Tuesday, September 30, 2014

US Ebola: Frieden Said Every Hospital Was Ready. He is Wrong.

Have you ever been face to face with a doctor dressed in rubber boots, a rubber suit, 2-3 pairs of gloves, 2 pairs of goggles and a hood?  I haven't.  Doctor journalist Richard Besser described the get-up he had to wear in an Ebola ward in Liberia.  I would faint if I had to wear all this for more than a few minutes, being unaccustomed to temperatures over 100 degrees coupled with high humidity.

If this outfit is truly necessary to care for Ebola patients, we are simply NOT prepared.  I do not believe hospitals have stockpiled rubber suits and boots, nor many pairs of goggles, as they have never been needed before for any infections transmitted within the US.

Hospitals do have isolation rooms, and a few negative pressure rooms, but not enough for dealing with a large outbreak.  

Despite the occasional disaster drill, very few of our medical staff have ever had to protect themselves from (life-threatening) hemorrhagic fever infections in their patients.  Hospital-acquired infections, due to infection control challenges such as the fact of shared doorknobs, sinks and toilets, still are common in the US. These infections affect both staff and patients. How well hospital staff will do, faced with possible Ebola cases, is unclear.

How well we will be able to separate Ebola from non-Ebola febrile patients will be a major problem.  The US could easily see healthcare facilities become places where Ebola spreads, just as is happening in Africa.  Why?  You can't isolate Ebola patients from other patients effectively, until after those with Ebola have become highly contagious, because you cannot diagnose them any earlier: the tests available today are not sensitive enough.  I cannot imagine everyone in a waiting room wearing a moon suit. For one thing, if it isn't put on and taken off perfectly, it does not help.

Where would they safely gown up? In a bathroom, where the disease is most likely to spread?  How would doctors and nurses know which patients to wear the gear for, and which not?

A significant related problem is the current inability to diagnose the infection at the local hospital level, coupled with the inability to diagnose cases until after they are highly infectious.  Only a few centers can currently perform tests for Ebola.  CDC's website has detailed information about shipping specimens to CDC for testing  But the website currently has no information on any other laboratories that can safely and accurately perform these tests at the local or regional level.  (Texas' state public health lab apparently has this capacity. Who else does?)  How long will it take to get a confirmatory test result when the CDC's lab capacity is overwhelmed?

Tests (according to CDC) are only expected to be positive after 3-10 days of clinical illness. Most people will be critically ill (or dead) by the time a confirmed laboratory diagnosis can be made. 

You have to ship the specimen carefully as it is infectious.  (See packaging instructions below.) You have to get permission from CDC before you ship any material for testing.  CDC does not accept materials for testing on weekends. From CDC:
Diagnostic Testing for Ebola Performed at CDC
Several diagnostic tests are available for detection of EVD. Acute infections will be confirmed using a real-time RT-PCR assay (CDC test directory code CDC -10309 Ebola Identification) in a CLIA-certified laboratory. Virus isolation may also be attempted. Serologic testing for IgM and IgG antibodies will be completed for certain specimens and to monitor the immune response in confirmed EVD patients (#CDC-10310 Ebola Serology).
Lassa fever is also endemic in certain areas of West Africa and may show symptoms similar to early EVD. Diagnostic tests available at CDC include but are not limited to RT-PCR, antigen detection, and IgM serology all of which may be utilized to rule out Lassa fever in EVD-negative patients.
Packaging and Shipping Clinical Specimens to CDCPackaging and Shipping Clinical Specimens DiagramPACKAGING DIAGRAM
Specimens collected for EVD testing should be packaged and shipped without attempting to open collection tubes or aliquot specimens.
The following steps should be used in submitting samples to CDC.
  • Hospitals should follow their state and/or local health department procedures for notification and consultation for Ebola testing requests and prior to contacting CDC.
  • NO specimens will be accepted without prior consultation. For consultation call the EOC at 770-488-7100.
  • Contact your state and/or local health department and CDC to determine the proper category for shipment based on clinical history and risk assessment by CDC. State guidelines may differ and state or local health departments should be consulted prior to shipping.
  • Do not ship for weekend delivery unless instructed by CDC...

UPDATE:  USAMRIID in Frederick, Maryland is one of the few facilities in the US with a specially designed clinical unit for treating patients infected with biosafety level 4 pathogens, such as Ebola. (Nebraska and CDC/Emory have two others.  Forbes says there are 5 such isolation units in the US.)  Ten years ago a researcher was stuck with a needle from Ebola-infected mice.  Dr. Mark Kortepeter describes the USAMRIID center and the circumstances of care of the affected researcher.  It is apparent that the facilities deemed necessary for such care of biodefense researchers go way beyond what is available in community hospitals in the US.

UPDATE:  The Forbes article mentions other logistical challenges of treating Ebola:
“At its peak, we were up to 40 bags a day of medical waste, which took a huge tax on our waste management system,” according to Emory’s Dr. Aneesh Mehta. But Emory’s waste management company wasn’t willing to take the infectious waste off of Emory’s hands, at first...

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