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Ebola from a North America perspective
Article Type: Ebola from a North America perspective: Clinical Governance: An International Journal, Volume 20, Issue 1
West Africa’s current Ebola outbreak underscores the maxim to “live locally but think globally.” It also reinforces the importance of maintaining North America’s prowess for innovation and health science research. In total, 20 years ago, the innovative Program for Monitoring Emerging Diseases (ProMED-mail, www.promedmail.org/) launched in recognition that infectious diseases of pandemic potential most often would arise in developing countries that need the collaborative support of developed countries. ProMED was an innovative 1994 North American initiative by the Federation of American Scientists and SatelLife that gave locally sustainable global communications technology to healthcare workers in numerous countries that lacked strong public health infrastructure. Since 1999, it has continued to run under support from the International Society for Infectious Diseases and private donations from non-governmental organizations (NGOs including Google, the Gates Foundation, the Rockefeller Foundation, Oracle and others).
The importance of NGOs today cannot be overstated. In decades past, the World Health Organization, The Centers for Disease Control and Prevention and other major public health agencies could respond with their own resources to emerging disease outbreaks. However, today, public health budgets like the annual budgets of their host countries have declined significantly throughout the world. Years of economic erosion compound a realization from prior epidemics that many public health organizations lacked effective organization (Garrett, 2000). Countries like Canada learned from the aftermath of SARS in Toronto that its public health programs needed a complete overhaul (Naylor and National Advisory Committee on SARS and Public Health, 2003; Campbell and Expert Panel on SARS and Infectious Disease Control, 2006). Leadership and financial support for public health interventions from NGOs like the Gates Foundation now provide greater investment and management of investment to achieve results than what has been provided by national governments, the World Bank or others. NGOs like the Gates Foundation provide leadership, funding and accountability, but cannot succeed without sufficient numbers of allied healthcare workers. Without groups like Médecins Sans Frontières (www.msf.org/), an international organization started in 1971 by doctors and journalists in France which itself is being overwhelmed by size of the current Ebola outbreak (www.msf.ca/node/42186), developing countries like those now suffering Ebola in West Africa cannot provide anywhere near the number of health professionals and supplies necessary to treat their own citizens. Beyond the medical treatment of individual patients by doctors and nurses, an important public health role is filled by several nations’ field epidemiology training programs. Those programs maintain a cadre of professionals who can trace the origins of disease outbreaks and epidemics (www.tephinet.org/, http://ecdc.europa.eu/en/epiet/Pages/HomeEpiet.aspx, www.phac-aspc.gc.ca/php-psp/cfep-pcet/index-eng.php, www.cdc.gov/globalhealth/fetp/). The fundamental understanding produced by epidemiologists and their allied scientists is essential to guiding the development of effective prevention programs. Their detailed study of factors accompanying the traditional agent-host-environment epidemiologic triangle (including wider consideration of animal reservoirs, social and cultural practices) often provides the key to developing effective interventions. For example, cultural practices such as funeral ceremonies have facilitated transmission of several diseases including Ebola and SARS. During an H1N1 pandemic that disproportionately affected Aboriginal communities in Canada, public health officials engaged cultural and community leaders to modify traditional practices in order to limit disease transmission. Since many emerging diseases are zoonotic, and amplified by changes in resource use practices, an overarching strategy of the One Health movement also is an important perspective to strengthen the bridge between the fields of human, animal and environmental health (www.onehealthinitiative.com/).
