Sustainability of High-Level Isolation Capabilities among US Ebola Treatment Centers

A narrative review of high-level isolation unit operational and infrastructure features

High-level isolation units (HLIUs) are specially designed facilities for care and management of patients with suspected or confirmed high-consequence infectious diseases (HCIDs), equipped with unique infrastructure and operational features. While individual HLIUs have published on their experiences caring for patients with HCIDs and two previous HLIU consensus efforts have outlined key components of HLIUs, we aimed to summarise the existing literature that describes best practices, challenges and core features of these specialised facilities. A narrative review of the literature was conducted using keywords associated with HLIUs and HCIDs. A total of 100 articles were used throughout the manuscript from the literature search or from alternate methods like reference checks or snowballing. Articles were sorted into categories (eg, physical infrastructure, laboratory, internal transport); for each category, a synthesis of the relevant literature was conducted to describe best practices, experiences and operational features. The review and summary of HLIU experiences, best practices, challenges and components can serve as a resource for units continuing to improve readiness, or for hospitals in early stages of developing their HLIU teams and planning or constructing their units. The COVID-19 pandemic, a global outbreak of mpox, sporadic cases of viral haemorrhagic fevers in Europe and the USA, and recent outbreaks of Lassa fever, Sudan Ebolavirus, and Marburg emphasise the need for an extensive summary of HLIU practices to inform readiness and response.

Applying the Plan-Do-Study-Act Approach to Support Healthcare Facilities in the Early COVID-19 Pandemic Response

The identification of a novel respiratory pathogen in late December 2019 and the escalation in the number of infections in January 2020 required healthcare facilities to rapidly assess their planning and preparations to identify and manage suspected or confirmed cases. As a Regional Emerging Special Pathogens Treatment Center, many of the policies, resources, and tools Massachusetts General Hospital had developed before the COVID-19 pandemic were based on the Identify-Isolate-Inform concept to enable rapid identification of persons under investigation; isolation from other patients, visitors, and staff; and appropriate information sharing with internal and external parties to ensure continued safety of the facility and community. Our team sought to leverage these existing resources to support other healthcare facilities and implemented a modified Plan-Do-Study-Act approach to develop, refine, and disseminate a novel coronavirus toolkit. The toolkit underwent 3 Plan-Do-Study-Act cycles resulting in revisions of specific products, and the addition of new products to the toolkit. The toolkit provided access to templated algorithms, policies and procedures, signage, and educational materials, which could be customized for local needs and implemented immediately. There was broad dissemination and use of the resources provided in the toolkit and response to end-user feedback was provided in subsequent revisions. This project demonstrates the role that Regional Emerging Special Pathogens Treatment Centers can play in supporting the sharing of resources and best practices, and the utility of a Plan-Do-Study-Act approach in meeting needs.

The utility and sustainability of US Ebola treatment centers during the coronavirus disease 2019 (COVID-19) pandemic

OBJECTIVE

In response to the 2014-2016 West Africa Ebola virus disease (EVD) epidemic, the Centers for Disease Control and Prevention (CDC) designated 56 US hospitals as Ebola treatment centers (ETCs) with high-level isolation capabilities. We sought to determine the ongoing sustainability of ETCs and to identify how ETC capabilities have affected hospital, local, and regional coronavirus disease 2019 (COVID-19) readiness and response.

DESIGN

An electronic survey included both qualitative and quantitative questions and was structured into 2 sections: operational sustainability and role in the COVID-19 response.

SETTING AND PARTICIPANTS

The survey was distributed to site representatives from the 56 originally designated ETCs, and 37 (66%) responded.

METHODS

Data were coded and analyzed using descriptive statistics.

RESULTS

Of the 37 responding ETCs, 33 (89%) reported that they were still operating, and 4 had decommissioned. ETCs that maintain high-level isolation capabilities incurred a mean of $234,367 in expenses per year. All but 1 ETC reported that existing capabilities (eg, trained staff, infrastructure) before COVID-19 positively affected their hospital, local, and regional COVID-19 readiness and response (eg, ETC trained staff, donated supplies, and shared developed protocols).

CONCLUSIONS

Existing high-level isolation capabilities and expertise developed following the 2014-2016 EVD epidemic were leveraged by ETCs to assist hospital-wide readiness for COVID-19 and to support responses by other local and regional hospitals However, ETCs face continued challenges in sustaining those capabilities for high-consequence infectious diseases.

