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Manoj Jain, MD, MPH | Physician | October 25, 2014

Recently at our community hospital, after we concluded a nearly two-hour standing room only Ebola preparedness meeting, I practiced donning and doffing the personal protective equipment (PPE) for Ebola cases.

PPE is the protective wardrobe health workers wear when examining a patient with a contagious infectious disease. Each disease has a different level of transmission and requires an appropriate level of protection. I wear gloves 25 times a day to examine each patient I see. (Not all doctors do this; in my specialty of infectious diseases, though, it is prudent.) I dress in a gown a dozen times when entering a room of a patient with antibiotic resistant bacteria like MRSA. I place on a mask a few times a day when I suspect that the patient has the flu or tuberculosis.

The risk of infection often times is to patients when health workers carry infectious agents like MRSA on their hands or clothes from one patient room to another or into the community leading to an outbreak of resistant bacteria. On other occasions the risk is to the health care workers of acquiring diseases such as flu, TB or meningitis from the patient.

Ebola poses both these risks. In fact, Ebola in America has completely overturned the thinking and practice of isolation precautions by its highly infectious nature. One billion Ebola virus particles are in two drops of blood, and it has a mortality rate of 70 percent.

In my hospital’s administrative boardroom, with guidance from my “buddy” the infection prevention nurse, I began my Ebola PPE practice. I first placed on the impervious booties and leg coverings, then the blue plastic impervious gown, then the N-95 mask, then the face shield, then head covering, and then two pairs of gloves.

A few weeks ago I thought that this was all overkill. But after I learned that Dallas nurses has contracted Ebola even with their protective gear, I wonder if this is sufficient. After a few minutes in the total body covering, I felt sweat on my neck. If I breathed heavily my face shield fogged up and when I walked across the room my boot and leg covers began to come off exposing my pants. A splash on them would mean that I could carry the virus home, putting my family at risk.

My “buddy” guided me through each step. Then I soaked my hands in water — as if I had a viral or blood exposure — and began the task of undoing the protective covering. First, removing the soiled gloves, replacing them with new ones, and then removing my head covering, gown, boot covers, face shield and mask, making sure to only touch the insides or backsides of the coverings. On three occasions the nurse stopped me from contaminating myself.

“It’s not easy,” another nurse who was on a hazardous material team remarked with a concerned look.

“So how can we do this better?” I asked. “We need practice.” While theoretically all hospitals should be able to manage an Ebola patient, in practice it is not possible. In my opinion, we cannot train hundreds of hospital staff including doctors, nurses, phlebotomists, and x-ray technician in meticulous isolation procedures.

I believe we need to treat every Ebola case under a hazardous material protocol, not as a hospital infectious disease isolation management protocol. A hazardous material management protocol requires a specialized team, specific equipment and trained practices. We need a local Ebola treatment center and a trained Ebola treatment team at one facility in each metro area, just as we have trauma centers and trauma teams.The Centers for Disease Control and Prevention is developing regional centers and will deploy rapid response teams however, we need to be prepared locally because Ebola will be a concern for months if not years and its course may be unpredictable.

One such team per metro area should be sufficient since we are unlikely to see thousands of cases of Ebola in America — as there are in Africa. Funding for training and preparing such a team could be shared by all the local hospitals because in large part it will save them tremendous internal resources to prepare for extensive hospital management of such patients and disruption if a patient has to be admitted to their  facility.

However, with such a team, local hospitals and emergency rooms cannot drop their guard. All hospitals, primary care doctors and minor medical clinics would serve as triage units to help identify and isolate potential Ebola cases, because this is where patients will come first. Locally, health departments, hospital executives and infectious disease experts need to quickly meet and develop an Ebola management center and a team, if a case occurs in their city.

The past weeks has taught me an important lesson. Either we are underestimating the infectiousness of Ebola or overestimating our ability to protect our health care workers with our present protocol and training. Or what is more troubling — it may be both.

