If you can ride a bike - YoU CaN't SpREAd EbOLa!!!!

Since Ebola is only spread very late in the disease, like when you are sick and in the ICU, it goes without saying that Kaci Hickox is no risk to her community. But she looks to be in great shape, so any squirrel in the road better watch out!

Ebola - Some Hope for Control in West Africa

Ebola, as we all know, is out of control. As an example, every time I turn on the TV there is Dan or Mike or Dan staring back at me. Eventually, we will calm down in the US and begin to focus our attention on the critical outbreak in West Africa. My prediction is that this will happen sometime soon after November 4th (Election Tuesday). In the meantime, there is some possibly, maybe, hopefully good news out of West Africa in today's NYT. As of a few days ago, fewer than half of the 649 available treatment beds in Liberia were occupied. Of course this could be good or bad, but I'm holding out for good.

There was also some potentially good news in a report published in the Annals yesterday. Dan Yamin et al. analyzed a stochastic model of Ebola transmission populated with parameters from a 2000-2001 Uganda outbreak and the current outbreak in Montserrado County Liberia. The authors used the model to determine the number of secondary cases infected by survivors or non-survivors and also evaluated the effect of isolating/hospitalizing patients. I have included the key figures from the paper below. In Figure 1a, they estimate the Ro stratified by whether the index case was a survivor or non-survivor. For the whole cohort, the Ro was 1.73. However, the difference between non-survivors and survivors is striking. It appears that non-survivors infect four times as many people as survivors (2.36 vs 0.66). This may explain why the two Dallas nurses were infected after being exposed to a non-survivor while no secondary cases have yet occurred in other US hospitals, where everyone else (so far) survived.

Figure 1a

In Figure 1c, the authors provide an estimate of the average number of secondary cases per day of symptomatic disease. You can see that there is very little transmission in the community at day 1 and it remains very low for survivors but jumps up after day 2 for non-survivors. This implies that waiting for symptom development is a scientifically valid strategy for preventing community transmission of Ebola even in Africa. (We expect these numbers to be far lower in the US where our communities are less crowded and we are fortunate to have toilets, indoor plumbing and clean water.)

Figure 1c

Finally, in Figure 2 the authors evaluated at what time point non-survivors (very sick individuals) must be actively isolated to prevent community transmission. They estimate that if 75% of the non-surviving cases are detected and isolated by day 4 this results in a 74% chance of disease elimination and if 100% are detected and isolated by day 4 then there is a 94% chance of disease elimination. Currently, the authors report that the average time from disease onset to hospitalization in Liberia is 5 days, so there is some room for improvement. However, I suspect that the current expanded efforts could achieve 4 days. When I put the results of this Annals paper together with the NY Times report of empty beds, it suggests that there is available capacity to hospitalize and isolate patients within 4 days of symptom onset and it might even suggest that current efforts are already working. I'm certainly hoping this is the case.

Oh, and if isolating patients 4 days after symptom onset works in West Africa, it means WE DON'T NEED TO QUARANTINE ASYMPTOMATIC FOLKS IN THE US. So please stop it...and sorry for shouting.

Guest Post: Ebola and the Reversal of Transmission Dynamics

L. Silvia Munoz-Price, MD PhD

This is a guest post by Dr. Silvia Munoz-Price, Enterprise Epidemiologist at Froedtert & Medical College of Wisconsin Institute for Health and Society/Department of Medicine.

There is an interesting phenomenon occurring during this Ebola outbreak. The relationship between health care workers and personal protective equipment (PPE) has shifted. Let’s state a fact: up until now, most Infection Control providers have permanently struggled to ensure compliance with the use of gowns, gloves, and hand hygiene among healthcare workers. Even though all healthcare workers know these interventions (PPE and hand hygiene) are necessary to prevent transmission of pathogens among patients, healthcare workers persist being non-compliant with these measures. Why do we continue behaving this way? This is probably due to several factors, but one of the most relevant ones might be our inability to pinpoint whose non-compliance end up causing acquisition of hospital pathogens to individual patients. So, when patient X gets Clostridium difficile colitis on day 15 of hospital stay, who among the dozens of providers in contact with patient X caused this transmission? Nobody can tell. The result is a lack of accountability of medical teams.

