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When to Quarantine: Criteria, Cases & Containment Strategies · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Brought to you by the Department of Pediatrics at UTHealth San Antonio.
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Today, I'm bringing you Grand Rounds. Let's listen in.
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Okay, so I'm going to get started. It is my honor to introduce Dr.
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Ted Seaslack, Colonel, retired United States Army, who is a pediatric infectious
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disease physician with over 30 years of experience in the field of biosecurity.
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He received his undergraduate medical degrees at The Ohio State University.
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He completed his pediatric residency at Baylor College of Medicine.
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He did his PEDS-ID fellowship at the Uniformed Services University of the Health
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Sciences in Bethesda, Maryland.
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During his military career, he served as the chief of operational medicine at
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the U.S. Army Medical Research Institute of Infectious Diseases.
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He was the consultant to the Army Surgeon General on biodefense matters,
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led the U.S. delegation to NATO's Biomedical Advisory Committee,
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and served as the Defense Department's liaison to the Centers for Disease Control.
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During his career, he also served as a chief consultant to the U.S.
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Army Surgeon General, and he deployed to numerous countries,
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including Panama, Iraq, and Jordan.
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And of note, he also served on the
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advisory committee for immunization practices back when it was a thing.
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After his military retirement in 2015, he became the Executive Director of Health Security for the,
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University of Nebraska Medical Center And was the Medical Director of UNMC's
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Quarantine Unit, where he led preparedness operations until retiring in 2021,
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He's an Adjunct Associate Professor of Epidemiology at UNMC and has ongoing
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research and advisory roles in both biodefense and pediatric disaster preparedness missions,
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And on a personal note, I vividly remember him teaching me in the hallway, Wilford Hall, 1999,
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on my ID rotation.
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He served as our department chairman subsequently, and I was lucky enough to
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be able to call him my partner at Brook Army Medical Center for his last two years on active duty.
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So please welcome me in joining Dr. C. Slack, who's going to talk about quarantine,
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isolation, and biocontainment.
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Well, thanks so much, Dina. It's very much an honor to be asked to kick off,
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this year's Grand Rounds.
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A couple of caveats here, as Dina indicated, I retired from the military in
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2015 and took a faculty position at Nebraska.
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And then I retired from that job four years ago.
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And so anything I say about recent events is gleaned from speaking with my former
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colleagues and stuff. My own experience at Nebraska ends four years ago.
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My other caveat is that not too much we're going to discuss today is really
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specific to children, but I will point out where it is.
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And so I think all of you are at least loosely familiar with the fact that there
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have been some serious infectious disease outbreaks in the news lately.
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The Andes virus outbreak in the South Atlantic Ocean on a cruise ship And then
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the ongoing Ebola outbreak in the Democratic Republic of Congo Which if you
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look at the trajectory of cases in that.
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Ongoing outbreak If it continues along as it has, it will soon dwarf
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the 2014 outbreak that resulted in 40-some thousand cases So a couple of very
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important things going on in the world now that are relevant to this discussion.
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So we're going to talk about quarantine and isolation and a little bit about
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the ultimate form of isolation, namely biocontainment.
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So when we talk about infection control and biocontainment, we can actually
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talk about laboratory containment and clinical containment.
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So I'll just outline those here, but then we'll spend the rest of this morning.
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Talking specifically about clinical containment.
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But when we talk about laboratory containment, and this hopefully is review
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for most of you, we divide microbiology laboratories into four levels,
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and we call those biosafety level one, two, three, and four.
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And so biosafety level one labs are, you can think of a high school biology lab.
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Obviously, we don't want 14-year-old high school freshmen playing around with
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anything that's pathogenic, anything harmful to humans.
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So these laboratories work with benign organisms to demonstrate to high school
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students what little red and blue things look like under a microscope,
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but they don't deal with anything harmful to humans.
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A BSL-2 lab does deal with things that are harmful to humans,
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but they're the common garden variety sorts of things that we see in clinical
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medicine all the time, strep and staph and gonorrhea and syphilis and a whole lot of other things.
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So most of your clinical labs in this country at small community hospitals and
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stuff, would be BSL-2 labs.
