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Ebola's lessons


Envisioning a public health threat, managed care recently notched up its readiness for an Ebola outbreak in the United States. Valuable lessons emerged from the latest effort, adding to the knowledge gleaned from other epidemics, such as the HIV/AIDS and SARS viruses and the bird flu.

Envisioning a public health threat, managed care recently notched up its readiness for an Ebola outbreak in the United States. Valuable lessons emerged from the latest effort, adding to the knowledge gleaned from other epidemics, such as the HIV/AIDS and SARS viruses and the bird flu.

“Each of those responses was a combination of building on previous experience and learning new approaches,” says Patrick T. Courneya, M.D., executive vice president and chief medical officer of Kaiser Foundation Hospitals and Kaiser Foundation Health Plan in Oakland, California.

“Even if we never see an Ebola patient, our Ebola preparation makes us much better prepared the next time something else comes up,” Courneya says. He adds that it’s important to “quickly reassure the communities that we serve-that we do have this in hand-and make sure that we are not responding out of fear, but out of abundant confidence and the appropriate level of humility.”

As part of its proactive strategy, the Kaiser Foundation convenes monthly conference calls with its infectious disease specialists across the country. They discuss emerging issues and trends and evaluate evidence-based practices.

Well-thought-out practices were necessary in welcoming back two Kaiser Foundation employees who overlapped in volunteering for six weeks in West Africa during the recent Ebola epidemic. The two physicians also were among the infectious disease specialists who engaged in the monthly phone calls.

Heeding recommendations from the Centers for Disease Control and Prevention (CDC), Courneya and his colleagues decided to honor their service with a 21-day paid period of performing administrative work from home such as answering e-mails and participating in calls, while prohibiting contact with health plan members. During that exclusion from patient care, the team could determine whether the physicians’ potential exposure to Ebola warranted more or less monitoring. The physicians showed no signs of Ebola and are now out of quarantine.

Protective measures underscore the importance of putting safety first. Emergency operations should focus not only on natural disasters such as hurricanes, flooding and power outages, but also on emerging infectious diseases, says Lisa Waldowski, MS, APRN, CIC at the Joint Commission in Oakbrook Terrace, Ilinois.

“This needs to be something that is planned for and drilled for, and staff are comfortable with training and education on an ongoing basis,” she says. “This is not something you want to be caught off guard with and unprepared for.”

In December, the U.S. Congress reached a budget deal that includes $5.4 billion to manage the Ebola crisis and to plan for future infectious disease eruptions. That is 13% less than the $6.2 billion that President Barack Obama’s administration requested. The U.S. Department of Health & Human Services expects to receive about half the allocated funds, of which $500 million will support worker training and other domestic efforts, and $1.2 billion will provide for global initiatives.

Also in December, the National Institutes of Health (NIH) made safety paramount with the return of an American nurse who had been a volunteer in an Ebola treatment unit in Sierra Leone. The patient arrived from an overseas location via private charter Medevac in isolation and entered the NIH Clinical Center for observation and enrollment in a clinical protocol.

Eight days later, the patient was discharged without any clinical or laboratory evidence of an Ebola infection and began a 21-day monitoring period at a private residence under the oversight of the Virginia Department of Health.

NEXT: Stopping the spread of Ebola


Stopping the spread of ebola

Early detection of an Ebola exposure is critical t

o curtailing spread of disease, and health plans can play an important role by communicating with their members and ensuring immediate access to care, says Don Hall, MPH, principal of DeltaSigma LLC, a healthcare consulting firm in Littleton, Colorado, and former president and chief executive officer of Colorado Access, an HMO focusing on Medicaid, Medicare and correctional facilities. 

Most data at health plans is so late that it really can’t be used for looking at real-time patterns of disease,” Hall says. However, “typically health plans can get pharmacy data on a real-time basis.” Prescriptions to treat infectious diseases “should be flagged as early-warning indicators.” Communication with state and local health departments about infectious disease potential is also of paramount importance.

In extreme instances when a lethal agent such as Ebola may be present, Hall suggests that health plans consider waiving deductibles and co-payments for members to visit the emergency department if they’re experiencing symptoms that may require prompt examination.

"You actually want to encourage people to get into the system for care as quickly as possible,” he says. “The lastthing you want is for them to stay away from the hospital and stay in the environment, whether it’s at work or at home, with a diagnosis that’s untreated.”