This topic reminds me of healthcare worker’s attire. We know that white coats are laundered on average every 14 days but scrubs are spontaneously laundered by providers every day. The former is in contact with patients and the latter is in contact with the provider’s skin. Why this difference in laundering frequency? Could it be that we care of our well being much more than what we care of our patients?

Many times I have discussed with hospital leadership about why there is such a difference in compliance with protocols between airplane pilots and healthcare workers. We thought this difference was probably due to the fact that if airplane pilots are not compliant…they die. In comparison, if healthcare workers are not compliant with hand hygiene or PPE usage…nothing happens to them.

Ebola has clarified this point for us. This tiny virus has successfully reversed the transmission dynamic in hospital settings. Now healthcare workers are not the only one spreading disease across the unit …now healthcare workers are actually getting sick if they are not compliant with infection control practice. What is the result? We are frantically re-learning how to cover every inch of our bodies before and after patient contact. That said, I understand that the mortality in West Africa has been very high, which is causing a generalized state of panic, but so far we are observing that patients treated early and adequately seem to do just fine. Compare this with C. difficile colitis among our immunocompromised patients which causes thousands of infections a year. I understand that C. difficile is not in CNN 24/7, and fails to have an exotic name, but it can certainly be as devastating and much harder to treat than Ebola in US healthcare settings. So, let’s reflect on our current state of generalized paranoia. Maybe patients with C. difficile, CRE, MRSA, VRE acquired in the hospital should run the same press campaigns 24/7 clamoring for better compliance with PPEs and hand hygiene among healthcare providers.

So, let’s think again about our behavioral drivers to comply with PPE and hand hygiene…maybe the answer to improved compliance with these interventions is to have a strain of C. difficile that would make healthcare providers sick.

We need better PPE

The bloggers have just published a viewpoint in JAMA on the need for better PPE in the era of Ebola. You can read it here.

Photo: John W. Poole, NPR

Bloggers in the News: Quarantine of Uninfected Health Care Workers

Earlier today MSNBC put Dan in the middle, Hollywood Squares style, and asked him very good questions about SHEA's recent press release that supports active monitoring but warns against mandatory quarantine of health care workers. After watching this, my hope is that future discussions are this informative. Great work Dan.

 

Postmodern public health

An absurd situation has unfolded in New Jersey, where Kaci Hickox, a nurse who recently returned from Sierra Leone, is being quarantined. While she certainly could be incubating Ebola virus disease given her work with Ebola infected patients, she is asymptomatic, has had two negative Ebola tests, and currently poses no public health risk. To make matters worse, she was escorted to the hospital by a caravan of eight police cars and is being held in a tent (see photo) with no shower or flushable toilet. It is hard to believe that this is happening in the United States in 2014.

It seems that we have entered a new era of postmodern public health. No longer are decisions being made on evidence by experts who understand the epidemiology of infectious diseases, but by politicians who pander to the misinformed for political gain. It's reminiscent of the situation that existed for nearly a decade in South Africa where President Thabo Mbeki denied that HIV was the cause of AIDS, despite all evidence to the contrary.

David Gorski, in his blog Science Based Medicine, writes that from a post-modern viewpoint “scientific medicine is no more valid a construct to describe reality than that of the shaman who invokes incantations and prayers to heal, the homeopath who postulates “healing mechanisms” that blatantly contradict everything we know about multiple areas of science, or reiki practitioners who think they can redirect “life energy” for therapeutic effect. In the postmodernist realm all are equally valid, as there is no solid reason to make distinctions between these competing “narratives” and the “narrative” of scientific or evidence-based medicine."

Returning to reality for a moment, we need to emphasize that mandatory quarantine of healthcare workers from West Africa will not make us safer. In fact, it is highly likely that fewer American healthcare workers will take on the difficult task of treating Ebola in Africa, despite the need for controlling the epidemic there. And without controlling the epidemic at its source, developing countries will continue to be ravaged, and there will continue to be sporadic imported cases in developed countries. Moreover, if one believes that returning healthcare workers should be quarantined, then logic would dictate that healthcare workers who care for Ebola patients in the US should also be quarantined. This will precipitate a crisis since it is highly likely that most healthcare workers would be unwilling to provide care in that situation. And the incredible expense of caring for the Ebola patient in the US would increase greatly.

