What We Learned from Ebola

In the last four decades, multiple outbreaks of emerging infectious diseases occurred in other countries, resulting in a potential risk of transmission in the United States (1). Emerging threats have included Lassa fever, severe adult respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and Ebola virus disease (EVD). For example, the epidemic of EVD that occurred in West Africa in 2014–2015 caused a total of 28,616 confirmed, probable, and suspected cases of EVD and resulted in 11,310 deaths (2). Because of high levels of virus present in vomitus, diarrhea, blood, and other body fluids, patients acutely ill with EVD are very contagious and pose a high risk to health care personnel. During the outbreak, 876 exposed health care personnel acquired EVD, with deaths occurring in 509 (3). Since five (19%) of 27 patients who received therapy in the United States and Europe required dialysis, hemodialysis personnel were potentially at risk. Nosocomial transmission of MERS has also occurred in a variety of settings, including outpatient hemodialysis units in Saudi Arabia (4).

Travel of nine individuals with EVD symptoms from West Africa to United States hospitals raised concern regarding the level of preparedness of health care facilities in this country to safely care for patients with emerging pathogens (5). One such case illustrated several gaps in EVD preparedness. In September 2014, a man who flew from Liberia to Texas was subsequently admitted to a Dallas hospital and eventually expired from EVD (5). Two nurses who cared for the patient subsequently developed EVD. Lessons learned from the events in Dallas included the fact that nonspecific signs and symptoms occurring early in the course of infection can delay recognition of EVD and that inadequate triage practices, suboptimal communication between medical staff, and lack of adequate and appropriate use of personal protective equipment (PPE) can result in nosocomial transmission (6). These same factors would likely affect many outpatient hemodialysis centers. Similar issues have resulted in nosocomial transmission of MERS, SARS, and influenza (1).

Patients with EVD and other dangerous viral pathogens may present with protean complaints, such as fever, headache, weakness, diarrhea, abdominal pain, and vomiting (7). As a result, when transmission of such diseases is occurring in the world, large dialysis organizations and independent hemodialysis units should have identified personnel responsible for monitoring appropriate news sources, and they should have plans for communicating a list of signs and symptoms as well as exposure history suggestive of the pathogen causing the outbreak to dialysis unit personnel, including the medical director and the clinical manager.

During the 2014–2015 outbreak, most patients with EVD treated in the United States were cared for in specialized inpatient units that had advanced notice of the patients’ arrivals. Although it is unlikely that patients requiring maintenance hemodialysis would be traveling to countries affected by an outbreak, those undergoing outpatient hemodialysis could come in contact with a person (e.g., family member) with undiagnosed or confirmed disease, and therefore, they could be at risk. During the EVD outbreak, the Centers for Disease Control and Prevention (CDC) believed that it was unlikely that a person with EVD would have presented to ambulatory settings, such as an outpatient hemodialysis center. However, the CDC recommended that ambulatory care centers be prepared for such an occurrence due to its potential catastrophic consequences (8). As a result, it is imperative that hemodialysis units have written plans for triaging patients during outbreaks. Currently, in many hemodialysis units, triage is seldom done before patients proceed to their assigned chairs. During periods when transmission of pathogens causing outbreaks is occurring, hemodialysis units should follow the CDC’s recommendations for identifying and isolating potentially infected patients and informing local and state health officials (8). Triage strategies should include notifying patients about the signs and symptoms of infection with pathogens causing the outbreak, such as EVD, MERS, SARS, or avian influenza; placing signs with questions about potential exposures and symptoms at entrances; and screening all patients immediately at the time of arrival at the dialysis unit.

The CDC recommends that patients who present to an ambulatory facility with signs and symptoms of EVD be placed immediately in a separate room or area where evaluation by a limited number of personnel can take place (8). During the EVD outbreak, some hemodialysis centers reported that they no longer had adequate areas for isolating patients who would have required evaluation for possible EVD. Accordingly, dialysis center administrators should identify or create areas or rooms where evaluations can be performed under conditions that will prevent unnecessary exposure of patients and staff.

Early during the 2014–2015 EVD outbreak, inpatient facilities dealing with patients with suspected or confirmed EVD often found that there were not enough personnel trained in the specific techniques required for donning and doffing PPE (9) and that acquiring and maintaining an adequate supply of appropriate PPE were problematic (5). In many outpatient hemodialysis centers, it is unlikely that even a few staff members had received adequate training and showed competency in donning and doffing PPE recommended for evaluating patients for suspected EVD before transfer of patients to an Ebola assessment or treatment center (10). Inadequate access to experienced infection control personnel who might train other personnel is also an issue. Questions have also been raised about who will provide in other countries the financial resources needed to maintain a dedicated supply of necessary PPE.

Dialysis of patients with EVD should be avoided in outpatient settings, and it should only be performed in an isolation room in which intensive care can be delivered and adequate supplies of PPE and resources for disinfection and disposal of large amounts of infectious waste are available (5). In the unlikely event that large numbers of patients with EVD or other dangerous pathogens (e.g., pandemic influenza) will overwhelm specialized inpatient treatment centers, it is not clear how patients requiring hemodialysis will be managed as outpatients. Of note, during the 2014–2015 EVD outbreak, Fresenius Medical Care (FMC) activated a multidisciplinary “disaster team” and used daily teleconference calls to assess the situation, answer questions, and address new challenges. When a patient on maintenance dialysis in the United States who was on the same flight as a person exposed to an individual with EVD required hemodialysis, FMC agreed to provide staff-assisted home dialysis using bagged fluids. The decision to dialyze the potentially exposed patient at home was made to limit potential exposure to staff and the public by not having the patient travel to and from the clinic.

In response to the EVD outbreak, FMC educated staff members, monitored all individuals entering facilities for fever in a dedicated space adjacent to waiting rooms, required personnel administering questions about travel and potential exposures to wear PPE, and dedicated space for isolating patients pending transfer to a hospital. Staff members who traveled to endemic areas were placed on paid leave for 2 weeks, and they were required to report their temperatures and symptoms on a daily basis.

Given the issues noted above, one might argue that the EVD outbreak should serve as a stimulus to establish the situations in which patients with highly transmissible infections might be dialyzed in outpatient settings, review emergency preparedness policies and infrastructure needs, and improve access to infection control expertise in outpatient hemodialysis units.

Disclosures

J.M.B. is a consultant to Diversey Care, GOJO Industries, and Sodexo and has recently been a consultant to 3M Company and PDI. J.M.B. has received research and travel support from Diversey Care and GOJO Industries. J.L.H. is an employee of Fresenius Medical Care, North America.