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

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

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,

“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.

Killed by an Abundance Of Caution?

Back in August, I wrote:

“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.”

In September, I wrote:

“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…..However, many hospitals plan not to let any samples from suspected Ebola patients cross the threshold of their laboratories. [This] 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.”

Well, the CDC has just released a report on their initial experience with “PUIs” in US hospitals, and there’s this disturbing little nugget buried within:

“At least two persons who tested negative for Ebola died from other causes. Based on reports from health departments and health care providers, in several instances efforts to establish alternative diagnoses were reported to have been hampered or delayed because of infection control concerns. For example, laboratory tests to guide diagnosis or management (e.g., complete blood counts, liver function tests, serum chemistries, and malaria tests) were reportedly deferred in some cases until there were assurances of a negative Ebola virus test result. In other instances, radiologic studies, such as computed tomography and ultrasound scans, or evaluation for noninfectious conditions, such as severe hypertension and tachycardia, were reportedly delayed while a diagnosis of Ebola was under consideration.”

Given the ratio of PUIs to actual Ebola patients presenting to US hospitals, it is quite likely that more patients will die in the US from AOC (“Abundance of Caution”) than die from Ebola. Back to CDC now:

“…it is important to recognize that the likelihood of Ebola even among symptomatic travelers returning from these countries is very low. In the hospital setting, where policies and procedures should be in place to safeguard health care workers, consideration of Ebola should not delay diagnostic assessments, laboratory testing, and institution of appropriate care for other, more likely medical conditions.”

In other words: diagnose and treat the patient, not your Fear of Ebola.

Image from The Keep Calm-O-Matic

An abundance of "abundances of caution"

Googling “abundance of caution Ebola” yields 213,000 hits and a treasure trove of misguided responses to Ebola fears. You can even refer to this excellent Washington Post article about how to make “an abundance of caution” work for you! It’s to the point now that if I hear “abundance of caution” being used in a sentence about Ebola, I translate it to “what I am suggesting makes no actual sense but demonstrates my extreme seriousness about fighting the very idea of Ebola”. 

Some “abundance of caution” (AOC) actions are completely off-the-rails, like preventing students or teachers from attending schools when they had no risk for Ebola exposure, while others may appear reasonable but have no scientific basis (like the excessive movement restrictions some states have applied to asymptomatic returnees from outbreak areas). Another example of the latter category of AOC actions recently took effect in California, as CalOSHA issued updated Ebola guidance for hospitals. The CalOSHA guidance for personal protective equipment meets CDC recommendations, but allows only one option for respiratory protection (PAPR) and only one option for skin covering (full body coverall). I’ll outsource the rest of this post to a SHEA press release from last week. Suffice it to say that I sincerely hope they dial this back, and that it doesn't become a standard for federal OSHA guidance.

SHEA Supports Scientifically Sound Approaches to Ensure Protection for Healthcare Personnel Fighting Ebola

November 24, 2014 (Arlington, VA) – The Society for Healthcare Epidemiology of America (SHEA) is dedicated to the prevention of infection in healthcare settings, including the protection of healthcare personnel (HCP) who provide care to patients with known or suspected Ebola virus disease (EVD). 

SHEA supports the current Centers for Disease Control and Prevention (CDC) guidance on Personal Protective Equipment (PPE) to be used by HCP caring for patients with EVD. This guidance is consistent with the established science regarding how EVD is transmitted.

Recently updated guidance from California's Division of Occupational Safety and Health (Cal/OSHA) meets the CDC recommendations, but specifies only one form of respiratory protection (powered air purifying respirator (PAPR)) and only one form of barrier protection (impermeable coverall) for all inpatient and emergency department (ED) care of those with suspected or confirmed EVD. However, there are no data to suggest that these specific forms of PPE provide better protection for HCP than alternatives that are also included in CDC guidance (e.g., N95 respirators, fluid impermeable hoods, AAMI-4 gowns and leg coverings). 

