A bioethics panel report on the response to the Ebola outbreak gave a ringing endorsement to infection preventionists, saying in times of a public health crisis U.S. policy should provide IPs the support to act to the fullest extent of their abilities.1
Once Ebola arrived in the U.S., it would appear there were not enough resources, infrastructure, and education regarding Ebola risks and transmission, reported the Presidential Commission for the Study of Bioethical Issues.
In addition, inconsistent recommendations from public health authorities led to stockpiling and subsequent shortages of personal protective equipment, the panel noted.
“U.S. policy should consider local and global interests to ensure that resources are appropriately allocated in a timely and consistent manner,” the Bioethics Commission recommended. “This includes identifying healthcare professionals, such as infection preventionists, who play a key role in public health emergency preparedness and response, and providing this group the support to act to the fullest extent of their licensure and abilities.”
LACK OF FORSIGHT
Unfortunately, such foresight was not in evidence during the Ebola response, as IPs were so inundated with Ebola training and related issues they warned during the epidemic that other infections may begin to rise. “Our fear is that while we are dedicating these resources to Ebola, are infection preventionists ignoring other types of things?” said Linda Greene, RN, MPS, CIC, of the Association for Professionals in Infection Control and Epidemiology (APIC). “Will we miss those red flags if we have a flu epidemic or we have a number of patients with CRE [carbapenem-resistant Enterobacteriaceae]?”
ETHICAL PRINCIPLE OF LEAST INFRINGEMENT
In other report findings, the bioethics panel said the misguided attempts to quarantine asymptomatic healthcare workers returning from fighting Ebola in West Africa last year were unethical and counterproductive.
“Needlessly restricting the freedom of expert and caring healthcare workers is both morally wrong and counterproductive — it will do more to lose than to save lives,” says Amy Gutmann, PhD, chair of the Bioethics Commission.
“The Ebola epidemic in western Africa overwhelmed fragile health systems, killed thousands of people, and highlighted major inadequacies in our ability to respond to global public health emergencies. It demonstrated the dire need to prepare before the next epidemic,” according to the commission report. “A failure to prepare and a failure to follow good science — for example, by not developing vaccines and not supporting healthcare providers — will lead to needless deaths.”
Future epidemics and public health emergencies should be guided by the ethical principle of “least infringement,” which means “any restrictive measures should be grounded in the best available scientific evidence and restrict individual and community liberties only so much as is necessary to protect public health,” the panel recommended. “These measures should not present unnecessary barriers to movement of healthcare workers to and from affected areas so that they can contribute their skills to the management of the public health emergency and other health problems.”
PANIC AND DEMAGOGUERY
After the first U.S. case of Ebola onset in a patient last year, two Dallas nurses were occupationally infected. Ebola fears began to triumph over science, particularly when the Dallas incident was followed by an asymptomatic physician out and about in New York City before developing symptoms related to his care of Ebola patients in West Africa.
Though he was monitoring for symptoms and presented for care appropriately, some states enacted or proposed 21-day quarantines for healthcare workers returning from the epidemic frontlines in West Africa. The three-week duration was to cover the outer limits of the incubation period of the virus, but these restrictions ignored the fact it reinforced the false perception that asymptomatic healthcare workers who treated Ebola patients could transmit the virus.
CDC RISK ASSESSMENT APPROACH PREVAILED
The CDC recommendations for self-monitoring policies and “individualized assessment” of healthcare workers who treated Ebola patients based on their risk of exposures ultimately prevailed. However, it appeared for a while that healthcare workers would refuse to volunteer to fight the epidemic in Africa if they were going to be quarantined for three weeks upon return. In fact, this actually happened while the quarantines were still in place, according to a nurse who participated in one of the Bioethics Commission hearings. Having previously completed a deployment to Africa, Kate Hurley, RN, MBA, MSN, was asked by the World Health Organization if she would return for a brief 10-day stint.
“I’ve come back from West Africa, I’ve integrated back into my job,” said Hurley, an ICU nurse manager at Providence St. Patrick Hospital in Missoula, MT. “So you look at it economically, okay, can you leave your job for another 10 days? Sure. You look at it socially. Can you leave your teenage children at home? Well, maybe.”
“But you decide that probably socially and economically, that you could probably leave for 10 days. So you’re ready to make the decision, and then you know what flashes in the back of your head? Twenty-one days [in quarantine upon return]. Twenty-one days. I declined — not based on economic or social issues, but based on the lack of clarity in what happens to someone when they come back [from West Africa].”
In comments submitted to the Bioethics Commission, APIC emphasized that “there is no scientific basis to justify placing a person who had contact with an infectious patient, but is currently asymptomatic into quarantine. …”
The experience of isolation during quarantine can be a traumatic experience for individuals, with serious financial and psychological hardships reported, APIC warned.
“In the absence of scientific evidence of a public health benefit to quarantine, we believe the ethical consideration of curtailment of personal liberty must be the primary deciding factor.”
- Presidential Commission for the Study of Bioethical Issues. Ethics and Ebola: Public Health Planning and Response. Feb. 2015: http://1.usa.gov/1BMv0Ut.