As an Ebola outbreak continues in the Democratic Republic of Congo (DRC), infection preventionists again face the threat of an ill traveler from the region walking through the doors of their EDs.
“I think we are better prepared now than we were in 2014 in relation to federal guidance, checklists, and information,” says Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology.
Although hospitals are generally better prepared than when the last Ebola outbreak began, there is some concern that facilities do not completely understand their roles in the new tiered healthcare network adopted after the 2014 outbreak, she says.
A government report1 found that many hospitals did not understand their roles in the tiered Ebola hospital system that was adopted after the chaotic response to the 2014 outbreak.
“About a third of hospital administrators could not verbalize their hospital’s designation related to the Ebola tiered system,” Hoffmann says. “That is concerning. There is also a lot of concern among all the hospital systems about sustaining their level of preparedness because of so many competing priorities.”
The tiered healthcare response system includes frontline hospitals, assessment facilities, and designated treatment centers. The vast majority of U.S. hospitals are considered “frontline,” which according to the Department of Health and Human Services2 means they should be prepared to:
- rapidly identify and isolate a suspected Ebola patient;
- notify appropriate facility staff and public health authorities. Contact an assessment hospital or Ebola treatment center to coordinate patient transfer;
- have enough Ebola personal protective equipment (PPE) for at least 12 to 24 hours of care.
At the next level, there are 217 Ebola assessment hospitals with lab testing capabilities, enough PPE for 96 hours, and a system to remove highly infectious waste.
In addition, the hospital network has 63 designated treatment centers, which have the capability to care for at least two Ebola patients for their duration of illness.
Beyond the elaborate measures, simple things can save lives. Infection preventionists should ensure travel history questions are asked on patient entry, Hoffmann says. “Not so much just for Ebola, but all emerging infectious diseases,” she says. “That is so important, and I know it is not always being done. We really need to re-emphasize this point to infection preventionists.”
Johns Hopkins is one of 10 designated Ebola treatment centers across the country that employ “enhanced capabilities” such as designated biocontainment units and other control and treatment measures. Despite that, the hospital still has to be ready for an ill traveler walking into the ED.
In this sense, the basic principles of “identify, isolate, and inform” apply to all facilities, says Jennifer Andonian, MPH, senior infection control epidemiologist and program manager for the Johns Hopkins Biocontainment Unit. “The only way we are going to be able to ensure the safety of our healthcare workers is to start with the initial identification of these patients,” she says.
That 2014 outbreak was characterized by a lot of confusion about PPE, particularly the finding that healthcare workers frequently contaminated themselves doffing their PPE. That may have been a factor in the case of two Dallas nurses who contracted Ebola but survived after caring for a dying patient from West Africa.
The basic PPE needed is considerable in the new tiered system, even for frontline hospitals that will be looking to quickly hand off a patient to one of the Ebola assessment facilities. The CDC recommendations for possible cases of Ebola in frontline hospitals include such PPE as disposable fluid-resistant coveralls and gowns; a single-use full-face shield; and two pair of gloves that include one with extended cuffs.3 More extensive measures are recommended if a suspected or confirmed Ebola patient is bleeding or vomiting.4
“It does take a lot of resources to prepare,” Hoffmann says. “[With PPE], it’s kind of like muscle memory. If healthcare facilities really aren’t maintaining their competencies on specialized care, PPE, and other equipment as they need, they are not going to be able to maintain their preparedness.”
Infection preventionists assisted healthcare workers in correctly removing the PPE in a recent drill at Hopkins. “If a healthcare worker was to become contaminated, we have training and protocols in place to remediate that depending on the severity,” Andonian says.
For example, healthcare workers involved in the care of Ebola patients can communicate by a mobile phone app to report any symptoms. “That allows us to send text message prompts for symptom monitoring,” she says.
“That is something we do for any healthcare worker who comes into contact with the patient themselves. We apply similar principles if someone had an exposure, depending on how high-risk.”
In addition to a focus on donning and doffing PPE, the Hopkins drill emphasized the importance of avoiding contaminating the patient care area and the surrounding environment in general. A lot of this is “spatial awareness” when working within patient rooms, in addition to establishing “clean spaces” and using mechanical disinfection systems or surface wipes, Andonian says.
Setting up protocols and practicing such measures will bolster treatment and response for pathogens more common than Ebola, she adds.
“These practices really transcend beyond high-consequence pathogens,” Andonian says. “These principles can help identify patients with measles, chickenpox, or tuberculosis. If we can do the basics really well, we should have better systems in place to identify these high-risk but low-probability cases.”