Biosafety and infectious disease occupational health training from the NIEHS Worker Training Program: A historical look at capacity building that supported a COVID-19 response

The COVID-19 pandemic demonstrated that large segments of the workforce–many of which were not previously considered or valued–are needed to keep the economy moving and critical societal functions going. From first responders to bus drivers, this expanded essential workforce needed training to build a solid knowledge of infectious disease protection practices. However, most workplaces had no existing plan or training for infectious disease exposure control. The National Institute of Environmental Health Sciences (NIEHS) Worker Training Program (WTP) was able to immediately respond with health and safety curricula, resources, and course delivery based on decades of building capacity for disaster and infectious disease response.

Capabilities of global high-level isolation units: A pre-workshop survey

OBJECTIVE

To assess experience, physical infrastructure, and capabilities of high-level isolation units (HLIUs) planning to participate in a 2018 global HLIU workshop hosted by the US National Emerging Special Pathogens Training and Education Center (NETEC).

DESIGN

An electronic survey elicited information on general HLIU organization, operating costs, staffing models, and infection control protocols of select global units.

SETTING AND PARTICIPANTS

The survey was distributed to site representatives of 22 HLIUs located in the United States, Europe, and Asia; 19 (86%) responded.

METHODS

Data were coded and analyzed using descriptive statistics.

RESULTS

The mean annual reported budget for the 19 responding units was US$484,615. Most (89%) had treated a suspected or confirmed case of a high-consequence infectious disease. Reported composition of trained teams included a broad range of clinical and nonclinical roles. The mean number of HLIU beds was 6.37 (median, 4; range, 2-20) for adults and 4.23 (median, 2; range, 1-10) for children; however, capacity was dependent on pathogen.

CONCLUSIONS

Responding HLIUs represent some of the most experienced HLIUs in the world. Variation in reported unit infrastructure, capabilities, and procedures demonstrate the variety of HLIU approaches. A number of technical questions unique to HLIUs remain unanswered related to physical design, infection prevention and control procedures, and staffing and training. These key areas represent potential focal points for future evidence and practice guidelines. These data are important considerations for hospitals considering the design and development of HLIUs, and there is a need for continued global HLIU collaboration to define best practices.

Preparing Frontline Hospitals for Dangerous Special Pathogens Beyond Ebola

Frontline hospitals are at the forefront of all travel-related, emerging and reemerging infectious diseases and special pathogens. Yet, the readiness of frontline hospitals and their ability to identify, isolate, and inform on Ebola and other special pathogens is uncertain. This article addresses the resources necessary to support screening for Ebola and other special pathogens and presents the decision-making algorithm for the transport of patients with high-consequence infectious diseases within the New York City Health + Hospitals integrated healthcare delivery network, which includes 10 frontline hospitals and the Region 2 Ebola and Other Special Pathogen Treatment Center.

The Risk of Not Being Ready: A Novel Approach to Managing Constant Readiness of a High-Level Isolation Unit During Times of Inactivity

The biocontainment unit at Johns Hopkins Hospital is a specially designed, inactive high-level isolation unit designated to care for patients infected with high-consequence pathogens. The unit team designed a facility-specific readiness scale and checklist that focus on infrastructure, consumable supplies, and staffing to assess activation readiness of the biocontainment unit. Over a period of 50 days and 14 days, these tools were used as part of a routine risk assessment to first identify barriers and then tier the impact of these barriers into activation categories of "Ready," "Ready with Considerations," and "Not Ready." The assessment identified the greatest risks to activation readiness were staffing and waste management capabilities. Assessing threats to activation readiness and the risk of not being ready should be a priority for maintaining facility, regional, and national capacity to safely isolate and care for patients infected with high-consequence pathogens while maintaining healthcare worker safety.

Update on Ebola Treatment Center Costs and Sustainability, United States, 2019

We surveyed 56 Ebola treatment centers (ETCs) in the United States and identified costs incurred since 2014 ($1.76 million/ETC) and sustainability strategies. ETCs reported heavy reliance on federal funding. It is uncertain if, or for how long, ETCs can maintain capabilities should federal funding expire in 2020.

