During his Sept. 16 testimony before a subcommittee of the Senate Committee on Health, Education, Labor and Pensions on the Ebola virus outbreak, AAFP member Kent Brantly, M.D., who was the first patient with the disease to return to the United States for treatment, explained the importance of fighting Ebola in West Africa and preparing to treat it should it come here.
Joel Montgomery, team lead for the CDC Ebola Response Team in Monrovia, Liberia, helps a colleague adjust his personal protective equipment before entering the Ebola treatment unit.
"Many have used the analogy of a fire burning out of control to describe this unprecedented Ebola outbreak," he said during his testimony. "We cannot fool ourselves into thinking that the vast moat of the Atlantic Ocean will keep the flames away from our shores. Instead, we must mobilize the resources needed to keep entire nations from being reduced to ashes."
Brantly's comments were prophetic, as the CDC predicted in a Sept. 26 Morbidity and Mortality Weekly Report(www.cdc.gov) that in Liberia and Sierra Leone alone, without additional interventions or changes in community behavior, there would likely be a total of about 550,000 cases of the disease by Jan. 20, 2015; that figure could increase to as high as 1.4 million to correct for underreporting.
As of Oct. 15, the World Health Organization reported(apps.who.int) a total of 8,997 confirmed, probable and suspected cases in seven countries (Guinea, Liberia, Nigeria, Senegal, Sierra Leone, Spain and the United States).
- The first steps in preparing your office for a possible case of Ebola virus infection are to make sure you have all referral contact information ready to go and that you educate each staff member on his or her role if a case presents.
- The critical starting point with any patient during the current Ebola outbreak is gathering a travel history.
- If a patient comes into the office with nonspecific symptoms and has a positive travel history to the affected countries, he/she should immediately be isolated and standard, contact and droplet precautions should be implemented.
After Brantly's return on Aug. 2, additional patients with Ebola disease were transported from West Africa to the United States for treatment. These were the nursing assistant who had been working at Brantly's side in Liberia, Nancy Writebol; another AAFP member and medical missionary, Richard Sacra, M.D., of Holden, Mass.; and NBC News cameraman Ashoka Mukpo. Each was treated in one of only four hospitals in the country that have top-level biocontainment units and where staff have been training for years to treat highly infectious diseases. These facilities are Emory University Hospital in Atlanta, the NIH in Bethesda, Md., Nebraska Medical Center in Omaha and St. Patrick Hospital in Missoula, Mont. These four hospitals' combined units can accommodate a total of eight to 13 patients at a time.
Then on Sept. 28, Thomas Duncan presented to Texas Health Presbyterian Hospital in Dallas and subsequently was diagnosed with Ebola infection, eventually succumbing to the disease. Due to apparent missteps by the facility's medical staff in preparing for its first Ebola case, as well as breakdowns in communicating protocols for handling an infected patient, two nurses caring for Duncan have since contracted the disease.
One of the nurses, Amber Vinson, R.N., was cleared by the CDC to travel to Cleveland after caring for Duncan, despite having a slight fever. When she arrived back in Texas on Oct. 13, her fever had elevated and she was diagnosed with the disease. Since then, the CDC has worked with Frontier Airlines to reach out to passengers on both the flight to Cleveland and the return flight to Dallas to determine whether they require monitoring for the disease. Twelve confirmed contacts of Vinson in Ohio have been quarantined, as well, said Donna Skoda, R.D., L.D., assistant health commissioner for Summit County in Ohio. Vinson has now been moved to Emory University Hospital for care. The other affected nurse, Nina Pham, R.N., has been moved to the NIH facility for her treatment.
White House Names Ebola Czar
On Oct. 17, President Obama named Ron Klain as the nation's Ebola response coordinator, or "Ebola czar." Klain, an attorney and a former chief of staff for Vice President Biden, will oversee health security in the United States and actions to help control the outbreak in West Africa. He will report to National Security Adviser Susan Rice, D.Phil., and to Homeland Security and Counterterrorism Adviser Lisa Monaco, J.D.
Clearly, most facilities are not equipped with the biocontainment units that are optimal when caring for infected patients. That makes planning and preparing for a potential encounter with a patient suspected of having Ebola infection in a family medicine setting all the more critical.
Advice From Disaster Preparedness Expert
The first steps in preparing your office for a possible Ebola case are to make sure you have all referral contact information ready to go and that you educate each staff member on his or her role should a case present.
