Ebola is spreading. There’s no denying that fact.
Thomas Eric Duncan, the first Ebola patient diagnosed in the U.S., died from the virus after being treated by a team of health care workers at Texas Presbyterian Hospital. Soon after his death, nurse Nina Pham, 26, was infected. Seventy-six people involved in Duncan’s care were being monitored for symptoms, and it’s now up to 125 after a second health care worker who treated Duncan tested positive.
It’s raised questions and concerns about everything from whether there was a safety breach when personal protective equipment was removed that allowed the virus to be transmitted, to whether or not our world has the resources to fight such a disease — and who is actually willing to be on the front lines fighting it?
I spoke with Dr. Alex Garza, an associate dean at the St. Louis University College of Public Health and Social Justice, medical director for the software firm FirstWatch, and former chief medical officer at the Department of Homeland Security, who says the answer should certainly not be community hospitals.
“There’s a huge leap,” he said, “between doing what is written on paper, and being able to adequately care for a highly infectious patient.”
How should we be managing Ebola?
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| (Dr. Alex Garza) |
Duncan was initially sent home with antibiotics from Texas Presbyterian Hospital, and later determined to have Ebola when he returned in an ambulance.
“One person treated so far has transferred the virus to two other people,” Garza said. It demonstrates that no matter how many safety protocols and training are in place, we should not be asking health care workers who have never dealt with the disease to don personal protective equipment and efficiently handle a patient who becomes more infectious as the virus takes hold, he said.
Instead, we should be handling Ebola patients the same way we handle trauma and neonatal patients — transfer them to a facility with the proper skills and equipment.
Ebola patients should be routed to the nearest bio-contamination center, in this case Omaha, Neb., and treated by a team of specialists, Garza said. He hesitated as to why the CDC is bringing experts into the hospital, rather than taking the patients out.
“The CDC is taking baby steps,” he said. But he suspects the agency will eventually take his position, and when it does, there needs to be the ability to safely transport Ebola patients.
“That’s where EMS comes in,” he said. “How do we build a bio-contained air ambulance or ground ambulance?”
What should the role of EMS be?
The first two American Ebola patients who were transported to Emory University Hospital by Grady EMS is one example of a successful ground transport, and Garza points out there are only two air ambulance companies he knows of with this capability — one is in France, and the other is Phoenix Air in the U.S., which was also involved in the initial transports.
Garza suggests establishing more specialized air ambulances that can be kept at a regional facility, and training nearby EMTs who would work their normal shifts, but are prepared to respond to an Ebola transport call.
He also points out that when a patient initially reports feeling sick, they are at their least infectious.
“Medical workers can accept that risk,” he said.
But as the patient worsens, the risk of exposure becomes higher. Therefore, a community hospital is not the place to be performing potentially life-saving measures such as a kidney dialysis, involving a lot of infectious blood.
“To me, it’s illogical you would expect every nurse in the nation to know how to take care of this very complex disease,” he said.
While we have dealt with epidemics before, including influenza and SARS that are more easily transmitted, it’s the 50 to 70 percent fatality rate that makes Ebola such a concern, Garza said.
“If you catch it, the odds are not favorable,” he said. “That’s what makes it really scary.”
What about a vaccine?
“Many of those therapies are in the very early stages,” Garza said. And with such a small patient pool, it’s difficult to determine if they actually work.
“It will take a while to see if they’re effective,” he said. “Even with ZMapp.”
The experimental drug was used on the first two American Ebola patients, who were treated at Emory University Hospital and survived. The available supply of ZMapp has since been exhausted, but tests and further developments of its use as a vaccine are ongoing.
There’s also no reason to not continue trying different therapies, Garza said. Dallas nurse Nina Pharm, for instance, has received blood from an Ebola survivor in the hopes it contains antibodies to fight the disease.
Garza also noted that most of the work around a possible antidote has been funded with bioterrorism dollars through the Defense Advanced Research Projects Agency, as opposed to through a traditional vaccine program.
The good news is that when Ebola was contained to West Africa, it was given little attention by research companies, which saw little financial benefit in the virus.
“But now, it is a big deal,” Garza said. “I wouldn’t be surprised if the feds started funding vaccine developers.”
How effective is Ebola airport screening and communication?
From the beginning, Garza pushed for more screening at airports, and the procedure has been met with mixed reviews.
“I think it needs to be balanced,” he said. “It depends on how specific the question is.”
If someone has been to South Africa or Egypt, where the virus hasn’t been detected, then there’s no risk, he said. By the same token, 911 screening is important for identifying any potential cases, since we don’t want to send emergency crews to a scene unprotected.
“The nuance is in how you ask the appropriate questions,” he said.
Garza also stressed that a strong communication chain between dispatchers, EMS, and public health workers is essential in both identifying and treating potential Ebola patients. It was clear this communication broke down when Duncan was initially sent home from the hospital after telling a nurse he had been to Liberia.
Triage nurses will traditionally come and find physicians where there’s something big, Garza said.
“I’m a little confused on how this did not ratchet up to this level,” he said.
He speculates there was simply a lack of awareness around the issue, coupled with a large Liberian population in Dallas that may not have raised any red flags. But getting patient history is a basic task for all health care workers, he said. Even if the nurse did not report it, the fact that Duncan had been to an area where the virus was prevalent should have been caught by others involved in his treatment.
“I don’t think that dissolves the rest of the care team,” he said. “You can’t put this on the triage nurse and a computer screen.”
Regardless, it was one of the worst ways that this patient could have been handled, Garza said. The incident triggered increased anxiety across the U.S. and the world, leaving many with questions as to how well prepared we are as nation to handle patients with Ebola.
How prepared are we as a world in terms of a strategy to fight Ebola?
“The only way to get to zero risk is to remove it from West Africa,” Garza said.
But how?
“I don’t know if anybody has a really good answer for that right now,” he said.
The U.S. military is currently being sent to West Africa to provide infrastructure in terms of building hospitals and laboratories, and providing ambulances and isolation units, but troops are not involved in direct patient care.
“If we build it, who’s going to come staff it?” Garza asked.
In terms of that help coming from the World Health Organization, he pointed out that the agency has had a pretty delayed reaction to the virus as it spread throughout West Africa, and questioned whether it has enough resources at its disposal.
“From everything I’ve read, they do not,” he said. “Their staff has been cut down, and it’s not like they have a deployable medical force.”
It’s also tough to send doctors and nurses, who are used to working in a protected and safe environment.
“With Ebola, doctors and nurses would be the front-line fighters, so to speak,” he said.
Although building an infrastructure is a good first step, and he suspects U.S. partnerships with agencies and other countries like France and England will speed up the process, that key question about who will actually care for infected patients remains.
Just as the military often needs to go into a country with overwhelming force, West Africa needs the medical equivalent, he said. But people with the skills and expertise to properly handle patients with Ebola are a lot harder to come by than soldiers.
“Where those people are going to come from,” he said, “I don’t know.”