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Odds are that Ebola, the virus that has swept through West Africa in the worst-ever outbreak of the disease, will not turn up in Arkansas. Only one case has emerged in the United States, in Dallas, where a Liberian American died. (A nurse who treated him has become ill, thus becoming the first case of transmissible Ebola in the U.S.)
But the state Department of Health isn't taking any chances. In the past six weeks, the health department has been engaged in "an extraordinary amount of preparedness" to deal with Ebola contact, Dr. Gary Wheeler, the department's branch chief of infectious diseases, said Monday. The department has discussed screening with hospital and emergency personnel; schools about exchange students; and companies, including Walmart, who see business travelers. These are entities that are the most likely to encounter people who may have been in the African countries affected by the outbreak. The Centers for Disease Control and Prevention and the health department recommend that persons who've been to outbreak countries should take their temperatures twice a day for 21 days to make sure they're clear of infection. All health care providers are to report to the Health Department patients from the outbreak countries.
As of Oct. 10, the Zaire strain of Ebola had killed more than 4,000 people in Liberia, where the outbreak started in March; more than 8,000 cases of confirmed and suspected Ebola have been reported. Symptoms begin with fever and a headache. Stomach pain and vomiting follow. At the end stage of the illness, internally hemorrhaging patients will bleed out from every orifice. It is a gruesome death. Liberia, where the outbreak began, Sierra Leone, Guinea, Nigeria, Senegal and the Republic of Congo have all reported cases. Nigeria and Senegal are considered to be close to stopping the spread; the last case in Nigeria was Sept. 5 and in Senegal Aug. 29. Bats are suspected to be the source. Thomas Eric Duncan, who died at Texas Health Presbyterian, presented with symptoms a day or so after arriving in the United States.
The University of Arkansas for Medical Sciences has been updating its protocols for dealing with infectious disease and training staff for several weeks, but Dr. Keyur Vyas said Duncan's death had added "urgency" to the preparations.
Nina Pham, the Dallas nurse, tested positive for Ebola on Sunday. Her infection was blamed in a breach in protocol in handling the patient. Tom Frieden, the director for the Centers for Disease Control in Atlanta, said on Monday it was possible that other health care workers who came in contact with Thomas Eric Duncan may also test positive because they "may have had a breach of the same nature."
The Health Department has been fielding a lot of calls from ERs and others concerned. Sometimes, "it's simple confusion about geography," Wheeler said, if, say, a person from Kenya (an African country not in the outbreak area) comes in for treatment. Other times it might be "from people who've stopped to get gas in Dallas," Wheeler said. "That's just fine. ... It's good people are thinking about it." The department has physicians on call 24 hours a day to handle calls.
Hospitals harbor super bugs, like antibiotic-resistant staphylococcus, and other communicable diseases, so doctors are already trained in containment. Any large hospital "should be able to handle a patient in isolation," UAMS infectious disease specialist Vyas said. At UAMS, doctors must be trained to deal with radiation sickness, since there's a nuclear power plant just up the Arkansas River. They must also treat patient with tuberculosis and other serious infections; the doctors must take precautions not just to protect themselves, but other patients at the hospitals.
Vyas and RN Rachel Hicks demonstrated for the Times on Friday how staff must suit up before had contact with a person suspected of having come in contact with the virus. First, rubber gloves, a hair covering, N95 respirator mask, a plastic face shield and an impermeable Tyvek suit. (The Tyvek suit is not required by the CDC, but UAMS has chosen to include it in its protocol.) Another set of gloves and a plastic surgical gown that goes over the Tyvek suit completes the layering. The goal is to guard against contact with the patient's bodily fluids — blood, mucus, sweat, etc. — and droplets from coughs and sneezes (which can travel up to 3 feet). It is hot in the suit; Hicks was drenched in sweat after her short demonstration. (Though not as hot as it is in Africa, where health care workers wear rubber suits that can be disinfected and worn again. They are limited to 35 to 45 minutes in the suits because they lose liters of fluid, Vyas said.)
As important as wearing the protective gear is, taking it off presents the same danger as contact with the patient. (The Spanish nurse who contracted Ebola told media that she may have touched her face with her gloved hand as she removed her gear.) The exterior surfaces of the gown, gloves, suit, etc. — which may have come in contact with the virus — must not be touched. The plastic surgical gown is designed to pull the outer pair of gloves off with it. Only the inside of the gown and the Tyvek suit are touched as they are torn off. The inner set of gloves must be removed carefully by slipping a finger underneath the glove at the palm to peel it off. Staff will stay with health care workers who are removing their garb to give reminders.
Because of the danger, the federal government does not allow Ebola medical waste — including the disposable gear worn by the staff — to be transported to an incineration site. It must be incinerated on site or sealed off. Wheeler said the Health Department has also met with Little Rock Wastewater management on dealing with possibly infected waste.
All who come to emergency rooms and doctors' offices are now being asked whether they have been in any of the African countries during this outbreak of Ebola. (Ebola outbreaks were first documented in the 1970s.) A sign on the entrance to the ER at UAMS lists the countries patients will be asked about; Dallas has been inked in by hand. The police officer at the security entrance will be the first to ask; if the answer is yes and the patient is bleeding, they'll be taken straight to an isolation room and the infectious disease team will be summoned. (Isolation units are outfitted with negative air flow to keep particulates from leaving the room.) Screenings will be "very individualized," Vyas said. If patients present with symptoms — fever, vomiting, stomach pain, diarrhea, bleeding — their blood will be drawn to get a diagnosis. If the blood test shows antibodies to Ebola, "supportive care" such as IV fluids will be administered. That is all that can be done. The only drugs now being administered to Ebola patients are highly experimental; none have been approved by the Food and Drug Administration. If a case is confirmed and intervention seems warrantable, doctors here would try to obtain them, Vyas said.
"Early interventions significantly improve chances of survival," said Greg Crain, vice president and administrator of Baptist Health Medical Center in Little Rock. He said Baptist administrators "have a huddle every day" and communicate with staff once a week on protocol and preparation. Baptist's emergency department handles more patients than any other in Arkansas — about 65,000 to 70,000 every year, Crain said — and its board-certified ER doctors are "the front line."
The "working plan" for now is that the blood will be sent directly to the CDC for testing, Wheeler said. The Health Department has not been provided testing probes by the CDC. The department is also working up plans for housing of people exposed to persons who've tested positive for the virus and arrangements for containment of homes, Wheeler said.
Vyas said it is "not out of the realm of possibility" that someone who's been in contact with Ebola could turn up in Little Rock: "Little Rock is pretty cosmopolitan; we have people here from around the world." But Vyas is far more concerned with a virus he knows will infect hundreds in Arkansas: influenza. He urged that everyone get vaccinated before flu season hits.
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