Kudos to Dr. Anthony Fauci for speaking truth to power today, and to the Society for Healthcare Epidemiology of America for issuing an official statement opposing quarantine of returning healthcare workers.

In an interview several years ago, Stephen Colbert said, "It used to be, everyone was entitled to their own opinion, but not their own facts. But that's not the case anymore. Facts matter not at all. Perception is everything. It's certainty.” And because of that, a few politicians have been able to trump the brightest minds in medicine and public health.

Photo: Kaci Hickox, CNN.

SHEA Supports Evidence-Based Measures to Prevent Ebola Transmission, Opposes Mandatory Quarantine for Healthcare Personnel

FOR IMMEDIATE RELEASE: CONTACT: October 26, 2014 Kristy Weinshel, 703-684-1008 kweinshel@shea-online.org

ARLINGTON, Va. (October 27) – The Society for Healthcare Epidemiology of America (SHEA) remains deeply concerned about the Ebola virus disease (EVD) outbreak. The recent news about Dr. Craig Spencer’s infection, along with the infections of the many other healthcare personnel (HCP) who have risked their lives to provide care during this tragic outbreak, illustrates how difficult it is to protect HCP serving patients with severe EVD.

SHEA supports the recent infection prevention guidance issued by the Centers for Disease Control and Prevention (CDC), and the commitment healthcare facilities across the country have made to train and prepare their teams for the care of patients with EVD.  SHEA continues to support the rigorous application of evidence-based measures to prevent EVD transmission. Based upon the strong evidence that Ebola is not transmitted by those who do not have symptoms of EVD, we do not support mandatory quarantine of individuals, including HCP, who have provided care for patients with EVD.  Our concern is about both the ramifications for HCP returning from West Africa and the potential application of this quarantine to all HCP caring for patients with EVD.  SHEA believes that mandatory quarantine will lead to fewer volunteers and increased difficulty in assembling care teams in West Africa and in other countries, including the United States, preparing to care for EVD patients.

SHEA and its membership of infection control and prevention experts support the active monitoring (twice daily, for fever and symptoms of EVD) of all HCP providing care for EVD patients, including returnees from Ebola outbreak areas in West Africa. Mandatory quarantine should only be implemented for those who do not adhere to such monitoring.

SHEA continues to work with the CDC and all relevant stakeholders to ensure the safety of HCP and to promote positive outcomes for those who contract Ebola. 

###

SHEA is a global professional society representing more than 2,000 physicians and other healthcare professionals with expertise and passion for healthcare epidemiology and infection prevention to improve patient care in all healthcare settings. SHEA's mission is to prevent and control healthcare-associated infections and advance the field of healthcare epidemiology. The society advances its mission through advocacy, science and research, expert guidelines and guidance on key issues, the exchange of knowledge, and high-quality education.  SHEA focuses resources on promoting antimicrobial stewardship, ensuring a safe healthcare environment, encouraging transparency in public reporting related to HAIs, focused efforts on prevention and more. 

Visit SHEA online at www.shea-online.org, www.facebook.com/SHEApreventingHAIs and @SHEA_Epi

link to SHEA press release: http://www.shea-online.org/View/ArticleId/318/SHEA-Supports-Evidence-Based-Measures-to-Prevent-Ebola-Transmission-Opposes-Mandatory-Quarantine-for.aspx

Bowling Alone

The big news tonight is that the governators of New York and New Jersey decided to institute quarantine for everyone returning from West Africa after having contact with Ebola patients. This decision was driven by political considerations, including the costs (in time and money) expended due to the decision to do extensive contact tracing around Dr. Craig Spencer’s movements in New York City since 7 am on Tuesday, October 21.

Nothing that has happened during this tragic Ebola epidemic has called into question this simple fact: Ebola is not transmitted in the absence of symptoms. Nor is it transmitted to casual or household contacts during early infection. Consider Mr. Duncan, sent home from the hospital with fever, spending the early days of his Ebola illness with almost 20 close contacts (mostly family members), until he was finally taken back to the hospital after vomiting “wildly” in an apartment complex parking lot. Let’s count the community and family transmission events: ……..ZERO. 

