Ebola Preparedness in Hospitals
By Carol A. Kemper, MD, FACP
SOURCE: Cummings KJ, Choi MJ, Esswein EJ, et al. Addressing infection prevention and control in the first U.S. community hospital to care for patients with Ebola virus disease: Context for national recommendations and future strategies. Ann Intern Med 2016;165:41-49.
During the next five years, the federal government will provide $12 million in funding to three institutions in the United States (Emory University, University of Nebraska Medical Center, and Bellevue Hospital Center) to co-lead the National Ebola Training and Education Center. This collaborative effort is intended to support training and education of U.S. hospital healthcare personnel in the management of high-level infectious diseases, such as Ebola. Previously, Emory and Nebraska Medical Center had worked in conjunction with the Centers for Disease Control and Prevention (CDC) to educate and train more than 460 healthcare personnel at 87 facilities.
Training efforts will focus on: the prompt recognition and isolation of at-risk patients with immediate use of appropriate personal protective equipment (PPE); basic PPE education and training; standardization of signage between facilities related to isolation procedures and PPE; and development of a “system-wide” inter-disciplinary group to address emerging infectious threats. In addition, they plan to expand high-level PPE training to all employees in the emergency department, inpatient care units, MICU, and labor and delivery at the above facilities. The CDC also has formed an “Ebola response team,” which can be deployed anywhere in the United States for a highly suspicious or confirmed case.
Other new national recommendations and policies for addressing emerging infectious diseases for hospital personnel include:
- Annual training and refresher course for basic PPE;
- Annual education on high-level PPE and respirator use with supervision by trained personnel;
- Annual training and competencies for high-level PPE with donning and doffing;
- Consideration of conducting one clinical disaster drill annually.
Although drills are costly and take personnel away from day-to-day tasks, there are numerous benefits to conducting clinical disaster drills. At our facility, repeated drills and education gave hospital staff a sense of control and comfort during the Ebola threat of 2014-2015. Although the chances that our facility would be affected were extremely low, it was challenging to enlist the support of some employees, and some of the nursing staff were so terrified they literally quit their jobs. Within six months, we conducted 25 drills for hospital personnel, including all staff potentially affected, followed by open debriefing sessions with the CMO, infectious disease, and infection control personnel. Not only did this allow us to identify gaps in our procedures and tighten up the plan, but it engaged people in open conversation, encouraged everyone to participate and express their concerns and ask questions, and went a long way toward allaying fear. It also engendered camaraderie among all levels of staff, and inspired everyone’s involvement in a way that made everyone feel they had something important to contribute. And I thought all that practice for Ebola responsiveness made the hospital run more smoothly in the following months.
Meningococcal Vaccine Recommended for HIV+ Persons
SOURCE: MacNeil JR, Rubin LG, Patton M, et al. Recommendations for use of meningococcal conjugate vaccines in HIV-infected persons — Advisory Committee on Immunization Practices, 2016. MMWR Morb Mortal Wkly Rep 2016;65:1189-1194.
As of Nov. 4, 2016, all HIV-infected persons 2 years of age and older should receive two doses of conjugate meningococcal ACWY vaccine (MenACWY-D [Menactra, Sanofi Pasteur] or MenACWY-CRM [Menveo, GlaxoSmithKline]), at least two months apart, with revaccination every five years. HIV-infected persons 56 years of age and older (for whom these vaccines are not routinely recommended nor FDA approved if not HIV-infected) are included in this recommendation. Persons who previously received one dose of meningococcal conjugate vaccine should receive a booster dose using the same vaccine when known.
Mandatory reporting requirements for meningococcal infection do not require information on HIV status, even when known, so the true incidence of meningococcal infection in HIV-infected persons is not known. During the past few years, the occurrence of several outbreaks of meningococcal infection within groups of men who have sex with men (MSM), many of whom were HIV-infected, has prompted much discussion about whether HIV-infected persons are at increased risk for meningococcus and the risks/benefits of vaccination in this group of individuals.
By now, the evidence is sufficiently compelling — HIV-infected persons do appear to be at increased risk for meningococcal infection. From 1995-2014, nearly 4,000 cases of meningococcal disease were reported through the National Notifiable Diseases Surveillance System. Sixty-two (2%) of these were known to be HIV-infected, the majority of whom were adults 20-59 years of age. Of these, 69% were due to serogroup ACWY, 21% to serogroup B, and 10% were not known or other. While recent observations from New York and the United Kingdom did not suggest an increased mortality in HIV-infected persons when infected with meningococcus, data from South Africa did observe an increased risk of death in HIV-infected persons with meningococcus compared with non-HIV infected persons (20% vs. 11%, respectively).
HIV providers should be aware that the immunogenicity of meningococcal vaccine improves with increasing CD4 count, and those with lower CD4 counts may have a poor response to vaccine. One recent study measured seroresponses in adult HIV-infected persons to one or two doses of MenACWY-D vaccine, as defined by either a four-fold rise in titer or a titer ≥ 1:128 using a rabbit complement bactericidal assay. In those with a CD4 count percentage ≥ 15%, seroresponses to serogroup C at 4, 28, and 72 weeks following a single dose of vaccine were 65%, 31%, and 21%. In those with CD4 counts ≥ 15% who received two doses of vaccine six months apart, seroresponses to serogroup C following the second dose were marginally improved at 59%, 64%, and 35%. However, in those with lower CD4 counts, all of whom received two doses of vaccine six months apart, responses to serogroup C were only 22%, 22%, and 6%. Seroresponses to serogroup Y were somewhat better than to serogroup C. Severe side effects were followed for six weeks post-vaccination and occurred in 2.2% to 6.5%. Seroresponses in HIV-infected children were somewhat better than in HIV+ adults.
Recommendations for meningococcal vaccine over the past few years have been evolving quickly. As of November 2016, current recommendations for routine vaccination with MenACWY in the United States include:
- all healthy adolescents;
- all persons with HIV-infection ≥ 2 years of age (including those ≥ 56 years of age);
- all persons ≥ 2 months with certain medical conditions (genetic deficiencies of complement pathway, persons receiving eculizumab, and persons with functional or anatomic asplenia, including those with sickle cell disease);
- microbiologists routinely at increased risk for exposure to meningococcal isolates;
- military recruits;
- first-year college students planning to reside in residence halls;
- persons who travel or reside in areas where meningococcus is hyperendemic (e.g., Hajj);
- persons at increased risk during an outbreak of meningococcus ACWY.
Recommendations for routine vaccination with serogroup B vaccine now include:
- those with persistent complement deficiencies;
- those with functional or anatomic asplenia;
- microbiologists (as above);
- those affected by an outbreak of meningococcus B.
For details, see the recent 2016 ACIP adult immunization schedule http://www.cdc.gov/vaccines/schedules/hcp/adult.html.