It has been about one year since the largest Ebola outbreak in history began claiming thousands of lives and decimated the already crippled public health infrastructures throughout Liberia, Sierra Leone and Guinea. This week the humanitarian medical organization Doctors Without Borders released a candid report outlining the successes and failures of the global response to the epidemic.
An important reflection highlighted in the report was the slow response by the Western world, particularly that of the US, where it wasn’t until the virus landed on our soil that we became seriously involved in the global response. That catalyst was in the form of a patient named Thomas Eric Duncan, a Liberian national who arrived in Dallas, Texas from Liberia on Sept. 20 and was admitted to Texas Health Presbyterian on Sept. 28. 2014 with Ebola where he subsequently died and spread the virus to members of his healthcare team.
In the wake of the first-ever transmission of Ebola in the US in October 2014, I requested an interview with Dr. Richard Wenzel, who has spent over four decades working to create safer hospitals, both in the US and overseas. Dr. Wenzel is one of the world’s leading infectious disease epidemiologists, having established his reputation in the field of infection control in hospitals. He is also the esteemed author of over 500 publications, including the Guide to Infection Control in the Hospital, 4th Edition, and Stalking Microbes.
Dr. Wenzel shared his insight into the true level of our preparedness, the public health challenges both here and abroad, the need for more epidemiological and laboratory investigation, the adverse effects of policies that result in budget cuts to important healthcare agencies, and the importance of challenging the assumptions of what we think we know about this virus.
Dr. Wenzel, thank you for agreeing to speak with me. Having worked on life-threatening outbreak containments both here in the US, and overseas, what is your opinion on the current efforts to contain the outbreak?
There are a lot of things to talk about, but the key issue is controlling the outbreak. I agree with the CDC that we must control it in Africa if we are going to control it in the rest of the world. Regarding the steps in that process, obviously the newest approach is checking travelers’ temperatures at the airport. I think that will be virtually no use at all, because the incubation period is so long. I think it’s being done primarily to show the public that something is being done, in an effort to calm public fears. However, in terms of controlling the epidemic, it will have virtually no effect at all. In my opinion, it is more political theatre than it is anything else.
Here’s what we have learned from having so many health care workers infected in Africa, and a couple hundred die like the nurse in Madrid. First, the infecting dose must be very, very low. Second, it is a very unforgiving virus. Therefore, infection control has to be just perfect. Also, I would wonder whether the environment is more contaminated than we are led to think. How could so many health care workers get infected—including really experienced health care workers like the first four that came to the US? Furthermore, how did a photographer get infected without any direct patient contact? I am concerned that the environment may be more contaminated than we think. Related to that, I would love to see the CDC and other agencies actually do more investigation while the epidemic is being controlled. They need to look at the environment: how much of a role contamination of the environment plays, and how widespread the virus truly is. I think we ought to attempt to learn more about the outbreak while we are attempting to control it.
I think one of the tasks of the CDC is to challenge all the assumptions — ALL the current assumptions — and then go out there and do more sophisticated laboratory work.
How can they go about doing that with the limited monetary resources they are currently being given?
Well, since this is such a big deal, more resources are being allocated for it. I think that is what they are trying to do, but I think that this is certainly a public health and security issue. I think you just have to make sure that you get the resources that you need, whether it’s from the NIH, the WB, or the US government. I’m not sure what the best ways are that this can be accomplished, but I think it is really important not to assume this virus is acting the same way it did before. We must learn more while we are controlling it. I think that is the basic principle: Learn more; test and question your assumptions all the time; and then try to see whether the questions can be answered by better epidemiological and/or laboratory data.
On the subject of testing your assumptions, what are your thoughts concerning the breakdown that occurred at Texas Presbyterian Hospital?
Well, the assumption again was that all hospitals in the US were well-prepared and I think that one fell very quickly. It was a real debacle that unfortunately added two extra days to the care of the patient—and the patient himself had already taken two extra days before he even sought help. In all, we lost four days. It means that there is great variation in the level of preparedness, the level of vigilance that people have for screening passengers that just got off the plane from Western Africa. I think one of the said benefits for us is that now people are and should be more aware, and hopefully are preparing for this vigorously by going through the drills of putting on and taking off the gear in a meticulous way.