Careful monitoring of symptoms and signs (fever) is sufficient for early detection of symptomatic Ebola infection and prevention of community transmission. Movement restrictions, including strict home quarantine, provide no additional benefit. The adverse consequences of misguided quarantine of caregivers are clear, however: fewer providers willing to assist in the outbreak area, and fewer providers willing to volunteer to join Ebola care teams in US hospitals, complicating preparedness efforts. If Ebola providers returning from West Africa are quarantined, how can we not also quarantine US healthcare workers who provide care for Ebola patients? How will such providers commute to work, if they depend upon public transportation? Conversely, how will we convince anyone to participate in care, if they cannot return home to family for the duration of caregiving (+ 21 days)?

Don’t take it from me, though. Listen instead to an infectious diseases doc who’s been fighting the outbreak in Sierra Leone:

Dan Kelly, 33, an infectious disease doctor and a founder of Wellbody Alliance, a nonprofit organization working in Sierra Leone, criticized the governors’ response as knee-jerk. 

“I think we are just digging the grave deeper,” he said in a telephone interview from Freetown, the capital. “Come on, that’s exactly the move to push people away from going to Sierra Leone and other affected areas. It’s going to escalate the epidemic and not help solve the crisis."

He added: “If we’re going to get in front of it, we need health care workers from abroad. They cannot feel shunned or discriminated against.”

Morebola

The news tonight about Dr. Craig Spencer, an MSF volunteer who recently returned from caring for Ebola patients in Guinea, is sobering for several reasons. There are many details to come, but I thought I’d post a few quick initial thoughts (or reminders) about how this tragic development should, or shouldn’t, change the way we think about the Ebola virus outbreak:

This outbreak is occurring in West Africa. Not in the US. West Africa. The level of hysteria in the US is directly proportional to the number of Ebola patients on US soil, but we should never forget, even for a minute, that the outbreak continues to rage in Liberia, Sierra Leone, and Guinea (where Dr. Spencer acquired the infection). This widely cited Lancet modeling study suggests that 2-8 Ebola infected individuals will board planes monthly during their incubation period. Thus the best way to combat Ebola in the US is to mobilize resources for West Africa.

In the US, those at risk for Ebola are healthcare workers who have cared for Ebola patients (whether here or in West Africa). Not mall-goers, bowlers, subway riders, or those who might have been in an airport terminal on the same day as an asymptomatic Ebola patient. The greatest transmission risk is borne by those who provide direct care for Ebola patients during severe illness, when viral shedding is very high. 

There may be no way to reduce Ebola transmission risk to zero in healthcare settings, given the current state of Personal Protective Equipment technology. Dr. Spencer reported no breaches in the MSF protocols, which are widely recognized as the most stringent (and effective) in use. Healthcare workers have always accepted some risk in provision of healthcare, and Ebola reminds us that the risks can be grave, and that healthcare workers willing to bear these risks are heroic.

This case may make it far more difficult to assemble care teams for suspected or confirmed Ebola patients. Not just because we have yet to determine how Nina Pham, Amber Vinson, Craig Spencer, and several other caregivers were infected, but because this case could result in more stringent protocols regarding self-monitoring and movement restriction (quarantine) for those willing to care for Ebola patients. Healthcare workers who learn they may be required to restrict their movement during the entire time they care for patients (and 21 days thereafter) may be less likely to step forward. 

All eyes now will be on Bellevue. If Dr. Spencer receives all of his care at Bellevue rather than being transferred to one of our four federally-funded and designated biocontainment facilities, the hypothesis that any well-prepared hospital can safely care for an Ebola patient will again be tested.

Photo credits: Facebook; Bryan Smith

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.

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.

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 with 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. 

Photo: Brynn Anderson (Associated Press), New York Times,

Infection Prevention Thoughts of the Day

Thoughts of the day. Start reading at the bottom (or not). Be careful out there.

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!

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

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 cuts, CDC 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.

Traveling With Ebola Is Not Traveling With Influenza

With everyone away at IDWeek, I've had time to think about Ebola and things like airport screening programs. I'm not supportive of outright travel bans. As many have eloquently said, bans will do more economic harm than good and hinder efforts in West Africa. However, I'm worried that we might be equating Ebola with Influenza. Many of the discussions concerning travel restrictions and Ebola spread have centered around models and estimates derived from respiratory viruses epidemics like the 2009 H1N1 influenza pandemic. Yes, influenza and Ebola are both viruses, but that's like equating a sparrow and an Allosaurus because they're both dinosaurs.