Restricted and Uncontained: Health Considerations in the Event of Loss of Containment During the Restricted Earth Return of Extraterrestrial Samples

The normal scope of an adequate public health response to released biological material is framed by working with biological vectors with known pathogenicity and virulence. Defining the scope of a response to the release of biological material with unknown pathogenicity and virulence enters into a novel and yet to be framed domain. A current case, in which extraterrestrial samples returned from a location such as Mars, which may harbor life as we know it, requires framing a public health response. An unintentional release of biological material with unknown pathogenicity and virulence may occur when biological containment mechanisms in the Earth-returning transport method are lost. This article raises initial public health and healthcare response questions during a return of extraterrestrial samples to Earth, in the event of its release from biological containment mechanisms: How does the public health community prepare for a response when there is release of samples that may contain potential extraterrestrial organisms from a planetary body or hardy terrestrial organisms surviving a round trip? If a mishap occurs during the return of these samples, what considerations need to be made to confine, decontaminate, and collect material in regions around the mishap? How will the public health community work with relevant government organizations to prepare the general public? The unknowns of exposure, potential extraterrestrial pathogenicity, and decontamination approaches underscore gaps in biopreparedness for this novel case from federal to local levels.

An update on US Ebola treatment center personnel management and training

BACKGROUND

In 2014, 56 US hospitals were designated as Ebola treatment centers (ETCs). ETCs had minimum augmented capability requirements for Ebola virus disease care, including for staffing and training. We sought to identify current ETC staffing challenges and frequency of staff retraining.

METHODS

In May 2019, an electronic survey was distributed to representatives of the 56 ETCs.

RESULTS

Sixty-six percent (37/56) of ETCs responded. Registered nurses comprised the majority of ETC staff. All responding units required orientation training (average = 15.21 hours) and all but one required retraining. Among the top challenges that ETCs reported to maintaining high-level isolation capabilities were staff training time, staff recruitment, staff retention, and training costs.

DISCUSSION

Five years after ETC designation, units face staffing challenges. Research is lacking on the effective number of hours and optimal frequency of staff training. ETCs reported smaller staffing teams compared to our 2016 assessment, but team composition remains similar. As units continue to maintain capabilities with decreasing external support and attention, the need for retraining must be balanced with logistical constraints and competing demands for staff time.

CONCLUSIONS

Our study shows that US preparedness capabilities are reduced. More research, support, and funding are needed to sustain the unique knowledge and proficiency acquired by ETC teams to ensure domestic preparedness for highly hazardous communicable diseases.

US State Public Health Departments Special Pathogen Planning

CONTEXT

US state public health departments played key roles in planning for and responding to confirmed and suspected cases of Ebola virus disease (EVD) during the 2014-2016 outbreak, including designating select hospitals as high-level isolation units (HLIUs) for EVD treatment in conjunction with the Centers for Disease Control and Prevention.

OBJECTIVE

To identify existing guidelines and perspectives of state health departments pertaining to the management and transport of patients with EVD and other highly hazardous communicable diseases (HHCDs).

DESIGN

An electronic 8-question survey with subquestions was administered as a fillable PDF.

SETTING

The survey was distributed to publicly accessible e-mails of state health department employees.

PARTICIPANTS

State epidemiologists, emergency preparedness directors, or chief medical officers from each of the 50 states and the District of Columbia were contacted; a representative from 36 states and the District of Columbia responded (73%).

MAIN OUTCOME MEASURES

Descriptive statistics were used to identify the proportion of state health departments with various existing protocols.

RESULTS

A majority of states reported that they would prefer patients confirmed with viral hemorrhagic fevers (eg, EVD, Marburg fever) and smallpox be transported to an HLIU for treatment rather than remain at the initial hospital of diagnosis. While most (89%) states had written guidelines for the safe transportation of patients with HHCDs, only 6 (16%) had written protocols for the management of accidents or other travel disruptions that may occur during HHCD transport within the state. Twenty-two state health departments (59%) had operationally exercised transport of a patient to an HLIU.

CONCLUSIONS

Nearly half of states in the United States lack an HLIU, yet most prefer to have patients with HHCDs treated in high-level isolation. Recent budget cuts and uncertainty of future funding threaten the abilities of health departments to devote the necessary resources and staff to prepare for and deliver the desired care to HHCD cases. The lack of HLIUs in some states may complicate transport to a geographically proximate HLIU. Moreover, limited guidance on diseases that warrant high-level isolation may cause disagreement in HHCD patient placement between health departments, diagnosing facilities, and HLIUs.

Perceived Benefits and Challenges of Ebola Preparation Among Hospitals in Developed Countries: A Systematic Literature Review

The 2014–2016 Ebola epidemic in West Africa provided an opportunity to improve our response to highly infectious diseases. We performed a systematic literature review in PubMed, Cochrane Library, CINAHL, EMBASE, and Web of Science of research articles that evaluated benefits and challenges of hospital Ebola preparation in developed countries. We excluded studies performed in non-developed countries, and those limited to primary care settings, the public health sector, and pediatric populations. Thirty-five articles were included. Preparedness activities were beneficial for identifying gaps in hospital readiness. Training improved health-care workers’ (HCW) infection control practices and personal protective equipment (PPE) use. The biggest challenge was related to PPE, followed by problems with hospital infrastructure and resources. HCWs feared managing Ebola patients, affecting their willingness to care for them. Standardizing protocols, PPE types, and frequency of training and providing financial support will improve future preparedness. It is unclear whether preparations resulted in sustained improvements.

