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Ebola in the U.S.: Reason to Fear, to Hope, to Prepare

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   September 25, 2014

At some point an Ebola case will probably show up at a U.S. hospital, most likely in a big-city ED. Here's what hospitals should be doing to prepare.

The rapidly evolving Ebola epidemic, with 4,507 probable and confirmed cases in West Africa by September 14—more than double those from the 33 preceding outbreaks combined—should make U.S. hospital providers wary, if not nervous, about what to expect next.

Ebola: 7 Questions About U.S. Providers' Response

Consider these evolving facts:

  • The new case count model for 2014 released Tuesday estimates that 21,000 people in Liberia and Sierra Leone will have become sick with Ebola viral disease in the next five days, and as many as 1.4 million by Jan. 20, 2015. That's up from 49 cases just six months ago, according to the Centers for Disease Control and Prevention.
  • The agency's projections factor the knowledge that cases are "significantly underreported by a factor of 2.5." In some parts of West Africa, case counts are doubling every 15-20 days, with fatality rates between 50% and 70%, the CDC says. "Fresh Graves Point to Undercount of Ebola Toll" read the New York Times page one headline Tuesday.
  • CDC director Tom Frieden, MD, in a warning published today in an Ebola-themed issue of the New England Journal of Medicine, writes, "If a single case is missed, a single contact becomes ill and isn't isolated, or a single lapse in infection control or funeral-practice safety occurs, another chain of transmission can start."

"Each month, several thousand travelers from affected areas enter the United States, and even more people travel to and from Europe, other parts of Africa, and Asia," he says. "As long as Ebola is spreading in these regions, clinicians need to be alert to the possibility of EVD, take a travel history, and promptly isolate and test ill travelers who have returned from these regions in the past 21 days and have symptoms consistent with EVD."

The CDC created a two-step screening bulletin.

  • Fear in the region is another formidable threat. In Guinea last week, a team of eight, including educators, medical officers, a cleric, and three journalists, were killed by a "mob" of villagers who apparently thought their visitors were causing the outbreak, another episode in a string of violence against healthcare workers attempting to isolate the epidemic.
  • U.S. hospitals may be unprepared to manage hazardous waste such as soiled linens and medical tools used to treat infected patients. A spokeswoman for Emory University confirmed a Reuters report Wednesday that quoted an Emory official saying bags of waste piled up when the hospital's waste management contractor initially refused to handle the material, used in treating two infected U.S. missionaries brought there from West Africa last month. The contractor said the material required special handling. 

According to American Hospital Association Senior Associate Policy Director Roslyne Schulman, "CDC guidance includes how to handle Ebola-related waste. However, there is a discrepancy between what CDC recommends and what the Department of Transportation requires that is still being resolved. Until it is, hospitals should follow CDC guidance.”

It’s unclear why governments and health officials haven't stopped the epidemic this time, or why it spread so much so fast, even though they've seen its geometric rise over the past six months. There were plenty of opportunities back in March and April. Why are major U.S. and international efforts only now being pledged?

We know better. We've done better. But we never seem to learn.

When Ebola shows up in a U.S. hospital ED

With such a rapidly moving target, how should providers prepare? How likely is it, providers wonder, that an unexpected infected patient from the affected regions in West Africa come through a physician's office, clinic, or emergency room door in the United States? And how soon?

David Kuhar, MD, a CDC infections disease specialist who leads the agency's domestic Ebola response, including healthcare worker safety, told me that "no one can predict with certainty what is going to happen.

"But I think, as the outbreak continues to progress, the likelihood that we're going to have someone return with Ebola and present to a healthcare setting increases. There is more potential for it to show up here."

The emergency department is likely to see Ebola first.

"I think that most prudent people that you talk with will say that it will likely occur," says Rade Vukmir, MD, spokesman for the American College of Emergency Physicians. A big city with international ports is his best guess.

And while front-line healthcare workers have prepared for other pandemics like H1N1, Middle Eastern Respiratory Syndrome (MERS), hantavirus, and bird flu, "Ebola is different," he told me, because of its high fatality rate, the potential need for special protective gear, and isolation capabilities that may be limited in some healthcare facilities.

"Where we're lucky is that until now, its transmission is not airborne," but is limited to contact with bodily fluids, Vukmir says.

The AHA's Schulman told me that U.S. hospitals are prepared and "on high alert. They're taking the possibility of a patient unexpectedly arriving from West Africa, having been exposed to Ebola, quite seriously." Hospitals should be double-checking their isolation units and taking inventory of necessary supplies, which they do as a routine, she says.

There are tabletop disaster preparation drills being planned in many states, including Kentucky and Maryland. The AHA urges hospitals to participate in a federal webinar about a new CDC hospital checklist of how to recognize and handle a patient with suspected Ebola infection.

"While we are not aware of any domestic EVD cases (other than two American citizens who were medically evacuated to the United States), now is the time to prepare, as it is possible that individuals with EVD in West Africa may travel to the United States, exhibit signs and symptoms of
EVD, and present to facilities," the checklist says.

There is good news. Frieden said during a news conference Tuesday about the CDC's new modeling tool that mobilization of teams from the United States—with 3,000 military troops and $175 million pledged by President Obama last week, and commitments from other countries and companies, including $1 million from Nashville-based HCA Healthcare—it now looks like the epidemic that was spiraling impossibly out of control a few weeks ago is now possible to contain.

"This is a fluid and dynamic situation," Frieden said. "What the modeling shows us is that even in dire scenarios, if we move fast enough, we can turn it around. And I’m confident that the most dire projections are not going to come to pass, given what we've already seen on the ground in terms of the response and what we're beginning to see in terms of some of the data coming in."

Just back from Liberia where he and others made recommendations to improve air travel screening and quarantine protocols, the CDC's Tai-Ho Chen told me that government and health officials are performing mandatory "temperature checks" through non-contact infrared thermometers on all passengers, under the authority of the Liberian government, to make sure a traveler who is running a fever is not permitted to travel and receives medical attention. "Throughout all countries, there have been a number of travelers who have been denied boarding and go through additional medical evaluation to clear them" before they can travel out of Sierra Leone or Liberia.

In the Tuesday news conference, Gayle Smith, senior director of the National Security Council, applauded a "tremendous surge in resources and response, even in the last few weeks," and said the CDC has "over 100 experts in the field" and others from the Department of Defense who could make containment possible.

The 33 Ebola outbreaks preceding this latest epidemic have claimed more than 2,000 lives over the last 40 years, for an overall case fatality rate of 67%. Most were more easily contained because they were in remote areas, away from big cities and fast-moving transportation systems, unlike this one.

Let’s all hope that the resources pledged now, and the heightened international resources, will not be too late.


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