NEWS & VIEWS
MACROSCOPY Addressing Fear, Fighting Complacency SA Pergam1,2,3 Nature has us wired instinctively to be cautious of things that are unknown or unfamiliar. Children may fear the dark, but even as adults we remain afraid of things that go bump in the night. Knowing this, I have come to understand how Ebola, a virus that the scientific community felt would minimally impact our healthcare system, came to dominate our national consciousness. The epidemic, which began in Africa in late 2013, emerged as a major news story when infected patients Dr Kent Brantly and Nancy Writebol arrived on US soil in August 2014. Within weeks, a study found that nearly 40% of Americans feared a large national outbreak and over a quarter were concerned that a family member would develop Ebola.1 After the first cases of transmission were documented in two nurses at Texas Presbyterian Hospital, alarm and panic led to general distrust of science and healthcare’s ability to control the infection. Misinformation entered chat rooms, media outlets, and even classrooms. It was the “fear of Ebola,” not the virus itself, that spread like a true epidemic. During this period of uncertainty, the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), among other international governmental and nongovernmental organizations (e.g., Medecins Sans Frontie`res) continued to document the epidemic and provide support in Africa. They developed recommendations for hospitals outside the outbreak zone and provided resources and education to the public. Hospitals around the globe organized to screen and isolate potential Ebola patients. Systems for moni-
toring travelers and healthcare volunteers were established. Within weeks of the events in Texas, patients grew accustomed to being asked “Have you recently traveled to Africa?” Subsequent transmission events did not occur and reports of Ebola cases outside the epidemic hot zone evaporated. The media and general public eventually moved on to other issues. As anxiety passed, indifference took over. Healthcare efforts need to address that our irrational fear of Ebola came at great cost to staffing and financial resources. County, state, and national health departments redirected funds and staff to address Ebola. Tremendous effort was required from physicians, nurses, administrators, and other hospital staff at the institutional level who planned and implemented local Ebola prevention strategies. Simple tasks such as dealing with medical waste and organizing necessary personal protective equipment (PPE) were challenging, particularly when requirements kept changing or when hospital requests outstripped available supplies; surgical hoods still remain on back order. All told, US healthcare allocations to fund Ebola preparation in the US are difficult to estimate. They will be substantial. Even though we couldn’t stop “Ebola” momentum, I believe we shouldn’t have. Initially, the potential for transmission was weighed against the calculated human and financial burdens of investing in local pre-
vention efforts. However, such tensions became irrelevant, as the developments in Texas changed the conversation, and it became clear that Ebola is most dangerous when patients are critically ill, putting hospitals and hospital staff at greatest risk. Ebola’s cruelest weapon, its effect on first responders, was perhaps most tangible in the losses of medical staff in Guinea, Liberia, and Sierra Leone, and the dedicated researchers who gave their lives to the early outbreak.2 With stark reminders of the importance of such efforts, extensive prevention efforts became inevitable, as we all set out to educate, support, and protect healthcare’s most important resource—the people. It was our obligation to prepare our staff as though an event was inevitable, knowing full well the chances were slim that an Ebola case would walk through our door. Sadly, it was also the cases outside of the continent that provided the impetuous for the eventual but delayed worldwide response in West Africa. The critically needed spotlight on the unfolding tragedy in Africa, increased political pressure, and the mobilization of billions in global funding, supplies, and logistics were essential to reshaping the epidemic. The research community has provided additional support through multinational scientific collaboration that has expanded knowledge of the virus, sped efforts to develop vaccine candidates, and even allowed patients access
1 Infection Prevention, Seattle Cancer Care Alliance, Seattle, Washington, USA; 2Clinical Research and Vaccine and Infectious Disease Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; 3Division of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, USA. Correspondence: SA Pergam ([email protected])
doi:10.1002/cpt.162 CLINICAL PHARMACOLOGY & THERAPEUTICS | VOLUME 98 NUMBER 4 | OCTOBER 2015
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NEWS & VIEWS to emerging/experimental therapies; all of which have the potential for a lasting impact on future treatment and prevention. Ebola has forced us to become introspective, to identify weaknesses in our own healthcare systems. Hospitals and healthcare organizations nationwide recognized a need to prepare for highly transmissible infections. They created training, multidisciplinary working groups, honed communication approaches, and prepared dedicated isolation units. Centers across the nation also readdressed PPE practices, solidified education, and spurred a renewed emphasis on infection prevention within the industry. Organizations also worked collaboratively to share best practices, and experienced centers openly made their policies and procedures available to the medical community, while