How to Prevent the Spread of Ebola Virus Infection

Effective Strategies to Reduce Hospital/Facility Acquired Infections and Reduce Superbug Outbreaks

by Yinka Vidal

Book Introduction

It starts with allaying people’s fear and discussing facts about the clinical aspects of Ebola virus infection. It discusses different types of Ebola viruses and their pathogenesis; routes of infection; clinical manifestations and progression of the disease; immunopathology and cellular toxicity; progressive tissue damage and multi-organ failures; effective management of the disease; and the discussion of some case studies.

The book does more, it provides up-to-date information for clinicians, nurses, healthcare workers, medical students, residents, and others in medical science, regarding information they need to know about Ebola infection and the mechanisms of infectious diseases. This information is ammunition for treating and preventing the spread of Ebola. For about 12 months, after the arrival of Ebola in the U.S. much misinformation passed around has confused many people in the medical community, raising the level of panic. The book demystifies fictional stories about Ebola while dealing with clinical facts and research information about the viral infection.

In working on this project, over 600 pages of medical and scientific journals were reviewed. Understanding that an average healthcare worker, especially a physician, cannot have time to read as many pages of medical journals, let alone be able to decipher the critical issues. This book is designed to help the understanding of Ebola infectivity, treatment, and nosocomial infection prevention which is currently an epidemic in the nation. Today, the spread of Superbug infections in hospitals is a real and more dangerous threat than Ebola virus infection. On February 18, 2015, the Los Angeles Times reported about the new outbreak of another Superbug at the UCLA’s Ronald Reagan Hospital Medical Center. The paper reported that 180 patients were exposed to deadly bacteria from contaminated medical scopes and two patients were already dead. The Superbug is known as CRE – Carbapenem-Resistant-Enterobacteriaceae. If the infection spreads through the blood stream, it can kill from 40 to 50% of the victims. Two deaths in North Carolina have been associated with the same bacteria - - CRE reported in California. The report indicated that patients might have contracted the bacteria infection from Carolinas Healthcare System hospitals in 2015. About 15 patients have been treated in the same hospital system for CRE. In addition to the Ebola virus infection, Superbug-nosocomial bacteria infection is one of the major reasons to revisit infection control protocols in ALL the hospitals, clinics and health facilities in the U.S.

In February 25, 2015, CDC raised a red flag about C. Difficile bacteria usually found in hospitals as a nosocomial infection has now spread to physicians’ and dentists’ offices. According to report from the CDC, the infection is currently on the rise in the nation causing deadly diarrhea. Half a million Americans are infected every year with resultant deaths of 15,000 people directly associated with the infection. Of the 150,000 people that contracted C. Difficile infection in 2011, 82% had visited their doctor’s or dentist’s office in the 12 weeks prior to their diagnosis. Lessa FC. Mu Y. Bamberg WM. Beldavs ZG et al. report about C. Difficile epidemic in "Burden of Clostridium Difficile Infection in the United States" (New England Journal of Medicine, Feb. 25, 2015). This journal article reports that based on their study in 2011 that investigated 10 geographical areas in the U.S. testing stool specimens for C. Difficile, about half a million of the patients were infected with C. Difficile and 29,000 deaths were reported. The incidents of the infections are higher in white females of 65 years and older.

This book, How to Prevent the Spread of Ebola extensively discusses very elaborate strategies to prevent the spread of infectious diseases and the necessary precautions to be taken by healthcare workers at every level to sustain infection control. One of the critical issues discussed in this book directly targets guidelines needed to be taken by hospitals, healthcare workers and patients to prevent the spread of facility-acquired infections like the Clostridium Difficile (C. Difficile), Superbugs, Ebola viral infections, and other infectious diseases. Infection prevention strategies are echoed throughout the entire book.

The monograph also serves as an important tool in the hands of healthcare professionals who want to understand the pathogenesis of Ebola, current treatment trend and the best practices to prevent the spread. Such knowledge can help to reduce Ebola as a nosocomial infection in hospitals while at the same time giving patients excellent care. The process of preventing hospital-acquired Ebola infection goes beyond the Ebola virus. It also stretches into the prevention of the spread of other infectious agents like the Superbug inside healthcare facilities and in the nation.

The pathogenesis and treatment of Ebola virus infection being discussed in this book also help to better understand the progressive pathology of any new viral infection or outbreak and the way such patient may be handled in the future. For example, although this book is about Ebola viral infection, another viral infection has been discovered in the U.S. that can be as dangerous as Ebola.