The first and perhaps most important difference between the current Ebola outbreak and the the 2009 H1N1 pandemic is that Ebola it is very slow moving. For example, the first case of Ebola is thought to have occurred 307 days ago on December 6th in a two-year old boy. Since that time there have been an estimated 8,032 cases (granted these could be underestimates). If you compare a similar 307-day period for 2009 H1N1, April 12, 2009 to February 12, 2010 CDC estimated that between 42 million and 86 million cases occurred in the US with a mid-level estimate of 59 million people infected. Think about that - 7300 times more cases of H1N1 using the mid-level estimate during the same 307 days.

Another difference between influenza and Ebola is the incubation period (time from exposure to symptoms). Generally, the incubation period for influenza is 1-4 days (2-day average). For Ebola symptoms appear 2 to 21 days after exposure with an average of 8 to 10 days.

A final difference between Ebola and 2009 H1N1, which seems to be overlooked in discussions of airport screenings and other control measures, is infectivity during the incubation period. Put another way, can you transmit the virus without knowing you are sick? With Ebola, humans are not infectious until they develop symptoms. In comparison, with 2009 H1N1 it's reported "that pre-symptomatic influenza transmission occurred via both contact and respiratory droplet exposure before the earliest clinical sign, fever, developed" in a ferret model. This finding has been confirmed in humans. Interestingly, SARS is not infectious prior to symptom development (see CDC and Zeng et al), which may explain why we were ultimately able to contain SARS (unlike influenza).

To summarize, Ebola is slower moving, has a much longer incubation period (especially compared to the duration of a transcontinental flight), and is not contagious before symptoms develop. What does this mean? It means that if Ebola was as infectious as influenza, millions would have already died - apocalypse. It also means that since Ebola is not transmissible during its long incubation period, it may be possible to quickly isolate patients when symptoms develop. Thus, airport screening on exit or entry could limit transmission and perhaps through early diagnosis allow Ebola infected patients to receive life saving treatment more quickly.

A more concrete example: Imagine a person infected yesterday with influenza but still asymptomatic during their two day-incubation period. This person would screen negative overseas and in the US. However, it's highly likely that they are already infectious or will become infectious during their flight. Thus, many other passengers in the airport and plane would take influenza home with them as a vacation souvenir. Screening doesn't work for influenza. This would not be the case with Ebola because they will detect their symptoms as they become infectious and only spread it though blood exposure - something unlikely so early in the infection even on a long transcontinental flight. And think about how many times another person has bled on you even when they were bleeding (i.e. the Ebola condition) versus how many times someone has coughed or sneezed on you when they were coughing and sneezing (the influenza condition). **cough**

Airport screening for Ebola symptoms may still be ineffective, but I would like to see a few more mathematical models analyzing the epidemiology of Ebola and the impact of specific screening programs. In the meantime, let's focus our attention and resources on the horrible plight in West Africa.

image source: xkcd

Ebola update: Dallas and Airport Screening

It's been another eventful day. We've learned the unfortunate news that Eric Duncan, the index patient with Ebola in Dallas, has passed away. There have been concerns about further transmission to three other Spanish healthcare workers and that the initial nurse may have contracted the virus through breaking PPE removal protocol. There is even news that a second person in Dallas might have acquired Ebola through contact with Mr. Duncan or his surroundings. President Obama announced increased screening at the five US airports that account for 94% of entry flights carrying people from West Africa. Finally, NYT Science Reporter Carl Zimmer said that "worrying about Ebola becoming airborne, is like worrying about wolves evolving wings."

You could read all of these reports and more but the quickest way to catch up on today's Ebola news is to listen to Dan Diekema's interview on this afternoon's PRI The World. Somehow, Dan pulled away from his SHEA presidential duties and IDWeek sessions to record the interview that I've posted below.