Innovative collaboration with academic and private sector organizations in North America also is an essential part of effective response. For example, in the past, a Canadian center of excellence gained attention as the first to determine the gene sequence of the virus causing SARS (www.bccancer.bc.ca/ABCCA/NewsCentre/NewsArchive/2003/GenomeSciencesCentrecrackstheSARSvirusgenome.htm, www.genomecanada.ca/en/). Non-profit public agencies like Genome Canada are uniquely able to provide this type of cutting-edge capability in a way that shares knowledge freely. There also are important roles for private sector companies. Today, private companies in Canada and California are leaders in developing a specific therapy for Ebola infection (www.tekmira.com/pipeline/tkm-ebola.php, www.mappbio.com/ebola.html), which probably would not have been produced without government investment. Experimental therapies and new drugs in short supply raise ethical issues, which also calls for rapid deliberation by review boards with sufficient expertise and authority to make definitive recommendations (www.cdc.gov/vhf/ebola/outbreaks/guinea/qa-experimental-treatments.html). This is an area in which North America traditionally excels, but which requires on-going effective clinical leadership to maintain.
It is axiomatic that emerging infectious diseases with pandemic potential are just an airplane ride away between all developing and developed countries. Therefore, coming plagues will continue to be a public health challenge in which there is motivated self-interest for all (Garrett, 1995). North American countries have had federal plans in place for years to deal with imported cases of infectious disease requiring the most stringent of infection control precautions. They also have select hospital facilities (e.g. in Georgia, Maryland, Montana and Nebraska) specially equipped to transport and house these cases as well as several biosafety level four laboratories specially equipped to study the pathogens. Fortunately, Ebola is only transmitted by very direct contact from ill person to another person, so with well-known infection control practices Ebola cases could safely be cared for in other North American hospitals (www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html) if their leadership is sure that those practices are followed reliably. However, as illustrated by Marburg, Ebola, SARS, MERS-CoV and other epidemic infections, health services and public health will constantly be challenged by new and adapting viral infections. As challenges and knowledge advance, state and federal plans evolve to adapt. For example, after American public health authorities and elected public officials saw the distinction between epidemiologic knowledge of low transmission risk vs public perception of higher risk from asymptomatic healthcare workers during the 21-day incubation period following their last care of an Ebola patient, several states took a lead in imposing formal quarantine (in place of twice-daily reported self-monitoring with self-limited public transit while free of fever or other symptoms) for 21 days. This imposition of quarantine is not without controversy, and faces challenge in the courts to redress the balance between broad curtailment of constitutional civil rights vs actual magnitude of any public health risk (Flegenheimer et al., 2014). Concurrently, CDC reiterated a preferred approach based on individual assessment and scientific knowledge about Ebola transmission. CDC’s update details four levels of potential exposure along with commensurate public health actions recommended for each level in asymptomatic individuals, distinct from specific actions recommended in symptomatic cases (www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html).
In order for public health agency advice to remain a trustworthy influence in this and future epidemics, clinical leaders with expertise to advise on control of pandemic infections need to consider an additional responsibility. Rival nation states are most vulnerable when experiencing one of these epidemics. Even among allies, economic implications of trade or travel restrictions cause friction (e.g. Toronto, during the SARS pandemic). Sanctions have sometime been imposed that had more political than prevention value (Garrett, 2000), so responsible clinical governance should make all effort possible to ensure that any proposed trade or travel bans have a clear, sound scientific basis. In the past, medical missions also have sometimes been covers for efforts to obtain pathogens, including Ebola virus, for the purpose of creating biological weapons through genetic engineering modification (Garrett, 2000; Henderson et al., 2002). Again, leaders with appropriate expertise need to remain vigilant against any future such clandestine activity.
