In crises, anxiety focuses attention. I am continuing to focus on the growing Ebola epidemic, which has no real restraints to keep it from becoming a global pandemic. Overpopulation, inequity, peak oil, and disturbed natural environment have converged with the problem of Ebola, to set up the conditions for a pandemic. If we add a slow response from complacent, frozen bureaucracies to this toxic mix, then a global pandemic is to be expected. We have met the enemy, and he is us.
Healthcare professionals need to speak on healthcare inequity and US readiness for pandemics–on big issue topics that we are afraid to speak up about. And I have a particular interest in this topic, since I am potentially most exposed as a nurse to acquiring Ebola through patients shedding the virus in body fluids, and women are at high risk as typical care givers in the home and hospital. And I have studied handwashing in hospital settings, with insight as to the gaps. So I will continue to perseverate here, and add my nursing voice to the choir of concerned healthcare professionals.
US foreign policy appears to be driven by arrogance, ignorance, or inertia, due to first world expectations of safety and frozen bureaucracies such as the military industrial complex bent on forever wars. Since TSA has implemented no policies to screen for fevers, Americans are displaying some arrogance in a belief that first world countries cannot be affected by pandemics. We screen assiduously for black swan terrorism events, but can’t seem to wrap our heads around a common plague. Yet we need health certificates for all dogs in the US when they travel–frozen bureaucracies lead to strange and sometimes contradictory policies.
Why do we choose to focus on Middle East terrorism, and ignore a burgeoning pandemic like Ebola? Perhaps a global pandemic will reset the priorities of our Security agencies and rewrite the meaning of terrorism. Our TSA obsession about shoes begins to look a little silly when one febrile Ebola victim on a plane to New York could rewrite the manual for the TSA, and change the face of healthcare in the US.
If the MSM does focus on Ebola, it is only an upbeat story about supposed cures, which experts say will not be available in enough time or enough measure to have much impact here. Or there’s an upbeat story about the saving of a single American healthcare worker (HCW), although there is no mention of how many resources went into that save, including vast amounts of disposable personal protective equipment (PPE), and a mainstream media focus on a single sick missionary’s status while ignoring the critical issues at the larger scale.
Epidemic to pandemic
First, a quick education on public health definitions. An epidemic is an incidence rate that exceeds the expected rate for an infectious disease. A pandemic is “an epidemic occurring worldwide, or over a very wide area crossing international boundaries and usually affecting many people” (Last, 2001, via Kelly). The pandemic phase 6 is “characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Indicates a global pandemic underway” (World Health Organization [WHO], 2009). We are in an Ebola epidemic phase 5 by WHO criteria, which suggests that the chance for pandemic is “high to certain.” There are currently about 5000 cases, and 2500 deaths in four countries in West Africa. Ebola 2014 may become a pandemic when outbreaks begin to occur in other regions or continents.
Case fatality rate (CFR) is the percentage of deaths within a population of cases. The touted 50-55%CFR for the current Zaire strain of Ebola may be underestimated, as suspected cases and mortality are both delayed and underreported. With patients lying at the doorstep of full field hospitals, CFRs are probably wildly inaccurate. A better estimate may come from Médecins Sans Frontières (MSF) field camps, where a more controlled count of cases and mortality lead to an observed 70-80% CFR, which is more in line with the historical data for this strain.
Epidemiologists and health policy experts are using words like “short, closing window of opportunity in terms of weeks,” and the need for a “massive global response,” or even “it is too late to contain,” while MSF says we’re “losing the fight” and they are beginning to create field hospitals in football stadiums. There is some discussion that because cases are grossly underreported in the chaotic environment, the real numbers may be 2 to 3 times as many as reported already (Garrett, 2014). The WHO’s latest situation report uses new language in its categories, describing Guinea, Liberia and Sierra Leone as countries with “widespread and intense transmission” and Nigeria and Senegal as countries with “an initial case or cases, or with localized transmission.” WHO has added a third class of countries that neighbor countries with active transmission, with identification of preparedness assessment and surveillance abilities for those countries. One could argue that in this era of global travel, any country with direct flights could be considered neighbors. The US has called an emergency meeting of the UN Security Council, so maybe policy-makers have figured that out.
There are many pundits asking how we could have known that this would be the break-out disease. Ebola this time is different, since it is occurring during a time of extreme population overshoot and massive global poverty and inequity. It is also different because it is the first break-out of a truly novel disease during a time of common global air travel. The ECDC has recently defined high-risk exposure criterion for Ebola as “close face-to-face contact (e.g. within one metre) without proper personal PPE, including eye protection, with a probable or confirmed case who was coughing, vomiting, bleeding, or who had diarrhea.” That definition contradicts WHO claims that air travel is “low risk,” especially as the epidemic spreads. The difference between airborne and droplet precautions is a matter of distance, and there is no established science on what distance is safe. Some have proposed that a larger distance may be safer, of up to 9 meters, considering the lethality of the disease. And if a HCW is working in a contaminated environment or going home to a crowded environment, hazmat suits may not do much good. There are many links in the chain of infection control, and with this disease, scrupulous attention to all details are necessary to prevent contagion. That level of control is very difficult in a complex, urban environment.
Other public transportation such as buses, trains, and taxis where people sit within three feet of each other are also high risk as this epidemic grows. Cleaning standards in public places would change, as would food preparation and serving standards. Tourism, education, places of work–all aspects of the economy would be impacted as worried citizens created self-imposed quarantines. Behaviors in all areas of one’s life would change, and adequate PPEs would become a new form of currency. An Ebola pandemic would be a game-changer–one very small virus could tip our modern, frozen bureaucracies upside-down, mandating a new set of rules.