 

Infectious Disease: JAMA Theme Issue

This week's JAMA is a special ID Theme Issue with a publication coinciding with IDWeek 2014. For the infection prevention inclined there is a Viewpoint by Dan Morgan (along with Dan Diekema and Keith Kaye) that asks us to consider contact precautions as secondary/adjunctive measures for MRSA and VRE but suggests that their use is prudent for MDR-GNR. I guess the BUGG study has me convinced that contact isolation works for MRSA, so I'll have to disagree with my esteemed colleagues. There are two important trials of candidate vaccines for avian influenza and an excellent editorial by John Treanor bringing us up to date on pandemic influenza options. There is also a cluster-randomized trial of SDD and SOD from the Netherlands by Marc Bonten's group with an editorial by Kollef and Micek. I'm sure we'll expound on this study more in the future. Besides the CDC's hospital antibiotic use study that I posted on earlier, there is a CDC outbreak investigation describing a 39-patient NDM-E. coli (CRE) outbreak associated with duodenoscopes. In the accompanying editorial, Rutala and Weber ask "whether current US endoscope reprocessing guidelines are adequate to ensure a patient-safe gastrointestinal endoscope."

I would be remiss if I didn't point you to the Editorial by the ID-Issue Editor, Preeti Malani. She did a wonderful job pulling this issue together and in her editorial outlines the many broad threats to human health that we still face from infectious diseases. In particular she highlights the "worldwide, major disparities (that) cause many individuals to lack access to clean water, safe food, and fundamental elements of infection prevention, such as hand hygiene and basic sanitation." She also worked closely with Cassio Lynm, the medical illustrator who created the cover image (above). Clouds ominously bring forth climate change as the sea harbors new pathogens and threatens those sequestered safely on shore. And the one barrier we have against the multitude of threats? Contact (and droplet) precautions. I couldn't agree more.

Antibiotic Use is Common in Hospitalized Patients

Even with Ebola and Enterovirus D68 on their plate, CDC still finds the time to do one of their day jobs - antimicrobial stewardship. In today's JAMA Infectious Diseases issue, Shelley Magill and her CDC EIP colleagues published (open access) a point-prevelance survey of antimicrobial use in acute care hospitals. The one-day survey included 11,282 randomly-selected patients from 183 hospitals in the 10 EIP states. In addition to recording which antibiotics the patient received, they also determined the rationale for use: treatment of infection (including empiric therapy), surgical prophylaxis, medical prophylaxis, a noninfection-related reason, or unknown.

Approximately 52% of patients received antibiotics that day or the day before. 58% of patients in ICUs vs 49% in other locations received antibiotics. Of those on antibiotics, half received one antibiotic, while the remaining 50% received two or more antibiotics. This seems like an obvious target for stewardship efforts. Encouragingly, 97% of the patients had a documented reason for receiving the antimicrobial: 76% for treatment of infection, 19% for surgical prophylaxis, and 7% for medical prophylaxis. The majority of patients treated had either a lower respiratory tract infection (34%), UTI (17%), skin/soft-tissue infection (15%) or GI infection (11%). I've included Table 3 below that highlights frequently used antibiotics for community vs health care facility-onset infections.

Overall a nice study and one that adds to the growing body of literature quantifying the rate of antimicrobials used clinically. The take home messages are a bit harder to identify. It would have been nice to follow these patients longer and capture their microbiology results to determine the proportion treated appropriately. It is also harder to make sweeping generalizations about antibiotic use in acute-care settings because the patients are very sick and could benefit from antibiotic treatment. If this were the outpatient setting, calls for improved use would be easier to make. Although, it does seems like we use too much vancomycin and pip-tazo in hospitals.

Ebola: Doc from Oklahoma City Calms the State of Texas

Many of you might not know that Kent Sepkowitz, while living and practicing in NYC, hails from the great state of Oklahoma. So when Stephen Colbert went in search of an infection control expert with Red-River roots, he couldn't do much better than our esteemed colleague, just a taxi ride away. If you're still left wanting more after watching this video, head on over to NPR to hear one of the better discussions of Ebola with Kent and Scott Simon from Weekend Edition. 

Ebola Screening: Hey CDC! Is it an AND or an OR?