That's according to AAFP member Thomas Mahoney, M.D., of Colorado Springs, Colo., who said the CDC has directed that all suspected Ebola cases be reported to local/state health departments, who, in turn, will notify the CDC's Emergency Operations Center (EOC).
"If physician offices do not already have established relationships with their health departments, they should ensure that they reach out and have appropriate business and after-hours phone numbers available," Mahoney advised. "Physician offices should also reach out to any hospital systems they might potentially transfer patients to and ensure they have appropriate contact numbers for those organizations, as well.
"Some jurisdictions have developed specific plans, and providers should follow whatever notification process is recommended by the health department."
After contact information for local health departments and hospital systems is disseminated to medical and office staff, the next step is the critical starting point with any patient who has symptoms suspicious for the disease during the current Ebola outbreak: gathering a travel history at any opportunity.
"Appointment clerks and front-desk personnel taking calls for appointments should inquire about African travel history in patients calling for appointments for fever, headache, weakness, diarrhea, vomiting, muscle aches or bleeding," said Mahoney. "Anyone with a positive travel history should be contacted by a provider to gather additional history and determine if public health authorities need to be involved before a patient even presents to the physician office."
Similarly, information should be posted in appropriate languages (the official languages in the currently affected countries are French and English) at entrances and check-in desks directing patients with fever and a history of travel from the affected countries to immediately report this to check-in personnel.
If a patient presents to the office with a positive travel history, he/she should immediately be isolated, and standard, contact and droplet precautions should be implemented in accordance with the CDC Ebola Algorithm(www.cdc.gov) guidance (shown at left), Mahoney said.
Precautions should include donning personal protective equipment(www.cdc.gov) (PPE) before interacting with the patient. It's important to note that doffing PPE is where the Texas Health Presbyterian Hospital nurses possibly experienced exposure. So care should be taken to remove the equipment away from the infected patient and under appropriate supervision.
The local or state health department should then be notified and further testing and care coordinated, said Mahoney. If needed, life-saving care should be rendered, but caregivers must be cognizant of risks associated with procedures that could potentially aerosolize body fluids.
If a medical staff member is exposed to a patient suspected of having the disease, he or she needs to be educated on what symptoms may indicate infection: fever greater than 100.4 F with headache, weakness, diarrhea, vomiting, muscle aches or bleeding. But note that Texas Health Presbyterian Hospital nurse Vinson exhibited symptoms of the virus while her fever still remained between 99.5 degrees when she boarded a plan to Cleveland and 100.3 degrees when she was admitted to the hospital upon her return.
If the staff member is not severely ill but has a fever after exposure to an Ebola patient, the employee should be isolated and public health authorities should be notified, Mahoney said. Then CDC guidance(www.cdc.gov) should be followed to minimize exposure to others.
"(The employee) should not continue to care for patients and should isolate themselves to avoid exposing family members, co-workers and the public to illness until they have been assessed by public health authorities," he said. "If (the employee) is sick enough that they need to seek urgent care, they should still notify public health authorities and should coordinate their arrival with the medical facility where they seek treatment."
For additional direction, the CDC EOC is always available at 770-488-7100 or email@example.com, Mahoney noted.
On Oct. 16, CDC Director Tom Frieden, M.D., M.P.H., testified before a U.S. House panel about what the CDC was doing to combat the spread of Ebola in the United States and overseas.
Frieden defended his organization's response to the outbreak in West Africa and its implementation of control measures inside the United States. He also said that he wasn't concerned about a similar outbreak happening here.
"There's zero doubt in my mind that barring a mutation which changes it -- which we don't think is likely -- there will not be a large outbreak in the U.S.," Frieden told members of the Energy and Commerce Committee, according to the Associated Press.(hosted2.ap.org) "We know how to control Ebola, even in this period."
CDC Advisory Committee on Immunization Practices Chair and family physician Jonathan Temte, M.D., Ph.D., of Madison, Wis., will present two CME sessions on the current Ebola crisis during the AAFP Assembly in Washington next week. Those sessions are scheduled for Thursday, Oct. 23, at 2:45 p.m. EDT, and Friday, Oct. 24, at 8 a.m. EDT. It is anticipated that the sessions will be available for purchase after the meeting -- stay tuned.
Related AAFP News Coverage
U.S. Physicians Should Be Ready to Recognize, Manage Ebola
FP Infectious Disease Expert Discuses Diagnosis, Treatment Options
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AMA Ebola Resource Center(www.ama-assn.org)