Speaking of adequate training, a National Nurses United spokeswoman stated that, even though the CDC has handed out guidelines, they are not getting out to the front-line healthcare workers and that these recommendations are not an adequate substitute for the hands-on training that anyone who is interacting with patients needs. Do you think her point is valid?
It is critical that you have the hands-on training, absolutely. We (VCU) are going through the drill at our own hospital and I just watched one of the demonstrations with mannequins. And it takes a while—about 20-25 minutes—to put the gear on efficiently and the same amount of time to take the gear off. We know you should have someone observing you the whole time so that they can remind you what step to take so you don’t break any protocol. The nurse who got infected in Madrid apparently touched her face with her glove while taking off her gear. One of the steps being implemented here (VCU) is that, before you begin to take anything off, you actually wipe down your gloves and the front of your spacesuit or apron with disinfectant so you can get rid of any virus that might still be lingering.
Well, obviously that was terrible. Another assumption that you hear from public health was that not only are hospitals ready and that any hospital can manage the case—and we saw how wrong that was—but also that the public health resources would be available to take care of things afterwards—and obviously that was wrong as well. Two significant things happened: First, it took so long for the apartment to be cleaned up and be rid of all the contaminated bedding, clothes, towels and so forth. Second, on the news, there was this horrible image of uninformed maintenance men—with no gear on—spraying down the pavement where the patient had vomited with a hose, creating all kinds of potential problems such as aerosols. It obviously shows, at the very least, miscommunication by public health authorities. They were slow to get on the activity list, I think.
Does our lack of public health preparedness as a country for something of this magnitude concern you?
Yes. It shows that the assumption is that we are all prepared. But the assumption is not true. There is probably a wide variation in the levels of preparedness depending on where you are in the country.
Recently there was an emergency congressional session called at the DFW International Airport due partly to the statement that Dr. Friedman made: that if we don’t act swiftly, this could be the next AIDS epidemic. Even with all the available scientific evidence at their fingertips, there was still serious discussion based on the fear that we need to close our borders. How can public health professionals help policy makers get past the fear barrier so they can make sound policy decisions based on scientific knowledge?
I think one of the things I haven’t seen enough of is real debate on what we know, what we don’t know, and what the current assumptions are. I think the more they debate these things in a visible way, the more ideas will come out and hopefully science will trump any kind of bias based on any fears or ignorance. So I would love to see more debate as far as that goes–and rigorous debate—to make sure people are up front about not only what they think, but up front about what the assumptions are as well. That is the most important thing to me: challenging the assumptions.
How do we do that at a hospital level? How do IC professionals get that message to hospital administrators so they clearly hear it?
What I would use here is, first, what we know about Ebola. Second, I would highlight what happened in Dallas and show that obviously they weren’t as prepared as the CDC would have wished, and make clear that we don’t want to be the next hospital that is shown nationally as not being prepared. I would then give them the steps we need to implement and we would repeatedly have drills on the implementation. In New York, hospitals are using actors as patients in the drills. Other places are using mannequins like we are at VCU. Either way, it is important to continue to prepare for this by repeating the drills over and over, not necessarily with everybody in the hospital, but with the teams that will be responsive and responsible.
How do you help alleviate the fears of health care workers that are responding and responsible for these patients’ care?
You review with them how you can get this disease and how the protective gear will help you. I think the best is to get them prepared. “Them” includes those people who will be on the front-line—the ICU and the emergency room—but also the OBGYN and pediatrics ER and ICU as well. There has to be a certain number of those people that will be the first responders. I think that the more they practice putting on and off the gear and reviewing their protocols, the more comfortable they are going to feel.
Currently, in Dallas, the county prosecutor’s office is looking into the hospital’s records concerning Mr. Duncan’s care, and they are thinking about potentially bringing a case against the hospital. Do you think that is a counter-productive message to send to hospitals?
I don’t know because we don’t know all the facts and I’m not sure how that will really control the epidemic anymore. That is an individual case. The assumption is that no other hospital would do that. I can’t answer that without more facts. I’m not sure it will help control the epidemic at all if they send fear throughout hospitals in an attempt to get the hospitals to get their act as polished as possible.
Going back to the current status in West Africa, Laurie Garret has stated that she commends the commitments that the US has declared for building hospitals, but that she is dubious about the capacity of responders to implement these changes rapidly enough, and that a better option is to provide home health kits so that care of patients can take place at home and the potential transmission list will be significantly lowered. What are your thoughts on that recommendation?