Like many of you, we've all been assisting with Ebola planning for the past several months. Just today, Mike and I were in another planning meeting and the subject of our screening algorithm came up. Mike had noticed that the September 4th CDC Definition of Person Under Investigation (PUI) that we've been using: "fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, AND additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage" is now different in the PDF algorithm that the CDC posted on October 2nd. It now says "FEVER OR EVD symptoms." I've included the relevant portion of the PDF algorithm above.

This may seem like a minor change, but for many facilities it will be a big deal. To go from a relatively sensitive "fever AND" to a very sensitive "fever OR" is not a small change. This may require EDs and clinics to screen additional patients and result in a large increase in laboratory tests being sent for Ebola diagnosis. I think that CDC meant to suggest that fever is enough to prompt a travel history, but now anyone with fever, headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain or hemorrhage will also need to be asked a travel history. In practice this will mean that every patient that walks into an ED or clinic should be asked a travel history first and then asked about symptoms. I'm not convinced this should happen and feel much more comfortable with having symptoms guide travel history. But since almost any general complaint is now included, we may be left with no other choice but to ask travel history first. And of course, we don't know what CDC wants us to do since both documents are live and offer conflicting advice.

So, which is it CDC?  Is it an AND or an OR?

Guest Post: The Danger of Ebola

This is a guest post by Philip Lederer, an ID fellow at Massachusetts General Hospital and Brigham and Women’s Hospital. He was a CDC Epidemic Intelligence Service officer and has also worked in Mozambique as clinical director of the UCSD-Maputo Central Hospital Educational Collaboration.

The danger of Ebola goes well beyond the thousands of cases reported so far in Liberia, Sierra Leone, Guinea, and neighboring countries. It goes beyond the models which estimate that up to 1.4 million cases could occur by next year (1). The danger doesn’t have to do with Ebola becoming airborne or spreading widely across the United States. 

Ebola is still centered in West Africa, and the danger is of collateral damage. Malaria control programs have shut down in the 3 countries, according to a recent report (2). Cholera could reemerge, as there was a 2012 outbreak in Sierra Leone (3). People are losing their jobs. Starvation and violence could kill many more people than the Ebola virus. It’s time for the world to act.

---
References:
1) Meltzer MI, Estimating the Future Number of Cases in the Ebola Epidemic — Liberia and Sierra Leone, 2014–2015 http://www.cdc.gov/mmwr/preview/mmwrhtml/su6303a1.htm?s_cid=su6303a1_w


2) Hayden EC, Ebola outbreak shuts down malaria-control efforts http://www.nature.com/news/ebola-outbreak-shuts-down-malaria-control-efforts-1.16029

3) Nguyen VD et al, Cholera epidemic associated with consumption of unsafe drinking water and street-vended water--Eastern Freetown, Sierra Leone, 2012. http://www.ncbi.nlm.nih.gov/pubmed/24470563

Ebola and WHO budget cuts

Anthony Harris used to (and may still) include this New Yorker cartoon in his antibiotic resistance talks. I've always thought it summed up the resistance crisis quite well. We don't have effective antibiotics, so we must resort to the ridiculous. One of the major reasons we lack new classes of antibiotics is the lack of public funding for basic research of bacterial pathogens. It's pretty simple really. Years of ignoring the problem have us in this situation and it will take many years of reinvestment to build up the laboratory and professional resources needed to be fully engaged in antibiotic discovery.

A similar situation has played out in public health preparedness. I encourage you to read Dan's posts (here and here) covering the Prevention and Public Health Fund. And it's not just the US. In the Guardian today, Peter Piot - the discover of Ebola, expressed his fears that the outbreak is out of control. It's an amazing account of how he discovered and named the virus. It also highlights the almost tragic accidents that occurred in his lab, yet no one caught the virus. When asked why the WHO responded so late to the Ebola outbreak in Africa, he responded:

"On the one hand, it was because their African regional office isn't staffed with the most capable people but with political appointees. And the headquarters in Geneva suffered large budget cuts that had been agreed to by member states. The department for haemorrhagic fever and the one responsible for the management of epidemic emergencies were hit hard...I think it is what people call a perfect storm: when every individual circumstance is a bit worse than normal and they then combine to create a disaster. And with this epidemic there were many factors that were disadvantageous from the very beginning."

