By Stan Deresinski, MD, FACP, FIDSA
Dr. Deresinski is Clinical Professor of Medicine, Stanford University; Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center.
Dr. Deresinski has served as a one-time consultant for Cubist and Bayer.
SYNOPSIS: Much was learned in the United States in dealing with the fear of Ebola virus infection — but can we avoid wasteful panic with the next outbreak of a novel pathogen?
SOURCE: Koonin LM, Jamieson DJ, Jernigan JA, et al. Systems for rapidly detecting and treating persons with Ebola virus disease — United States. MMWR Morb Mortal Wkly Rep. 2015;64(8):222-225.
The Ebola outbreak in West Africa appears to be winding down, and the panic in the United States spread by cable news and politicians (a strong argument for urgent improvements in science teaching in the United States) appears to have subsided. Given the enormous efforts put forth and money wasted for activities within this country, it is a good time to review the current status of activities here.
Since August 2014, exit screening procedures for international flights leaving countries with Ebola activity (Liberia, Sierra Leone, Guinea — and for several months ending in January 2015, Mali) include administration of a health questionnaire, measuring body temperature, and, if fever is detected, assessment of the likelihood of the fever being caused by Ebola. Travelers who have fever or symptoms compatible with Ebola or who report a high risk for exposure to Ebola are, as a consequence, denied boarding on international flights.
Travelers to the United States from Liberia, Sierra Leone, or Guinea are all routed to one of five international airports — JFK (New York City), Dulles (Washington D.C.), Liberty (Newark), O’Hare (Chicago), or Hartsfield-Jackson (Atlanta). Those with a possible Ebola exposure risk are further evaluated by onsite CDC public health officers. Individuals with symptoms such as fever undergo additional assessment and may be referred for care at a local hospital.
State and local health authorities are notified by CDC within hours of individuals who require monitoring. Monitoring continues until 21 days after their departure from one of the target countries, during which time they are required to measure their temperature at least twice daily. Some with greater exposure, such as those who provided health care to an Ebola patient, must also report twice daily to public health authorities, including once with direct visual contact. Anyone who develops Ebola-compatible symptoms is immediately referred for medical assessment at a health care facility.
Acute health care facilities (AHCF) serve one of three roles in dealing with Ebola: frontline health care facilities, Ebola assessment hospitals (EAH), and Ebola treatment centers (ETC). Although patients with possible symptomatic infection are generally referred to higher level facilities, they may in some cases initially may be dealt with at acute health care facilities — most acute hospitals with emergency departments meet criteria for this designation (assuming, of course, proper training of personnel). AHCFs should be prepared to rapidly identify and isolate patients who might have Ebola, promptly inform the hospital/facility infection control program and state and local public health agencies, and quickly transfer these patients to an EAH or ETC.
EAH facilities are able to safely provide care until an Ebola diagnosis is confirmed or excluded, and manage other conditions present (e.g., malaria) until, in confirmed cases, transfer to an ETC where they may receive comprehensive care for the duration of illness. As of February 18, 2015, there were 55 U.S. hospitals with designated Ebola treatment centers. Three U.S. biocontainment units (Emory University Hospital, the National Institutes of Health Clinical Center, and Nebraska Medicine) also serve as Ebola treatment centers.
The Office of the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services is taking this tiered approach further by developing a regional approach. As many as 10 Ebola treatment centers with enhanced ability to care for patients with highly infectious diseases, including Ebola, will be designated to serve as regional Ebola and other special pathogens treatment centers. These centers will be able to receive patients with confirmed illness from anywhere in the United States, as well as patients who have been medically evacuated from outside of the United States. Patients with confirmed Ebola will be preferentially referred to one of these regional centers, as necessary. In addition, CDC Ebola response teams are deployed by request to any Ebola treatment center or hospital with a confirmed or highly suspected case of Ebola to provide technical assistance for infection control procedures, clinical care, and logistics of managing a patient with Ebola.
What have been the results of these activities? From October 11, 2014, through January 31, 2015, a total of 7,587 persons arriving from affected countries have been screened upon entry to the United States. Of these, 543 (7.2%) were referred to onsite CDC screening at the airport for additional exposure risk assessment. At the time of assessment, 12 (0.16%) travelers were referred for medical evaluation at a local hospital, and none had Ebola diagnosed. During October 11, 2014–January 31, 2015, at least 136 persons were identified as “persons under investigation” (PUIs) (individuals with an epidemiologic risk factor within the preceding 21 days with symptoms compatible with Ebola). None of these persons under investigation had Ebola; the most common diagnoses were malaria and influenza.
In December 2014, Gregg Gonsalves, taking lessons from dealing with the panic that accompanied the early years of the AIDS epidemic in the United States, addressed the Ebola panic by saying that, “We all have to become activists if we are to protect the public health from being used as a tool to serve primarily political purposes, as it has been over the past few weeks in the United States.”1 In other words, don’t let the politicians and cable news bloviators run the asylum.
- Gonsalves G. Panic, paranoia, and public health — the AIDS epidemic’s lessons for Ebola. N Engl J Med 2014;371:2348-2349.