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A BSL-3 lab is a lab that works with highly hazardous human pathogens.
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And most medical centers and
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all 50 state public health labs would have at least a BSL-3 laboratory.
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Uh, BSL four lab is also a lab that works with highly hazardous human pathogens.
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Uh, but the difference between BSL three and BSL four is that for the BSL four
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pathogens, there are no effective countermeasures.
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And for many decades, we had two of those labs, uh, in the United States,
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one at the centers for disease control and one at USAMRID, the U S army's medical
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research Institute of Infectious Diseases.
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But after the terror attacks of 9-11 and the anthrax attack that followed a
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few weeks later, Congress did what Congress does.
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They threw money at the problem of bioterrorism, and many academic institutions
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won grants to open up their own BSL-4 laboratory.
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So we now have 13 of those in the United States, and two of those are in Texas,
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one at the University of Texas Medical Branch at Galveston, and the second right
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here in San Antonio at the Southwest Foundation for Biomedical Research.
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So again, that's all I'm going to say about laboratory containment,
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and I want to focus most of this talk on clinical containment.
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So I think all of you, hopefully, are familiar with basic clinical infection control practices.
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So we,
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speak of standard precautions and who should we approach using standard precautions?
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Well, obviously everybody.
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And I think you all know what those are. That's common sense stuff.
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So we as infectious disease docs, for example, we recommend,
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it's only a recommendation, but we recommend that if you're doing a rectal exam, you wear gloves.
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So standard precautions are, again, those common sense things that we do when
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we approach any patient in a clinical setting.
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But you also realize that some patients require something more.
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They require transmission-based precautions, and we have three levels of those,
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contact droplet and airborne precautions.
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And airborne precautions are ideally applied in a special facility,
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an airborne infection isolation room.
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So that's a negative pressure room. Most medical centers will have a couple
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of those rooms. Most small community hospitals probably won't.
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So if you have a patient that requires airborne isolation, those patients you
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would ideally transfer to a facility that could provide that.
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But then beyond those transmission-based precautions, there's this very specialized
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kind of ultra high-level containment care that we call biocontainment.
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Now, I'm going to talk a little bit about that because that's,
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again, been in the news quite a bit
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lately with respect to the Andes virus patients and the Ebola patients.
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So the birth of biocontainment, I think, is a fascinating story.
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It occurred in 1969 with a complex number of events all coming together at the same time.
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So first of all, Richard Nixon in 1969 renounced the use of biological weapons.
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And some of you may not know this, but the United States from 1943 until 1969
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actually had an offensive biological weapons program.
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So that program started in 1943 in response to active German and Japanese programs,
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and the United States decided that it had better get into the business as well.
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Most of the work done in that program was defensive, was aimed at coming up
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with countermeasures for things like anthrax and smallpox.
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But we did have a small offensive capability. It was dwarfed by that of our
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Cold War adversary, the Soviet Union.
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But in 1969, Nixon made the unilateral decision to get rid of this program.
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And we can argue about his rationale, but basically he said to one of his advisors
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that, you know, if anyone tries to use biological weapons against us,
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we'll just nuke the hell out of them.
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So I think he felt those weapons were ineffective anyway, and there was no great
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loss getting rid of them.
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And the reason that's important to us is because back in 1969,
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all of the media coverage of this decision brought a lot of these diseases out
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into the public and they became household names.
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So it was the first time a lot of Americans heard of things like anthrax and
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plague and smallpox and tularemia and things like that.
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Then at the same year, an investigator, Jordy Casals at Yale University,
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discovered one of the first highly morbid viral hemorrhagic fevers, namely Lassa fever.
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And one of his nurses in the course of doing work with this virus in Nigeria,
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one of his nurses contracted the disease.
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She recovered, fortunately. then Dr. Casals himself caught the disease.
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He recovered only after a transfusion of convalescent plasma from his nurse.
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And then one of his technicians caught the disease and unfortunately succumbed to that disease.
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And so that frightened Dr. Casals quite a bit. He decided it wasn't safe to
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work with viruses like LASA in conventional laboratories.
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And he moved his work to what was then the Communicable Disease Center,
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now the Centers for Disease Control in Atlanta. And that was the birth of BSL-4
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laboratory containment.
