By Cathryn Domrose
More than four months after the largest outbreak of Ebola began spreading throughout West Africa and about six weeks since the first case appeared in the U.S., healthcare workers and the public are trying to figure out which concerns are grounded in evidence and which are exaggerated. “We’re all learning,” said Marilyn Chow, PhD, RN, FAAN, vice president for national patient care services and innovation at Kaiser Permanente, Oakland, Calif. “We can get real-time information right away that doesn’t get filtered.”
Groundless public fears
An example of the struggle between fear and evidence, and the speed of information, came recently after some states issued a mandatory 21-day quarantine of all healthcare workers exposed to people with Ebola in West Africa, whether or not they show symptoms. Though popular with the public, the ruling raised an outcry from public health and infectious disease specialists who said the requirement was not based on evidence and will discourage clinicians from traveling to West Africa, where the disease has killed thousands.
Though symptoms of Ebola can take up to 21 days to appear, the disease is not contagious in asymptomatic people. Kaci Hickox, an RN returning from West Africa who was held at a New Jersey hospital although she was asymptomatic, criticized the quarantine as dehumanizing and based on groundless fears. Eventually she was allowed to return to her home in Maine, as the state and federal agencies modified their policies. As of this writing, Hickox had stated to the media she would not enter public places until the 21-day incubation period expires Nov. 10.
“The incident illustrated the need for public officials to determine quickly whether and how to sequester and monitor healthcare workers returning from West Africa in a way that treats them humanely and with respect,” Chow said. “They deserve the highest honor for what they have done.”
Fears – both evidence-based and not – have always been part of epidemics, from plague to HIV to H1N1 influenza. Even though people have a greater chance of dying from influenza than Ebola, because they hear about Ebola constantly in the news, some see it as more frightening, said Chad Priest, JD, MSN, RN, assistant dean for operations and community partnerships at the Indiana University School of Nursing in Indianapolis. Priest has worked in Liberia. Unlike the flu, he said, Ebola is a hard disease to get. It requires a lot of direct contact with bodily fluids. The only U.S. cases of Ebola that did not originate in Africa were of two Dallas nurses who cared for Thomas Eric Duncan, a Liberian patient who died Oct. 8 in Dallas from the disease. Both nurses recovered.
Public misconceptions about Ebola may pose the greatest concern for U.S. healthcare workers, said Lauren Johnston, MPA, RN, NEA-BC, FACHE, senior assistant vice president and corporate CNO for the Health and Hospitals Corporation, which includes Bellevue Hospital in Manhattan. “People who think they can contract Ebola by touching a doorknob or sitting next to someone on a plane or riding in a cab either lack information or have the wrong information,” she said.
Nurses can help correct these misconceptions by familiarizing themselves with the facts, acknowledging patients and colleagues concerns without dismissing or minimizing them and offering evidence to counter misinformation, said Linda Greene, MPS, RN, CIC, an infection prevention manager at Highland Hospital in Rochester, N.Y., and a member of the regulatory review panel for the Association for Professionals in Infection Control and Epidemiology. “Never make someone feel less than adequate for expressing their fears,” Greene said.
Healthcare staff concerns
Based on what is known so far about Ebola, the threat to the U.S. public is almost non-existent, said Philip Alcabes, PhD, MPH, professor of public health at Adelphi University College of Nursing in Garden City, N.Y. “But it’s not an imaginary threat if you’re a nurse,” he said. “There’s a real worker safety issue here.”
Healthcare workers on the front lines and the public should feel reassured that the family who cared for Duncan in the early stages of his illness, clinicians who sent him home with a fever and ED workers who treated him when he returned, have all remained Ebola-free, further evidence the disease does not spread through casual contact and that patients with early onset symptoms may not be very contagious, Greene said. But it’s also well known that close contact with someone in the later stages of Ebola can be dangerous, she said.
New protocols from the CDC, including more observation of workers and personal protective equipment that completely covers the skin, should protect caregivers from coming into contact with bodily fluids of patients with Ebola, she said. Greene expected nurses would have a greater degree of comfort with the new protocols, as well as assurances that CDC teams will help guide healthcare facilities that encounter a patient with Ebola, and a national plan to transfer those patients to designated regional centers for care.
After training for two-and-a-half months, nurses at Bellevue felt ready to care for a New York physician who contracted Ebola while working in West Africa, Johnston said. “To help instill trust and confidence, nurses need to feel comfortable asking questions and raising hypothetical situations,” she said. At Kaiser, labor representatives are included in daily update calls to find out their concerns and make sure they are addressed, Chow said.
Hospitals need to prepare for the possibility of treating a patient with Ebola, said Priest, who is co-director of the IU School of Medicine’s disaster medicine fellowship. But they also need to use resources efficiently, which is difficult, since they can’t predict the future. Since 2001, hospitals have spent nearly $2 billion on emergency preparedness equipment like command center CDs, much of it now outdated or useless, he said.
Priest believes it makes more sense to focus on clinical agility – training a healthcare workforce that can adapt quickly to any crisis. This includes having staff work to the full extent of their education and training and teaching clinicians to make good, evidence-based decisions under difficult conditions. Another good investment, he said, is to create teams of clinicians who are well trained in using PPE and working with highly infectious diseases and would be ready to respond to future epidemics.
Ebola underscores the need for more planning and resources for infectious disease control, said Jennie Mayfield, BSN, MPH, CIC, president of APIC. “Infection preventionists who are focusing so much attention on Ebola are worried about missing other infectious diseases such as methicillin-resistant Staphylococcus aureus and clostridium difficile infections,” she said. “Facilities that are inadequately staffed to begin with are stretched beyond capacity at a time like this.”
Though AIDS is a very different disease, Alcabes said, real and imagined fears over the course of the HIV epidemic were similar to those surrounding Ebola, and the lessons learned from both diseases also may be similar. People eventually learned they couldn’t get AIDS from doorknobs or toilet seats. New tests allowed healthcare facilities to quickly diagnose the disease. Healthcare workers demanded proper equipment and protocols, which have helped protect them against other infectious diseases, including Ebola. “In some ways, the HIV story had a good resolution for healthcare workers,” Alcabes said.
Perhaps the greatest worldwide lesson from Ebola may be one more reminder that viruses don’t respect borders. The most effective way to protect ourselves from Ebola would be to devote more resources to West Africa, Alcabes said.
The media fervor over Ebola reflects a transparent public health system that changes policies to reflect changing evidence, and an information system that immediately alerts health officials when someone is sick, Priest said. They don’t have that in West Africa, he said, and that’s why thousands of people are dying.
Cathryn Domrose is a staff writer.