Kosoy OI. Lambert AJ. Hawkinson DJ. et al. in conjunction with Center for Diseases Control (CDC) report about a patient who contracted a viral infection from the bite of ticks in eastern Kansas, U.S.A. (Emerging Infectious Diseases May 2015; vol 21, #5). He was a healthy farmer in his fifties, bitten several times by ticks. He suffered from persistent fever and fatigue. His blood work showed thrombocytopenia and leukocytopenia. Testing revealed that the patient was infected with a virus from the genus Thogotovirus of the family of Orthomyxoviridae. The virus was named Bourbon virus where it was discovered in Bourbon County in Kansas. The following day after admission, the patient developed persistent fever, anorexia, chills, headache, myalgia, arthralgia, diarrhea, and dehydration. Patient later developed left axillary lymphadenopathy, diffused maculopapular rash on his chest and back, and petechiae on his soft palate and lower extremities. The persistent high fever continued. Despite treatment with antibiotics and supportive therapy, the patient developed progressive dyspnea, pulmonary congestion and interstitial edema, progressing to congestive heart failure, renal failure, and hypotension. He went into shock, developed respiratory failure, all attempts to resuscitate the patient failed. On the 11th day of the illness, the patient died. Interestingly, the progressive symptoms observed in this patient are similar to some of the symptoms manifestation in Ebola viral infection. The management of Ebola can also be a key into the management of other viral infections in the future. The critical point is to learn about the pathogenesis of Ebola virus, the manifestations of the illness in different organs of the body, and how effective management using a multi-pronged approach, helps to successfully treat the patients. Consequently, some of the lessons learned from Ebola treatment can successfully be applied to the treatment of other viral infections like the Bourbon virus newly discovered in the U.S. with similar clinical manifestations.

One of the pieces of information reported during the interview by Julia Belluz of Dr. Erin Staples, a medical epidemiologist located in Fort Collins, Colorado can be misleading to practicing physicians. This interview was reported online on Vox website titled, "The deadly, new ‘Bourbon virus’ was just discovered in the U.S." The interview gives more information about this mysterious illness about the new deadly virus from ticks in the U.S. However, the question was asked about what physicians and patients should do with such information about the Bourbon virus. According to the report, Dr. Staples implied that fever, muscle aches, gastrointestinal issues are non-specific signs and symptoms. This is grossly very misleading. This farmer who died in Kansas based on all the symptoms at the onset of the illness and the progressive worsening of the clinical conditions and the manifestations of thrombocytopenia, leukocytopenia, and increase in liver enzymes are the classical presentations seen in viral infections and also classical manifestations seen in Ebola infected patients as well. To claim the classical features of this viral illness are non-specific leaves any practicing physician in rural or agricultural areas in confusion. The point being, the entire presentations of this patient and the progressive illness to death displayed classical features to look for in any possible viral infection. The clue is not only the correct diagnosis as well as how to manage the viral illness from what has already been established in the treatments and management of other viral infections such as Ebola.

On December 31, 2014 BBC News published the story of the first British Ebola patient (Pauline Cafferkey) arriving in Britain for treatment. The report indicates the patient will be treated with an experimental antiviral drug and convalescent serum from a patient who survived Ebola at the Royal Free Hospital in Hampstead, England. Successful treatment of Ebola infection can be achieved by reading some of the aggregates of treatment strategies discussed in this book. Physicians should be careful in giving convalescent serum to treat Ebola patients because of concerns raised by such treatment. Just because the blood is negative for Ebola virus does not mean the Ebola virus is completely out of the patient’s body. This is a shocking and very important discovery about Ebola pathogenesis. More about this issue to be discussed later in the book. According to the report, Dr. Michael Jacobs, an infectious disease specialist expressed his frustration about the treatment options for an Ebola infected patient. He implied that they do not have the best treatment strategies. At the time he was interviewed he said that there was no adequate information to confirm the effectiveness of antiviral agents being used to treat Ebola patients. He sounded an alarm that treatment uncertainties hanged over the treatment of Ebola patients.