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That same year, I think all of you realize, Apollo 11 landed on the lunar surface
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and Buzz Aldrin and Neil Armstrong walked on the moon.
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And it seems a little silly now, perhaps.
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But back in 1969, there was a palpable fear that these astronauts would bring
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back with them space pathogens, moon viruses.
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And so there was a lot of interest in quarantining these astronauts when they got back.
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And so NASA built a Lunar Receiving Laboratory at the Johnson Mann Space Flight Center in Houston.
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And they did that in consultation with Army experts from Fort Detrick.
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And at the time, they made that decision to build the Lunar Receiving Laboratory.
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They also made a decision to build a facility at Fort Detrick.
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And that's where I spent some of my career. And we'll talk about that in a minute.
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So, again, it seems a little silly now, but back in 1969, there was this palpable
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fear of the astronauts bringing back space pathogens.
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And that fear was amplified when Michael Crichton published his fictional work, The Andromeda Strain.
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And that was clearly fictional, but it caught the attention of a lot of politicians and news media people.
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And wrapping all these things together in 1969, there was this strongly perceived
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need to do something about these new emerging pathogens, such as loss of fever.
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So the Apollo 11 astronauts, when they splashed down in the Indian Ocean.
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They were picked up by the aircraft carrier Hornet and they were immediately
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put into this mobile quarantine facility, which is a converted Airstream trailer.
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And they were taken to the Johnson Mann Space Flight Center,
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along with all of the other detritus from the space capsule.
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So the capsule itself, the moon rocks, the samples that were collected,
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were all taken to the Lunar Receiving Laboratory and quarantined for three weeks.
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And that was done partly because of, again, fear of space pathogens,
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also to give the astronauts some time away from the media and time to recover
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from prolonged weightlessness.
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The same thing was done with Apollo 12 and Apollo 14.
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After those three missions, after none of them revealed the presence of any
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moon pathogens, it was decided they didn't need to do this anymore.
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So, Apollos 15, 16, and 17, they didn't bother to quarantine the astronauts. So, I said the...
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Work that NASA did was done in conjunction with the military.
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And the military, at the same time they were building the Johnson-Mann Space
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Flight Center, the military was building its new research laboratory, again, the U.S.
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Army's Medical Research Institute of Infectious Diseases at Fort Detrick,
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Maryland. So the plans were drawn up, the blueprints in 1969.
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Construction started then, and it was opened in 1972.
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And when it opened, it had a two-bed clinical facility, which we used to call a BSL-4 facility.
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Now, remember that terminology of BSL-1234 was designed to apply to laboratories,
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not to clinical facilities, but we kind of bastardized it and applied it that way anyway.
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But this two-bed hospitalization facility had the same sorts of controls that
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you would expect in a BSL-4 laboratory.
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And the facility was affectionately called the Slammer, presumably because the
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very heavy steel airlock doors made a nice slamming sound when they were locked
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behind you and you were locked into this facility.
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But you can see the doctors, nurses, and technicians are working in spacesuits
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with air hoses supplying external air.
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You can see in the lower right-hand corner there, an air transportable isolator.
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That's the device we would use to transport patients from the place we picked
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them up to the slammer at Fort Detrick.
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In the lower left-hand corner, you can see the air transportable isolator actually
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docks to a docking port in the external wall of the building,
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and the patient is passed
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through a plastic sleeve into the slammer and never needs to leave.
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The isolation capability. And there in the upper right-hand corner,
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that was my job as I was the flight surgeon for this team.
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And my job was to lay there and let all the medics practice starting IVs on
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me and drawing blood and those sorts of things.
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So again, a unique facility, but it was two beds. That was our nation's entire,
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BSL-4, if you will, hospitalization capacity.
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Nowadays, things have advanced somewhat.
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We've gone from a system where the theory was enveloped the patient to a system
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where the theory is now enveloped the inside of the aircraft.
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So this is the transport isolation system, which the Air Force has developed over the last few years.
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And this is what we would use now to transport a patient.