Well, I think it is an adjunct that is reasonable. I don’t think it should replace what we are doing now, but as an adjunct I think it would be terrific. I think one of the hurdles that we need to address even more broadly than it is being done now is to recognize the cultural differences, so that people can do a number of things that might help. For example: 1. Don’t have contact with bats or primates, whether it’s eating them or seeing them in markets. That contact should be stopped. 2. You have to be vigilant about recognizing anybody who may be sick and getting them care, but without touching them or the bodies, which is obviously a big deal; and 3. You continue to work to say that Western medicine is really there to help and not hinder the problem in their country. We have big cultural issues, so I think I would take Laurie’s idea as an adjunct, not as a replacement.
And as someone who has worked overseas on outbreak control in remote resource-poor areas, did you have any experience with suspicion from locals that turned violent against health care workers, like what has happened in W Africa?
I’ve never seen that. I know people have discussed it. I lived in the Philippines and Bangladesh working on various outbreaks, and with H1N1 all over South America and Mexico. They were mostly very grateful for any kind of care Western medicine was able to offer. The problem with H1N1 was they were running out of resources—not enough oxygen, not enough respirators, etc. There is a lot to do, obviously, when you are trying to quell a complicated epidemic.
How does the politicization of an outbreak hinder those efforts further, and how can those on the ground get past it?
I’m sure it is a natural part of any epidemic. You are going to have the politicians try to figure out how they can gain momentum as a result of this. It is human nature. As much as we can get away from that and focus on what the problem is, that’s what needs to happen. I think it is a job of our leaders and certainly public health officials to keep people focused. As soon as you get caught up in political rhetoric, you are in some deep trouble.
How can public health professionals keep people focused on accurate information, when we live in a 24-hour news cycle?
Well, one of the things they have to be careful about is the rhetoric in their communication. You can’t assure people that we are all prepared, that all hospitals are ready, or that all public health authorities will come in and take care of the clothing, bedding and so forth. That has been shown to be a problem. Public health professionals have to stay very focused—we have to be very honest and communicate what we know and what we don’t know. We also have to challenge our own assumptions about the outbreak. I think if we do that and stay on course, we can and will do better than just making general statements.
And with the statements they have released it doesn’t seem as if they are challenging their own assumptions, such as “we know how to do this—every Ebola outbreak in the past has been stopped.”
I agree. I would love to see a little bit more of that, and that is a critical point. I think I have used the term ‘lexicon of uncertainty.’ It needs to be part of the communication, because we don’t know everything and not everything is known about this disease. It wasn’t long ago we were debating what kind of mask to use, whether the surgical mask or N95, for influenza H1N1, and that disease has been around for centuries. Ebola is just emerging, so to think we know everything is naïve.
An article in Foreign Policy magazine stated that the WHO said that they could have combatted this outbreak early on if they had had the budget to do it, but they didn’t, because in 2011, they were pressured to decrease their ID work in favor of non-communicable diseases such as Cancer and HD. Margaret Chan stated that they are only a normative agency, when asked why they didn’t have more initial involvement. What do you think about that transition, because we would think that the WHO are the “boots on the ground,” but it no longer seems like they are in situations such as this?
Well, it’s an interesting question. I would love to know the specifics of their budget. But the WHO is a smaller organization than what most people think. On the other hand, when SARS came around, they took the international lead, and then later on partnered with the CDC and others, so the perception out there was that they would be the lead organization. I do think their budget is low. I think that they probably could have responded more quickly. They do have a low budget. We expected them to respond earlier. I don’t think they responded early enough and I think that if they had more budget that wouldn’t have changed the initial response but it would have changed what they were able to do perhaps once they did respond:
Respond with more healthcare providers or in what other way?
They could do a couple of things that they do generally pretty well: first, muster all the international support for an outbreak, which they did well with SARS; second, come in a little earlier, with the CDC. So we expect them not to foot the entire bill but to take the lead, and I think for them to say they didn’t take the lead because they didn’t have the money is not quite accurate. We expected them to take the lead–they could have banged on the table and said, “Hey! We need more resources, because this is a really important problem.”
So, going forward, if the international community has to deal with something like this again in the future, do you feel as if all healthcare regulatory agencies need the WHO to be that lead?