Based on the interview report of Dr. Michael Jacobs in Britain, U.S. physicians have raised similar concerns about the uncertainties about Ebola treatments. The truth is, there are effective and curable treatments for Ebola infected patients. Delivering this information to clinicians is one of the major objectives of this book. This interview report of Dr. Jacobs raised a problem currently endemic in the medical community between clinical research scientists and practicing clinicians. Practicing physicians depend of clinical medical researchers to supply information to them about how to proceed in the treatment of any disease. Clinical researchers, many of which are not practicing physicians, conduct many laboratory and field research projects to gain critical medical information. This may include information about disease pathogenesis and manifestations, drugs and toxicity, and different treatment strategies. Interestingly, many of the people doing research are not physicians, but are research specialists in the areas of their expertise. Only a very few physicians are currently in research for obvious reason. Not too many practicing physicians have time to work with test tubes while servicing long rows of patient lineup. If these physicians are not given the information from the research community, it creates a lot of frustrations in the practice of medicine for clinicians. Part of the reasons for physicians’ frustration over Ebola infection is the reality that any time things go wrong in medicine, the public tends to blame physicians. This is just not fair! However, many are unaware that physicians tend to practice medicine based on the clinical and research information supplied to them by medical researchers. Why should we blame practicing physicians for sometimes misleading information from medical researchers?

For the first time in the history of medicine, research scientists crippled the practice of medicine by not delivering prompt and effective treatment strategies already resolved to practicing physicians. That was the alarm bell raised by Dr Jacob, a practicing physician. The emergence of Ebola infection brings to light the disconnection between these two groups of healthcare professionals. The solution is the urgent need between clinical researchers, and practicing physicians to communicate better through a forum more than just writing journal articles. At times, it is interesting to see Dr. Nancy Snyderman on NBC News or Dr. Sanjay Gupta on CNN attempting to explain to the public the clinical relevance of the new medical research reports by the medical researchers hiding inside the research laboratory. Shouldn’t these medical researchers be explaining the results of their work to the public?

Like Ebola infection, measles infection is caused by a virus, more contagious than Ebola virus. By February 2, 2015 the outbreak of measles according to CDC report was over 100 cases affecting 14 states in the nation just in 2015. From January 1 to February 20, 2015, total number of measles reported cases of 154 from 17 states. In 2014, 644 cases of measles were reported in 27 states, very high number compared to previous years. Some parents are concerned about vaccinating their children because of the chances of developing autism as part of the side effects. This controversy came to light years ago when a medical researcher alluded to the possibility that vaccination might cause autism. In this case, this medical researcher happened to be a physician. Subsequently many parents became skeptical about vaccinating their children against measles in spite of many more research studies which disputed the initial assertion. The follow-up study reports were unable to link autism with measles vaccination. The issue is not the parents, or even the person who gave misleading research report years ago. The critical problem is the lack of effective mass education of the public about subsequent research reports that disputed the initial misleading report. Bad preliminary news report tends to attract more attention than corrective report. By nature people tend to associate their decision with the first bad report. It takes more efforts and mass education of the public to correct misleading report with correct information. This is where the news media has a critical role to play in correctly educating the public. Such mass education should present convincing evidence through research reports that vaccination against measles does not cause autism. In the process, the report need to directly interview medical researchers putting out such information. This will give the medical researchers opportunity not only to educate the public but also to explain the convincing reasons for their corrective report. Unfortunately, medical researchers appear to hide in the closet of research institutions with their white coats and bowties, and are hardly ever interviewed while physicians who do not even take part in the study have to explain the clinical interpretation to the public. Unfortunately, the physicians explaining and using the research report to treat patients ended up facing the brunt of public outrage when things go wrong. Same thing happened with Ebola. For the time being where are the medical researchers to explain the results of their research report to the public? How do we hold medical researchers accountable for their published research reports while they are busy hiding under the microscope table in the research laboratories?

Unfortunately, some of the media information about medical science can be inadequate or misleading. For example ZMapp is not a magic drug for the treatment of Ebola infection contrary to what was reported in the media. The treatment of any viral infection is more complex than just the utilization of one magic drug. Effective treatment of Ebola infection is a multi-pronged approach with up to 15 different clinical strategies depending on the manifestations of the pathogenesis of the viral infection. This approach is discussed in detail in chapters 12 to 15 and 17 to 25.

With measles outbreak in the U.S., this book explains the process of vaccination and immunization, especially to worried parents. The news media need to interview medical researchers more often as they interview physicians when issues are raised about medical information. It is easier to blame the gatekeepers and ignore those working inside the building who appear to be invisible. An online information center should be established where best practices of Ebola and other infectious diseases can be shared in a concise format to help other physicians. Most of the practicing physicians do not have the time to read through 600 detailed pages of medical journal articles and statistics to treat a patient. Do we expect them to do this? Is this possible while they are expected to treat large number of patients? This book has done the work. The information is therefore placed in How to Prevent the Spread of Ebola – Pathogenesis of Ebola Virus discussing effective and curable treatment strategies for Ebola viral infection. Some of the clinical management strategies of Ebola can also be applied to treating other viral infections as well.