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So it wouldn't be quite as claustrophobic, although I think being in this and
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having that fear that you've been exposed to Ebola, you know,
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a potentially highly lethal pathogen, still pretty unsettling.
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But again, at least this takes away a little bit of the claustrophobia from it.
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So, there were some problems with this slammer besides the fact that it was only two beds.
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First of all, it was underutilized. We admitted 21 patients to the slammer between
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the time it opened in 1972 until 1985.
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And then we didn't admit a single patient for 20 years from 1985.
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To 2004. And I think part of that is luck. Part of that is the fact that laboratory
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infection control procedures got better and better and fewer and fewer scientists
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got exposed to their experiment.
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But all of these admissions, all 21 of them were for quarantine.
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They weren't for isolation.
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And we're going to talk about the differences between isolation and quarantine.
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But basically, none of these patients were sick. They were all people who got
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exposed to highly hazardous diseases like Ebola and Lhasa.
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And the military made a decision to put them into this facility for quarantine
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and wait and see if they caught their experiment, so to speak.
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And fortunately, none of them did, and they were all able to walk out the front door.
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But because this slammer was very underutilized, that obviously caught the attention
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of the budget people and congressmen who were appropriating funds for this.
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And a decision was made that maybe we don't need to fund this.
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And then the company that supplied a lot of the equipment for this,
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its owner died in Britain and the company folded and it was getting difficult to get repair parts.
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And then probably most importantly, there were some serious issues with the
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Joint Commission. So back in 1972, when this facility started.
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Uh, open the fact that there was a two bed clinical facility and what was otherwise
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a research laboratory really didn't bother too many people.
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Um, but, uh, by, by 2000, uh, the fact that there was no, uh,
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significant clinical support, um,
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within 35 miles, our support was at Walter Reed army medical center,
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35 miles South, uh, of Fort Detrick.
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And that didn't sit very well with the Joint Commission.
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And then you all probably are familiar with the military and how things work
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in the military. There's rapid turnover. And so a lot of these highly trained
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technicians were constantly turning over and that made it difficult to continue to staff this.
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And then finally, civilians got into the business of providing biocontainment.
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And again, after the anthrax attacks of October 2001, Congress did what Congress does.
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They appropriated a lot of funds, A lot of academic institutions sought grants for those funds.
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And so we started building civilian counterparts to this military and NASA biocontainment apparatus.
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So the picture here is of my mentor and former boss, Phil Smith.
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He was chief of infectious diseases at Nebraska, and after the anthrax attacks,
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Congress appropriated money to the CDC, who partialed it out to the 50 states.
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And all 50 states got grants of some degree.
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Most states use that to buy drugs and vaccines for stockpile.
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Phil had the idea to build a civilian biocontainment unit. I met Phil when I
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was still on active duty.
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He sounded like he would have a great place for me to work after I...
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Got out of the military, so I started sucking up to him many years before I
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retired, and it worked. And so I left to join Phil at Nebraska upon my retirement
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from the military in 2015.
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So why a civilian biocontainment unit?
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Well, we've already talked about the fact that the terrorist attacks on the
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World Trade Center in September of 2001 obviously caught the attention in the world.
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That was followed three weeks later by the mailing of anthrax.
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22 people were sickened by those. 11 had inhalational anthrax and five of those died.
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That caught people's attention.
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In December of 2002, there was a huge tabletop exercise called Dark Winter that
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involved a lot of officials at the very highest levels of government.
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They used smallpox as a potential bioterrorist agent.
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I think the outcome of this tabletop exercise was so grim that it scared a lot
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of congressmen and senators, and that led to the appropriation, again, of funds.
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And that was followed closely by SARS outbreak in Canada and by a monkeypox
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outbreak in the United States.
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And so I think that's what led to Phil winning his grant. And you can say that
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our biocontainment unit in Nebraska
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traces its origins to the problem of bioterrorism. So why Nebraska?
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Well, we're located in the center of the country, and we're co-located with
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Offutt Air Force Base, which is the headquarters for U.S.
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Strategic Command. So we've got 12,000-foot runway. We can take evacuation planes
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from anywhere in the world, and we've got easy coordination with the military there.
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This was at the time when a new federal agency, the Department of Homeland Security,
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stood up. They had money.