transparently discussing the challenges in treating Ebola-infected patients. More recently, the CDC finalized plans to expand the number of medical centers capable of caring for Ebola-infected patients. Such hospitals could serve an important foundation, which with continued support will be critical to managing a wider variety of future pandemics— including those that are more contagious and with infinitely more pandemic potential than Ebola. The CDC was right however, Ebola was not a major risk nationally and did not lead to additional outbreaks in the US In fact, there was an overwhelming sense in the medical community that the human, financial, and political capital allocated to Ebola in hospitals throughout the US was superfluous when compared to the absolute number of domestic cases identified. In a national survey from October 2014, hospital epidemiologists and Infection Control staff estimated that between 70–80% of their efforts were spent on Ebola preparations, even though only 5% of those surveyed felt they would have a case of Ebola in their hospital. More important, those in Infection Prevention also estimated that nearly three-quarters of their normal work could not be completed.3 Data such as these should remind us to be cautious of how and where we allocate 360
our resources, and that when we do, we use them wisely. The need for rapid development of complex institutional systems and structures to address Ebola and other emerging infections must not come at the expense of transmittable infections that are well known to impact our health. It is estimated, for example, that influenza-associated deaths range from thousands to tens of thousands annually in the US alone. With our aging population, it is expected that influenza will carry an even heavier burden in the future. Although there are both vaccines and antiviral therapies, less than 50% of Americans are vaccinated, many eligible patients never receive treatment, and vaccine effectiveness is often inadequate. In developing countries, where mortality from influenza may be higher than anywhere else in the world,4 vaccinations and treatment are generally unavailable, and epidemiologic data to plan future interventions are lacking. Influenza, however, is only the tip of the proverbial iceberg. Other respiratory viruses, such as respiratory syncytial virus, metapneumovirus, and parainfluenza viruses, among others, in their own right can lead to outbreaks, morbidity, and death that rival even influenza. Diarrheal disease, which is the leading cause of childhood mortality, may be even more important. Without vaccines, improved treatment options, and ongoing research, these infections will continue to cause excess mortality throughout the world that far outpaces Ebola. Recent outbreaks of vaccine-preventable infections also should give us pause. In the past decade we have seen the reemergence of pathogens that many of today’s physicians have never seen. Measles outbreaks in the US and Germany, and the explosion of pertussis cases throughout North America and Europe, serve as evidence of important shifts in vaccine compliance. If a single day at Disneyland can lead to nearly 150 cases of measles in seven states, imagine the devastation that could occur at hospitals like mine, where the majority of patients are immunocompromised, or better yet, a country with inadequate vaccine coverage. With 10 times the basic reproduction number (R0) of Ebola, outbreaks from these agents require intense public health intervention and significant cost. As a potential
second wave of misery, there are also concerns that vaccine-preventable diseases will emerge in the wake of Ebola in Western Africa. It has been estimated that if a comprehensive vaccination program is not developed, hundreds of thousands of cases of measles will occur, and measles-related deaths could be on a par with those due to Ebola.5 Perhaps most concerning is the spread of multidrug resistant (MDR) organisms worldwide. Multidrug and extensively drug-resistant tuberculosis, drug-resistant gonorrhea, and fluoroquinolone-resistant Salmonella species are of major concern on an international scale. Expansion of hospital-acquired infections such as Clostridium difficile, and the nosocomial spread of multidrug-resistant Enterobacteriacae with extended spectrum betalactamases or those harboring Klebsiella pneumoniae carbapenemase (KPC) genes also have become international problems. Until we can develop better methods for preventing misuse of antibiotics, the frequency and mortality associated with these agents will continue to expand throughout the world. Ebola and the events of the last year show us how small the world has become. Ebola should serve as a catalyst to support international transparency, education, and research on emerging pathogens and to improve pandemic preparedness worldwide. But our experience with Ebola should also remind us that we cannot allow fear to drive decision-making. The need to address emerging infections and the next pandemic must be balanced with ongoing efforts to stop infections already in our homes, hospitals, and communities. We need to promote international support from drug and vaccine development, antimicrobial stewardship, and Infection Control efforts to both treat and limit transmission of both those infections we can and cannot predict. It is our responsibility to focus on collaborations, such as WHO’s recent global action plan for antimicrobial resistance, aimed at improving education and prevention worldwide. Tools and solutions that emerge from these efforts to protect patients locally from infections in our own backyards will help everyone to be ready for those coming to an airport near you.
