North Carolina’s freshly built front line of defense against Ebola is a simple question: “Have you traveled outside of the country in the last 21 days?”
With the epidemic of the deadly hemorrhagic fever accelerating in West Africa and worst-case predictions of well over 1 million infections, in the past few weeks triage staff at hospitals across the state have begun asking that of arriving patients. The rare “yes” then leads to more questions to determine whether the patient has been to the three countries struggling to contain the unprecedented outbreak and, if so, to what level of risk they have been exposed.
For now, the likelihood that Ebola will turn up here is extremely low, said several Triangle-area experts in epidemiology. But hospitals here and elsewhere in North Carolina have begun that verbal patient screening, and also training staff and tuning up plans for handling such a disease just in case.
Duke Medicine ran a test last week in one clinic of its freshly implemented triage method; UNC is planning a larger Ebola exercise, and WakeMed in Raleigh held a training session Thursday for staff on procedures such as running an intravenous tube on a patient while wearing the full-coverage Tyvek suit, face shield, respirator and three layers of gloves. Rex Healthcare and Wake County EMS held an Ebola drill in Rex's emergency department recently, with a "patient" posing as an N.C. State University student who had been studying in Africa.
Most of the steps are standard in hospitals’ plans for handling infectious disease, including screening questions about travel, special protective clothing, plans for isolating patients and protocols for staff who would test and treat the patients. There are tweaks, though, including more extensive protective clothing.
“There is a high level of awareness in hospitals right now, and all have their highly communicable disease plans, so they tend not to do it by one disease at a time,” said Megan Davies, North Carolina’s state epidemiologist.
“They tend to say, ‘If we have a communicable disease that is airborne, here is how we deal with it. If it’s spread by contact, here’s how we deal with it,’ and they have all been looking at that in reference to Ebola,” she said. “I think that especially the bigger hospitals have talked through their Ebola plan very carefully at this point.”
Informing health departments
Her office has been working with the Centers for Disease Control and Prevention to stay abreast of the risks, and then it shares what it learns with the 85 local health departments in the state. It runs communicable disease surveillance networks and would team up with local officials to determine the risk of exposure if a case is identified.
The chances are “vanishingly remote” of an outbreak here, but it’s always possible that someone who was infected while traveling will turn up at a hospital here, said Dr. Cameron Wolfe, an expert in infectious diseases at Duke who helps with planning to control and prevent infections with that health care system.
U.S. hospitals, Wolfe said, are well set up to help prevent the possibility of an epidemic, unlike their counterparts in, say, Liberia.
“I don’t think the chance of an outbreak here is very high at all, but even if we get someone who has traveled, or for example just done some work in one of those countries who comes here sick, we’ve got very good setups to diagnose and contain them,” Wolfe said.
If a patient who has traveled to the affected countries develops the early symptoms of Ebola – things common to many illnesses, such as fever, fatigue, muscle soreness, a sore throat – the cause is likely to be something else. A hospital will test for several other likely culprits, too.
“Someone coming out of West Africa, the more likely causes of fever would be from flu to typhoid to malaria,” Wolfe said. “And each of those things has to be evaluated.”
Just a few weeks ago, a main concern was faculty and students at universities and colleges who might have spent time over the summer in West Africa for scholarly reasons, or students from the affected countries coming here for school. State and local health department officials teamed up with hospital and university officials to identify and screen such travelers.
That faded as a concern once classes had been in session for more than 21 days, the maximum incubation period for Ebola, from the date of infection to appearance of symptoms, without any sign of issues, Wolfe said.
It’s something to continue monitoring, he said, but it’s important to note that university officials who evaluate the risks of any official travel are considering Ebola before they grant approval.
Though the risks may be remote here, this week the CDC said that up to 1.4 million Africans will be infected with Ebola by the end of January.
U.S. sending help
President Barack Obama has committed to send 3,000 U.S. troops to West Africa to help fight the epidemic. That, along with a growing cadre of volunteer U.S. health care workers heading over to help, will increase the chances that some of them will return with infections, said Dr. David Weber, medical director of hospital epidemiology at UNC Hospitals.
The plans that all of the hospitals are fine-tuning now probably cover most scenarios, but not everything, Weber said.
“We have an incident command system, because each case is individual and each disease is slightly different, and we need to be prepared to rapidly institute and change things” he said. “You need to build in flexibility because things may not be exactly as you expect. What if we get a pregnant woman with Ebola? We can do some general planning, but you can’t plan for every possible contingency. What if an Ebola patient had to go to the operating room? We can never cover every eventuality. You just need to have the people there and the resources and flexibility, and I think we do.”
The preparations at WakeMed Health and Hospitals are similar to those at the region’s other large hospital systems, but it has an additional responsibility when it comes to travelers who fall ill on aircraft traveling into Raleigh-Durham International Airport and need hospitalization. WakeMed has an agreement with the county and the CDC to receive such patients at its main Raleigh hospital.
WakeMed has eICU
It has an unusual asset to help with cases of highly contagious diseases such as Ebola: an “eICU,” a kind of a command center in North Raleigh where, miles from the intensive care rooms, doctors and nurses can monitor patients via audio, video and data.
Some health care workers still have to work directly with patients, but the eICU can reduce the number who must, and also provide an extra layer of safety for those workers by monitoring their safety practices, said Barb Bissett, WakeMed’s executive director of emergency services.
So far, WakeMed has had a few patients appear who had traveled in West Africa, but after the chain of questions, it was clear that none of them were considered to be high risk for Ebola or need testing.
None of the preparations are particularly tricky, Bissett said, as the hospital frequently has to set up protocols for contagious diseases that haven’t appeared here. Just a few weeks before Ebola became a concern, WakeMed was focused on Middle East Respiratory Syndrome, or MERS, she said.
In the midst of all the planning and preparations, public health officials and health care workers across the state are hoping for the same outcome here with Ebola that they wish for with every other communicable disease that springs up elsewhere in the world, said Davies, the state epidemiologist.
“We always like it when nothing happens,” she said.