This Ebola monograph also discusses some of the lingering questions raised by the public about Ebola and addresses these controversial issues with facts. Some of the questions discussed include, What are the indicators for the survivability of the Ebola virus once a patient is infected? Can Ebola virus be aerosolized? What are the differences between the acute phase of the illness and the subclinical, asymptomatic, or nonclinical Ebola virus infections? Where was the first Ebola infection, in West Africa or in Europe? Can the Ebola virus infection be caught through kissing an infected person? When a blood test is negative for Ebola virus, is a patient free of Ebola virus? Can Ebola virus be transmitted through breast milk, semen or vaginal fluids? Was the virulent Ebola virus able to enter the human population by an accidental release due to a lab accident? Can the outbreak of Reston Ebola virus infections in the Philippines among nonhuman primates be dangerous to human population with the evidence of abortive infection in some farm workers? What is the nature of the current virus epidemic in U.S. farms, killing millions of piglets? Is this epidemic swine virus similar to Ebola and how dangerous is it to the human population? What are the lessons learned from the clinical management of Ebola patients that can be applied to the treatment of other viral infections? What is the chronicity of Ebola infection and the long term effects, after clinical cure? For answers to these questions and more, read the book, How to Prevent the Spread of Ebola Virus Infection.

Based on the review of studies on treatment strategies reported in scientific journals, it is important to declare that there are effective and curable treatments for Ebola virus infection. These treatment strategies may also be applied in the future to other viral infections as well.

The book provides fascinating answers to these lingering questions. These answers are mostly from credible journal articles by scientists on the frontline of Ebola research. Some of the revelatory answers may be surprising and shocking. The monograph provides solid information as a powerful educational tool for healthcare workers not familiar with Ebola infection, pathogenesis, and the progression of the disease. These answers should also help healthcare workers to answer the concerns of their patients and allay public anxiety over Ebola virus infection. When we give conflicting answers to simple questions, the public is confused, and the level of anxiety goes up.

In addition to information about Ebola, the monograph also discusses one of the nagging issues in our hospitals across the nation: the persistent increase in nosocomial infections and strategies for their reduction. The book tackles the most difficult issues about ways to fix systemic failures in hospitals associated with the spread of hospital acquired infections. It offers a detailed outline on how to prevent a healthcare worker from taking Ebola or other infectious diseases home to family members. From many years of experience working on fixing systemic failures, I share some hints that should help hospital administrations and quality improvement managers to update infection-control protocols.

The last segment of the book deals with human nature regarding infection-control strategies and quality control. It deals with identifying systemic failures in healthcare facilities associated with infection control, designing corrective actions, pilot testing the new design, implementing tested corrective actions, measuring the outcome, and sustaining positive outcome through a monitoring system. With the process outlined in this book in conjunction with other infection control-strategies already in place, the chances of Ebola outbreak in the U.S is very low. This book tells the nation how to effectively achieve this objective and to reduce the risks of other infectious diseases.

The process also discusses cost-containment strategies and the process of funding quality improvement. With the information presented in this book, clinicians, other healthcare workers, hospital CEOs, and administrators should be able to benefit immensely from this book because it deals directly with some of their concerns.

On Sunday, November 30, 2014, CNN aired computer innovative program of Fareed Zakaria. He was interviewing successful inventors on the Internet and discussing businesses like Facebook, Twitter and Amazon Books. Different people successful in online businesses were interviewed. He interviewed Vinod Khosla, an American businessman, considered by Forbes Magazine as a billionaire. He said, "Some of the physicians’ work of diagnosis will be replaced by machine in the next 20 years." As soon as this statement was made, it was evident he was not talking about present lifetime. He appeared to be bluffing! We have yet to invent a computer that will do a physical examination on a patient, take a history from patients and relatives, and do other things needing a human touch. It is not clear if we are at that point in technological innovation. So, no need to panic; your job is secure for now. Ask a computer to take a medical history from a non-responsive patient.