Manoj Jain is an infectious disease physician and contributor to the Washington Post and The Commercial Appeal.  He can be reached at his self-titled site, Dr. Manoj Jain. This article originally appeared in the Huffington Post.

http://www.kevinmd.com/blog/2014/10/ebola-local-hospitals-prepared.html
 и ряд комменатриев от медперсонала, которые дорисовывают картину:

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94359159
No, there is no such technology available. Presumably (i.e. it hasn't been reported in literature yet to my knowledge), RT-PCR should be able to catch cases just before they become symptomatic, but not necessarily in the couple of days immediately after exposure. I hope someone is working on this!

127315262 Eric Strong •
The 21 day quarantine is hyper-effective. Each person infected with the Ebola virus only infects two others on average, even in West Africa, where the funerary practice is for the entire family to pretty much bathe in the fluids of the victim. If 90% of infections are apparent by 21 days, then the infection rate is 10% * 2 = 20%. The outbreak will die out within a few cycles. This approach successfully took smallpox to extinction, and it was vastly more infectious.

There is the possibility that the virus will evolve to adapt to the quarantine period, but that is not necessarily a bad thing. Indolent viruses tend to lose their hazardousness. (Ebola's trick of blocking interferon signalling is not compatible with a 21 delay.) Selective breeding can turn a killer virus into a vaccine within a few viral generations

41423175
By recommending that community hospitals should be the forefront of fighting possible Ebola epidemic, CDC made a political decision to prevent panic related to Ebola over prevention of disease. This decision contradicts CDCs own rules of handling bio safety level 4 (BSL4) infections which Ebola is. Specifically, the standards for personal protective equipment (PPE), general security standards and the extent of training recommended to community facilities is much less stringent than that of BSL level 4 labs, CDCs bio containment units or their military equivalents. This move was supported by some nearsighted healthcare experts, who I am sure never have and never will deal with real Ebola patients. Healthcare professionals in tranches were thrown under the bus and blaimed for CDCs shortcomings. And hospital administrators were quick to announce their facilities readiness to handle Ebola cases as one more marketing ploy, playing Russian rulette and hoping they would never see real Ebola case.

57494404 Тhe military has the luxury of rotating soldiers out of combat (which is their job) and into less active settings where they have time to engage in intensive training, undistracted by having also to complete combat duties.

Our healthcare enterprise does not wish to rotate doctors and nurses out of their active jobs and into intensive training sessions, and so training for healthcare workers is rarely all that effective, since it is done on the fly, generally on the worker's own time, or in brief sessions that are squeezed into the worker's usual work day.

26910633
This, this and more this. Rapid comprehensive training of the entire healthcare workforce of the united states, of sufficient quality to ensure virtually no accidental transmission of Ebola in the event of a true epidemic, is a pipe dream.

Just ask yourself - how much training would you personally insist on, and how much practice, before you would don the space-suit, and walk into a room for 6-8 hours with a fluid-spewing ebola patient, in the terminal stages of their ilness, and know with near certainty that you won't contaminate yourself, or your family when you return home? Now imagine that time commitment, multiplied by 200,000, in a system that is already short on manpower, with sufficiently frequent retraining and practice to commit the protocols to muscle memory. You would also need to continue that degree of preparedness pretty much forever (never know when the next Ebola will strike).
So...follow that train of thought: it would cost a hospital hundreds of thousands of dollars to properly train all front-line workers to safely manage an Ebola patient. Do you think that your typical hospital CEO making a seven-figure salary is likely to approve a budget item which would adversely impact the hospital's ability to pay that salary? Highly unlikely.
At my hospital, there have been zero training sessions, at least for me and my peers. Instead, we were all forwarded a 45 minute video of an informational meeting (that we were not given time off to attend) and encouraged to "take a few minutes of your time" to watch the entire tape, presumably at home, at night, after all of our regular work was done for the day.