Prospero Registration. CRD42018090988.

Caring for patients with Ebola virus disease: Are U.S. biocontainment centers ready for the next outbreak?

The 2014 West African Ebola virus disease (EVD) outbreak is the largest and deadliest EVD epidemic to date, resulting in fivefold more cases than all other outbreaks combined. This outbreak was particularly devastating to healthcare workers in West Africa and resulted in several EVD patients being medically evacuated for treatment in the U.S. and Europe. Governmental agencies provide recommendations for triaging and testing patients with EVD, however best laboratory practices are still unknown and are very resource dependent.

Consequences of delays and imperfect implementation of isolation in epidemic control

For centuries isolation has been the main control strategy of unforeseen epidemic outbreaks. When implemented in full and without delay, isolation is very effective. However, flawless implementation is seldom feasible in practice. We present an epidemic model called SIQ with an isolation protocol, focusing on the consequences of delays and incomplete identification of infected hosts. The continuum limit of this model is a system of Delay Differential Equations, the analysis of which reveals clearly the dependence of epidemic evolution on model parameters including disease reproductive number, isolation probability, speed of identification of infected hosts and recovery rates. Our model offers estimates on minimum response capabilities needed to curb outbreaks, and predictions of endemic states when containment fails. Critical response capability is expressed explicitly in terms of parameters that are easy to obtain, to assist in the evaluation of funding priorities involving preparedness and epidemics management.

Personnel Management and Biosecurity of U.S. High-Level Isolation Units

OBJECTIVE

To describe strategies used by US high-level isolation units (HLIUs) to recruit, train, and sustain a full team of multidisciplinary staff and identify how units are secured.

BACKGROUND

Fifty-six US hospitals have been designated HLIUs, capable of providing safe care to patients with highly infectious disease.

METHODS

An electronic survey was administered to the 56 HLIUs in spring of 2016. Responses were collected via a fillable PDF and analyzed using descriptive statistics.

RESULTS

Thirty-six HLIUs (64%) responded; 33 completed surveys, and 3 reported no longer being a designated HLIU. HLIUs reported large numbers of multidisciplinary staff, primarily consisting of RNs and critical care clinicians. Nearly all HLIUs (94%) required orientation training, although hours varied.

CONCLUSIONS

Over a short period, HLIUs recruited and trained significant numbers of staff with little guidance. Costs of ongoing trainings are considerable, and it remains unclear how HLIUs will continue funding these activities.

U.S. High-Level Isolation Unit Clinical Laboratory Capabilities Update

In late 2014, 56 hospitals in the United States were designated by state and federal public health authorities as specially designed high-level isolation units (HLIUs) equipped with advanced infrastructure, laboratory capabilities, and trained staff to care for patients with highly hazardous communicable diseases (HHCDs), such as Ebola virus disease. This survey describes the clinical laboratory support capabilities of U.S. HLIUs, including the specific test menus that HLIUs have identified to safely manage HHCD patients and the locations where such testing would be performed. In spring 2016, a survey was electronically distributed, as a fillable pdf file, to the 56 U.S. HLIUs. Site representatives completed the surveys, and data were coded and analyzed in an electronic spreadsheet, using descriptive statistics. Thirty-six HLIUs (64%) responded, and 33 completed the laboratory capabilities section. Thirty-one HLIUs (94%) had performed risk analyses for all laboratory procedures and equipment. Twenty-nine (88%) had decontamination procedures specified for all laboratory equipment used for patients with suspected or confirmed HHCDs. On-site laboratories in 27 HLIUs (81%) had the capacity to inventory and to securely store HHCD patient specimens. Ten HLIUs (31%) had at least one test they would conduct within the patient isolation room. The high-risk nature of HHCDs and the occupational exposures that may occur in clinical laboratories demand advanced preparation and risk assessment of work practices, laboratory equipment, and instrumentation by HLIU laboratories. Although risk analyses of clinical laboratory testing and equipment that HLIUs have conducted have likely focused on those for Ebola virus, HLIUs must be prepared to revise their current procedures for other HHCDs.