There are several types of PPE that provide full protection against Ebola transmission, and the local preference of nurses, physicians and other HCP is paramount to select the best PPE for their facility (from among CDC-adherent options). Considerations of familiarity, tolerability (e.g. discomfort, overheating), risk for self-contamination during doffing, and amenability to training all require local input. Thus wide adoption of the narrow requirements established by Cal-OSHA could have unintended adverse consequences. For example, hospitals that have already trained their HCP in safe use of AAMI-4 gowns may inadvertently increase exposure risk by switching to unfamiliar coveralls that are widely considered to be more difficult to doff without self-contamination. Furthermore, mandating PPE that is excessive for the fluid risk of a suspected or confirmed EVD patient results in unnecessary impediments to timely and effective clinical care (e.g., requiring PAPR and coverall for evaluation of an ED patient with low grade fever and no other symptoms). Since most suspected EVD patients cared for in US hospitals test negative for EVD but may have other life threatening conditions that require timely therapy (e.g., malaria), such impediments can lead to harm. Finally, unnecessarily narrow limitations on PPE types will exacerbate already critical PPE shortages and limit the ability of US hospitals to be prepared to care for those with known or suspected EVD. 

HCP have a right to a safe work environment during the care of patients with any communicable disease, including Ebola. SHEA believes that the current CDC guidance, when practiced correctly and reinforced by adequate training of HCP, protects HCP from Ebola transmission. 

Photo by John Spink

Post-exposure Vaccination for Ebola

The ongoing Ebola virus outbreak in West Africa continues to underscore the importance of a strong international public health infrastructure and continued investment in both basic and clinical research targeting infectious pathogens. The first line of defense for infectious diseases, if available, is a safe and effective vaccine. However, approved vaccines do not exist for many pathogens like Ebola, so well-designed personal protective equipment becomes critical. But even the best available PPE can't protect us from sharps injuries. Which brings us to a fascinating case report of post-exposure vaccination of a physician with a needlestick injury obtained while working in an Ebola treatment center in Sierra Leone.

The report by Lilin Lai and colleagues was just published online in JAMA along with a very well-written editorial. The 44-year-old physician from the US was stuck by an 18-guage hollow-bore needle through two layers of gloves after caring for Ebola patients with very high viral loads. Because doffing procedures had to be followed, there was a 10-minute delay in cleaning the wound with bleach, soap/water and CHG. The patient was evacuated and while boarding the jet received an experimental vaccine - a first-generation recombinant vesicular stomatitis virus–based Ebola vaccine (VSVΔG-ZEBOV) - 43 hours post-exposure.

Post-vaccination, he developed fever and malaise but made it safely to the NIH Clinical Center for further care and evaluation. His course was a bit rocky the first few days with fever, lymphopenia and diminished O2-sats but symptoms and signs slowly improved over 3-5 days and he was asymptomatic by day 7. He was discharged to complete the 21-day mandatory isolation-period at home. Ebola virus was never detected.

You can read the full report (free online) if you're interested in the many tables and figures outlining his immune responses. Briefly, the vaccine did elicit a strong innate and virus-specific immune responses. Most importantly (per the editorial) it was "able to induce an IgG antibody response against the Ebola virus glycoprotein at a level that has been associated with protection of nonhuman primates." However, the editorial correctly notes that no definitive conclusions can be drawn since it is unclear if the patient was ever infected with the virus and the adverse events the patient experienced could have been secondary to his concurrent travelers diarrhea.

What is important is that while numerous candidate Ebola vaccines have been shown to effectively prevent transmission in nonhuman-primate models, post-exposure treatments and vaccines have been harder to develop. I wonder if a trial seeking to reduce sharps injuries in Ebola-treatment settings is in the works or if NIH would fund such a trial? Last time I checked, sharps injuries were on the rise, so investment in prevention research remains critical.

image source: wikipedia

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.

