Battling a Destructive Virus
By Kara Nuzback Texas Medicine January 2015

Ebola Tests Texas' Public Health Funding, Prompts Hospitals, Primary Care Doctors to Prepare for Future Cases of the Disease

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Public Health Feature — January 2015

Tex Med. 2015;111(1):49-53. 

By Kara Nuzback
Reporter

Ebola, an infectious and often fatal virus, hit Dallas in October, prompting a frenzy of media attention directed toward Liberian Thomas Eric Duncan, who died from the disease at Texas Health Presbyterian Hospital on Oct. 8. Despite the destructive nature of the virus, the two nurses who contracted Ebola from Mr. Duncan, Nina Pham and Amber Vinson, both recovered, proving early detection is vital in battling the disease. 

Experts like Robert Haley, MD, chief of epidemiology at The University of Texas Southwestern Medical Center, urge physicians to educate their patients about Ebola and explain that most patients are not at risk. But, he adds, physicians should not brush off the disease as media hype, and hospitals across Texas should be ready in case an Ebola patient walks through the door.

Dr. Haley and the Texas Public Health Association (TPHA) note the Ebola scare — like the spread of West Nile virus — is further proof local health departments need funding for public health preparedness.

Dr. Haley spent 1973 to 1983 at the Centers for Disease Control and Prevention (CDC), serving as a commissioned officer in the U.S. Public Health Service. He was the director of CDC's hospital infections program when the agency developed its isolation guide for Ebola, which experts thoroughly vetted before its implementation. Dr. Haley says Presbyterian Hospital followed the isolation guidelines precisely, "yet two nurses got infected. It was not due to lack of preparedness or lack of attention. The problem is, the plan somehow failed, and they don't even know how it failed." 

In response, CDC sent experts to Presbyterian Hospital who "were modifying Ebola protocols on a daily basis," Dr. Haley said. Shortly after the nurses recovered, CDC officially released a new, more stringent set of guidelines for hospitals dealing with Ebola patients. Dr. Haley says CDC and Presbyterian Hospital should be commended for adapting quickly to the situation and bringing the nation's top Ebola experts to Dallas to develop new, better guidelines for isolation.

"The CDC and the hospital are unwitting heroes in this," he said. "The rest of the country is going to benefit from that very trying experience." 

Physicians in Texas should be concerned about Ebola because it is more likely to be fatal than most contagious viruses, Dr. Haley says. Usually, by the time an Ebola patient gets to the hospital, the patient shows symptoms of the virus, which means he or she is more infectious.

Dr. Haley says it is "very likely" more cases of Ebola will emerge in the United States, and if several cases pop up in one region, a single hospital likely won't be able to handle them all.

"Every hospital must be reading the new guidelines and preparing and getting ready," he said.

And he has advice for physicians working in clinical settings: "All physicians who deal with the public need to be ready to ask the travel question and be ready to act on it."

CDC recommends patients who report a fever be asked by medical staff about recent travels. If patients have traveled to West Africa in the past 21 days, they are at risk for Ebola.

What Can Primary Care Doctors Do?

While hospitals now have tried-and-true guidelines to prepare them for Ebola cases, Brian Rogers, DO, says CDC hasn't offered much guidance for community physicians.

"[There is] nothing for primary care doctors — zero, zip, zilch," he said.

Dr. Rogers is the Dallas-Fort Worth area director of nine health clinics, one of which is just six miles from Presbyterian Hospital.

"There's a lot of panic going on at the primary care level," he said. "If I'm nervous about something, I'll research it and try to write a paper about it." 

Dr. Rogers, along with David Weitzman, MD, who serves on the board of directors for the American Academy of Urgent Care Medicine; Gregory Buzard, PhD, a molecular biologist at Booz Allen Hamilton; and Alexandra Boyd-Rogers, Dr. Rogers' daughter, who is studying to become a physician, wrote, "Updated Emergency Response Protocols for Suspected Ebola in Urgent Care and Primary Care Settings."

The protocols pull from recommendations by CDC, Doctors Without Borders, and the U.S. Army Medical Research Institute of Infectious Diseases. The piece details how to determine whether a patient potentially has Ebola, what to do if a patient is at risk for having Ebola, what to do if exposure occurs, and how to connect the patient to specialized, extended care. Read the article on the Texas Medical Association's Blogged Arteries blog.

Dr. Rogers expects the primary care protocols he and his colleagues created will be an evolving document as experts continue to study and treat the virus. Dr. Rogers says the key is to expose as few people as possible to the potential Ebola patient and transfer the patient to a hospital immediately.

"Don't try to save the world in your little clinic," he said. 

Also, he adds, physicians should make sure the hospital is aware of the patient's Ebola status before receiving the patient. 

If the clinical staff must perform a lifesaving procedure to stabilize the patient before transferring him or her to a hospital, the staff should wear personal protective equipment (PPE) such as boot covers, impermeable gowns, and surgical hoods. Read CDC's recommendations for PPE. If the clinic does not have the recommended PPE, staff should wear standard N95 masks, gowns, and gloves, Dr. Rogers says. 

CDC is stockpiling PPE, he says, but physicians should find out if they can obtain supplies locally in an emergency. The Texas Department of State Health Services (DSHS) lists contact information for local health departments in every district in Texas on its website. 

If a patient was in a country or facility with a known Ebola patient in the past 30 days but is asymptomatic and has had no direct contact with an Ebola case, the physician should give the patient written self-monitoring instructions. They include taking body temperature twice a day, avoiding public transportation, and tracing their contacts since the time they think they may have been exposed.

