A Highly Infectious Disease Care Network in the US Healthcare System

Abstract

During the 2014-15 Ebola outbreak in West Africa, the United States responded by stratifying hospitals into 1 of 3 Centers for Disease Control and Prevention (CDC)–designated categories—based on the hospital's ability to identify, isolate, assess, and provide care to patients with suspected or confirmed Ebola virus disease (EVD)—in an attempt to position the US healthcare system to safely isolate and care for potential patients. Now, with the Ebola epidemic quelled, it is crucial that we act on the lessons learned from the EVD response to broaden our national perspective on infectious disease mitigation and management, build on our newly enhanced healthcare capabilities to respond to infectious disease threats, develop a more cost-effective and sustainable model of infectious disease prevention, and continue to foster training so that the nation is not in a vulnerable position once more. We propose the formal creation of a US Highly Infectious Disease Care Network (HIDCN) modeled after 2 previous highly infectious disease consensus efforts in the United States and the European Union. A US Highly Infectious Disease Care Network can provide a common platform for the exchange of training, protocols, research, knowledge, and capability sharing among high-level isolation units. Furthermore, we envision the network will cultivate relationships among facilities and serve as a means of establishing national standards for infectious disease response, which will strengthen domestic preparedness and the nation's ability to respond to the next highly infectious disease threat.

During the devastating and historically significant 2014-15 Ebola virus disease (EVD) epidemic, numerous public and academic leaders voiced concerns about the United States's healthcare system's ability to diagnose, safely isolate, and provide high-level care for patients with suspected or confirmed EVD and other highly infectious diseases.^1-3 At the height of the outbreak, hospitals across the country responded with emergency purchases of new personal protective equipment (PPE), requiring just-in-time training or retraining for large numbers of staff on donning and doffing procedures and alterations of their protocols to care for people at risk of EVD infection, commonly incurring substantial costs.^4-6 During this same period, the US Centers for Disease Control and Prevention (CDC) stratified US hospitals into 1 of 3 different tiers according to their ability to identify, isolate, assess, and provide care for patients with suspected or confirmed EVD. Most hospitals were subsequently designated as frontline hospitals, assessment hospitals, or Ebola treatment centers in their states.³

Supplementing the hospitals designated as Ebola treatment centers, the US Department of Health and Human Services (HHS) also funded the creation of the regional Ebola and other special pathogen treatment centers (RESPTC) network, through 2019, as part of the Hospital Preparedness Program (HPP). Existing hospitals were designated as a regional Ebola and other special pathogen treatment center in each of the 10 HHS regions throughout the United States to add “regional capability [to increase] our domestic preparedness posture to protect the public's health.”⁷ These centers were selected based on their enhanced capabilities to treat a patient with confirmed Ebola or other highly infectious diseases. Regional Ebola and other special pathogen treatment centers are intended to be positioned to provide care in future outbreaks of highly infectious diseases and are required to conduct quarterly training and exercises, to have the capacity to treat at least 2 EVD patients at a time, to have the isolation capacity or negative pressure rooms for at least 10 patients with highly infectious respiratory diseases, and to be able to treat pediatric patients with EVD or other infectious diseases with a partner or neighboring facility.⁷ However, since the last of the 10 regional Ebola and other special pathogen treatment centers was not designated until June 2016, post-Ebola outbreak, they have not had an opportunity to demonstrate successful use of their supplemental resources on repatriated or domestically acquired cases of highly infectious diseases, nor have they exercised operational communication and coordination with each other.⁸ In addition to the regional Ebola and other special pathogen treatment centers, the Assistant Secretary for Preparedness and Response (ASPR) and CDC also funded the creation of a National Ebola Training and Education Center to conduct national training and education activities based on the best practices of US institutions (ie, the Nebraska Biocontainment Unit, Emory University, NYC Health + Hospitals/Bellevue, and the National Institutes of Health Clinical Center), which have successfully cared for patients with EVD, in conjunction with CDC guidance.⁹