94359159
I agree with the previous responses. It is a virtual impossibility to prepare every hospital to be adequately prepared for Ebola. For training of adequate number of staff, providing adequate supply of PPE, and ward/room retrofitting, I would guess a minimum of half a million per hospital (yes, that kind of stuff is super expensive) x 5000+ hospitals = 2.5 billion dollars. Profound waste of money and resources. Plus, this isn't a one time cost. Training would need to be ongoing in order to prevent loss of knowledge and skills.

You think they can train Private Moron to reliably handle serious biohazards? You must be joking. Have you seen this story? http://www.nbcnews.com/news/us...   Finally, the idea of putting an Ebola patient into a neonatal-type incubator is laughable. The amount of vomit and diarrhea produced during the peak of illness severity renders this completely implausible.

94773551

One thing about the article bothers me. The author talks about washing the gloves before removing the rest of the suit. If I read the news stories from Liberia properly Medecins sans Frontieres (even under the conditions there) has staff step into a sealed shower where the entire suit is washed with a chlorine solution to sterilise it before disrobing begins. Why was this step skipped?

94359159

Hospitals aren't physically designed for this. Most isolation-specific rooms have an antechamber for putting on/taking off facemasks, gowns, and gloves. There is a sink present for washing hands. However, I've never seen an isolation antechamber with its own shower, and most of them are physically too small to retrofit them with one. This is yet another reason why it is implausible to make every hospital ready to handle an Ebola patient.

A network of 14 public laboratories scattered around the U.S. is geared up and ready to test for Ebola -- including the Texas state lab in Austin.

They're backed up by federal labs at the CDC and the U.S. Army Research Institute of Infectious Disease (USAMRIID), whose researchers developed the test that's being used, according to Chris Mangal, MPH, director of public health preparedness and response for the Association of Public Health Laboratories, based in Silver Spring, Md.

"The list will expand," Mangal told MedPage Today, "as the CDC looks to distribute the assay to other laboratories."

The labs are selected members of the Laboratory Response Network, which was set up to allow rapid detection of a host of chemical or biological threats, including emerging infectious diseases.

In August, the FDA issued an emergency use authorization for an Ebola test, using real-time polymerase chain reaction methods (RT-PCR), and the CDC asked several labs to gear up for testing using the assay, Mangal said.

Aside from Texas, the labs now in the network include state facilities in Nebraska, Montana, Maryland, Florida, Minnesota, New York, Michigan, Virginia, North Carolina, Pennsylvania, and Washington, as well as local labs in New York City and Los Angeles County.

The testing process begins, of course, with a patient -- someone who fits the profile of a possible Ebola victim. That profile includes fever and recent travel to West Africa, the center of the current Ebola epidemic.

But the initial symptoms are nonspecific and mimic several other diseases, including malaria, which is also endemic in the Ebola hot zone.

So the first step in the process is a consultation between the hospital, local or state health department, and the CDC to decide if the clinical picture is worrisome enough to warrant testing, Mangal said.

When Duncan was diagnosed Sept. 30, the CDC had taken part in about 100 such discussions and had suggested going forward to full testing in just 15, according to agency Director Tom Frieden, MD. In all but the Dallas case, results were negative.

Once it's decided to test a patient, the hospital collects blood, using its usual precautions associated with blood-borne pathogens, and ships samples to both the CDC and its designated reference lab.

The blood is shipped in watertight plastic tubes placed within a watertight secondary packaging, with the whole enclosed in a rigid box. Samples are often shipped using commercial couriers, but some locations might also have their own transportation facilities, Mangal said.

At the lab, "everyone knows this is on the way," Mangal said, and only designated staff members are permitted to accept the shipment and move it into the test area.

The CDC's guidance for testing suggests that laboratories can use biosafety level 2 (BSL-2) methods, but most are taking the additional precautions associated with BSL-3 facilities, Mangal said. None of the 14 labs has BSL-4 capability, although both the CDC and USAMRIID do.