One of those being interviewed made a comment that deserved attention. The same statement was collectively echoed by the rest of the people interviewed for the report. They supported the assertion that, what made those entrepreneurs successful was not technological innovation, contrary to popular belief. The success in such innovation is always based on collaboration with others. It was explained that working with dedicated people with like mindset ready to work together is the key to any innovative success. Nobody is an island. There are many people with ideas that will fail because they have no team of collaborators to work with. Regardless of how small you start or how big you get, the success is based on the chain reactions of like-minded people working together to achieve a common goal of the computer innovation. The key to success in such a group is the respect for individual contributions to the goal about to be achieved. Many have died with their innovative ideas buried with them because they lacked the collaborative support of others to bring alive their inventions.

At this point, I realized where the current healthcare system is failing the people. In the U.S., we work in a very disjointed healthcare system, driven by egos with poor appreciation for the contributions of each healthcare professional. We operate on very dangerous and toxic models of creativity, such as "You either do what I say, or you’re fired!" As a result, we stop listening to each other or appreciating the creative nature of individual healthcare professional. When the businessmen came into the management of healthcare, they tried to force cohesiveness in healthcare services. It failed. They themselves did not understand the complexity of the healthcare system. Because of the desire to increase revenues, the business managers took out the axe, and started cutting staffing to reduce cost. Then, some of the CEOs went overboard in staff reduction. The healthcare workers started screaming! Patients are now looking for ways to take care of themselves through self-empowerment because the present system is no longer working for them. The inadequate staffing in hospitals is because of the lack of collaboration among healthcare professionals to design policies and achieve better patient care.

Here are the true stories of the impact of other healthcare workers. The medical researchers supply vital information to clinicians to help them treat patients. The housekeeping staff keeps the surgical suite clean and sterile. When the room is infected with bugs, no matter what the nurses and surgeons do, the result of patient care will end in a disaster. The Dietary Department inadvertently gave a breakfast tray to a patient going to surgery. The patient aspirated during the operation and sustained brain damage. In a recent case, it was a nurse who noticed Duncan, the Ebola patient, was from West Africa. The fact that physicians do not pay attention to nurses’ notes led to a missed step and a missed diagnosis. The patient later died. In another instance, the lab tech did a complete blood count test – CBC on a patient in surgery. He noticed low platelet count the physician did not notice. At that point, the surgeon was wondering why the patient was bleeding in surgery. That information stopped the surgery. Subsequently, the patient was transfused with platelets prior to any further surgical procedure. Similarly, Jesica Santillan received the wrong organ because somebody forgot to send her blood type to the donor center. She eventually died. It was a case of simple systemic failure that could have been prevented. In another situation, the X-ray tech saw pneumonia on the chest picture he took of a patient dying in ICU. Nobody saw the picture because the patient was admitted to ICU from emergency room. He called the attention of the chief resident to the X-ray, leading to treatment of the patient who almost died.

The point is, if we as healthcare workers do not learn to value each other’s contribution to healthcare as the computer industry does with innovative ideas, we are doomed. The last data report about Ebola deaths of healthcare workers was 366, including physicians in December, 2014. Most, if not all of them, contracted the infection while working on duty to save other patients’ lives. These are the healthcare soldiers who died in the battlefront of taking care of others. They are our fallen heroes. Nobody had a parade funeral for them. No fanciful eulogy. No news coverage of their funerals. No plane flies over their caskets. Many of them have been forgotten in the pages of death lists. They are reduced to only medical records, as if they never existed. Yet, they took infection bullets with their chests so others could stay alive. They are our forgotten heroes! They remain voiceless.

Collaboration of healthcare workers is badly needed today. The titles or degrees do not matter when a patient’s life or your life may be at stake. The person who has a hint about the survival of a patient in critical state may not even be a healthcare worker. As healthcare professionals, if we all learn to work together as a collaborative team, we may be able to achieve better quality of care for patients. However, if we continue to fight each other as we have been doing over the years, we will eventually destroy the present healthcare system. This present system is riddled with many structural and operational problems leading to many systemic failures. Lack of cohesiveness among healthcare professionals is one of the key failures. The book discusses not only about Ebola infection, but about other structural and operational failures within the healthcare services and how to solve them. Ebola may be the opportunity for hospitals across the nation to be motivated to revisit hospital management styles and the problem of nosocomial infections. Perhaps, this will lead us to work together in a collaborative effort to fix other problems of wrong diagnosis, wasteful spending, quality improvement, and transparency towards patient-centered care.

Published by Lara Publications Inc.

ISBN # 978-0-9640818-8-8

Book is available at Amazon Books by March 5, 2015.

Book Table of Contents