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.

Getting to zero

By my count, there are now zero persons in the United States who are actively infected with Ebola virus.  This is the perfect time to donate your time or your money to Ebola response in West Africa.

Also, Kaci Hickox still doesn't have Ebola. She should be allowed to go bowling.

Finally, one observation about our weirdly, uniquely American response to Ebola virus. The CDC Guidance for Monitoring and Movement Restriction treats healthcare workers who have "direct contact while using appropriate personal protective equipment (PPE) with a person with Ebola" differently based upon whether they were caring for patients in countries with or without "widespread Ebola transmission". Thus brave volunteers returning from West Africa are under more stringent monitoring and movement restriction guidance than are those who might care for a patient in New York, Texas or Iowa. Yet if you compare the ratio of 'healthcare worker acquisitions/Ebola infected patients' in the US versus West Africa, I'm not sure there is any contest (2 acquisitions/9 Ebola patients = .22--what's 22% of 13,268, the total number of cases thus far in West Africa?).  This isn't an argument to be more restrictive about those who care for Ebola patients in the US, it's an argument to chill the #&*% out about humanitarian healthcare workers returning from the outbreak zone.

Why are we dialing it up to eleven?

Yesterday, Dan posted an excellent summary of what's happening in US hospitals as they scurry to plan for the public health issue du jour--Ebola. He astutely points out that there seems to be a disconnect between what we know about Ebola transmission and what we're doing (or planning to do) with regard to safely caring for patients infected or suspected to be infected. I thought it would be interesting to examine what's driving the disconnect. As I see it, a number of factors are at play here:

Mixed messages

Michael Ramirez, Investors.com

As noted by Dan, at a press conference prior to the transport of two Americans with Ebola infection to Emory University Hospital, Dr. Bruce Ribner stated: "Emory University Hospital has been asked to accept two patients who are currently in Africa infected with Ebola virus infection. Our facility was chosen for this because we are one of only four institutions in the United States capable of handling patients of this nature." Not stated, but nonetheless presumed by the infection prevention community is that the agency doing the asking was CDC, given CDC's physical proximity and given that quite a number of CDC physician-epidemiologists hold faculty appointments at Emory's schools of medicine and public health. However, just a few days later, CDC's primary message was that any hospital in the US should be able to safely care for Ebola patients.

Photo: Cellou Binani/AFP/Getty Images

It's also difficult to reconcile the CDC recommendation for contact and droplet precautions--highly familiar to all healthcare workers--with the images of healthcare workers on the ground in the outbreak epicenters and in Atlanta dressed in Tyvek spacesuits. And who hasn't seen the video footage of the infected American doctor emerging from the ambulance in Atlanta also dressed in the same manner? However, it's important to keep in mind that the exposure risk for healthcare workers in the outbreak setting, caring for multiple very ill, infected patients with scarce resources, is far different than the controlled setting of the average American ICU.

Fear and managing risk

Our greatest fears often revolve around areas where we lack experience, and very few healthcare workers in the US have ever cared for a patient with viral hemorrhagic fever. Importantly, not only does Ebola Fever have a high mortality rate and no proven effective therapies, there is also no post-exposure prophylaxis. A simple lapse in infection control protocol cannot be undone with a pill or injection. One way we attempt to manage fear is to overprotect: if one barrier works, two must be better. In general, redundancies mitigate risk, but this isn't absolute. As Dan pointed out in his post yesterday, we may inadvertently increase risk by complicating infection control protocols with gear that healthcare workers may find distracting, uncomfortable, and lack training to use. The litigious nature of American society also impacts our decisions regarding infection prevention strategies. And many healthcare workers, while willing to accept much greater health risks in their personal lives, demand zero occupational risk.

