The Ebola outbreak is presenting "some of the same challenges we saw with HIV: fear of contagion, questions of professional responsibility to care, awareness of potential risk of caring," but some lessons learned in the 1980s seem to have been forgotten, says an AIDS expert.
In many ways, the AIDS epidemic in the early 1980s was the best thing to happen to healthcare.
There was panic. There were mistakes. There was backlash against homosexuals, users of IV drugs, prostitutes, and even people from Belle Glade, FL, after an erroneous report that Everglade mosquitoes transmitted the virus.
Some doctors and some hospitals declined to take infected patients. Some frightened embalmers refused to accept the dead.
But in time, reason prevailed. And we learned a lot from HIV/AIDS.
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The epidemic spawned universal precautions after providers began to assume all patients were potentially infected. Healthcare workers institutionalized the proper use of gloves, masks, surgical tools, and needles. The virus pushed science, drug and vaccine development, and inspired the PCR genetic sequencing tool, which earned its creator a Nobel prize.
It also helped epidemiologists develop effective, not counterproductive, strategies for contact tracing to prevent spread.
And on the human front, AIDS helped a largely homophobic public see normal families and communities, not freaks or misfits. Experience and time have taught us the folly of stigma and fostered anti-discrimination laws.
Forgotten Lessons?
But the Ebola epidemic in West Africa has shown providers that they haven't learned some lessons well enough. Or maybe some lessons have been forgotten.
- Ebola has been spiraling out of control in West Africa since March, yet only in recent weeks has there been a call for an international response.
- Though 33 outbreaks prior to this year's since 1976 resulted in some 2,000 people being infected and more than 1,000 dead in Africa—and scientists predicted it was only a matter of time for the next one—pharmaceutical companies have developed no proven therapies or vaccines. Experimental compounds are exhausted or in short supply.
- A patient's travel history should be easily viewable in an electronic health record to all providers in a hospital emergency room or clinic, not just because of Ebola, but because of numerous other infectious diseases of international concern. Yet something went wrong with the EHR system at Texas Health Presbyterian. In a statement, the hospital acknowledged a flaw in the system, only to issue a retraction the next day.
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It's obvious this workflow disconnect is not uncommon. To borrow National Institute of Allergy and Infectious Diseases Director Anthony Fauci's reference to how the hospital treated Thomas Eric Duncan, who died Wednesday, the healthcare community has in many ways "dropped the ball" in its response so far.
Some of the Same Issues, Challenges
"It's feeling as though Ebola is following very closely the history of the HIV epidemic, although in an incredibly accelerated time frame," says Paul Volberding, MD, an oncologist who practiced during the earliest days of the epidemic and created the first inpatient ward for AIDS patients at San Francisco General Hospital in 1983.
"Ebola is following some of the same issues, leading to some of the same challenges we saw with HIV: fear of contagion, questions of professional responsibility to care, awareness of potential risk of caring," Volberding said by phone this week.
"And all of that is happening in a kind of breathless scale of time, where every day there is another important development. Last week Texas. This week the Spanish case. The acuity of fear. The issues of quarantine."
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"Ebola is reminiscent of some of the HIV issues, especially now that it's a healthcare worker who was contaminated, not in the Ebola epicenter of West Africa, but in a nurse in Spain," he says.
Volberding, now board chairman of the International Antiviral Society-USA and head of the UCSF Center for AIDS Research, acknowledges that there were opportunities to better manage Ebola, with knowledge learned from dealing with AIDS and other infectious diseases. But in Texas, and apparently in Spain, some lessons weren't learned well enough, or have been forgotten.
"Boy did we blow it in terms of being sensitive and supportive of the family," Volberding says. "We focused all of our efforts on the fear of that patient. We tossed the family back in, locked them into an apartment that's contaminated with [towels, linens and mattresses that weren't removed for almost a week].
"The insensitivity with which they treated the people surrounding that patient is a big lesson."
One we should have learned from HIV/AIDS? I ask Volberding. "Exactly," he says. "We forgot."
Better Gear Needed
Another HIV lesson learned not quite well enough is the need to develop and more carefully use personal protective equipment such as gowns, shields, booties, and gloves. The ones used by U.S. healthcare workers in Africa were designed to be used in controlled environments such as intensive care units, not out in the field.
"In Africa, it's hot and humid. And the idea that we're putting people out there, really, in harm's way in terms of responding to sick people with equipment that's not designed for that setting, is crazy," Volberding says.
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"I'm sure this has to be happening now: the design of materials that are more comfortable, easier to use and safer has to be a high priority."
But why so late?
Another lesson from HIV that appears to have been forgotten is the importance of learning how to safely put on and take off protective gear, which may be the route of infection implicated in the case of the Spanish nurse. "It's tricky," Volberding says. "Because you have to do it without touching the outside of it… because the outside is what might be contaminated."
'Still Learning'
Volberding also thinks a critical lesson learned from HIV/AIDS that has lapsed is that public health officials should tell the public only what they know for sure, not what they hope, about any emerging infectious virus.
During the early years of HIV/AID, he was a national spokesperson for healthcare workers, and a symbol of calm and reason in an era of fear and panic.
"We always tried to tell what we knew and explain the limitations, in what we didn't know. We said we didn't know how it was transmitted exactly, and as we learned more we refined that statement. Now," Volberding says, "in the interest of reassuring people, maybe we're sounding like we know more than we really do."
Unfortunately, he says, CDC officials and others have made "absolute" statements that the Ebola virus can't be spread by aerosolized droplets.
"We don't know everything about the transmission of this virus yet. We can't say that we absolutelyknow it's not an airborne spread, because there is that possibility," Volberding said. With hundreds of healthcare workers becoming infected in Africa, he said, "We're still learning about each of these exposures. And that's exactly my point."
"We have to be a bit more cautious about what we're saying," he says.
Years from now, I hope some will say that Ebola helped providers improve their delivery of care. We can only hope.