as an object lesson and rebuke to those who tolerate anaemic state funding of, or even cutbacks in, public health and healthcare delivery. Without staff, stuff, space and systems, nothing can be done.
In other words, this epidemic is driven more by the lack of medical and public health infrastructure than it is by a filovirus.

Sunday, October 19, 2014

Ebola Preparedness and the Lab


By Lab, of course, I mean my yellow lab Mindo, pictured above during this morning's walk along the Iowa River. Look carefully and you’ll note a few important things: (1) she is alert, poised, vigilant for any potential threat (including, in her case, a random squirrel or rabbit); (2) she nonetheless appears calm—she understands that loud barking, tail-chasing, and similar behaviors are wastes of energy, counterproductive, foolish; and finally, (3) she is a dog, and probably doesn’t know anything about filoviruses. 

How does this inform Ebola preparedness? We similarly must remain calm as we continue improving our preparedness, and increasingly we must differentiate between appropriate readiness and counterproductive overreactions. Most efforts currently being made in US hospitals to improve preparedness, particularly those directed toward screening and triage, are absolutely necessary and on target. The nonsense we're hearing about border closings, quarantine of asymptomatic individuals without documented exposures, closing of schools, diverting of cruise ships—it’s all the equivalent of nuisance barking and tail-chasing.

Saturday, October 18, 2014

What I learned this week

It's Saturday morning and I'm sitting at my dining room table trying to reflect on and process the events of the last week. Without a doubt, this week will go down in the annals of infection prevention as a pivotal point in time. Hospitals across the country furiously raced to prepare for Ebola, propelled by the unfortunate news of transmission of the virus to two nurses at Texas Presbyterian Hospital in Dallas. I'll share with you what I think are the lessons of this incredibly interesting week:

  1. Texas Presbyterian Hospital isn't the exception, it's the rule. It's easy to be the Monday morning quarterback and criticize the emergency medicine providers for initially missing the diagnosis of Ebola, but given that this was the first case to ever present to an emergency department in the US, it should not be surprising. In the process of diagnosis physicians are trained to use probability in their reasoning. And Ebola simply wasn't on their radar screens. It's also important to keep in mind that even today given everything we know, fever in a returning traveler from Liberia is most likely not caused by Ebola virus disease. Malaria remains a much more common diagnosis. For this reason, our Ebola plan reminds physicians to consider infectious diseases consultation in the setting of a person under investigation for Ebola, so as to avoid having a patient die of falciparum malaria while Ebola is being ruled out. In addition, there may have been, and likely were, systems issues at play. There are many distractions in the hectic environment of an emergency department that may have had impact as the physician worked through Thomas Duncan's case. Nosocomial transmission to healthcare workers would have also likely happened at almost any hospital with the exception of the four hospitals that have a biocontainment unit. While American hospitals have made great strides in reducing healthcare associated infections over the last decade, the challenges posed by Ebola virus in terms of the prevention of transmission are unparalleled.

  2. The efficacy and effectiveness of personal protective equipment (PPE) need to be considered. By efficacy we mean how well PPE works in the ideal setting to protect the healthcare worker. Effectiveness is how well it works in the real world. For most pathogens, this difference is likely quite small. Not so for Ebola. Removing PPE in the Ebola setting without contaminating yourself is a Herculean effort, and we are dealing with what Dick Wenzel calls "an unforgiving virus." Before Ebola, the implications of minor errors in doffing were trivial. Now they're life-threatening. An article in today's New York Times sums it up beautifully:

    Debra Sharpe, a Birmingham, Ala., biosafety expert, has overseen safety at a nonprofit laboratory that researches emerging diseases and bioweapons, and has run a company that trained workers to handle biological agents... “It’s totally shocking...It would take me anywhere from four to six weeks to train an employee to work in a high containment lab in a safe manner. It’s ludicrous to expect doctors and nurses to figure that out with a day’s worth of training.


    To her comments I would add that the challenging setting of an ICU with an Ebola patient having 10 liters of vomiting and diarrhea per day is nothing like the controlled environment of a specialized laboratory dealing with contained aliquots of the virus. How well PPE works in the lab approximates efficacy. How well it works in the ICU is a measure of effectiveness.

  3. The most advanced ICU in the best US hospital is not a biocontainment unit. It's absurd to think that the standards of a biocontainment unit can be met outside of that special setting. These units have special physical layouts with lab facilities, specimen dip tanks, employee showers, and autoclaves. They were created and supported with federal funding, and their providers have had ongoing training over years. So we need to realistically attempt to match the facility with the expected function: all hospitals should be proficient at rapidly identifying a potential Ebola patient, quickly isolating them and providing initial care, but once the diagnosis is confirmed, these patients should be transferred to a specialized biocontainment unit if a bed is available.