Personnel carrying out the test need both training and practice, Mangal said, but the "good thing for us" is that all of the designated labs had staff with the appropriate knowledge. "These are the types of things they prepared for and were ready to respond to," she said.

The test gives a "presumptive" positive or negative verdict, which must then be confirmed by parallel testing at the CDC, Mangal said. If the results differed, she said, the CDC would likely do additional testing, but "we have not seen that."

Nurses Feel Left Out

Meanwhile, a large nurses' unions says hospitals aren't communicating effectively with registered nurses about how to prepare for a possible Ebola patient.

In a survey of members by National Nurses United, also based in Silver Spring, nearly 80% of respondents said their hospital has not yet told them what the policy is regarding admission of Ebola patients.

And 85% said hospital education on Ebola has not allowed nurses to interact and ask questions.

"Handing out a piece of paper with a link to the Centers for Disease Control, or telling nurses just to look at the CDC website -- as we have heard some hospitals are doing -- is not preparedness," said union spokeswoman Bonnie Castillo, RN.

"Hospitals can and must do better, and we should have uniform national standards and readiness," Castillo said in a statement.

Some 1,400 RNs at more than 250 hospitals in 31 states have responded to the survey, the statement said. The union has about 185,000 members, according to its website.
http://www.medpagetoday.com/InfectiousDisease/Ebola/47980

If another Thomas Eric Duncan sought medical treatment today, Dallas County guidelines might well lead a doctor to send him back home.

Duncan met three Ebola criteria when he first walked into the emergency room of Texas Heath Presbyterian Hospital Dallas last month. He had recently lived in Liberia. He had a fever. And he had symptoms consistent with Ebola: abdominal pain and headache.

But the county health department says that isn’t enough to test someone for the virus that made Duncan its first fatality in the U.S. and has killed thousands of other West Africans.

Why? Because Duncan reported no known exposure to infected people or animals. A county screening document says that such patients are considered unlikely to be infected if an alternate diagnosis exists for their symptoms and they need not be tested for the virus. Federal guidelines call for greater scrutiny of such patients.

The early symptoms of Ebola — Duncan’s symptoms — resemble those of other diseases. That can make it difficult to rule out other diagnoses. Everything boils down to a clinical judgment in what may be a frantically busy emergency room.

Why not just test anyone who meets the three criteria that Duncan met?

Its important to try to eliminate likelier diagnoses such as malaria first, Dr. Wendy Chung, Dallas County’s epidemiologist, said in an interview Friday. “You don’t want to waste resources.”

Chung, who is responsible for the county’s algorithm establishing Ebola guidelines, said she didn’t know the cost of testing.

The Texas Department of State Health Services and the federal Centers for Disease Control and Prevention perform the tests. Carrie Williams, a spokeswoman for the state agency, said in an email Friday evening that she did not have enough information to estimate their cost.

See a related video on Dallasnews.com

“The test kit itself is from the CDC at no cost,” she said, “but there are costs to us” for example, staffers’ time and the need to equip them with special protective gear.

Presbyterian says it has depended on the county’s screening document. However, that apparently wasn’t what led the institution to discharge Duncan early Sept. 26, without consulting the county health department. The hospital blames that on an ER doctor not knowing — for unexplained reasons — what a nurse knew: that the patient was newly arrived from West Africa.

After four hours in the ER that first visit, doctors decided he had sinusitis, gave him antibiotics and sent him home, according to a timeline released Friday by the U.S. House Energy and Commerce Committee.

(ежу понятно, что при синусите наблюдается так же острая боль в животе, а не только голова болит и температура)

On Sept. 28, Duncan returned to Presbyterian. This time he was in an ambulance, much sicker, having vomited uncontrollably. This time the hospital suspected Ebola and contacted the county.

But there was still no rush to test him for Ebola, said his nephew Josephus Weeks. So on Monday morning, Sept. 29, he complained to the CDC. Officials there, he said, referred him to the Texas health department.