The outbreak in West Africa has now been contained,¹⁰ and Ebola is no longer prominently featured in the news. However, there is little doubt that future outbreaks of highly infectious diseases will continue to occur and that there will be new infectious pathogens emerging and re-emerging on the global stage.^11,12 Following the recent EVD epidemic, there is a critical opportunity to act on the lessons learned from the 2014-15 response—to broaden our perspective on infectious disease mitigation and management, and to build on our newly enhanced national capabilities to respond to infectious disease threats. Indeed, further investment—including but not limited to financial, infrastructural, and educational resources—in strengthening and maintaining these capabilities will be more cost-effective in the long term than spending in response, and will save lives when the next global infectious disease epidemic emerges.¹² However, there is also a significant risk that, without the impending threat of infectious disease morbidity and mortality, much of the funding that has been spent, the training that has been conducted, and the plans that have been made will deteriorate and diminish in significance again until the next major outbreak occurs, leaving the nation vulnerable once more.

Previous Consensus Efforts

Previously, 2 consensus efforts have been conducted to try to characterize portions of the capabilities that Western health systems needs to effectively provide care for people infected with highly infectious diseases. In 2004, the European Union established the European Network for Highly Infectious Diseases (EuroNHID) in response to the 2001 SARS outbreak and 2002 H5N1 influenza virus.¹³ EuroNHID was established with national representatives from 16 countries, “to exchange information, share best practices, and improve the connections between national (or regional) centers designated for the care of patients with highly infectious diseases.”¹³^(p00) The network was groundbreaking, representing the world's first efforts to coordinate consistent national approaches to highly infectious diseases. EuroNHID's consensus effort highlighted the need to provide patients with highly infectious diseases with safe, secure, and high-quality medical care with high-level infection control in a high-level isolation unit. EuroNHID also emphasized the need for specially trained staff and detailed recommendations that covered such topics as clinical care provision, diagnostic services, transport, health and safety, infrastructure features, support, and planning.¹³ A previous assessment, in 2009-10, of EuroNHID's collective isolation capabilities and capacities in high-level isolation units demonstrated that they were well positioned to provide optimal infection containment and infection prevention and control procedures. During the recent EVD outbreak, members of the EuroNHID consortium stated that high-level isolation units, in nations where they are available, should play a key role in providing safe, secure, high-quality, and appropriate care for a single or small number of patients with a highly infectious disease, such as EVD.^14,15

In 2005, an ad hoc US-based consensus group was organized by the then–medical director of the Nebraska Biocontainment Unit (NBU) and 30 infectious disease experts from academic institutions, federal and state agencies, and military personnel. The group developed a consensus statement detailing key considerations required for establishing biocontainment patient care units to standardize the planning, design, construction, and operation of high-level isolation units as one element to manage highly infectious diseases and to increase US preparedness efforts.¹ Although the 2005 US recommendations for designing biocontainment patient care units presented were frequently referenced during the 2014-15 Ebola outbreak, the US consensus group was a one-time consensus conference that lacked sustained funding and consequently had no plans for continuance beyond the statement.

Suggestions

In this “peacetime” period following the EVD epidemic, government, public health, and medical leaders have the opportunity to build on prior pioneering efforts and to nurture and strengthen our capabilities for identifying, isolating, and caring for patients with highly infectious diseases while considering how this can be accomplished in a cost-effective and sustainable manner. In order to suggest a path forward to achieve this goal, we propose the formal creation of a US Highly Infectious Disease Care Network (HIDCN). We envision that the network would link the US Ebola treatment centers and regional Ebola and other special pathogen treatment centers, forming a platform for common training, protocols, research, knowledge sharing, and capability sharing among high-level isolation units. The network could facilitate access for patients needing high-level isolation care to a geographically proximate facility.

Furthermore, the Highly Infectious Disease Care Network would support further development of the additional necessary components for national healthcare and public health preparedness for highly infectious diseases, including:

• Establishing a consensus network among key experts from the participating Ebola treatment centers and regional Ebola and other special pathogen treatment centers in order to have a large body of engaged individuals, mirroring EuroNHID's consensus efforts.

• Expanding the scope of current plans and systems for EVD to be appropriate for the care of other highly infectious diseases of public health significance.