  4. We need to think about exposures differently. In infection prevention, we tend to classify exposures to infectious agents on the basis of whether the exposure was protected: Did the nurse have on an N95 mask when she treated the patient with tuberculosis? Did the young man wear a condom when he had sex last night with an HIV-infected man? Typically, unprotected exposures pose greater risk of infection than protected exposures. In Dallas, the same paradigm was applied: the unprotected healthcare workers in the ER who evaluated Mr. Duncan before he was suspected to have Ebola were thought to be at higher risk than those who cared for him in the ICU will full PPE. This turned out to be wrong. Early in the course of Ebola the infectivity is low, as demonstrated by the fact that none of Mr. Duncan's unprotected household contacts became infected. Late in disease, infectivity is very high and two nurses in gowns, gloves and face protection became infected.

  5. Equipment and supplies for state-of-the-art care are inadequate. Several of us this week tried to find a stethoscope without ear tubes so that auscultation could be performed without bringing a device close to your face. We had no success. Much has been made of the fact that the Dallas nurses used PPE that didn't cover their necks. This was even noted in an editorial in the New York Times yesterday. However, almost all (if not all) products that provide neck coverage, including bunny suits, are difficult to doff, making self contamination likely. Fortunately, our hospital has an in-house seamstress who rose to the occasion and rapidly began designing an item to cover the neck that is easy to remove. In addition, the supply chain for PPE is tenuous. Already, many items are on allocation and the national supply for some is not robust. Just-in-time manufacturing processes are not advantageous in the current situation.

  6. Investment in infection prevention infrastructure and research is necessary. The healthcare system in the US has talked a good game regarding the importance of infection prevention, but if budgets are statements of what we value, infection prevention has been a stepchild. Ebola should be our wake up call. Funding is needed to answer basic questions of infection control and to train hospital epidemiologists. Mandates for all hospitals to have infectious disease trained hospital epidemiologists should be considered. New models for compensation of infectious diseases physicians must be developed to encourage young physicians to pursue training in our field. 
It was a truly challenging week. But from an infection prevention standpoint, it was challenging in a really good way. It allowed us to collaborate with experts across the health system and think creatively with them, while providing us an opportunity to demonstrate the value we add. I am very lucky to work with an amazing group of epidemiologists and a strong leadership team at the University of Iowa. And the Society for Healthcare Epidemiology of America (SHEA) staff did an outstanding job of promoting what we do in the mainstream media.

Lastly, we must keep all of this in perspective. Every issue I have talked about in this post is a first world problem. The tragedy of what is happening in West Africa remains incomprehensible. 

Thursday, October 16, 2014

Wednesday, October 15, 2014

Ebola: N=2, Now What?

A lot of us woke up again to the horrible news that yet another health care worker in Dallas has acquired Ebola from the index patient during patient care. There are a lot of accusations flying around most of which will prove misleading or unfounded and some others might be true. We do not know. My sense of the situation is that what we learned from the first transmission still applies. We have further evidence that the standard way of wearing droplet/contact precautions during routine care of patients with pathogens like MRSA or Acinetobacter is ineffective in protecting health care workers.

Each hospital with an ICU must develop infection prevention training teams that utilize existing PPE protocols or adapt them to their local PPE supplies (e.g. their unique gowns, masks or PAPRs). These training teams must initially target experienced ICU nurses and physicians and this training must occur before any patients with Ebola can be cared for in their hospitals. You can't just practice this once. Most of us who have tried donning and doffing have failed to do it correctly the first time. We failed when there was no stress and no risk and will be much more likely to fail when focusing on the care of a sick patient. Once these trained cohorts of health care workers are established, they should be organized into buddy-teams. For example, while one trained ICU nurse provides care, another is watching his every move from donning of PPE, to caring for the patient, to doffing of PPE. The buddy must be in PPE themselves. The buddy's job is to be the second "infection control" brain for the nurse focusing on the clinical care. It is simply impossible to focus on critical care and PPE at the same time. Let's implement a system for success.

A final note today: I want to acknowledge the many many infection preventionists, hospital epidemiologists, ICU nurses, critical care physicians, emergency department staff, environmental services staff and the many unnamed others who are working tirelessly to prepare their hospitals. Most of their hard work will go unnoticed. Most of their hospitals will never care for a patient with Ebola but they are the backbone of our health care system. So, thank you!