Dialing it up to eleven

While I was away on vacation, I did my best to keep up with the advancing Ebola outbreak in Africa (see Mike’s excellent summary post). I also joined a couple conference calls about the interim infection prevention guidance from CDC. I believe this guidance to be reasonable and consistent with the mode of transmission of Ebola, combining Standard, Contact and Droplet precautions with an emphasis on eye and face protection and use of additional barriers and precautions as required by the clinical situation (e.g. copious body fluids in the environment, aerosol generating procedures, etc.). I was also gratified to see some common sense interim laboratory guidance from CDC, guidance that included reassurance that

“When used according to the manufacturer’s instructions, EPA-registered disinfectants routinely used to decontaminate the laboratory environment (benchtops and surfaces) and the laboratory instrumentation are sufficient to inactivate enveloped viruses, such as influenza, hepatitis C, and Ebola viruses."

There’s only one tiny problem: nobody seems to be listening to this guidance. Like Nigel Tufnel, we’re dialing our responses up to eleven. The early returns from our infection prevention listserve favor airborne isolation, N95 masks, full Tyvek suits, anterooms for decontamination hose-down, etc. Similar returns from the clinical microbiology side included labs that didn’t plan to submit any testing to their main lab until they got Ebola testing results back, or requiring elaborate specimen decontamination protocols prior to any standard lab testing (some of which invalidate such test results). 

This reaction is predictable and understandable, given media coverage and the early approaches taken at Emory:

“Those working at Emory also can take comfort in that they have a unique place -- one of only four such facilities in the United States, according to Ribner -- to treat such a contagious disease…The isolation unit was created 12 years ago in conjunction with experts from the U.S. Centers for Disease Control and Prevention, which is based down the street. It features "special air handling," strict protocols on everything and everyone who goes in and out of a patient's room, and other measures to ensure that any potential dangers are contained.”

Combine this with the only images most Americans, including healthcare workers, associate with Ebola, and you can see how it becomes extremely difficult to recommend anything but the most stringent possible precautions.

The problem is that such precautions are wasteful of time and resources (invest in Tyvek, now!), and can interfere with patient care. As one example, most patients returning from the outbreak area with febrile illness (those meeting the Person Under Investigation (PUI) definition) will not have Ebola, but they may be very sick. If an overly stringent lab protocol prohibits or delays laboratory testing, substandard medical care may lead to adverse outcomes. Another concern—introducing healthcare personnel to new and unfamiliar forms of personal protective equipment without time for adequate training may inadvertently increase the risk for transmission. Do you know how to safely remove a full-body zippered Tyvek coverall without contaminating yourself? I don’t.

I wish I knew how to dial it down, maybe to 8 or 9, but I fear that the window for clear and consistent messaging may have passed. If only we could magically package all of the resources and person-power currently being applied by US hospitals in preparedness efforts and transfer them to West Africa, we’d be a long way toward containing this tragic outbreak.