Ebola in America: Reign of fear ending, will science prevail?
Panic and politics, mistrust of CDC, bode ill for next pandemic
By Gary Evans, Executive Editor
A U.S. Ebola outbreak characterized more by fear than science — marked by distrust, rumor and false assumptions — may yet yield something positive: A rededication to basic infection control practices in the nation’s hospitals and increased support for infection prevention programs and public health.
As this issue went to press, an American physician who acquired Ebola fighting the epidemic in West Africa had been released from a hospital in New York City, and the outbreak in Texas appeared to be over as well. The index case, Thomas Duncan, acquired Ebola in Africa and traveled to the U.S. while the virus was in the incubation phase. He died Oct. 8 at Texas Health Presbyterian Hospital in Dallas. Two nurses who cared for Duncan acquired Ebola, but subsequently were treated and have fully recovered. The cause of transmission has not been determined, but investigators theorize that exposures could have occurred during removal of personal protective (PPE) equipment after performing high-risk procedures like hemodialysis and intubation on the patient. In the aftermath of the incident the hospital conceded in a letter of apology that "training and education programs had not been fully deployed before the virus struck."1
Texas Health also apologized that Duncan was not admitted when he first appeared at the hospital on Sept. 26 with the initial signs and systems of Ebola. His travel history from Liberia was noted in the medical record, but was not "communicated effectively" between medical staff, the hospital reported. Duncan returned to the hospital and was admitted two days later, raising the painful and inevitable question whether he might have survived Ebola if he had been admitted on the first visit. The hospital was roundly criticized, but some wonder if other U.S. hospitals that have never seen a case of Ebola would have suffered a similar fate, particularly in the practice of infection control when a single breach could lead to transmission.
"Who knows what happened in the [transmission to the nurses], but I would challenge anyone to look at the practices they used before the first case was identified and to answer honestly, Were you adhering with standard precautions and the other activities that guidelines say we should do to practice safely both for patients and ourselves?" says Ruth Carrico, PhD, RN, FSHEA, CIC, a former infection preventionist who is now an associate professor of infectious diseases at the University of Louisville (KY) School of Medicine.
"How many of us could have said, Yes I am willing to go into [an Ebola] environment because I’m confident in my practice,’" she continued. "I think if you asked 100 people that, 99 of them would have taken a step back. Because we know that is not what we were doing. We have been kind of flying loose and easy [with infection control] because up till now it has been OK — so we think. Now we are seeing that almost’ practicing infection control is not OK. Mother nature has given us a stern reminder."
An era of pandemics
Moreover, there is every expectation among epidemiologists and researchers that emerging infections and potential pandemic pathogens will continue to arise, as the speed of global travel and continued encroachment of humans on animal habitats yield highly mobile zoonotic agents like Severe Acute Respiratory Syndrome (SARS), H1N1 pandemic flu and Middle East Respiratory Syndrome (MERS) coronavirus.
Those pandemic pathogens all emerged this century, but the reaction to Ebola in this country has been more reminiscent of the early days of the AIDS epidemic in the 1980s. Some of the same themes seen with Ebola characterized the early days of AIDS — stigmatization of certain groups, mistrust of public health officials, rumors of airborne spread and a litany of other falsehoods and fears that undermined the response to the epidemic. (See related story, p. 125.)
"As we gathered the [HIV] science we were able to figure out what was relevant and what was not — what were we doing just because of fear?" Carrico says. "Then unfortunately over the last 30 years we’ve become very complacent. We thought that almost’ practicing good infection control was good enough."
Ebola’s arrival in America — and whatever future pandemic pathogens will follow — demands a new rigor and dedication to infection control in the nation’s hospitals. The Ebola crisis also revealed that infection prevention departments are understaffed and insufficiently resourced for the kind of surge capacity and training that is needed to meet an emerging epidemic threat, the Association for Professionals in Infection Control and Epidemiology (APIC) emphasized. (See related story, p. 127.) Though the CDC has promised to dispatch rapid response teams to the next hospital that has an Ebola case, facilities large and small must still be able to determine by travel history and symptoms if a patient sitting in their emergency room has the deadly virus. Identification and initial isolation are still necessary no matter how quickly the CDC arrives on site.
"At the base of all this, infection control practice has to be excellent," Carrico says. "That has to be the core, fundamental foundation to every single thing we do. We can’t change this for the disease of the day. As we push our reset’ button we hope the new normal is a practice that is more precise with less deviation. It also points out that infection control is everyone’s responsibility The infection preventionists has be the leader of this process, [but] we need to build a capacity within our healthcare settings [that includes other health care workers and administration]."
The CDC has done a good job in responding to the changing challenge of Ebola and updating and revising guidelines, she notes.
"Hindsight is great — anybody can go back and say you should have done this and that after the situation has been well revealed," she says. "We need to trust the science to help us make these decisions, but we are a very risk-averse society. We’re not willing to accept one situation occurring and because of that then we have to ask how do we reach zero? With Ebola, to reach zero requires a massive undertaking with many unintended consequences."
A delicate balance
Throughout the Ebola outbreak the CDC has had the difficult task of being reassuring without inviting complacency and, on the other hand, issuing urgent warnings without inducing panic. From the onset there were some mixed messages or at least perceptions, as the CDC was originally recommending a combination of contact and droplet isolation (airborne for aerosols) and saying any U.S. hospital should be able to admit and isolate an Ebola patient. Yet the first American cases of care workers infected in Africa were brought in under heavy barrier precautions and treated in virtually failsafe biocontainment units at Emory University in Atlanta and the University of Nebraska in Lincoln. Likewise some hospitals were apparently already preparing to use N95 respirators or powered air purifying respirators (PAPRs) if they had an Ebola case, even though those measures went beyond the initial CDC guidelines.