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They were appropriating funds. And of course, we were interested in obtaining some of those funds.
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I told you the monkeypox, there was a big monkeypox outbreak in the upper Midwest.
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We had no cases in Nebraska, but our surrounding state, neighboring states had,
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many. There were 71 total cases. Fortunately, no one died.
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But there was some problems with health care workers being afraid to take care
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of patients. And I'll talk about that a little more in a second.
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Again, this was the time when SARS emerged. And then finally, we were lucky.
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We had a very, very active emergency preparedness community.
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An EMS department and stuff.
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So at this time, many cities, EMS departments were kind of shying away from
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this notion that they would ever transport an Ebola victim, for example,
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or a loss of fever or a smallpox victim.
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So for some reason, our community in Omaha kind of embraced this,
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and they embrace it to this day.
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They're proud of the fact that they are one of the few departments that is expert
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in managing some of these highly hazardous communicable diseases.
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So Phil got his grant, and we built the biocontainment unit in Nebraska that
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kind of took the place of the military's facility at Fort Detrick.
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So this is just a story of a little 10 year old girl, uh, Rebecca McClester.
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She got monkey pox, um, in Wisconsin in, uh,
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uh, at that, back at that time. And, uh, the doctors, uh, there,
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uh, at her facility refused to care for her, uh, fearful of bringing monkeypox
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back home, uh, to their own families and stuff.
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And so again, this was what, uh, one of the things caught Phil's attention.
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And, uh, uh, a lot of the appropriators vowed that this wouldn't happen again,
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that we needed a facility that could treat.
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And who had physicians and nurses who were willing to treat patients with these
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highly hazardous communicable diseases.
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Dina told you I spent three and a half years at the CDC. I was the military's
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liaison there. This is my CDC boss, Julie Gerberding.
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She was the director at the time, and she came down and cut the ribbon for the
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opening of our biocontainment unit there.
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Um, so we now, uh, have, uh, spread, uh, our capability throughout the nation
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through NEETEC, the National, uh, Emerging Special Pathogens Training and Education Center.
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That's a second degree acronym, an acronym within an acronym.
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The military would be proud of that.
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Um, so you could see, uh, number seven there, that's our facility in Omaha.
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We divide the nation up into, uh, FEMA regions and DHS regions. They mirror each other.
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And so we are the facility for Region 7.
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Region 6, which includes Texas, now has its own facility at UTMB Galveston.
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And you can see the rest of those facilities scattered throughout the country there.
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The three in black are the ones that are the three facilities that actually
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received Ebola patients during the 2014-2015 Ebola outbreak there.
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So they're the three with actual experience, um, in, in managing some of these
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highly hazardous communicable diseases.
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And, um, and they're the ones that have trained up a lot of the people that
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staff the other facilities, including ours here in Texas.
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So we've now, as a result of a lot of this thinking, divided the nation,
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um, uh, into various tiers of, uh,
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clinical capability based on their ability to deal with highly hazardous communicable diseases.
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So all healthcare facilities would fall in Tier D. They ought to be able to
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safely isolate patients who they suspect of being infected with a highly hazardous condition.
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They should be able to safely isolate them, not necessarily treat them,
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but isolate them until they can get them out of there.
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Tier C are the assessment centers, the ones that can initiate care and initiate diagnostic testing.
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And then Tier B are those capable of delivering specialized care throughout the course of illness.
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And the Tier A are the ones that are strategically positioned,
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the ones that you just saw that have access to a lot of sophisticated laboratory testing, can do,
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genetic analysis on strains and stuff like that.
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So we'll talk a little bit about our unit here. If you saw it in Nebraska,
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you would be very, very underwhelmed. It looks like a normal,
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very small hospital ward.
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All of its magic lies in the invisible aspects of it, but it's basically a five-room ward.
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Each of those rooms is potentially a double room So in theory,
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we could take care of 10 patients.
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In this facility. That assumes you could double them up. They would have to
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have the same disease in order to be doubled up.
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We also learned in taking care of Ebola patients here how much waste they generate,
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and how much nursing care is required to care for them.
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And there's no way we could take care of 10 Ebola patients.