Non-epidemiologic decision making

In many hospitals today, healthcare epidemiology staff have become advisors to hospital administrators who ultimately make decisions regarding the logistics of infection prevention. And their decisions may not be purely based on science. They often have aversion to approaches that would appear to be out of the mainstream of what other hospitals are doing, even if that's suboptimal. In addition, infection prevention seems to be increasingly used as a public relations tool. If you don't believe that, do a simple Google search and you will find scores of press releases published in local newspapers from hospitals who have purchased germ-zapping robots. By the way, I believe that one of the best uses for a hydrogen peroxide vapor robot would be terminal disinfection of the Ebola patient room. Perhaps those hospitals who have invested in this technology should be the first to receive Ebola patients.

Paramilitarization of public health

In the run-up to the Iraq War, the Bush administration sought to engage the public health and medical communities in the war on terror. Much effort was devoted to preparations for bioterrorism. Who can forget the smallpox vaccine debacle? Preparedness was all the rage, and the Joint Commission couldn't resist jumping on that bandwagon.  Admittedly, some of the impacts of this were positive. For example, hospitals became more tightly linked to public health agencies and those agencies became much more engaged and proactive. But a new group of professionals emerged who are employed to make us prepared, and perhaps a little scared. A physician colleague who works in the IT world tells me that the constant fear mongering by IT security specialists is in part a job security tactic. So the folks who work in preparedness stand ready to help, perhaps in a more aggressive way than necessary this time.

Ok, anyone still surprised we've cranked it up to 11? I'm with Dan in hoping that we'll be able to dial it down to 8 this week.

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

How transmissible is Ebola? About the same as pandemic flu.

There seems to be very little good news associated with the Ebola epidemic in West Africa. The death toll is now approaching 2,000, and the disease continues to spread. The World Health Organization reports that a lack of resources has hampered its efforts. And we have recently learned that another physician has developed the disease. What's worrisome about his case is that he had no known contact with an Ebola infected patient.

Over the past few weeks, I have read several times that the Ebola virus is not efficiently transmitted. At first glance it seems hard to reconcile that with the reports we are receiving from Africa. So let's look a little closer at this. The basic reproduction number (R0) is a metric that quantifies transmissibility. R0 is defined as the average number of secondary cases generated by a case in a susceptible population. For example, measles, one of the most highly contagious infections, has a R0 of about 15, though it can range from 7 to 29 depending on the study evaluated. Thus, each case of measles would be expected to lead to 15 additional cases in a susceptible population.

A new paper in PLoS uses data from the current outbreak in West Africa to determine transmissibility. The investigators found that the R0 is 1.5 in Guinea, 1.6 in Liberia, and 2.5 in Sierra Leone. To provide some context, it is interesting to look at another paper, published today, which is a systematic view of the literature on the transmissibility of influenza. These investigators report that the R0 during the 1918 influenza pandemic, which killed an estimated 30-50 million people, was 1.8. No one remembers that pandemic, but we do remember the 2009 H1N1 pandemic, for which the R0 was 1.5.

Because Ebola virus is primarily transmitted via direct or indirect contact, as opposed to true airborne transmission, the virus seems to have less of a terrorist effect. That is, Ebola infection has the appearance of a much less random event compared to other infections like influenza or SARS. Sitting in my comfy office in Richmond, I have no reason to fear Ebola. On the other hand if I were working in Liberia, I wouldn't be too comforted by Ebola's relatively low R0. As David Hartley eloquently writes in his blog, "no where is it written that dangerous pathogens must have a high R0."

Photo: CNN

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.”

Wanted: Ebola test with perfect negative predictive value at time zero

The tragic death of Dr. Martin Salia has triggered a spate of news articles about the limitations of Ebola diagnostic testing. According to news reports, Dr. Salia tested negative twice early in his symptomatic period, and was already quite ill by the time he tested positive.