Well, what I would love to see is the forging of a new first response team. The partners for me would certainly be the WHO, WB, and I would add Google because I think we need to account for and track these infections over time and space. Then obviously the UN would be a partner, in order to get all the political support. They would be the sponsors and the key players, and then there would be people around the world that would agree ahead of time that if we have people dying (like in the GD province during SARS), we don’t wait four months to get on top of it. You try to get it early. If you remember, there was the physician who left for Hong Kong and infected 10 people in the hotel, and that was the tipping point for the pandemic, and I keep imagining an early response team that would get in there before then. The point was trying to get them to admit they had a problem. So we may have to possibly look at a new international organization with (at least in the beginning) some of the members I suggested and enumerated.
That is a great idea. Are there any current initiatives to make that happen?
None that I am aware of, but I may not be in the loop for all the international organizations.
The personal protective equipment (PPE) that are currently recommended by the CDC are considerably less than what hospital administrators seem to be comfortable with and are reluctant to follow. Instead, hospitals are investing in ‘space suits’. Do you think hospital administrators need to use their finite resources to invest in such equipment?
You need both the equipment and the training. I think that one of the things that strikes me is that there are over 200 deaths in Africa among health care workers. That, to me, means that this is really an unforgiving virus with a very low infecting dose. We do everything we can to protect the health care worker—and it’s a complicated outfit—it’s not like getting ready for the flu or a GI disease—it takes 20-30 mins to get the suits on as well as all the gear-and then the suits off in a safe way. I keep thinking of this poor nurse’s aid in Madrid, presumably just touching her face with her glove at the end and whether that glove was contaminated or wasn’t disinfected properly before she began to take the gear off, I’m not sure, but this is going to require a lot of drills and from what I hear around the country, some hospitals are doing a lot of it using simulations, and some repeating getting the gear off and on while someone is observing making sure they don’t break technique until they are really sure—other hospitals haven’t gotten the messages out so I think we have to gear up and make sure literally I mean, make sure that there isn’t such a wide disparity of preparedness and preparation.
Do you think the CDC is doing an adequate job in bridging that gap?
I haven’t heard much about how they are interacting with hospitals at all, so in that sense I guess I have to say I think they could probably do more. I think they need to be more consistent about their case-definitions. There was one definition of a case in September and then another in October, so it is important that they don’t get caught up in the inconsistencies. I think that their job is to continue to stay and keep us all focused on the key problems: we have to be prepared, we have to be vigilant, we have to go through the drills, I don’t see any way around that for now.
It is projected that we can get this outbreak in W Africa under control by the end of Jan 2015. A major concern for public health and clinical workers in those areas is what will be left of the already strained public health infrastructure in those regions, and how do we keep the international community on task to help even after the outbreak is under control?
I think that is going to be an enormous challenge for many reasons. First, we are talking about a place where there has been a global recession and resources are limited. Second, if people in the West think that because it’s solved, now they have to go work on some other problems, and they stop the resources from coming in as well, the risk for other problems surfacing is inevitable. When you look back at the big picture, almost every new disease of public health importance in the past 30 years has been a zoonosis, and where those are likely to come out of–certainly Africa is a big player, whether we are talking about Ebola, Marburg, Asia with SARS, the ME with MERS, these are all zoonosis, and I think we have to continue to be aware of that and then be able to respond globally. That is going to be an enormous problem. I don’t see any easy solutions right now.
Any other thoughts/opinions on the current situation?
One overriding thing is that, in general, the CDC is right to talk about the control therapies: identification and containment of all patients and all contacts. But what I would love to see more of is more investigation along the way which would be focused on confirming our currently-held assumptions about Ebola. We think, based on the studies on Marburg, that the bat is the primary reservoir, and that primates are secondary. We ought to be in there proving that hypothesis. We think the environment isn’t too important, but I would like to see that examined much more rigorously. We think that it is impossible for this virus to be aerosolized, but it occurs to me that a patient late in stages could cough, and some of those droplets could be small enough to not fall to the ground and might stay in the air like microscopic hot air balloons and be air-borne. I would love to see that dismissed as a possibility. It would be really reassuring to prove that isn’t so. I think the more we learn the better it will be, and I think one of the tasks continues to be to question assumptions.
Disclosure: Interview date October 11, 2014