“These go to eleven”, Laboratory Edition

We’ve covered some of the controversial issues around Ebola planning in US hospitals (recognizing that planning meetings in places where Ebola isn’t seem trivial compared with the disaster unfolding where Ebola is). A couple more opinion pieces have come out in the past week, one from The Lancet and one from Annals of Internal Medicine. Despite ongoing disagreements regarding transmissibility, I think most US hospitals will take a similar approach: to ensure that patients don't have to be moved for procedures, and to ensure there is an anteroom for PPE removal, hospitals will identify airborne isolation rooms as their Ebola isolation rooms, and ample PPE will be provided. The major difference will be that some hospitals will routinely use N95s or PAPRs and others will use them only for aerosol-generating procedures. In my view, the most important thing is education, and more education, with 24/7 monitoring of PPE use (including careful doffing procedure).

On the laboratory front, though, I sense a lot more disagreement, and the trend is toward extreme caution. As I’ve pointed out before, the overwhelming majority of those with febrile illness upon return from the outbreak areas will not have Ebola—but they may well have something requiring urgent attention and appropriate therapy (malaria, typhoid, meningococcemia). Prompt laboratory testing will be essential, and potentially life-saving. The CDC guidance provides adequate protection for specimen collection, transport, and handling, while recognizing that “U.S. clinical laboratories can safely handle specimens from these potential Ebola patients by taking all required precautions and practices in the laboratory, specifically designed for pathogens spread in the blood”. A partial list of viral pathogens that may be found in high concentrations in blood we test every day in our labs includes HIV, CMV, EBV, HCV, HBV, parvovirus, HSV and VZV.

However, many hospitals plan not to let any samples from suspected Ebola patients cross the threshold of their laboratories. In addition to doing “minimal testing”, these hospitals plan to purchase point-of-care (POC) instruments so that they can do all testing in (or near) the patient room. This expensive approach could paradoxically increase risk both to the patient (limited test options, quality control, accuracy) and to personnel (requiring training on new instruments with which they may be unfamiliar).

The “point-of-care (POC) plan” is likely to gain even more traction after this report from Emory regarding their approach to testing of their two Ebola patients: 

“…our strategy was to establish a self-contained POC laboratory that could support all requisite testing within the quarantine facility itself and to develop a team of volunteer clinical pathologists and laboratory technical staff with expertise in POC testing who could perform all assays on site.”

This approach, unattainable for most US hospitals, is awkwardly at odds with the CDC’s guidance. The authors recognize this, going on to say:

“Our approach exceeded the requirements of the CDC for safe management of patients infected with Ebola. This description is not intended as a recommendation or endorsement of any specific instruments, tests, or procedures.”

So why did the Emory team decide to take this more conservative approach to lab testing? To their credit, the authors also address this issue head-on:

"The degree of containment afforded by this facility substantially exceeds CDC guidelines for managing Ebola, a nonairborne pathogen that is transmitted principally via bodily fluids or direct contact and is readily inactivated by conventional disinfectants. The risk and routes of contagion with Ebola are judged to be comparable to.….pathogens that are handled safely and routinely in conventionally equipped hospitals and clinical laboratories using universal, contact, and droplet precautions. Given the availability of this specialized quarantine facility at our institution, however, it was deemed appropriate to use it in caring for these patients in order to afford maximal safety and reassurance to our hospital staff and patients, to avoid disrupting other hospital operations, and to respect the heightened public and media attention prevailing at the time, as these were the first cases of Ebola infection to be treated in North America"

To paraphrase: (1) we have an awesome quarantine facility so we’re damn well going to use it, and (2) everybody is freaking out, so we need to respect that.

My paraphrase sounds snarky, but I'd argue that their response was completely understandable and I can’t say I wouldn’t have done the same if I were in their shoes (or leg covers, or Tyvek suits). The problem is that generalizing from the Emory experience is not realistic for other hospitals, and could be dangerous for patients presenting with “severe non-Ebola infection” who happen to have been in an outbreak area in the prior 21 days.