The fact that the most sensitive Ebola virus diagnostic test (PCR applied to a blood sample) may not be positive until 3 days after symptom onset is well known, however. The reason for this has to do with the pathogenesis of Ebola virus infection. The point of entry and initial replication for Ebola is the “dendritic” cell. Present in large numbers in the skin, mucosa and intestinal lining, dendritic cells are sentinels, guarding the interface between the human immune system and a hostile environment. They encounter invaders, engulf them, and present their antigens to cells of the adaptive immune system. Dendritic cells carry the virus to lymph nodes and other organs of the “reticuloendothelial system” (liver, spleen). So before the virus reaches detectable levels in the blood, there may be hours-to-days of replication in these cells and organs, along with symptoms of fever and fatigue. A test, even a very sensitive test, that is applied to blood will not detect the virus until it appears in the bloodstream in larger numbers. 

This lack of a rapid and accurate diagnostic test early in the Ebola disease course is a major problem—not only for early initiation of therapy for those infected, but also for the management of “persons under investigation” (who may require Ebola-level isolation precautions for several days while awaiting a negative test that has been taken at least 3 days after symptom onset). 

But this problem plagues infectious diseases diagnostics generally. As this recent Lancet ID article points out, the lack of early and sensitive diagnostic testing is one reason why so many patients in our hospitals receive days of unnecessary antimicrobials. More on this study later, perhaps from Eli, one of the authors!

Image by Sean Gallup, Getty Images

For every rule, an exception

The current Ebola virus disease (EVD) epidemic has repeatedly confirmed a stark “gradient of infectivity”. On the one hand, those severely ill with EVD represent transmission risks so high that safe care can only be provided in the most well-prepared treatment units. On the other hand, those with few or no symptoms of EVD represent nearly zero transmission risk. The best evidence for this is that there have been over 850 health care worker EVD cases (and almost 500 deaths) since the beginning of this epidemic, yet of the several hundred community contacts of cases in the US, UK and Spain, there hasn’t been a single transmission event outside of an intensive care unit.

Thus the rule I’ve heard, and stated, at various times during the epidemic: “no symptoms, no transmission risk.”

Now the exception: sexual transmission. We’ve long known that filoviruses can be detected in semen for weeks and even months after disease recovery (a 1995 study reported Ebola virus RNA in seminal fluid for up to 101 days, and infectious virus up to 82 days, and in 1968 the sexual transmission of Marburg virus was reported 13 weeks into convalescence). Now a concerning case in Liberia has the WHO recommending indefinite safe sex practice for EVD survivors. From the New York Times article:

"The new guidelines came one day after the death of Liberia’s single confirmed patient with Ebola, Ruth Tugbah. Before her illness, the country had gone three weeks without a new Ebola diagnosis, and hopes had risen that Liberia was nearing the end of a yearlong epidemic that killed more than 4,000 people there. Ms. Tugbah’s only known risk factor was having a boyfriend who was an Ebola survivor. 

Scientists detected the genetic material of Ebola from a semen sample the boyfriend provided to infectious disease investigators, officials from two Ebola response agencies said, speaking on background because they were not authorized to speak publicly."

If further investigation confirms this transmission event, it would indicate that she was infected several months after his recovery from EVD (more than the three months currently suggested as the maximum time virus may be present in semen). Given the sheer number of cases that have occurred in the affected countries, this poorly-understood sexual transmission risk adds an unwelcome twist as the outbreak winds down.

Ebola protection: How much is enough?

There's an excellent piece in today's New York Times that focuses on the key question hospital epidemiologists across the country are struggling with: what are the appropriate infection control measures to protect healthcare workers caring for patients infected with Ebola virus? We've blogged on this issue to some extent before (here and here). Are contact and droplet precautions enough (as recommended by CDC), or do we need Tychem suits, PAPRs, and fluid resistant booties, or maybe even something beyond that?

What do we know about Ebola viral disease to guide us in this decision?