Ebola Simmers in the DRC
Meanwhile, as the Ebola outbreak in the DRC threatens to spill beyond its borders and get into more populated urban areas, there are increasing calls for a greater global response.
“We saw when we had a lot of resources from multiple agencies and countries that they were able to turn around the 2014 outbreak,” Hoffmann says. “I think they neeed to allow the amount of resources needed to turn around this outbreak.”
As of March 5, 2019, the Ebola outbreak in the DRC region of North Kivu had reached 907 cases (841 confirmed and 66 probable), the World Health Organization reports.5 Overall, there have been 569 deaths, a case fatality rate of 63%. Earlier reports indicate at least 68 healthcare workers have been infected and 21 have died. The outbreak began in August 2018.
An experimental vaccine has been deployed that was found to be highly effective in one trial,6 but amid the chaos of disease, civil unrest, and armed conflict, no scientific assessment of vaccine efficacy in the DRC has been reported.
“The unofficial impression from the folks on the ground there is that it has been effective, but I think there are some instances in which people have been vaccinated and haven’t been protected, which is pretty common with any vaccine,” says Jennifer Nuzzo, DrPH, SM, a senior scholar at the Johns Hopkins Center for Health Security in Baltimore.
Healthcare workers are vaccinated pre-emptively, but the strategy for the general population is ring vaccination. “When a case is identified, they try to find their contacts and offer them vaccine,” she adds.
“Healthcare workers are one of the few, if not the only, groups that do not have to be tied to cases in order to get vaccine,” she says.
“Some people have called for an enlargement of pre-emptive vaccination that they are doing, some kind of geographic campaign to try to anticipate where future cases may be headed. So far, that hasn’t been done.”
Nuzzo says the situation in the DRC is deteriorating and urged action in a recent commentary on the outbreak.7 Concurring in this concern is Lawrence Gostin, JD, a professor of global health law at Georgetown University in Washington, DC.8
“It’s definitely getting worse,” he says. “I think the World Health Organization made an error in not calling a global emergency in October . At the time, the situation on the ground met the criteria for a Public Health Emergency of International Concern.”
Nuzzo agrees, saying the highest level of emergency has not been called because “It’s very political. The fear is that countries would take non-evidence-based actions, like decide to make it harder to travel to and from the area.”
An Ebola care center established by the highly respected Doctors without Borders volunteer group was recently destroyed. The CDC — the healthcare agency that probably has the greatest Ebola expertise in the world — was previously pulled from the DRC due to the security concerns.
In what is likely to be a sign of future outbreaks, the DRC is suffering co-epidemics of disease and violence. Rather than withdraw, the world must step in to secure the region and stop Ebola before it gets into more urban, mobile populations, Gostin argues. “Job one is to protect health and humanitarian workers,” he says.
“We should never be in a situation where people have to put their life on the line to provide care. We should also quell the violence so the CDC can be back on the ground in the hot zone providing their expertise.”
The UN mission preceded the Ebola outbreak, and they are there for general peacekeeping. They are not trained, nor do they have a specific mandate to protect healthcare workers, he explains.
“The potential for global spread is ever-present,” Gostin says. “Certainly, the greater danger is to the region. Imagine if it gets across the border to Somali or Uganda or to major cities — it would spread like wildfire. If it carries on the way it is, it will only be a matter of time before it appears in a major global city in the U.S. or Europe.”
- HHS. Office of Inspector General. Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak. Report (OEI-06-15-00230). Oct. 16, 2018. Available at: https://bit.ly/2TrOjH3.
- HHS. Regional Treatment Network for Ebola and Other Special Pathogens. November 2017. Available at: https://bit.ly/2VrnvTP.
- CDC. Interim Guidance for Preparing Frontline Healthcare Facilities for Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD). Available at: https://bit.ly/2XulQ1M.
- CDC. Guidance on Personal Protective Equipment (PPE) To Be Used By Healthcare Workers during Management of Patients with Confirmed Ebola or Persons under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE. Available at: https://bit.ly/2T2RJzS.
- WHO. Ebola virus disease – Democratic Republic of the Congo. March 7, 2019. Available at: https://bit.ly/2J4P6c7.
- Henao-Restrepo AM, Longini IM, Egger M, et al. Efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein: interim results from the Guinea ring vaccination cluster-randomised trial. Lancet 2015;386:857-866.
- Nuzzo JB, Inglesby TV. Perspective: Ramping Up the Response to Ebola. N Engl J Med 2018; 379:2490-2491.
- Gostin L, Phelan A, Coutinho AF, et al. Ebola in the Democratic Republic of the Congo: Time to sound a global alert? Lancet February 04, 2019. DOI: https://doi.org/10.1016/S0140-6736(19)30243-0.