VOLUME 98 NUMBER 4 | OCTOBER 2015 | www.wileyonlinelibrary/cpt
NEWS & VIEWS CONFLICT OF INTEREST The author declares no conflicts of interest. C 2015 ASCPT V
1. McCarthy, M. Four in 10 US people fear large outbreak of Ebola. BMJ. 349, g5321 (2014).
2. Gire, S.K. et al. Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak. Science 345, 1369–1372 (2014). 3. Morgan, D.J. et al. Lessons learned from hospital Ebola preparation. Infect. Control Hosp. Epidemiol. 36, 627–631 (2015).
CLINICAL PHARMACOLOGY & THERAPEUTICS | VOLUME 98 NUMBER 4 | OCTOBER 2015
4. Katz, M.A. et al. Influenza in Africa: uncovering the epidemiology of a longoverlooked disease. J. Infect. Dis. 206, (suppl. 1) S1–4 (2012). 5. Takahashi, S. et al. Reduced vaccination and the risk of measles and other childhood infections post-Ebola. Science 347, 1240– 1242 (2015).
361
MACROSCOPY Addressing Fear, Fighting Complacency SA Pergam1,2,3 Nature has us wired instinctively to be cautious of things that are unknown or unfamiliar. Children may fear the dark, but even as adults we remain afraid of things that go bump in the night. Knowing this, I have come to understand how Ebola, a virus that the scientific community felt would minimally impact our healthcare system, came to dominate our national consciousness. The epidemic, which began in Africa in late 2013, emerged as a major news story when infected patients Dr Kent Brantly and Nancy Writebol arrived on US soil in August 2014. Within weeks, a study found that nearly 40% of Americans feared a large national outbreak and over a quarter were concerned that a family member would develop Ebola.1 After the first cases of transmission were documented in two nurses at Texas Presbyterian Hospital, alarm and panic led to general distrust of science and healthcare’s ability to control the infection. Misinformation entered chat rooms, media outlets, and even classrooms. It was the “fear of Ebola,” not the virus itself, that spread like a true epidemic. During this period of uncertainty, the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), among other international governmental and nongovernmental organizations (e.g., Medecins Sans Frontie`res) continued to document the epidemic and provide support in Africa. They developed recommendations for hospitals outside the outbreak zone and provided resources and education to the public. Hospitals around the globe organized to screen and isolate potential Ebola patients. Systems for moni-
toring travelers and healthcare volunteers were established. Within weeks of the events in Texas, patients grew accustomed to being asked “Have you recently traveled to Africa?” Subsequent transmission events did not occur and reports of Ebola cases outside the epidemic hot zone evaporated. The media and general public eventually moved on to other issues. As anxiety passed, indifference took over. Healthcare efforts need to address that our irrational fear of Ebola came at great cost to staffing and financial resources. County, state, and national health departments redirected funds and staff to address Ebola. Tremendous effort was required from physicians, nurses, administrators, and other hospital staff at the institutional level who planned and implemented local Ebola prevention strategies. Simple tasks such as dealing with medical waste and organizing necessary personal protective equipment (PPE) were challenging, particularly when requirements kept changing or when hospital requests outstripped available supplies; surgical hoods still remain on back order. All told, US healthcare allocations to fund Ebola preparation in the US are difficult to estimate. They will be substantial. Even though we couldn’t stop “Ebola” momentum, I believe we shouldn’t have. Initially, the potential for transmission was weighed against the calculated human and financial burdens of investing in local pre-