• The virus is transmitted via multiple routes: direct or indirect (fomite) contact with blood and body fluids (including urine, stool, vomitus, sweat, tears, semen, breast milk, and saliva), droplet, and fecal-oral. Airborne transmission is also possible if aerosolization occurs.
• Healthcare workers are a major risk group for infection.
• The disease manifestations drive transmission (bleeding, vomiting, diarrhea), leading to environmental contamination and contamination of HCW clothing, unprotected skin and mucosal surfaces. Simulated vomiting studies have shown that droplets can travel over 10 feet. The virus can remain infectious 1-2 days outside the human body.
• Healthcare workers have become infected despite use of maximal barrier precautions.
• If transmission occurs, the disease has a high mortality. 
• There is no known effective antiviral therapy. Experience is too limited to understand the impact that state-of-the-art supportive care can have on improving mortality.
• We have no post-exposure prophylaxis.

Now put yourself in the shoes of a 26-year-old ICU nurse with a 1-year-old child at home who has just been assigned to care for an Ebola-infected patient with active vomiting and diarrhea for a 12-hour shift. What level of protection would you want? It's nurses who will likely face the highest risk since they care for patients for long periods of time and have the most contact with blood and body fluids.

It's interesting in the New York Times piece to contrast the perspective of Nancy Foster, a non-HCW executive of the American Hospital Association, who works in an office far removed from the patient care setting, to that of Dr. Michael Callahan, an infectious disease specialist who has direct experience in Africa with Ebola outbreaks. Ms. Foster tells us that gloves, gown, face mask and eye protection are “perfectly fine.” Dr. Callahan notes that the "perfectly fine" strategy “led to the infection of my nurses and physician co-workers who came in contact with body fluids.” The Ebola veteran notes, “I understand the desire to maintain absolute protection in U.S. hospitals.”

How we deal with perceptions of risk is fascinating. The risks we choose to accept and those we don't can't be explained rationally. But that's quintessentially human. As I see it, healthcare workers that accept the challenge of caring for Ebola patients are providing a great service and face a level of risk that is hard to define. These brave souls deserve to have input on the personal protective equipment they wear. And if they want Tychem suits, so be it. Our job is to then ensure that they can safely use them.

Photo: Newsweek.com. Boris Roessler/DPA.

To CDC or not CDC - That is the Ebola Question

It's been a busy couple weeks out here in infection control land. We had our SHEA 2015 planning committee meeting in DC. There's an exciting program planned - can't wait to share it with you. While I've been planning Ebola symposia for the May meeting in Orlando, Dan and Mike have been very busy discussing and implementing Ebola management plans. If you haven't had a chance to read their excellent posts, you can peruse them all here.

The debate over the CDC droplet+contact precautions guidance is strangely similar (in an opposite day kinda way) to discussions around N95 masks during the 2009 H1N1 outbreak. To remind yourself of the debate, you can read one of Dan's 2009 posts on the topic. What is almost ironic is a quote included in the post: "when did influenza become Ebola." What is actually ironic is that back in 2009/2010, CDC recommended "respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for healthcare personnel who are in close contact with patients with suspected or confirmed 2009 H1N1 influenza." Yet now, CDC does not recommend N95s in most clinical situations for Ebola. And if you're keeping score, in 2009 CDC wanted "higher-level" protection and hospital epidemiologists wanted "lower-level", while in 2014 most hospital epidemiologists are implementing policies that extend way beyond CDCs recommendations.

All of that is by way of background to a thoughtful commentary in Annals of Internal Medicine by Michael Klompas, Daniel Diekema, Neil Fishman and Deborah Yokoe. The authors carefully review the data behind the CDC's current guidance and suggest that hospitals stick closely to the current recommendations. They claim that exceeding the CDC guidance could paradoxically increase health care worker risk and anxiety while also increasing cost and waste. They also suggest that exceeding "CDC's recommendations fans a culture of mistrust and cynicism about our nation's public health agency." The only thing I would add is that no matter what's included in your local Ebola management plans, don't forget the ice cream.

image source: The Onion

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.