"I think this fear of Ebola’ started this summer when the first patients were brought back home to Emory for care. Somehow transmission was not emphasized enough at that time," says Patti Grant, RN, BSN, MS, CIC, director of infection prevention at Methodist Hospital for Surgery in Addison, TX. "Not placing blame on the news media or the CDC, yet in retrospect that might be a lesson learned. When any new’ disease comes into a geographic region we should emphasize transmission facts as we know them today.’"
The public was more forgiving about lack of transmission knowledge with a truly novel agent like SARS, but there was the perception that the CDC has been aware of Ebola for decades and should know "everything" about the virus, she adds.
"Well, they did know everything’ there was to know about Ebola until the U.S. health care system introduced dialysis and intubation into the mix -- creating the opportunity for aerosolization of Ebola," Grant says. "That’s aerosolization — not airborne."
The situation is similar to what occurred during the 2001 anthrax mail attacks, which included inhalational infections in the Brentwood postal processing facility in Washington, D.C. CDC officials later conceded that they thought the postal workers were at risk of cutaneous anthrax from handling mail but not inhalational exposures from the sealed envelopes.
"Today it is still true that anthrax is not an "airborne" pathogen, yet who in their wildest dreams would have thought anthrax spores would be placed in an envelope, subjected to high-speed mail sorting machinery and then become airborne?" Grant says. "Some of these very real situations can be misconstrued as lack of CDC knowledge, or one hand not knowing what other is doing, or flat-out deliberate misrepresentation of the facts."
Although Ebola is a bloodborne pathogen like HIV, and hepatitis B and C, the relatively short incubation period and high mortality rate of the virus have contributed to "Ebola hysteria," Grant observes. Even HIV in the era when there was no treatment progressed slowly when compared to Ebola’s typical onset within 8 to 10 days of exposure.
"Ebola has a short incubation period and can kill quickly, and the [misperception] is if it can happen to a health care worker then it must be easy to get," she says.
Mistrust of government
Another factor in the criticism and distrust of the CDC during the Ebola outbreak was the buildup to the Nov. 4 midterm elections. Future outbreaks are going to be difficult to contain if CDC recommendations are ignored, as was the case when Draconian quarantine laws were initially enacted to confine symptomless health care workers for three weeks after their return from the Ebola outbreak in West Africa.
"We are in a period where we don’t have a lot of trust in government because the government hasn’t been functioning well," says Eddie Hedrick, MT(ASCP), CIC, an infection preventionist for decades who is now project coordinator in the state Bureau of Communicable Disease Control & Prevention in Columbia, MO. "The political aspects of the quarantine they put on that young nurse from Maine polarized people. A lot of people looked at her as being some kind of pariah and others on the other side recognized what was happening — that these guys were using this for political gain. It just further divided people."
Infection control groups immediately came out against the harsh measures initially adopted in New York and New Jersey, which were triggered by a symptomless physician who traveled about the city after returning from the frontlines of the Ebola outbreak in Africa. Craig Spencer, MD, was recently discharged from Bellevue Hospital in NYC. Spencer was self-monitoring for symptoms and called in when he began to spike a fever. Ebola is not communicable until the viral titer builds and begins triggering symptoms in the host — fever, headache, nausea, diarrhea, et al. Though the CDC has been emphasizing that point for months, it seems to have been largely lost amid the public fear of Ebola.
Ironically, misguided Ebola quarantine laws for asymptomatic health care workers — ostensibly enacted by states to ensure public safety — could have the opposite effect both in the U.S. and at the outbreak epicenter in West Africa.
"If we turn them into pariahs instead of recognizing their heroic work they may be less likely to disclose their health care worker status and we lose the opportunity to directly monitor them," said Tom Frieden, MD, MPH, director of the CDC. "They may be less likely to go help stop it at the source in Africa, and with that, if it spreads further or longer in the three countries the risk to us would increase."
Urging "individualized assessment" of health care workers returning to the U.S. after treating Ebola patients, the CDC unveiled a risk stratification approach at an Oct. 27 press conference. The three risk categories are high risk (i.e., needlestick); some risk (close contact with someone with symptoms); and low, but not zero risk (air travel with a symptomatic patient). Based on the risk assessment, monitoring, travel restrictions and other control measures are recommended as health care workers report to their state health departments.2
Appealing to reason, APIC reminded that no one in the community was infected by index case Duncan. "The evidence is clear that individuals are not infectious until they show symptoms of the illness," APIC said in a statement. "[Ebola] is not transmitted through the air. It is important to be guided by the scientific evidence, and apply the lessons learned so far from other experiences, including the fact that even family members who were in close contact with Mr. Duncan in Dallas have not gotten sick."
That is a point well taken, as the late Duncan was clearly symptomatic for two days in the community after Dallas Presbyterian failed to admit him when he first presented for care. No one has acquired Ebola in a U.S. community and Duncan remains the only person to die of the disease in the U.S. The only people who have actually acquired the virus in the U.S. are the two Dallas nurses. Thus, after all the sound and fury, as this issue went to press no one was hospitalized with Ebola in the U.S. and eight people had been successfully treated for the disease. With one death among the nine U.S. cases we have a mortality rate of 11%, suggesting that part of the reason Ebola is so deadly in Africa -- with 50% to 90% fatal cases -- is that the level of patient care demanded cannot be adequately delivered. In particular, Bruce Ribner, MD, who treated some of the first cases at Emory University, said Ebola patients have massive fluid loss — rivaling conditions seen in cholera — that can be difficult to restore.
- Berdan, B. Texas Health Presbyterian Hospital. A letter to our community. Dallas Morning News Oct. 19, 2014: http://bit.ly/1whY5oZ
- Centers for Disease Control and Prevention. Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure. 2014: http://1.usa.gov/1wEAq5Z