vention efforts. However, such tensions became irrelevant, as the developments in Texas changed the conversation, and it became clear that Ebola is most dangerous when patients are critically ill, putting hospitals and hospital staff at greatest risk. Ebola’s cruelest weapon, its effect on first responders, was perhaps most tangible in the losses of medical staff in Guinea, Liberia, and Sierra Leone, and the dedicated researchers who gave their lives to the early outbreak.2 With stark reminders of the importance of such efforts, extensive prevention efforts became inevitable, as we all set out to educate, support, and protect healthcare’s most important resource—the people. It was our obligation to prepare our staff as though an event was inevitable, knowing full well the chances were slim that an Ebola case would walk through our door. Sadly, it was also the cases outside of the continent that provided the impetuous for the eventual but delayed worldwide response in West Africa. The critically needed spotlight on the unfolding tragedy in Africa, increased political pressure, and the mobilization of billions in global funding, supplies, and logistics were essential to reshaping the epidemic. The research community has provided additional support through multinational scientific collaboration that has expanded knowledge of the virus, sped efforts to develop vaccine candidates, and even allowed patients access
1 Infection Prevention, Seattle Cancer Care Alliance, Seattle, Washington, USA; 2Clinical Research and Vaccine and Infectious Disease Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; 3Division of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, USA. Correspondence: SA Pergam ([email protected])
doi:10.1002/cpt.162 CLINICAL PHARMACOLOGY & THERAPEUTICS | VOLUME 98 NUMBER 4 | OCTOBER 2015
359
NEWS & VIEWS to emerging/experimental therapies; all of which have the potential for a lasting impact on future treatment and prevention. Ebola has forced us to become introspective, to identify weaknesses in our own healthcare systems. Hospitals and healthcare organizations nationwide recognized a need to prepare for highly transmissible infections. They created training, multidisciplinary working groups, honed communication approaches, and prepared dedicated isolation units. Centers across the nation also readdressed PPE practices, solidified education, and spurred a renewed emphasis on infection prevention within the industry. Organizations also worked collaboratively to share best practices, and experienced centers openly made their policies and procedures available to the medical community, while transparently discussing the challenges in treating Ebola-infected patients. More recently, the CDC finalized plans to expand the number of medical centers capable of caring for Ebola-infected patients. Such hospitals could serve an important foundation, which with continued support will be critical to managing a wider variety of future pandemics— including those that are more contagious and with infinitely more pandemic potential than Ebola. The CDC was right however, Ebola was not a major risk nationally and did not lead to additional outbreaks in the US In fact, there was an overwhelming sense in the medical community that the human, financial, and political capital allocated to Ebola in hospitals throughout the US was superfluous when compared to the absolute number of domestic cases identified. In a national survey from October 2014, hospital epidemiologists and Infection Control staff estimated that between 70–80% of their efforts were spent on Ebola preparations, even though only 5% of those surveyed felt they would have a case of Ebola in their hospital. More important, those in Infection Prevention also estimated that nearly three-quarters of their normal work could not be completed.3 Data such as these should remind us to be cautious of how and where we allocate 360
our resources, and that when we do, we use them wisely. The need for rapid development of complex institutional systems and structures to address Ebola and other emerging infections must not come at the expense of transmittable infections that are well known to impact our health. It is estimated, for example, that influenza-associated deaths range from thousands to tens of thousands annually in the US alone. With our aging population, it is expected that influenza will carry an even heavier burden in the future. Although there are both vaccines and antiviral therapies, less than 50% of Americans are vaccinated, many eligible patients never receive treatment, and vaccine effectiveness is often inadequate. In developing countries, where mortality from influenza may be higher than anywhere else in the world,4 vaccinations and treatment are generally unavailable, and epidemiologic data to plan future interventions