Weeks said Chung called him that afternoon and refused his plea for expedited testing.

“I said, ‘You know he came from Liberia, and it’s infested with Ebola,’” Weeks recalled. “She said, ‘We can’t send it out [on a rush order] unless he said he had contact with an Ebola patient.’”

Chung said she notified her bosses about Duncan that afternoon. Ordinarily, she said, she would not tell them about an infectious disease case until a test confirmed it.

Chung said she shared Weeks’ concern about Ebola “and let him know that testing had already been ordered.”

Officials in Liberia and the U.S. have accused Duncan of concealing contact he had with a dying Ebola victim shortly before flying here. Weeks vehemently disputes that. Duncan’s family says he told them he was unaware he’d been exposed.

Chung said that expedited testing after Duncan returned to Presbyterian would not have changed the care he received. Presbyterian promptly isolated him, she said.

And there is no established treatment that leads to a cure for Ebola, which has killed about 50 percent of people who contracted it in Africa.

But expedited testing does enable a faster public health response — faster identification and assessment of those who may have been exposed to the virus.

It isn’t clear whether Weeks’ complaint speeded testing. He said Chung told him on Sept. 29 to expect results in three to seven days. But the Ebola confirmation came on Sept. 30.

The actions of Chung and the hospital might have seemed reasonable to many health care experts at the time. Nobody had ever developed Ebola in the United States. And no hospital or doctor was required to use government screening guidelines.

Dr. Christopher Perkins, the Dallas County health department’s medical director, stressed that the county’s guidelines are “ not the law. Each clinician has at his or her discretion to evaluate in real time what’s going on.”

A questionnaire that accompanies the screening document says doctors should isolate patients who have the symptoms and history Duncan did on his first visit to Presbyterian. Doctors are also told to consult their hospitals’ infectious disease experts and the health department.

“These two pages are connected,” Perkins said.

The questionnaire is on the page that follows the algorithm. The questionnaire appears to offer the proper procedure, conflicting with the algorithm. But if doctors were to use the algorithm to diagnose Duncan, his stated lack of known exposure might not have pointed doctors to that other page.

Dr. Daniel Varga, chief clinical officer of Presbyterian’s parent, Texas Health Resources, said the county guidelines were issued to the staff in August.

“The [Ebola algorithm] that we communicated to the staff was the county health department’s algorithm,” he said.

The hospital has since issued its own guidelines to caregivers that appeared to be consistent with CDC protocols.

Dallas County’s health department is not the only one to offer its own guidance on Ebola. For instance, the Florida Department of Health distributed a flow chart on Sept. 5 that is almost identical to the Dallas County screening tool. As in Dallas, someone in Florida with the history and symptoms of Duncan’s first visit would be classified “NOT CURRENTLY SUSPECTED – NO TESTING.”

Some hospitals have developed their own protocols. Parkland Memorial Hospital in Dallas developed its own response to Ebola, officials there said.

On Aug. 1, the CDC sent health providers an Ebola alert. Shortly thereafter, Parkland changed its intake procedures, said the hospital’s disaster medical director, Dr. Alexander Eastman.

All patients are asked at intake about travel to the Ebola-active parts of West Africa, he said. If the answer is “yes,” that patient is isolated immediately and met with staffers wearing protective gear before any additional examination or testing, he said.

That’s far above what either the county or CDC recommends. The process was developed by a committee of infectious disease experts who looked at recommendations available and came up with their own checklist, Eastman said.

More than 44,000 patients on the main hospital campus alone have faced those new Ebola-related initial questions since August, he said.

After Duncan’s diagnosis was made public, Parkland added another early question having to do with contact with someone with Ebola in Dallas.

“We are constantly tweaking it,” Eastman said.http://www.dallasnews.com/news/metro/20141017-dallas-county-protocol-could-let-ebola-carriers-slip-through-the-system.ece