Preparation is key. Before a crisis occurs, health plans should confirm contact information for all members and determine the preferred method of communication. Some members may favor text messa

ge alerts while others may decide that e-mail is the best way to receive such notices from their health plan, Hall says.

" Periodic reminders about the basics of infection control can help prevent illness. “Universal precautions can buy a lot of protection for both staff and patients,” says Albert W. Wu, M.D., MPH, professor and director of the Center for Health Services & Outcomes Research at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. “But staff need to be aware and execute. Proper hand hygiene is the best place to start.”

NEXT: The roots of Ebola


The roots of ebola

The 2014 Ebola epidemic is the most significant ever, according to the CDC. As of December 24, 2014, there were 19,497 confirmed, probable, and suspected cases of Ebola virus disease in Guinea, Liberia, Mali, Nigeria, Sierra Leone, Senegal, Spain and the United States, and 7,588 reported deaths. The U.S. cases encompass two imported cases including one death, and two locally acquired cases in healthcare workers.

Outbreaks have occurred sporadically in Africa since Ebola was first identified in 1976 near the Ebola River in Sudan and Zaire, now known as the Democratic Republic of the Congo. The first outbreak in Sudan (Ebola-Sudan) infected 284 people and had a 53% mortality rate, while a second virus that emerged in Yambuku, Zaire (EBOZ) infected 318 people and had a 88% mortality rate.

Despite the tremendous effort of experienced and dedicated researchers, Ebola’s natural reservoir was never identified. The third strain of Ebola, Ebola Reston (EBOR), was first identified in 1989 when infected monkeys were imported into Reston, Virginia, from Mindanao in the Philippines. Fortunately, the few people who were infected with EBOR (seroconverted) never developed Ebola hemorrhagic fever (EHF).

The last known strain of Ebola, Ebola Cote d’Ivoire (EBO-CI) was discovered in 1994 when a female ethologist performing a necropsy on a dead chimpanzee from the Tai Forest, Cote d’Ivoire, accidentally infected herself during the necropsy.

There aren’t any licensed Ebola vaccines, but two possibilities are undergoing evaluation. Meanwhile, the average Ebola fatality rate is about 50%, according to the World Health Organization.

While there were so few cases of Ebola in the United States, it was wise to prepare for other disease outbreaks. Johns Hopkins’ Armstrong Institute recently created interactive training videos for the CDC on the use of personal protective equipment.

“It is likely that they [other outbreaks] will be both more mundane and more deadly than Ebola was in the U.S.,” says Wu, who is also an internist at Johns Hopkins Hospital. “For example, there may be 50,000 or more deaths from influenza this season, as there are most years.”

As a result, “leaders in managed care should ramp up their efforts to handle real pandemics such as influenza.” But preparing for Ebola wasn’t in vain. “Ebola may serve a useful role as a dress rehearsal for the next pandemic,” he says.

While policies may be in effect at healthcare facilities, the compliance could be less than optimal, particularly when it comes to donning and removing protective equipment. A second pair of eyes would be helpful to enforce compliance, says Linda Greene, RN, MPS, CIC, a senior advisor to the regulatory review panel at the Association for Professionals in Infection Control and Epidemiology.

Ebola training “sets a tone for the fact that in healthcare we must rely on our colleagues,” says Greene, manager of infection prevention at Highland Hospital in Rochester, New York. “It has highlighted how important the idea of teamwork is-working with each other and watching out for each other.”

NEXT: Ebola treatment centers


Ebola treatment centers

At hospitals’ requests, in September SIA-EPIC added an Ebola benefit to its pre-existing needle stick and workplace violence coverage. “We received the request to cover Ebola from our existing customers via the hospital administrators who deal with the actual policy,” Kosinski says. “But the need originated with the staff nurses and doctors.”

The benefit can be purchased individually or by a hospital, union or professional association for its members. Coverage can provide a lump sum of $200,000 for the employee to use at his or her discretion, he adds-to apply toward a mortgage, child’s tuition, or healthcare if the policyholder is unable to return to work.

Nonetheless, Kosinski says: “Promoting early diagnosis and treatments is the best way for managed care organizations to protect both their members and themselves. The sooner a patient is diagnosed and treated, the better the chances of limiting further spread of the disease, while improving survival rates without incurring extensive and expensive treatment options.”

Susan Kreimer is a New York-based freelance medical writer.


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