This is not the first time that Ebola has caused a crisis in Africa (Garrett, 1995). Before, it was an unfamiliar disease with an unknown cause. Much more is now known. However, then as now, its spread is linked as much with a virus transmitted through direct contact as with issues of poverty and social capital. Developed nation responses to prevent emerging infectious diseases must include biomedical expertise and clinical governance leadership, but also consideration of sustainable economic and social development consistent with different cultures around the world. The spread of Ebola has been stopped before. The leadership challenge today is to go beyond just stopping this single epidemic, to also promote sustainable disease prevention on the broadest scale possible. North America can contribute immediate aid and innovative technology to combat this epidemic (www.whitehouse.gov/blog/2014/09/16/major-increase-our-response-ebola-outbreak, http://news.gc.ca/web/article-en.do?nid=884669, www.phac-aspc.gc.ca/media/nr-rp/2014/2014_0915f-eng.php). This government-to-government aid includes both immediate consumption supplies and temporary placement of personnel but also items of lasting value (new facility construction, education of local workers). North American individuals also contribute collaborative partnerships of lasting value – for example projects like the Patan Academy of Health Sciences (Courneya and Dunn, 2009), or the March of Dimes and Rotary International’s significant roles in providing immunization to eradicate polio globally. Ebola, unlike polio, cannot be eradicated by community immunization alone; however, immunization may be the best future strategy for preventing more outbreaks. No vaccine has been proven effective and licensed as yet, but an experimental vaccine developed by Canada’s National Microbiology Laboratory in Winnipeg Manitoba is entering human safety trials, as is another vaccine developed by GlaxoSmithKlein in conjunction with the US National Institutes of Health. Questions have been raised that have important implications about public health funding and oversight in the clinical trial stage of vaccine development, and current lack of transparency related to the present model of contracting clinical trials to private companies (www.cbc.ca/thecurrent/episode/2014/11/19/canada-should-break-newlink-ebola-vaccine-contract-critics-say/). Questions suggesting undue years of delay in bringing the Canadian vaccine to trial were raised by a distinguished Canadian professor of law (Branswell, 2014), who also has doctoral-level qualifications in immunology.
An update on the current situation in West Africa, and insights gained from experience with the first cases of Ebola transported to treatment in the USA, were provided at the October 2014 IDWeek conference (an annual conjoint meeting of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association and the Pediatric Infectious Diseases Society). The medical director of a program at Emory University Hospital dedicated to care of highly infectious serious diseases told attendees that he received three days’ advance notice of the first known patient with Ebola arriving. His presentation in a special plenary session (session No. 8, annual program agendas available at: www.idweek.org/) explained the need for effective internal and external communication with all concerned to address their issues while respecting patient confidentiality. Dr Bruce Ribner outlined key aspects from their experience regarding:
Biocontainment facility (Smith et al., 2006; virtual tour of Emory’s facility available at: www.youtube.com/watch?v=63cTXQxntbw) – specially designed biocontainment unit patient rooms with anterooms (noting they are not required with Ebola because there is not airborne transmission, but they were convenient in this situation to provide a separate space with ICU-level care for 1:1 nurse:patient ratio staffing and point-of-care laboratory assay equipment).
Planning – noting that no part of the institution is not involved, starting with how a patient would be transported into the facility (details summarized here are expanded in Isakov et al., 2014).
Patient Care Clinical Issues – a facility like Emory can provide a level of care far above even the best of Africa’s, which led to discovery that these patients are significantly hypovolemic as fluids shift to third-space, losing up to five liters per day, so are hypokalemic, hypocalcemic and hyponatremic despite earlier care in Africa. Studies conducted around the patient recovered Ebola viral RNA from skin, blood, urine, semen, endotracheal suctioning, vomitus and stool but not in dialysate fluid nor on any high-touch surfaces (thus illuminating why Ebola spreads so easily among close-contacts but also supporting effectiveness of normal housekeeping and surface disinfection).
