by Tia Will
This is a three-part article. I have been asked to write an article on Ebola I have included some factual information about the disease, a description of our local precautions for the management of Ebola and my perspective on other impacts of “ Ebola preparedness” as they affect our community now and in the future.
Ebola infection is a disease caused by a specific type of virus. There are five known strains of this virus, which occur in various regions of Africa and are not known to occur naturally in other geographic areas. The strains have different favored hosts and different degrees of lethality to humans. These viruses are known to exist in fruit bats and primates and the killing and preparation of these animals for food is believed to be the principle means for initial human infection. This virus is not transmissible by mosquitoes or other insects. It is not transmissible by indirect human contact.
In human-to-human contact, the transmissibility (the ease of passing the virus from one person to the next) of the virus is quite low. Catching the virus from another individual requires that live virus, present in bodily fluids of the carrier must enter the body of the uninfected individual through either a mucous membrane such as the eyes, nose or mouth, or a break in the skin such as on the hands or face. Another very important point about the transmissibility of the virus is that it cannot be transmitted by asymptomatic persons. No symptoms, no transmissibility. This brings us to the basis for an effective containment strategy.
I will start with the system I know best, Kaiser Permanente. Within this health care delivery system we are blessed with the facilities, expertise, and funding to be able to take on this problem internally with consultation from local health authorities and the Centers for Disease Control (CDC).
Our approach is based on four principles and actions. Identify, isolate, protect, and escalate. In Davis, our response protocol is outlined below.
- Identify: All patients contacting our system for care will be asked at the point of initial contact be it a call center, the reception desk of a medical office building, or at point of entry to a hospital, two screening questions. The first is have you recently travelled to West Africa? The second is, do you have any of the symptoms associated with Ebola (check list read off and recorded by the initially contacted employee).
- Isolate: If the screening questions elicit a positive response, the individual will be asked to remain where they are, separate from other patients
- Protect: One designated, and fully trained member of our assessment team (3 doctors – 2 internists and one pediatrician) will suit up, escort the patient to a pre designated isolation room and perform a thorough history and examination. If the patient is identified as at risk they will move immediately through an escalation protocol.
- Escalate: The escalation protocol (which is continuously being updated to comply with NHS guidelines as more information is obtained) is currently as follows:
- A call is made from the isolation room initiating notification of security, nursing administration, our local Infectious Disease experts, the county infectious disease designee, the state infectious disease designee and the NHS.
- If there is a need for urgent care, that will be initiated by the individual provider already in protective gear on the spot. If the case is questionable and no immediate care is needed, infectious disease consultants will make the decision of whether the individual is a candidate for transport to our designated isolation unit located in our South Sacramento Hospital, which has the needed isolation and containment capability.
The Yolo County Department of Health Services protocols for dealing with Ebola are summarized on the following memorandum of October 21, 2014, which states in part:
The risk of an Ebola in the United States remains very low. There are no Ebola cases in Yolo County. The Yolo County Department of Health Services has been preparing, and will continue to prepare, for the unlikely chance that a person sick with Ebola comes to a Yolo County hospital.
The Yolo County Department of Health Services is in regular and frequent communication with local hospitals to share information about Ebola. These communications provide guidance from the Centers for Disease Control (CDC) and the California Department of Public Health (CDPH) about how to identify possible cases and prevent the spread of Ebola.
Hospital staff throughout Yolo County and the United States is routinely trained to put protections in place when dealing with contagious patients. Protections include gloves, waterproof gowns, facemasks and eye protection. These measures are very effective in preventing the spread of infection. The Department of Health Services continues to make recommendations to local hospital staff and emergency responders for proper personal protection equipment.
Full information including a flow sheet for county protocols is available on the Yolo County Department of Health Service web site.
All of these special preparations come at significant cost. Notification and fact sheets have been sent either electronically or by mail to all of our members. So far all Kaiser doctors have spent at least one hour in mandatory Ebola preparedness information sessions. Other local health providers have initiated similar plans.
Those in leadership roles have all spent at least one to three more hours in more detailed training. The first responders have spent still more time being trained in the safe use of their specialized personal protective equipment. And this does not include the many hours spent by upper level administrators including doctors, nursing staff, leadership of ancillary services such as EVS and security on Ebola preparedness planning, The cost of maintenance of the isolation rooms at each facility and the isolation / confinement ward at South Sacramento, we are looking at many hundreds of thousands of dollars spent in preparation for an extremely unlikely event. Similar preparations are occurring in other health care systems with similar costs.
There have been to date nine cases of Ebola ever diagnosed or treated in the United States. All have been directly linked to recent travel from, or care of an individual from, the known endemic area. None of them have been in Yolo County. None have been in California.
So let’s compare this with some with some other infectious diseases in California.
In the flu season of 2013-2014 there were reported to the CDHP, 7 fatal influenza cases in children, and 196 severe or lethal cases in adults under age 65. Ninety percent of flu related deaths are in people over age 65. Influenza is a much more common, potentially lethal, and highly human-to-human transmissible disease than is Ebola.
West Nile Virus is another concern in California. Although not transmissible human- to-human, it is a disease strongly related to human activities in terms of our individual and agricultural water management practices. Since the beginning of 2014, 604 human cases have been reported in California. There are active efforts to minimize the risk of West Nile Virus through the city of Davis working in conjunction with the Sacramento–Yolo Mosquito and Vector Control District.
Ebola, influenza, and West Nile viruses along with a large number of other infectious diseases or those strongly related to human behaviors are in competition for our attention and resources. We have a choice. We can assess the relative risk and allocate our resources effectively focusing on those problems most likely to affect large numbers of individuals in our community or we can respond emotionally and irrationally to headline-precipitated fears. The latter may course may result in feelings of safety based on the belief that “every effort” is being made and “no expense is being spared” to keep us safe.
Or we could make sound, risk and evidence based assessments of our needs knowing that we can never limit risk to zero. We could place our time, energy, efforts and dollars into those measures demonstrated to provide protection in our setting. We could focus on such tried and true primary prevention tactics as immunization, sick leave or other compensation or aide to enable children and workers to stay home when ill. We could provide education on means to protect one’s self, one’s children and other members of the community from transmissible diseases coupled with an ethic that rewards voluntary self-isolation behaviors rather than penalizing them. Money could be spent on development of vaccines and antivirals rather than on excessive numbers of isolation units and personal protective gear unlikely to ever be used.
Each choice we make for our protection and risk reduction carries with it both readily visible and unseen costs. Each allocation of resources means that those resources are not available for other pressing needs. It is my personal opinion that all needs should be taken into account when making any decision about where to allocate our limited resources. I welcome your questions and comments about my perspective.
* Due to the rapidly evolving situation and changing recommendations regarding best practices as more information is gathered, the precautions being enacted are current as of the time of this writing based on information from 10/24/14 and may have changed by the time you read this. If there is enough interest, I will be happy to update as I receive more information.