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Ebola Cases Bring Practical and Clinical Challenges

CARING FOR THE FIRST TWO EBOLA virus–infected humanitarian workers in the United States required high-level clinical services for the patients as well as practical strategies to deal with fears among hospital staff and the local community.

For hospital staff, twice-daily “town hall” meetings were initially held to ensure that people who weren’t part of the Ebola virus disease (EVD) treatment team were “more comfortable” with the presence of the patients, said Aneesh Mehta, associate chief of infectious diseases at Emory University Hospital in Atlanta.

“The members of the team knew what we were doing, but not everyone at the hospital did,” said Mehta on September 8 at the Interscience Conference on Antimicrobial Agents and Chemotherapy meeting in Washington, D.C.

Mehta said the hospital sent out regular e-mail updates to staff about the Ebola virus–infected patients and also informed all patients at the hospital about its decision to treat the humanitarian workers.

The hospital also had to respond to concerns within the local community.

For example, in early August, as Emory was receiving the two patients, Internet reports stated that the hospital planned to flush the patients’ liquid waste down the toilet to undergo standard sewage processing.

That, in turn, set off fears among area residents that their water supply would be contaminated by the Ebola virus. Comments on the hospital’s blog included one by a resident who claimed to be so “terrified” about the safety of the water that her health was suffering.

Ultimately, Mehta said, “local and civil authorities requested that no untreated [Ebola virus–containing] patient waste enter the municipal waste stream.” To comply with the request, liquid waste from the patients was disinfected with bleach or a detergent before being flushed.

Mehta also said Emory had to deal with “surprises in shipping” when some hospital staff refused to come to the isolation unit to pick up samples, and local couriers at one point “refused to touch” any containers labeled for transport to the Centers for Disease Control and Prevention (CDC), which is located about a mile from Emory.

It’s not surprising for people to be frightened by the Ebola virus. About half of those reported to be infected during the current outbreak in West Africa have died so far; uncontrolled bleeding has been portrayed as a symptom of EVD; and there is no approved vaccine or drug therapy for the disease.

ASHP has developed an Ebola resource center on its website to update members on the latest information and provide critical resources concerning this ongoing public health crisis.

The United States classifies the Ebola virus and other hemorrhagic viruses as level A “select agents” that pose a risk to national security—the highest threat level. Level A select agents can be easily transmitted from person to person, result in high death rates and a potentially major public health threat, may cause public panic and social disruption, and require special action for public health preparedness.

CDC in September released interim guidance about how the select agent regulations apply to activities associated with the diagnosis and care of patients with suspected or confirmed Ebola virus infection.

According to CDC, any hospital that follows the agency’s infection control recommendations and can isolate a patient in a private room can safely care for Ebola virus–infected patients.

In clinical settings, CDC specifically recommends that hospitals “implement standard, contact, and droplet precautions” while caring for these patients.

CDC’s website contains several documents related to EVD preparedness, including a detailed hospital checklist. According to CDC, the checklist contains “practical and specific suggestions to ensure your hospital is able to detect possible EVD cases, protect your employees, and respond appropriately.”

“I think, at the very least, every institution needs to go through the checklist,” said Deanne E. Tabb, infectious diseases clinical pharmacist at Columbus Regional Healthcare System in Columbus, Georgia. Tabb said the document is being reviewed by her hospital’s infectious diseases and infection-control staff as part of their preparedness efforts.

“I think we’re always prepared for any infectious disease influx that comes our way,” Tabb noted.

Removing the Personal Protective Equipment (PPE) properly was the key to preventing contamination.

She recommended that hospitals be aware that CDC’s recommendations include droplet precautions in addition to the standard and contact precautions that hospitals routinely follow to prevent disease transmission.

Emory’s Ebola virus–infected patients were housed in the hospital’s serious communicable diseases isolation unit, but Mehta said such a resource “is not necessary to take care of patients with Ebola.”

“We have it, so we used it to make it easier for our processes,” Mehta said. He said the team had “dedicated medical equipment” for the isolation unit and made use of disposable supplies and equipment whenever possible.

Mehta said Emory staff was trained in “donning and doffing” personal protective equipment (PPE), and a team member observed the process each time it was performed in the unit.

“Removing the PPE properly was the key to preventing contamination,” Mehta said. But he noted that “some complacence” among staff in the donning and doffing of PPE was observed over time and had to be addressed.

According to Emory’s website, hospital staff were trained to use face masks and goggles when caring for the Ebola virus–infected patients but instead used powered air-purifying respirators even though the virus is not transmitted in the air. The hospital stated that this equipment was used because it is more comfortable to wear for long periods than a mask and goggles.

A small laboratory was quickly built for the isolation unit, which Mehta said was convenient but not a necessity and helped to ensure that Emory’s regular laboratory services weren’t interrupted for Ebola virus–related work.

A disadvantage to the dedicated lab, he said, was that only “a very limited testing panel” was available to clinicians.

Laboratory testing for both patients revealed “very marked electrolyte abnormalities,” including hypokalemia, hypocalcemia, hyponatremia, and nutritional deficiencies, Mehta said.

He said the ability to provide “high-level nursing and supportive care” around the clock to the patients likely had a “significant impact” on survival. Both patients were discharged from the hospital in mid-August.

Emory has since cared for a third humanitarian worker with EVD who was evacuated from West Africa. The hospital’s website states that being prepared for and receiving such patients will be the “new normal” at Emory.

A fourth patient received treatment for EVD in the biocontainment unit at the Nebraska Medical Center in Omaha after being evacuated from Liberia in early September. He was released from the hospital in late September.

At presstime, a patient who had been exposed to the virus was being monitored in isolation at the National Institutes of Health’s Clinical Center in Bethesda, Maryland.

Also at presstime, the first patient to be diagnosed with EVD while in the United States was being treated at Texas Health Presbyterian Hospital Dallas.

–by Kate Traynor, reprinted with permission from AJHP (Nov. 1, 2014; volume 71, pages 1822-1823, 1827)

Editor’s Note: ASHP recently launched an Ebola resource center, which features the latest information and resources on this public health crisis. ASHP is also working closely with federal officials and stakeholders, and is monitoring the response of the CDC and other federal agencies to the Ebola outbreak.