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So, in fact, we probably couldn't take care of more than two at the same time,
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just because of all the resources they consume.
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We'll talk a little bit more about that in a minute. But I guess if you had 10,
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patients with an airborne disease, because airborne disease patients don't generate
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as much soiled linen and all that sort of stuff, in theory, we could take care of 10 patients.
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So we have a separate air handling system from the rest of the hospital.
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We have serial negative pressure gradation throughout it. So when you go from,
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the outer hallway into the inner hallway,
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you get into a more negatively pressurized environment.
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When you go from that inner hallway to the nurse's station, from the nurse's
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station to the back hallway, and from the back hallway to the patient room,
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you're going through serial negative pressure gradation. And all air out is double HEPA filtered.
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The standard is 15 air exchanges per hour.
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Every time I tested it, we'd have 26 to 28 air exchanges per hour.
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So very negatively pressurized, very...
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Frequent air exchange. The air is, again, HEPA filtered out.
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And one of the advantages we have, we have a BSL-3 laboratory on our campus
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because the Nebraska State Health Lab is actually on the University of Nebraska campus.
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And then we had a little lab, point of care lab in the biocontainment unit.
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So a lot of basic laboratory tests could be done without ever having to break
29:46
containment, without ever having to take a specimen out of the facility.
29:51
But those specimens that did need to leave the facility,
29:56
for example, for more sophisticated analysis, we had the ability to bag,
30:01
double bag, triple bag those specimens and then pass them out through a secure
30:06
airlock to a transport system that would take them to the regular laboratory.
30:10
And we drilled regularly with both civilian and military agencies.
30:15
So when we talk about trying to control infection in this environment,
30:19
we kind of borrow the Occupational Safety and Health Administration's hierarchy of controls.
30:25
And not all of these apply necessarily in every case, but OSHA would say that,
30:32
the best way of dealing with a hazard is to eliminate the hazard.
30:37
So obviously, as a biocontainment unit, we can't do that. It's our job to take
30:41
care of some of the most dreaded infectious diseases in the country.
30:48
But when we talk about elimination, we can tell you, if you work at a community
30:53
hospital, that that's what you should do.
30:55
You should eliminate the hazard by sending the patient to us and not try to
31:01
care for an Ebola victim in a small community hospital.
31:06
We talk about substitution, replacing the hazard. That really doesn't apply in most cases here.
31:12
But the bottom three are where we as a biocontainment unit differ from conventional
31:17
hospital settings. So we have a significant number of engineering controls.
31:21
We'll talk about those in a minute.
31:23
We have a significant amount of administrative controls.
31:27
We change the way, we limit who can enter the facility.
31:32
We stipulate the type of training they need to have, et cetera, et cetera.
31:38
And then finally, the bottom line is personal protective equipment.
31:41
That's actually the bottom of the pyramid, the least effective way,
31:46
but it does add protection to the other four mechanisms of protection.
31:53
So just show you a little bit of our facility. So our air handling system vents
31:58
out to the roof through double HEPA filters.
32:00
There's no recirculated air. The exhaust air is more than 25 feet from any building intake.
32:07
And we have, again, dual redundancy. And there's not only dual redundancy of
32:11
the HEPA filters, but of the exhaust fan. So if one goes out,
32:15
the other automatically kicks in. We've got a lot of digital.
32:20
Equipment in the unit, inside the room, outside the room, at the nurse's station.
32:25
We can monitor ambient temperature and humidity and air pressure,
32:31
the negative pressure in the room, et cetera, et cetera.
32:34
So there's some of our, again, specialized equipment.
32:37
So the thing there on the left is an isopod. On the upper left is the isopod.
32:43
That's how we would transport patients throughout the hospital if they needed
32:47
to move throughout the hospital. Now, we try to limit that movement.
32:51
And in fact, we never had to do that for any of our patients.
32:55
We do have in-suite radiography and ultrasound.
33:00
So we cannot do CT scan or MRI in the unit.
33:05
And if we ever decided that that was absolutely critical, we would move the
33:10
patient down to CT scan or MRI in this device.
33:14
But again, we try to not do that if we don't have to.
