Friday, October 3, 2014

The US Ebola Approach - what we are missing?

This story on NPR highlights the mishandling of the first case of Ebola to be diagnosed in the USA in spite of "training" and information efforts.  Numerous officials have claimed that the course of Ebola in the USA will be very different as it will be easy to contain due to better health care facilities and literacy.  The problem is that the focus has been on containment after the fact rather than limiting the early exposure.

We have known for a long time that the current scenario of an asymptomatic person from West Africa entering the USA and then developing symptoms was quite likely to happen.  Let us look at our current approach to this scenario happening and what we could do differently.

Hospitals are training their staff to ask about travel history and symptoms and then invoke the appropriate protocols using checklists.  This approach does not address a potential much earlier point of intervention that would decrease exposure and limit the chaos.

The current approach requires a patient who has traveled to the US from West Africa who gets symptoms to actually get to hospital and navigate the intake process to make it to a provider who may still fail to do the right thing as happened in this first case.  Along the way the patient may use a cab or public transport, touch door knobs, counter tops and railings and be in physical contact with several people. While it is not easy to spread Ebola by contact (usually the patient would have to be quite sick) just the fear of possible transmission and the amount of effort it would entail to track down people at real risk vs those with just insignificant contact would be huge and cripple the system.

This person if he develops symptoms, since he came from West Africa, has only one fear dominating his mind, "Do I have Ebola?"  The  approach needs to be to have this person stay in his hotel room or home and call a dedicated hotline that is manned by a trained person who can invoke the appropriate protocol.

How can we make this happen?  The process needs to start at the international airport where a person first lands.

  • There should be signage at the airport informing travelers from West Africa about the hotline if they get symptoms.  They could pick up a sticky note with the phone number and paste it to their passport.
  • Each person from West Africa should be given a simple thermometer at entry to the US.
  • They should be entered into a database 
  • They should be required to check their temperature each day and report it via a phone line/text/website that enters it into this database.
  • The hotline phone number should be imprinted on the thermometer cover
  • If they fail to enter the temperature, it should trigger someone should contact them.
  • If their temperature is >threshold someone should contact them to ensure that they called the hotline.
This seems to be common sense but we are not doing this.  How do we know this?  A recent report by CNN highlights the abject failure of communication at the airport where 3 reporters returning from West Africa got three completely different experiences when they mentioned where they were coming from. The agents were not aware of or could not locate the information regarding how to handle these travelers.

If somehow this step does not work, and the person does end up at a healthcare facility with symptoms without calling the hotline, we need to intervene before they have to navigate the intake process like any other patient.
  • Every entrance needs to have signage regarding steps to follow for a traveler from these countries with symptoms
  • It should have a touchless skin sanitizer next to the signage
  • After using it, the person should be able to use a phone with a speed dial to a trained infection control staff who would direct the patient to appropriate location limiting exposure to others.

Just the one case of the unfortunate Mr. Ducan has highlighted the tremendous effort that it will take to monitor and keep quarantined his approximately 100 contacts.  As more of these cases happen, we will be left with the scenario of a large number of healthcare workers exposed and quarantined.  This will cause a huge burden on our already fragile health care system.

We need to adopt an approach of earlier intervention.  The only risk of such an approach is causing anxiety but it has the potential of preventing exposure of large number of people.  We had many months to prepare for this.  We have a short window when such an approach might still work.  Now that the danger is clear and present, can we do this right?

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