• Proposing standards for key characteristics and capabilities required of high-level isolation units in the United States, based on the best available evidence, practice, and science.

• Maintaining a formal inventory of current capabilities and capacities of high-level isolation units in the United States.

• Establishing a formal relationship with EuroNHID and the European high-level isolation units to facilitate a global exchange and sharing of research, best practices, and lessons learned on organizational structure, operational capacity, and high-level isolation unit sustainability.

• Assisting the National Ebola Training and Education Center in the peer review of metrics and other training materials.

• Facilitating frontline clinicians' ability to easily access information 24/7 on current outbreaks of relevant emerging highly infectious diseases via easily accessible, curated internet portals and applications.

• Providing frontline clinicians, frontline providers, and other first-response personnel with resources and information on where to obtain up-to-date highly infectious disease and infectious disease education and training. One such example is the new Ebola Biosafety and Infectious Disease Response Program, part of the National Institute of Environmental Health Sciences (NIEHS) Worker Training Program, which promotes the development and implementation of occupational safety and health, and infection control training programs and education for workers at risk of exposure to infectious diseases in healthcare and non-healthcare settings.¹⁶

• Partnering with federal officials and other key stakeholders to strengthen and formalize the ties among, resources available to, and best practices shared among frontline personnel, Ebola treatment centers, and regional Ebola and other special pathogen treatment centers facilities.

• Including emergency medical services experts, representing the diversity of the emergency medical services system in the United States, in the design and implementation of interstate and intrastate highly infectious disease patient transportation capabilities among frontline, assessment, treatment, and regional highly infectious disease centers to form a cohesive national network.

• Including other industries affected by the care of patients in high-level isolation units, such as medical waste, law enforcement, death care, environmental services, and the like.

The Highly Infectious Disease Care Network can begin by building on the prior consensus work to improve overall national highly infectious disease preparedness, and it could use similar processes to help unify and advance the protocols and capabilities of the US Ebola treatment centers and regional Ebola and other special pathogen treatment centers.

To date, 4 high-level isolation units in the United States have demonstrated the ability to receive and treat repatriated EVD patients from Africa.¹⁷ Three of the 4 high-level isolation units were already established as biocontainment patient care units following the consensus criteria outlined by Smith et al.¹ However, no new units were built in the 10 years preceding the EVD outbreak, and, largely due to their rapid construction, most of the 55 CDC-designated Ebola treatment centers, as well as many of the 10 regional Ebola and other special pathogen treatment centers, have not been created to meet the same criteria as the 3 biocontainment patient care units.^1,3 In fact, as the recommended capabilities of Ebola treatment centers provided by the CDC for EVD care can be found in advanced preexisting inpatient care units, many Ebola treatment centers and regional Ebola and other special pathogen treatment centers may not have been created as separate, dedicated isolation facilities.³ These newer units are used for routine patient care, as well as care for patients with EVD and other highly infectious diseases only if the situation arises. This creates significant limitations on the design, training, exercise, and real clinical experience opportunities available to staff operating in these facilities.

Additionally, the new national network of Ebola treatment centers still has significantly varying approaches to the clinical services that may be offered, as well as to hospital preparedness and infection control. Not surprisingly, a high degree of variability has been found in both laboratory support approaches and infection control capabilities among Ebola treatment centers.^4,6 A Highly Infectious Disease Care Network could be of great value in not only better defining the operational and clinical capabilities needed to successfully and safely care for patients with highly infectious diseases in an appropriate facility, but it could also assist facilities in building capacity to address highly infectious diseases in light of new and evolving CDC and government guidelines and designations. Building capacity includes the increase and optimization of available adult and pediatric beds, flexible-use units, efficacious staffing models, and regular training and drills.⁴

Moreover, a Highly Infectious Disease Care Network can help to clarify the specific capabilities that are expected of frontline and assessment hospitals across the United States and could help to provide toolkits, training, and other materials that help to limit the burden of maintaining these capabilities on the hospitals. Currently, the roles of frontline hospitals and assessment hospitals in the United States vary by state, and there can be little similarity among state plans that anticipate caring for patients with highly infectious diseases.^3,18 A Highly Infectious Disease Care Network could shepherd differing state highly infectious disease plans toward a common national goal, while still allowing for the preservation of unique state infrastructure elements. This could not only reduce variation among the plans but also better ensure that the nation's plans are consistent with the best available science, research, and practice and are consistent with Ebola treatment center and regional Ebola and other special pathogen treatment center protocols and procedures.