Spread to other countries appears probable to certain, since there are many mechanisms and few barriers to international dissemination. We had better start preparing, as a country. What does that mean for the US and its healthcare system?
Weakest links in the chain of American readiness
WHO and MSF have calculated that isolation field clinics in West African countries demand 250 healthcare workers for every 80 patients, and that is what is required for a “low resource” environment, meaning bare minimum healthcare standards (perhaps not even intravenous therapy) which has still resulted in 1 in 10 HCW in those countries with high transmission contracting Ebola. In the US, the healthcare standards are much higher, with biohazard isolation, hazmat suits, and intensive staffing. The team at Emory caring for the two imported missionary Ebola patients required 5 physicians, 21 nurses, and a supporting cast of hundreds.
In West Africa, beds, PPE, and healthcare providers appear to be the primary constraining factors in dealing with this disease appropriately. Of those three, PPE and nursing care are probably the larger constraints. Beds can be erected in field camps, but infection control-trained nurses or caregivers are another matter. And without PPE, caregivers in centralized locations only spread the disease. And as acuity of care rises in complex isolation patients, the ability to comply with handwashing and isolation standards declines. In a recent US study of handwashing, if a critical care staff washed their hands or used handrub as many times as they needed to comply 100% with hygiene policies, they would have to collectively wash their hands for about 230 minutes a day per patient. Which doesn’t leave much time for care.
“On average, each patient was contacted directly 159 [95% confidence intervals (CI) 144-178] times and contacted indirectly 191 (95% CI 174-210) times/day. Observed post-contact hand hygiene rates were 43% for direct contacts and 12% for indirect contacts. Staff contacting more than one patient during routine care, who carry the highest risk of transmitting infection between patients, made, on average, 22 direct and 107 indirect contacts without adequate hand hygiene/patient/day. One hundred percent hand hygiene compliance by all healthcare workers would require about 230 min/patient/day (100 min for direct and 130 min for indirect contacts)” (McArdle, Lee, Gibb, & Walsh, 2006).
This study didn’t count the violations based on not washing your hands or using alcohol handrub before you enter the room, just after exiting. So if one really adhered to US healthcare infection control standards, the fail rate for handwashing would be much higher, since most staff are going from room to room and only wash on exiting a patient room. Four hours at the sink is the needed cumulative total time per patient per day for all the caregivers going into that room. And the study above is not describing isolation patients, or patients with excessive vomiting and diarrhea and deadly body fluids, as happens in Ebola. In Ebola care, the highest viral loads are in diarrhea, blood, and corpses, as the virus requires body fluids to survive. Thus, arguably, the most dangerous jobs in this epidemic are nursing care and post-mortem care. Nurses in the current healthcare system are already under-staffed and overworked. The further this epidemic spreads, the less ability we will have to stop or contain it, because the work becomes more chaotic and dangerous, isolation standards collapse as patient acuity rises, healthcare workers become sick, and resource supply lines fail. Add in the need for careful and extensive isolation garb with complex gowning and de-gowning for each patient (over and above already time-consuming isolation procedures), and standards start to slide, making staff very vulnerable. In a previous handwashing study of mine, housekeepers had the worst compliance, with a handwashing compliance average of about 10%, followed by physicians with 15-20% handwashing rates. What does that mean for infection control in hospitals during pandemics?
Samaritan’s Purse just called for extra-hospital care of Ebola patients either in stand alone isolation units or at home, and it seems clear to me that this is a better model in a pandemic. Setting up a local healthcare communication system of community preparedness, with a system for safe, humane quarantine, food delivery, proper disposal and incineration of medical waste, stocking of isolation and contamination gear in communities, and education of non-HCW volunteers are things that need to happen now to prepare for a pandemic.
Should we send aid?
The United States has finally chosen to send some token military help, to set up a single field camp for the care of foreign (non-African) healthcare workers who acquire Ebola. Cuba, which has a much more sustainable and low-resource-based system, is sending 165 physicians and nurses. If this turns into a global pandemic, do we have the HCP and isolation gear to spare? Our US healthcare system is very high-resource, with 2.42 physicians per thousand population, while Sierra Leone has 0.02/1000. Similarly the US has 9.8 nurses per thousand population, while Sierra Leone has 0.2 nurses/1000.
There is some discussion that HCW from first world healthcare systems are simply not equipped to work in low resource environments–that is a given. American aid organizations with hospital ships appear leery to send their ships into the Hot Zone because of the risk of contamination. In a pandemic situation, our high-tech healthcare system could be become a hindrance instead of a help, as our expectations and standards would quickly devolve from over-burdened hospital care to home care with PPE to, eventually, home care without PPE as chaos ensued and supplies and resources, which are all disposable, were used up (but perhaps not disposed of, at least not properly).
And all of this depends on oil, of course. I am afraid to do the math on what high-resource healthcare Ebola isolation would need in terms of a steady stream of isolation disposables. In a pandemic situation, we would probably not be able to keep up. Full biohazard gear for protection would devolve into standard PPE, which would then devolve into a mask and gloves, good handwashing, and some prayer. Home care might end up as it now is in West Africa, with no gloves available unless you bought them on the black market. Viruses are Nature’s equalizer. One country can use disposable, high-tech isolation gear, while another country struggles to provide clean water for basic handwashing. Viruses act as economic equalizers to reorganize the global landscape into units appropriate to available resources.
So how does a pandemic impact a high-resource economy and healthcare system differently than a low-resource system? I’m not sure, but I’m not sure it makes a difference. As control of this epidemic weakens, cases will expand. Expanded cases will lead to even weaker control. If you want an idea of how quickly any healthcare system can become overwhelmed in an exponentially growing pandemic, go back and watch the movie, Contagion, which was a pretty accurate representation of what might happen to us if we fail to contain this epidemic.