33:17
We try to get by with standard radiography and ultrasound. On the lower left
33:22
there, that's the military's version of the isopod. It's painted green and it
33:26
costs 10 times as much, but there you go. And then on the bottom right.
33:31
Is the device that we seal remains in. So we had one patient succumb to Ebola.
33:39
That made us the world's expert based on an N of one, I guess.
33:42
And so we were constantly asked how to deal with potential deceased bodies,
33:49
and that's a device for triple sealing them in plastic bags and stuff.
33:54
So, we've activated our biocontainment unit three times.
34:00
The first was for the Ebola outbreak in West Africa, in Guinea,
34:07
Liberia, and Sierra Leone.
34:09
So, these were all, you all probably remember the outbreak with about 42,000
34:15
cases and 11,000 some deaths.
34:20
But a number of American expatriates were,
34:25
affected by that We had a lot of missionary doctors and nurses working,
34:31
in West Africa And some of them caught this disease And so we felt that we owed
34:37
it to these people to get them back to the United States for care,
34:42
We brought 10 patients back We took care of three of those at,
34:46
Nebraska and I'll talk about them a little bit in a second.
34:50
And then in the very earliest days of the COVID pandemic, we took care of some SARS-CoV-2 patients.
35:00
This was at a time when we still thought we had a shot at containing this pandemic.
35:06
It soon became obvious that the horse was way out of the barn and we weren't
35:11
going to be able to do that, but I'll talk about that in a minute.
35:14
And then just recently, we admitted one patient with Andes virus.
35:19
So you can see in the picture there, one of our Ebola patients in the room talking.
35:25
To his wife. I don't know if he's,
35:28
She's reading to him or she's reading because she's bored and he's complaining. But anyway, whatever.
35:35
We have a facility where spouses and family can talk via Zoom to their loved ones in the unit.
35:42
So getting to this unit, the aircraft lands either at Office Air Force Base
35:48
or at Epley Airfield in Omaha.
35:51
And I don't know if you know much about the geography here, but I think it's
35:56
fascinating. The Missouri River separates Nebraska from Iowa.
36:01
But back in the 1870s, there was a big flood shifted the course of the Missouri
36:06
River, and it left this little enclave called Carter Lake, Iowa,
36:11
completely surrounded by the state of Nebraska.
36:15
I actually lived in Carter Lake when I was working in Omaha.
36:20
So you can see in the upper right-hand corner of this map, there's Epley Airfield.
36:25
That's where the aircraft lands. And it travels down Abbott Drive there to get
36:29
to downtown Omaha to the medical center.
36:32
And you can see Route 165 there is 500 meters long. It crosses 500 meters,
36:38
half a kilometer of Iowa territory.
36:42
Well, the governor of Iowa said that no Ebola patient would be transported through her state.
36:48
And so that was a big political controversy. And we eventually ended up having
36:52
to drive several miles around this little enclave so that we'd stay in Nebraska
36:59
when we deliver these patients to the biocontainment unit.
37:02
And then we take them in through the back door, through the side doors.
37:07
We're not sneaking in the back door of the hospital. This is a side door.
37:11
And they're transported up to the biocontainment unit. And you can see here,
37:15
it's a fairly unimpressive looking facility.
37:18
This is the outer hallway there. And I'm joking about the Ebola virus is not
37:23
being permitted to cross the line.
37:25
But the line is there just to warn people that they're entering a hotter zone.
37:31
There's, again, serial negative pressured radiation as you go down this hallway
37:36
and as you go into patient rooms and stuff.
37:38
So again, we activated in 2014. We had three patients admitted to this facility.
37:46
None of them were there at the same time. So all were there in series rather than in parallel.
37:54
So the first one was admitted on day eight, discharged on day 21.
37:59
And you can see the rest there. The third one, unfortunately,
38:04
was in extremis in multi-organ failure before he even got on the aircraft in
38:10
Africa and unfortunately didn't stand much of a chance and passed away on day three.
38:15
That's the only death we've had so far.
38:19
Okay, so that's a lot about the history and the show and tell of what we're doing in Nebraska.
38:27
Now I want to talk a little more scientifically about this, though.
