An ongoing dialogue on HIV/AIDS, infectious diseases,
October 15th, 2014
Second U.S. Healthcare Worker with Ebola Further Underscores Urgent Need for Enhanced Preparedness — and Perhaps Designated Care Centers
If you’re like most of us, when you heard that a healthcare worker in Dallas had been diagnosed with Ebola virus disease, you assumed that the exposure occurred during his first visit to the hospital.
That is, before he was diagnosed with Ebola, and before infection precautions had been instituted.
But no, it happened after he was diagnosed, and isolated, and presumably when all the care providers were using infection prevention measures of some sort. The same is true for the second Dallas healthcare worker, and the nurse in Spain, and in none of these cases can a specific breach in precautions be definitively pinpointed as the cause.
Yes, the nurse’s union in Dallas is citing major problems with their protocols, and certainly there were issues in Spain as well. But regardless of what actually happened, these cases emphatically reinforce that safe care for Ebola virus disease is a monumental challenge. Which is why all of us ID doctors are on high alert for the time when such a case occurs, and why yesterday CDC stated they would send out an expert response team to any hospital that has a confirmed case — a decision that makes tons of sense.
I confess the magnitude of this infection control challenge did not fully strike me until last week — this is before the Dallas care providers were diagnosed — when I heard a fascinating, brilliantly clear plenary talk at IDWeek from Bruce Ribner, the doctor in charge of the Emory team that cared for two Ebola patients. If you have half an hour, I cannot recommend this presentation strongly enough.
There’s a shortened text summary here on the IDWeek website, and many of his slides can be downloaded here (they were used for a national teleconference yesterday).
A remaining question — should all Ebola virus disease patients be cared for in designated centers only? The CDC is actively considering this recommendation, which needless to say has huge ramifications for our healthcare system.
Your thoughts?
7 Responses to “Second U.S. Healthcare Worker with Ebola Further Underscores Urgent Need for Enhanced Preparedness — and Perhaps Designated Care Centers”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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Public health emergencies that have to be court litigated for compliance are poorly treated as a usual infectious disease. Somebody in the State or Federal Government, needs to take control .and oversee this 50% fatal disease. We do not need another Tuskegee study on the population
If CDC implements program where all Ebola virus disease patients are cared for in designated centers only, there will be uniform best of class care with in situ control for all ancillary interface issues with community at large. There will have to be new self contained dedicated transport system. Followup services for site of origin will have to be uniformly implemented. Let’s do it right and right now.
Texas is only an “N of 1”; however, even this is one too many and we must recognize that this virus requires excessive caution rather than minimal or adequate precautions. I believe that the CDC Protocols that were distributed yesterday to all hospitals and healthcare workers send unclear and mixed messages for this particular virus in that some do not require shoe covers, lower leg/neck/head cover or double gloves. These to me, are minimal precautions for PPE. In addition, the removal of the PPE is a critical step and according to the nursing association representatives, they are not adequately trained in this regard and I can guarantee that most physicians are not either.
Containment of this virus goes well beyond the healthcare system as evidenced by the complaints and reports from the airline personnel. I personally had an exposure on a Delta flight from Amsterdam to Atlanta on Sept 30th. I was in Business class, so the surrounding passengers and environment were more visible than in coach, and the head purser went around and shook everyone’s hand thanking them for their business at the end of the flight. Nice gesture. However, there were 2 passengers behind me who were obviously sick with cough/sneezing and one actually appeared febrile and sick enough that she should not have been allowed on the plane. This is a difficult situation for the airlines to handle without the appropriate government mandated orders for refusing to board these passengers and these systems have yet to be put in place thereby leaving the airlines exposed discrimination lawsuits, etc. The CDC and all Healthcare Officials Worldwide need to urgently put systems in place the protect citizens rather than political aspirations or an individuals personal hurt feelings or travel plans.
Getting the airlines to transfer a suspected or confirmed Ebola patient is going to be very difficult. The time lost could be critical especially considering the extreme fluid and electrolyte imbalances in this disease. It is like Cholera only much more deceptive
This is idiotic so far. It’s a 70% lethal disease. Monitored? Monitored? Who had that decisive idea for the contacts of the Dallas patient? It’s death walking around! There is more likely than not, but hopefully not, one or more Typhoid Marys already out there on US & European streets. Quarrantine should be immediate & strict. Yes it’s terrrible to interrupt people’s lives forcefully, but when they are a walking time bomb that can directly and in short order kill innocent others, sorry, but there is no reasonable or sensible choice.
