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.