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!

Tuesday, October 14, 2014

Ebola: The questions keep coming

The progression of the Ebola epidemic, particularly the recent episodes of transmission to healthcare workers who wore appropriate personal protective equipment, raises interesting questions. Certainly we need to continue to work on learning everything we can about the best approach to personal protective equipment and minimzing the risk of transmission during the process of care. But it’s also time to rethink some of the rituals surrounding care that have persisted in hospitals for decades.

Academic medical centers by their very nature increase the number of interactions with patients. Trainees at all levels need to interview and examine patients, and participate in their care to acquire necessary skills. While the benefits to the trainee are obvious, in some cases the patients benefit as well, via the therapeutic effects of another empathetic ear or the uncovering of a critical clue by the careful history of a novice interviewer. However, with a disease like Ebola, which can be transmitted in the healthcare setting, has no post-exposure prophylaxis, no effective treatment, and a high mortality rate, a strict approach to limiting the number of individuals in the physical proximity of the infected patient is appropriate as recommended by CDC.

Limiting contact typically means that in addition to students, other trainees such as residents and fellows also do not enter the room. But perhaps this needs to be taken a step further. Perhaps there should be one “examining” physician whose documented exam is used by consultants in their evaluations so as to limit room entry. In many cases, an additional exam probably doesn’t add much value, and is often performed because it's expected or to maximize billing. Even before Ebola, as hospital epidemiologists we’ve asked ourselves the simple question: does every person on the care team need to examine every patient every day? Every encounter adds some level of risk for transmitting pathogens in the healthcare setting, but with Ebola the implications of transmission are taken to a whole new level. Fortunately, given technologies such as Skype, the ability to interview patients should not be impacted. 

Ebola also pushes us to reconsider therapies that have a reasonably high probability of futility but increase risk to healthcare workers. In the case of the Dallas patient, who underwent endotracheal intubation and hemodialysis, we are left to question whether these procedures played some role in infection of the critical care nurse. Should CPR, which would seem to involve a very high degree of risk to bedside providers, not be performed? The ethical issues associated with withholding these procedures typically associated with "routine" critical care need to be explored since the risk-benefit calculus is markedly shifted by the level of risk to healthcare workers.

Lastly, should healthcare workers be compelled to work with Ebola infected patients? Do they have the right to opt out? Should those who volunteer receive hazard duty pay? Should there be a compensation fund for families in the event a healthcare worker contracts Ebola disease occupationally and dies? How do we handle the issue of pregnant healthcare workers? In the long run, how do we design the hospital of the future to maximize safety of the patient and provider?

These initial questions demonstrate that the Ebola crisis is challenging us in many ways and will likely continue to do so for quite some time. But perhaps we’ll emerge from this with a more thoughtful approach to patient care that improves safety without sacrificing quality.

Ebola: Bloggers in the News

UPDATED October 19

Last night, Dan, Mike and I sat around a table and drafted an op-ed at the suggestion of several colleagues. We would eventually like to include it here, but that will have to wait pending editorial reviews and rejections. Media requests have been frequent and we are doing our best to speak with as many reporters as we can. Dan has been very busy with SHEA duties, as he is currently the Society President. SHEA has just released a statement on infection prevention funding needs where Dan is quoted. He spoke (audio below) this morning on NPR-KPCC in Southern California and also appeared on NBC Nightly News. He also was quoted in USA Today.

Mike spoke to Iowa Public radio about what we've learned from the transmission of Ebola to healthcare workers in Iowa and what we can do to prepare. He also appeared on MSNBC.

I've done several interviews, including one with Bloomberg News yesterday (I didn't write the headline) and a few more that are scheduled to appear. I've also posted an MP3 below of an interview I did with CBS radio out in LA (KNX 1070) yesterday. I tried to emphasize the importance of PPE protocols, particularly doffing and the need for a buddy to monitor every step. Buddy is my new favorite word.

Perencevich Interview on CBS KNX - LA

Diekema Interview of NPR KPCC - So Cal

Sunday, October 12, 2014

Ebola: What can we learn from an N of 1?

Most of us woke up to the very unsettling news that a health care worker had acquired Ebola during the care of the index patient in Dallas. Those following the blog know that we've been worried about just this type of event since July, when Mike provided an Ebola primer. Specifically, we've been worried about the complexity of the PPE required and how this could paradoxically increase risks to health care workers. We've also highlighted the massive WHO budget cutsCDC cuts and Prevention and Public Health Fund cuts since at least 2012.

In addition to the national cuts, individual hospitals have seen reduced support for infection control programs just as more and more is being asked of them. It used to be that hospital epidemiologists and infection preventionists could do surveillance rounds on the wards and educate from-line staff. Now, many hospitals have barely enough staff to complete their surveillance and public reporting duties leaving many trapped at their desks analyzing data. There is zero excess capacity to educate clinical staff on basic infection prevention practices like contact precautions. At many hospitals there is no capacity to add additional training in Ebola PPE protocols. As Marc-Oliver Wright said to me once: "You can't fight and prepare for the maybe (insert scary virus) when the required was due yesterday." Yet many hospitals are managing by shifting staff away from MRSA, away from CLABSI and away from influenza, which leaves our patients vulnerable to these more likely threats. If this were the military, there would be claims about fighting with one hand behind our back. That's the case here - we are fighting a war against Ebola and we've got an un-gloved hand behind our back.

So what are the lesson's from Dallas?

First, PPE is not 100% effective with current technology and training protocols. If health care workers auto-contaminate their hands when removing gloves 11% of the time when they caring for VRE colonized patients and 4.5% of the time when caring for patients with Acinetobacter, there is little room for error in PPE removal and hand hygiene when caring for patients infected with Ebola, particularly near the end of their disease course.

Second, the focus of Ebola preparedness in the US has to be 100% directed towards hospitals, initially the ICU settings. It's a simple fact that patients aren't infectious until after they develop symptoms and they are highly infectious once they are in shock in the ICU. Each and every hospital must walk through PPE donning and doffing and plans for Ebola patient care. They must train a cohort of doctors, nurses and environmental services staff now. Practice, Practice, Practice. Once the ICU staff are trained, the net should be widened to include the emergency department and other clinical settings. Work backwards from the highest risk settings where patients are most infectious (e.g. ICU) to the least.

Third, we need to demand funding for infection control in our hospitals. Double the number of infection preventionists and make sure each hospital has an Infectious Disease trained physician responsible for ensuring that all infection prevention protocols are followed. If we aren't even prepared for Ebola, how will we ever be prepared for a far more infectious avian influenza or MERS?

Fourth and finally, we must increase national funding for infection prevention. We must develop new PPE technologies and new methods to improve compliance and education. Right now we are using ancient technology - gloves, gowns, masks. We must also fund local and regional public health departments, as well as CDC, WHO and the PHEP, whose funding has been cut if half since 2006 (see below). We might get lucky with Ebola in the US (sadly it continues to get worse in Africa), but I doubt we'll be so lucky with the next virus.

***And for reading beyond the events of today, I suggest reading Judy Stone's excellent post on the problems with politics and public health mixing. She's covered many of the same topics that I've mentioned but with a broader scope.