Lastly, a Highly Infectious Disease Care Network could play an important role in better unifying the disparate guidance that is currently available to prehospital and frontline clinical staff regarding awareness of the current highly infectious disease outbreaks of concern as they evolve. There is currently not a clear, single, curated way to inform the millions of emergency medical technicians, paramedics, nurses, doctors, and others who work on the front lines of the ambulances, clinics, offices, and emergency departments of the US healthcare system of case definitions and updated outbreak geographic data from expert government sources for the highly infectious disease in question, while simultaneously linking that information to the appropriate degree of isolation and personal protective equipment (PPE) required. In the current absence of such easily accessible, coordinated, and vetted national guidance, frontline staff are often asked to rely on their own personal or organizational vigilance, which has a high potential for failure.¹⁹ Based on lessons learned from the EVD response, in order to best protect public health workers, first responders, and healthcare personnel, the United States now needs to develop new and innovative ways to ensure that all frontline personnel in the United States can have current and reliable access to up-to-date outbreak information for existing or emerging highly infectious diseases.

Clearly, creating a Highly Infectious Disease Care Network will require new resources to initiate and support the efforts suggested above, and in the current fiscal climate we acknowledge that it will be challenging to secure those resources. However, as demonstrated in the recent national response to EVD, the costs incurred by individual hospitals preparing in an uncoordinated system far exceeded the amount of federal resources that were ultimately dedicated to supporting a more coordinated network of Ebola treatment centers and regional Ebola and other special pathogen treatment centers.⁵ We hypothesize that a nationwide, sustained effort to continually improve the US health system's ability to detect, isolate, and care for patients with highly infectious diseases will potentially be more cost-effective in the long term and may potentially decrease the magnitude of future supplemental appropriation requests, as have been funded in recent years for Ebola and Zika viruses.

Conclusions

In this new and complex arena of providing care for patients with both known and unexpected highly infectious diseases, especially in view of the lessons learned from the nation's response to EVD, the changing landscape necessitates the coordination and development of a cohesive network of experts involved in such care. The current national network of Ebola treatment centers has been designed based on CDC guidance for EVD. However, varying approaches to infection control and laboratory support among current Ebola treatment centers emphasize the need for collective nationwide standards, especially in preparing Ebola treatment centers for other highly infectious diseases beyond EVD. In addition, the complex and costly nature of both preparing for and providing highly infectious disease treatment, as well as the lack of common regulations, currently threatens to degrade the US healthcare system's future ability to safely adapt to manage emerging highly infectious disease threats.⁴

A new US Highly Infectious Disease Care Network would be positioned to not only facilitate expert communication and information exchange on best practices, but it could also foster connections among facilities, establish standards for response capabilities and capacities, use the best available science and evidence to offer recommendations on infection control practices and infrastructure features, and increase the overall preparedness of the United States for the next highly infectious disease outbreak.

Conflict of Interest Statement

Dr. Biddinger reports grants from the Assistant Secretary for Preparedness and Response (Massachusetts General Hospital is one of the 10 Regional Ebola and Special Pathogen Treatment Centers), grants from Massachusetts League of Community Health Centers (to assist with evaluation and exercising of emerging infectious disease preparedness), outside the submitted work. Additionally, the National Institute of Environmental Health Sciences (NIEHS) Worker Training Program (WTP) funding for RFA-ES-15-018 Ebola Biosafety and Infectious Disease Response Training UH4 Information, grant number UH4 ES027055-01, does not financially support this commentary statement, but this training program is suggested to be considered in the development of the Highly Infectious Disease Care Network. Drs. Gibbs, Lowe, and Biddinger and Miss Le report to this cooperative agreement funding. Drs. Levy and Smith and Miss Herstein have no conflicts of interests or financial disclosures.

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