Monday, August 17, 2015

MJA: Ethical Considerations In The Management Of Ebola Virus Disease


Full PPE – Credit Emory University


# 10,422

Up until 18 months ago, Ebola was viewed as a rarely seen, usually self-limiting, disease outbreak threat relegated to a few very remote regions of interior Africa. Between 1976 and 2013, fewer than 2000 deaths had been attributed to its various incarnations, and the only doctors and HCWs likely to encounter it were stationed in Uganda, the DRC, or a handful of other African nations.

The events of the past 18 months – with roughly 28,000 cases and more than 11,000 deaths, and a geographic expansion of the virus to Western Africa and the export of cases to several non-African nations -  means the number of health care facilities around the world that either have - or will be -  called upon to treat Ebola has expanded greatly.

With our increasingly mobile society, it is no longer inconceivable that an Ebola (or MERS, Lassa Fever, or Avian Flu) patient could show up – unannounced – at the door of any hospital, clinic, or doctor’s office in the world.  Moving forward, the risks are considered high enough that this summer the HHS Launched a National Ebola Training & Education Center to prepare HCWs for that possibility.

While most well equipped hospitals should – in theory – be able to safely care for highly infectious patients, the reality has been less than reassuring. As a result, earlier this summer the HHS announced they had Selected 9 Regional Ebola & Special Pathogens Treatment Centers to provide specialized care for Ebola, MERS, and Avian flu cases.


Saudi Arabia continues to struggle with nosocomial MERS outbreaks, South Korea saw 1 imported case lead to 185 additional cases this summer (including 23 doctors and nurses), and two nurses were infected with the Ebola virus at a Dallas hospital last fall. 


While their working conditions are far less exacting that those found in modern medical facilities, the Ebola outbreak in Western Africa has also resulted in the infection of more than 800 Healthcare Workers, and 500 deaths.


It is hard to argue that both the perception, and the reality, of treating exotic infectious disease cases (like Ebola, MERS, Avian flu, etc.) is that it is not without some personal risk, even in modern hospital settings.


Through proper infection control practices, those risks can be greatly reduced,  but not 100% eliminated.


Add in the lack of a vaccine, and few if any specific treatment options, and a heightened level of concern among healthcare providers is to be expected.


All of which leads up to an article, appearing last night in the MJA (Medical Journal of Australia) that looks at some of the ethical dilemmas surrounding the treatment of Ebola Virus Disease (EVD) cases. 


The full article is worth reading in its entirety, so follow the link below.  When you return I’ll have a bit more on how these considerations might also apply in a future pandemic.


Ethical considerations in the management of Ebola virus disease

Thomas Solano, Gwendolyn L Gilbert, Ian H Kerridge, Vineet Nayyar and Angela Berry

Med J Aust 2015; 203 (4): 193-195.

doi: 10.5694/mja15.00168


  • Is it ethically appropriate in some circumstances for HCWs to decline to care for patients with EVD?
  • How should treatment decisions be made regarding limitation of therapy for patients with EVD?
  • There are two main ethical questions regarding the critical care of patients with EVD in an Australian setting:
    • Is it ethically appropriate in some circumstances for HCWs to decline to care for patients with EVD?
    • How should treatment decisions be made regarding limitation of therapy for patients with EVD?
  • The key concern is ensuring that no patient is denied therapy that should be provided, while preventing unnecessary risk to HCWs.
  • It is imperative to develop an approach that facilitates rigorous, evidence-based and ethically justifiable decision making, which should include a predetermined, institutionally endorsed process for assessing difficult clinical scenarios as they arise.

(Continue . . . )


While the ethical decisions surrounding the admission of an Ebola patient to a hospital are considerable, they would pale in comparison to a truly severe pandemic; one caused by a virus without a vaccine or effective treatment. 

Over the past year we’ve seen updated guidance on PPE (Personal Protective Equipment) standards, and procedures, for dealing with Ebola and other highly infectious diseases (see CDC Ebola Guidance: Web Based PPE Training, Video: The Emory Ebola PPE Doffing ProtocolThe Ebola PPE Demonstration Video) and the takeaway is that protecting HCWs against these types of dangerous pathogens is both complex, and resource intensive.


While it seems probable that the majority of HCWs - when provided with the proper PPEs - would be willing to provide care to a limited number of Ebola, MERS, or Avian flu patients, that equation could very well change in times of a major outbreak, particularly one exacerbated by equipment shortages.


Ebola is an unlikely candidate to spark the kind of outbreak that would severely tax our national supplies of PPEs, but respiratory viruses like avian or swine flu, SARS, or MERS could conceivably spread quickly and affect millions of people.  


Even were Healthcare workers to agree to work without adequate protection, their attrition rate from infection would likely reduce their numbers quickly, rendering any noble gesture on their part short-lived. 


And it isn’t just doctors and nurses who at risk. Non-medical (and often low paid) employees such as housekeeping, food service, laundry, security, lab, and even clerical workers are vitally important to the operation of any healthcare facility.


Two years ago, in Study: Willingness of Physicians To Work During A Severe Pandemic, we looked at a study  published in the Asia Pacific Family Medicine journal, that polled Canadian doctors to try to determine under what circumstances they would be unwilling to work during a pandemic.


Although limited by only a 22% response rate to the poll, under certain scenarios, fewer than half of the doctors who responded would be willing to report for work during a severe pandemic.


The numbers from this Canadian poll are not out of line with previous studies we’ve seen, including a 2010 report (See Study: Willingness Of HCWs To Work In A Pandemic) that polled 18,612 employees of the Johns Hopkins Hospital from January to March 2009, and found:


Demographic and professional distribution of respondents was similar to all hospital staff. Overall, more than one-in-four (28%) hospital workers indicated they were not willing to respond to an influenza pandemic scenario if asked but not required to do so. Only an additional 10% were willing if required. One-third (32%) of participants reported they would be unwilling to respond in the event of a more severe pandemic influenza scenario.


While there are a lot of personal factors that could influence an individual HCWs decision to work or not (severity of the virus, personal health, family obligations, safety & security of the workplace,  etc.) the number one deal breaker would almost certainly be a lack of PPEs. 


Our Strategic National Stockpile has hundreds of millions of N95 and surgical masks in reserve, but the numbers needed as envisioned last April in the CID Journal report Potential Demand for Respirators and Surgical Masks During a Hypothetical Influenza Pandemic in the United States run into the billions.


From their Results and Conclusions:

Assuming that 20% to 30% of the population would become ill, 1.7 to 3.5 billion respirators would be needed in the base case scenario, 2.6 to 4.3 billion in the intermediate demand scenario, and up to 7.3 billion in the maximum demand scenario (for all scenarios, between 0.1 and 0.4 billion surgical masks would be required for patients). For pandemics with a lower attack rate and fewer cases (eg, 2009-like pandemic), the number of respirators needed would be higher because the pandemic would have longer duration.

Providing these numbers of respirators and surgical masks represents a logistic challenge for US public health agencies. Public health officials must urgently consider alternative use strategies for respirators and surgical masks during a pandemic that may vary from current practices.


The take away from all of this is that many of the same ethical dilemmas discussed in the MJA article above – particularly `a duty to treat’ - could just as easily arise in a moderate to severe influenza pandemic.

The time to face those dilemmas is now, before the next flu falls.