There has been failure at every level so far:
– not responding to the Pt.’s travel Hx statement when he came to the ER
– sending him home from the ER the first time
– not having appropriate strict contamination protection protocols in the hospital
– not confining the most obviously grossly at risk attending heatlh care personnel immediately
– not confining all known contacts immediately
– the nurse knew she had a low grade temperature when she got on the plane
– an educated professional should have known that: a) she was at very high risk, b) she should never have been in a crowd or public transport regardless
c) the low grade fever was her early warning sign
– not checking travel history on incoming passengers at all, until a major news channel reporter and her team came back from West Africa, announced where they had been and that they had been covering Ebola – e.g. in the thick of it ! – and none of them were asked anything nor screened in any way. Only one immigration staff responded at all, called after the reporter after she had gone through to say ‘wait a minute I got an email about this’, had to check something, and then simply stated a warning to be alert for Ebola symptoms!!
– not banning travel from endemic countries
Not ban travel from affected countries because the CDC then can’t track the ones who will be motivated to enter under false pretenses from 3rd countries? People would be trying to do that anyway and we’re just making it easier but letting them enter directly under false pretenses. Not track? How not track? They still need a passport to fly in from another country and that should have a stamp as to where someone came from. If they have two passports or a false identity, that is still going to happen, so do we leave the doors open because you can’t possibly patch all the leaks around the windows? How does Interpol track persons of interest?
People are going to die because of these failures. People are going to panic and kill the economy if more of these instances come to light. Yes we do have the resources to stop this where ever it is. But only when professionals at all leves do their job and respect this disease for what it is: immediately treat any one and everyone potentially exposed like they are radioactive for at least three weeks.
Entry of travellers from ebola pandemic areas must be restricted
Restriction on travel out of areas affected by the ebola virus pandemic is crucial to controlling the spread of this crisis. Past pandemics have taught us that “travel restriction is an immediate and non-pharmaceutical means of retarding incidence growth. It extends the time frame of effective mitigation, especially when the characteristics of the emerging virus are unknown.”(1)
No good reason has been given by any CDC or U.S. government official for the failure to institute travel restrictions. The often-repeated objection that travel restrictions would “exacerbate the West African epidemic by impeding the flow of aid workers and supplies” (2) is nullified by simply exempting aid workers and supplies from the restrictions.
If the recent index patient had been refused a visa to enter the U.S., then the two young women nurses who were infected while caring for him would still be healthy, a large number of other hospital workers and contacts would not have required quarantine, and the hospital would not be left with large unpaid bills for his care and disposal of the associated biohazard waste. Multiply all this suffering and expense by the number of ebola patients who would come to the U.S. if they could. The sad fact is that all of the painful and invasive procedures the first ebola patient underwent did not prolong his life significantly, nor was his death more comfortable than it could have been at home.
It is time for the CDC to recommend travel restrictions on ebola pandemic areas, and for the U.S. government to enforce them, which will be far more effective protection for our population than all of the other measures discussed.
References
1: Chong KC, Ying Zee BC. Modeling the impact of air, sea, and land travel restrictions supplemented by other interventions on the emergence of a new influenza pandemic virus. BMC Infect Dis. 2012 Nov 19;12:309. doi:10.1186/1471-2334-12-309. PubMed PMID: 23157818; PubMed Central PMCID: PMC3577649.
2: Gostin LO, Hodge JG Jr, Burris S. Is the United States Prepared for Ebola? JAMA. 2014 Oct 17. doi: 10.1001/jama.2014.15041. [Epub ahead of print] PubMed PMID: 25325877.
Hello Dr. Sax,
in Mexico we’re preparing as much as we can for the fisrt case to arrive. Hopefuly th
Until now, doctors supect Ebola based on where they come from, however I can’t help thinking about the accuracy of this. What if someone evaluates a patient from a country where no EBOV cases have been declared, but is near a country where there are EOBV cases (Ivory Coast for example) and thus, let him go home with a possible Influenza diagnosis; then the next day the first EBOV case is declared in that country… that changes the probable diagnosis on this particular patient, doesn’t it? How many patients like this are travelling to Europe and United States already?
What do you think?