are lacking. Influenza, however, is only the tip of the proverbial iceberg. Other respiratory viruses, such as respiratory syncytial virus, metapneumovirus, and parainfluenza viruses, among others, in their own right can lead to outbreaks, morbidity, and death that rival even influenza. Diarrheal disease, which is the leading cause of childhood mortality, may be even more important. Without vaccines, improved treatment options, and ongoing research, these infections will continue to cause excess mortality throughout the world that far outpaces Ebola. Recent outbreaks of vaccine-preventable infections also should give us pause. In the past decade we have seen the reemergence of pathogens that many of today’s physicians have never seen. Measles outbreaks in the US and Germany, and the explosion of pertussis cases throughout North America and Europe, serve as evidence of important shifts in vaccine compliance. If a single day at Disneyland can lead to nearly 150 cases of measles in seven states, imagine the devastation that could occur at hospitals like mine, where the majority of patients are immunocompromised, or better yet, a country with inadequate vaccine coverage. With 10 times the basic reproduction number (R0) of Ebola, outbreaks from these agents require intense public health intervention and significant cost. As a potential
second wave of misery, there are also concerns that vaccine-preventable diseases will emerge in the wake of Ebola in Western Africa. It has been estimated that if a comprehensive vaccination program is not developed, hundreds of thousands of cases of measles will occur, and measles-related deaths could be on a par with those due to Ebola.5 Perhaps most concerning is the spread of multidrug resistant (MDR) organisms worldwide. Multidrug and extensively drug-resistant tuberculosis, drug-resistant gonorrhea, and fluoroquinolone-resistant Salmonella species are of major concern on an international scale. Expansion of hospital-acquired infections such as Clostridium difficile, and the nosocomial spread of multidrug-resistant Enterobacteriacae with extended spectrum betalactamases or those harboring Klebsiella pneumoniae carbapenemase (KPC) genes also have become international problems. Until we can develop better methods for preventing misuse of antibiotics, the frequency and mortality associated with these agents will continue to expand throughout the world. Ebola and the events of the last year show us how small the world has become. Ebola should serve as a catalyst to support international transparency, education, and research on emerging pathogens and to improve pandemic preparedness worldwide. But our experience with Ebola should also remind us that we cannot allow fear to drive decision-making. The need to address emerging infections and the next pandemic must be balanced with ongoing efforts to stop infections already in our homes, hospitals, and communities. We need to promote international support from drug and vaccine development, antimicrobial stewardship, and Infection Control efforts to both treat and limit transmission of both those infections we can and cannot predict. It is our responsibility to focus on collaborations, such as WHO’s recent global action plan for antimicrobial resistance, aimed at improving education and prevention worldwide. Tools and solutions that emerge from these efforts to protect patients locally from infections in our own backyards will help everyone to be ready for those coming to an airport near you.
VOLUME 98 NUMBER 4 | OCTOBER 2015 | www.wileyonlinelibrary/cpt
NEWS & VIEWS CONFLICT OF INTEREST The author declares no conflicts of interest. C 2015 ASCPT V
1. McCarthy, M. Four in 10 US people fear large outbreak of Ebola. BMJ. 349, g5321 (2014).
2. Gire, S.K. et al. Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak. Science 345, 1369–1372 (2014). 3. Morgan, D.J. et al. Lessons learned from hospital Ebola preparation. Infect. Control Hosp. Epidemiol. 36, 627–631 (2015).
CLINICAL PHARMACOLOGY & THERAPEUTICS | VOLUME 98 NUMBER 4 | OCTOBER 2015
4. Katz, M.A. et al. Influenza in Africa: uncovering the epidemiology of a longoverlooked disease. J. Infect. Dis. 206, (suppl. 1) S1–4 (2012). 5. Takahashi, S. et al. Reduced vaccination and the risk of measles and other childhood infections post-Ebola. Science 347, 1240– 1242 (2015).
361