Oftentimes, physicians in a clinical setting encounter what Dr. Rogers calls the "worried well," or patients who have no reason to suspect exposure but become paranoid due to media hype. Educate these patient about the spread of the disease, he says, but don't send them home with self-monitoring instructions.

"You're simply feeding into the paranoia," he said.

Epidemic of Fear

Dr. Haley, a member and former president of Dallas County Medical Society (DCMS), says clinical physicians play an important role in educating patients about how the virus spreads.

"The epidemic of fear was really rampant," he said. DCMS gave media interviews and spoke at town hall meetings to enhance the public's understanding of Ebola. TMA assisted DCMS in responding to media requests for information and expert sources.

DCMS also worked with local schools to quell parents' concerns about the spread of the virus.

"We think that made a big difference in quieting the public's concern," he said. "We need to educate our citizens that this virus is not a threat to the public."

The truth is, the virus is contracted only by touching the wet bodily fluids of a person who is dying from Ebola, he says. Watch a video of Dr. Haley explaining how Ebola spreads. 

According to CDC, people can spread the virus to others through direct contact with blood or body fluids, such as urine, saliva, sweat, feces, vomit, breast milk, and semen. Ebola also spreads through objects contaminated with the virus, such as needles and syringes, and through infected fruit bats or primates.

"Ebola is not spread through the air, by water, or in general, by food," according to CDC. 

Health care professionals run the greatest risk of contracting the virus because they are more likely to come in contact with infected blood or body fluids, CDC states, adding Ebola exposure can occur among hospital staff not wearing appropriate PPE.

Health Departments Underfunded

Dr. Haley says Presbyterian Hospital collaborated successfully with federal, state, and local health officials to manage the Ebola scare.

"On the other side, virtually all health departments in our state are underfunded, under supported, and taken for granted," he said. "That's a chronic problem that someday needs to be addressed."

In 2012, the spread of West Nile virus in Texas highlighted the role of county health departments in protecting citizens, Dr. Haley says.

"Now, this Ebola case further illustrates that you can't let your health department languish. It has to be funded and supported," he said. 

The Texas Task Force on Infectious Disease Preparedness and Response, created by Gov. Rick Perry on Oct. 6, held its first public hearing Oct. 23 to discuss medical and public health preparedness for identification and isolation of patients with Ebola.

In written testimony, TPHA emphasized the need for more public health funding in Texas, saying spending caps and sequestration had devastating effects on federal agencies like CDC. The cuts, in turn, affected funding to state and local health agencies, TPHA testified.

"Public health is on a par with police and fire, protecting the community from disease. Preparedness and response to both natural and bioterrorist-related infectious disease outbreaks cannot be done without adequate resources," TPHA wrote.

More than one-quarter of local health departments in Texas experienced a budget cut this year, "reflecting a six-year trend," TPHA testified.

TPHA recommends the state eliminate disease-specific funding streams because "disease-specific funding streams tie public health's hands when prioritizing activities." The association also recommended more funding and support for epidemiologic and laboratory capability to prepare and respond to infectious diseases, and increasing promotion of immunizations against vaccine-preventable diseases.

At the same hearing, TMA Council on Science and Public Health member William "Chip" Riggins, MD, testified on behalf of TMA. He is assistant professor and deputy program director of the Preventive Medicine Residency Program at Texas A&M Health Science Center at Round Rock. He recommended the task force find a way to train physicians in public health and prevention medicine and have epidemiologists available to support disease surveillance for every county and the state. 

"The shortage of physicians in Texas is well-documented for primary care and prevention-related specialties. As Texas addresses the gap in critically needed graduate medical education, these specialties should be included among the top priorities for investment," Dr. Riggins added.

He and TMA also recommend the task force address the need for regional and local health departments to receive automated disease reporting and syndrome surveillance data from physicians, clinics, and hospitals via the health information exchanges.

The task force should also improve the Public Health Information Network/Health Alert Network to ensure timely delivery of urgent communication and targeted outreach to physicians, Dr. Riggins says. 

Clearing Texas of Ebola

On Nov. 14, DSHS announced the last person being monitored for Ebola in Texas — a hospital worker who handled medical waste Oct. 17 — was free from twice-daily monitoring, after reaching the 21-day mark, the standard incubation period for the disease.

"No additional cases of the disease have been diagnosed in Texas," DSHS said. 

The state monitored a total of 177 people — health care workers, household contacts of patients, and community members — who had contact with at least one of the three Texas Ebola patients, specimens, or medical waste. 

"We're happy to reach this milestone, but our guard stays up," said DSHS Commissioner David Lakey, MD. "We reached this point through teamwork and meticulous monitoring, and we'll continue to be vigilant to protect Texas from Ebola."

Kara Nuzback can be reached at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.

SIDEBAR

Ebola Help on the Web

TMA Ebola Virus Resource Center
Texas Department of State Health Services information about Ebola
Centers for Disease Control and Prevention Ebola webpage 
U.S. Army Public Health Department Ebola virus disease 
World Health Organization Ebola outbreak

SIDEBAR

Public Health Emergency Funds in Decline

The Hospital Preparedness Program is part of the U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response. The program provides leadership and funding through grants and cooperative agreements to states, territories, and municipalities to improve surge capacity and community and hospital preparedness for public health emergencies. 

Hospital preparedness funding in Texas:

2013: $24.8 million
2012: $26.4 million
2011: $28.4 million
2010: $26.2 million
2009: $28.9 million

Source: Trust for America's Health  

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April 28, 2017

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