I'm not a military historian, but this situation seems terribly similar to what I've read about simultaneous wars on two fronts. Although in public health, it can be four or five fronts. We have Ebola, MERS, avian influenza and Enterovirus D68 knocking on our doors (and I'm sure I left out a few.) These are all on top of the CDC and WHO's "day jobs" fighting foodborne outbreaks, antibacterial resistant bacteria, TB, HIV and malaria (and I'm sure I left out many). Long term cuts to public health infrastructure can't be repaired in one month or one year. You can't go buy extra diseases detectives quickly off the shelf much like you can't quickly buy an extra aircraft carrier. We can already see how outbreaks respond to intensive budget cuts.

image source: Conde Naste

Whither infectious diseases?

One morning in October 1983, when I was a 22-year-old second year medical student just recovering from infectious mononucleosis, I arrived at school for my medical microbiology lecture. At that point, several weeks into the course, I found myself with no real affinity for the subject matter. The lectures seemed to focus on the minutiae of biochemical tests for various bacteria that I planned to memorize for the exam then forget. But that October morning we were scheduled to have a clinical correlation lecture. I always looked forward to those lectures--talks about real diseases by real doctors. The lecture was on meningitis and given by Rashida Khakoo (shown in photo), a young infectious diseases doctor. It was incredibly fascinating and I was forever hooked. Over the course of the next several years, I rotated with Rashida several times on the Infectious Diseases consultation service, and knew that ID was my calling. It's hard for me to estimate how much I learned from her. She's an amazingly brilliant physician and incredible bedside teacher who reads incessantly and has the capacity to remember everything that she has ever read. The joke among the medical students was that you could not find a bound journal in the library that did not have her name on the library check-out card (I realize younger readers won't get that joke). Three decades later, I still believe she's the best doctor I have ever encountered.

For me and many others, Infectious Diseases remains a fascinating specialty. What other field has new diseases and challenges continuing to emerge at the rate of our specialty? We remain the disease detectives, the go-to doctors when no one else can figure out what is wrong with the patient (think Gregory House, MD, only nicer!). We add value in many other ways by working as hospital epidemiologists, antibiotic stewards, and public health experts. This morning's New York Times has multiple articles regarding infectious diseases. This should be our heyday. But instead, the field of infectious diseases appears to be in rapid decline. This past year, only 137 US medical school grads applied for fellowship positions in Infectious Diseases and only 41% of available positions were filled. We have recently heard numerous reports that fellowship programs, increasingly desperate for trainees, are violating rules of the National Resident Matching Program (NRMP) and offering candidates positions outside of the match process.

The cause of ID's demise is purely economic. Put yourself in the shoes of a 30-year-old 3rd year internal medicine resident with two young children and a $300,000 educational debt. You find the field of infectious diseases to be very interesting but you are forced to make a choice between 2-3 years of additional training at a fellow's salary or entering the workforce now as a hospitalist. The median annual salary of a hospitalist currently exceeds $250,000 and on average a hospitalist works 40 hours per week. As a hospitalist you will earn a salary 30% higher than your ID colleagues and work 30% fewer hours. Most hospitalist positions offer predictable hours and frequent, extended periods of time off. Can we blame young doctors for choosing the hospitalist option?

Unfortunately, most physician compensation plans reward volume not value, and that's a losing proposition for us. You can't evaluate a patient with fever of unknown origin in 20 minutes. There are no RVUs earned for spending three hours reviewing the medical records of a highly complex patient. In my previous job, the departmental administrator chastised me for spending too much time with my patients. Although I knew my work was important, that referring physicians were pleased and that my patients were grateful, I no longer felt valued.

The work of the ID doctor has never been glamorous, the pay has never been as good as most other specialties, and the hours have always been long. You don't enter ID to have a good lifestyle or get rich. But what has changed over the past decade is that internal medicine residents now have an option that offers higher pay and better hours, without pursuing additional training. Until ID becomes more economically competitive with hospital medicine, the odds of a comeback are slim. This isn't rocket science. And it's really a shame that the Infectious Diseases Society of America, our professional society that should be advocating for us, seems incapable of articulating an effective message about the crisis that the field of ID faces, the value that we add to health care, or potential economic solutions.

Sadly, we must ask: will the last ID doctor please turn out the lights?