Laboratory, staff and environmental issues – pragmatic compromises had to be reached on several points (e.g. statements on laboratory safety from one authoritative organization suggest that with proper bloodborne pathogen precautions the specimens from Ebola patients can be processed in normal laboratory spaces, while another expert organization on laboratory safety advises a separate space should be established at the point of care; while the former can be safe, the prospect of losing laboratory services if any breakage or spillage contaminated the hospital’s laboratory led to setting dedicated analyzers in the biocontainment unit immediately adjacent to point of care. Similarly, when commercial shippers refused to transport specimens from the Ebola patient, regardless of the fact that specimens were properly packaged in compliance with federal standards, Emory staff made arrangements to carry materials to CDC’s laboratories themselves. Finally, although CDC guidelines indicate medical waste can be disposed of in the normal manner (flushed into a sanitary sewer system or hauled in proper packaging for disposal by incineration and in hazardous waste landfills and soiled linens processed by normal hospital laundering, the local wastewater regulatory agency and the hospital’s trash haulers refused to accept this so the hospital compromised by using bleach or quaternary ammonium detergent with five minute contact on liquid and large volume autoclaving of hundreds of boxes of medical waste prior to disposal). Emory also took personal protective attire for staff very seriously, and like several Southern California hospitals (personal communication, California Metrics Group) built in a requirement that anyone donning or doffing such attire be observed by a co-worker trained in its use. This harkens back to the SARS outbreak in Toronto with transmission to staff possibly due to self-contamination while removing protective attire incorrectly (Offner-Agostini et al., 2006; Shigayeva et al., 2007). Dr Ribner also commented that his team initially trained to use masks but later chose to use powered respirators instead of surgical masks only because masks are more uncomfortable to wear while in a patient’s room for long periods of time.
Media and communications – the unit team worked closely with their hospital’s media relations experts to plan a comprehensive campaign for educating as well as allaying fears, yet also protecting patient confidentiality. They held “town meetings” with staff, provided information sheets to all patients admitted to the hospital, and emphasized that internal and external communication is critical. They created a comprehensive frequently asked questions blog (www://advancingyourhealth.org/highlights/posting-policy/faqs-about-the-ebola-virus-and-emory-university-hospital/).
Dr Ribner also noted that patients with Ebola are exceptionally expensive to treat. Others at the conference echoed how much of their hospital epidemiology and infection control resource was being dedicated to advance planning at many hospitals, in anticipation that each could receive a patient in whom Ebola-like symptoms might raise clinical suspicion and many concerns.
This contrasts with the handling in Texas of a person recently arrived from Liberia whose Ebola symptoms developed soon after landing in the USA. Miscommunications within that hospital when he first went for care led to several days’ delay in hospital admission and treatment initiation for an infection that ultimately proved fatal; additional exposure of others which increased public concern (Swanson et al., 2014); and two of their staff nurses involved in his care subsequently tested positive for the virus (Cohen et al., 2014; Levs and Yan, 2014). As well, there was delay and confusion about how to clean the apartment where the Liberian stayed prior to hospitalization (Sack and Fernandez, 2014). This contrast underscores the necessity for clinical leadership in:
Conducting drills to prepare proficient teams.
Implementing protocols to ensure full compliance with correct use of preventive measures throughout patient care (e.g. the requirement of buddy teams to observe donning and doffing of personal protective attire – see, for example a different Dallas hospital’s instructional video at: http://youtu.be/1GNKJL1_ejg which was made before a later revision in CDC guidelines that added extra layers of protection to the attire, and CDC videos made after the revision available at: www.medscape.com/viewarticle/833907 and www.cdc.gov/vhf/ebola/hcp/ppe-training/index.html).
Applying the learning from one’s own drills and experience reported by others, in order to refine their facility’s operational plans.
Consistently communicating effectively among all stakeholders.
Tabletop exercises are a practical tool for advancing regional planning among all stakeholders, and a few state health departments that ran exercises made available their tabletop exercise resource materials for others to use (www.kyha.com/kentucky-public-health-ebola-tabletop-exercise/ ; www.aha.org/content/14/141003-comb-tn-ebola-tabletop.pdf). Also by October 2014, the Emory University and University of Nebraska hospitals’ Ebola infection control protocols became available on the internet (www.emoryhealthcare.org/ebola-protocol/ehc-message.html; http://app1.unmc.edu/nursing/heroes/ppe_posters_vhf.cfm).
Applied Epidemiology, North Saanich, Canada
The author thanks Dr Marcus Lem and Kathleen Quan for their helpful review comments on the initial draft.
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