38:31
So the question comes up, so who is a candidate for admission?
38:34
You know, which diseases would we put in that type of a biocontainment unit?
38:42
And the way I like to look at it is there are five criteria that we use.
38:47
And the first three are illustrated in this diagram.
38:51
So diseases that are highly infectious, highly contagious, and highly hazardous
38:57
are those that are our big candidates for admission.
39:01
So there are diseases that are very infectious, like brucellosis and Q fever.
39:05
Both of those diseases, as little as a single organism can infect you.
39:11
There are diseases that are highly hazardous. Anthrax, inhalational anthrax
39:16
has a mortality rate approaching 100% in untreated patients.
39:22
There are some diseases that possess a couple of these criteria.
39:27
Tularemia is very hazardous and highly infectious.
39:31
But it's the diseases that possess all three attributes, like Ebola.
39:36
It's highly infectious, highly contagious, and highly hazardous.
39:40
And those are the ones that are the targets for admission to the biocontainment unit.
39:45
And I provide a little bit of data here. So Ebola, as little as one biocontainment.
39:51
Particle or one plaque forming unit can cause infection.
39:55
Anything with an R0 value, R0 is a number of secondary cases that emanate from
40:02
a single primary case, and that figure
40:05
applies only in the absence of any interventions or any herd immunity.
40:10
So anything with an R0 greater than is capable of causing an outbreak, a pandemic, if you will.
40:20
And so Ebola is highly infectious. It is communicable enough to cause an outbreak.
40:27
And it's clearly highly hazardous. And we measure that by morbidity and mortality.
40:31
And you can see the rest of that here. So there are certain influenza strains
40:36
that would meet our criteria.
40:37
You know, H7N9, H5N1 influenza in a human could potentially be a candidate for,
40:46
admission to the biocontainment unit.
40:48
And you'll see Andy's virus has an R0 well under one. We don't know what it
40:56
is. No one's ever done the study, but it's clearly well under one.
41:00
So it's not particularly communicable.
41:03
And in all likelihood, we wouldn't need to admit an Andy's virus patient to
41:09
the biocontainment unit. We did one.
41:11
I suppose some of that is you've got it, you might as well use it kind of thinking.
41:15
But certainly that type of facility wouldn't be necessary to safely manage one
41:21
of these patients. So I said there were five.
41:24
Criteria that we use. And I showed you the first three, but here's the fourth,
41:30
and a very important one, and that's the presence or absence of countermeasures.
41:35
And so polio, which this article is talking about, certainly meets the first
41:41
three criteria. It's very infectious, it's very communicable,
41:45
and I would argue it's pretty hazardous.
41:48
But we can protect ourselves against polio. We have a very, very effective vaccine.
41:52
So nurses and caregivers wouldn't need to worry about contracting polio from
41:59
one of their patients should they ever be required to take care of a patient with polio.
42:04
So we would not need to admit a polio victim to the biocontimum.
42:08
And the same argument would apply for measles. Very infectious, very contagious.
42:12
I would argue pretty hazardous. 200,000 children in the developing world still
42:16
die every year of measles.
42:18
But we certainly wouldn't need to admit a measles patient to the biocontainment unit.
42:23
We would need to admit them to an airborne infection isolation room if we needed
42:28
to admit them at all. Obviously, we try to keep patients with highly communicable
42:32
diseases out of the hospital if we can.
42:36
So when you apply those four criteria of infectivity, communicability,
42:40
hazard, and presence or absence of countermeasures, what are you left with?
42:44
These are the highly hazardous communicable diseases of concern.
42:47
These are the kind of things that, you know, we might admit to our biocontainment of smallpox for sure.
42:54
Plague, I put a question mark because you definitely would not need to do that for bubonic plague.
42:59
You might consider it for pneumonic plague. Certainly, pneumonic plague has
43:03
been managed successfully in conventional hospital settings,
43:07
but you could say the same thing about all of these diseases.
43:10
You could also say that all of these diseases have been unsuccessfully managed
43:15
in conventional hospital settings. So that's one where we would consider it.
43:18
Certain viral hemorrhagic fevers, monkeypox, you know, we have monkeypox in this country.
43:25
We have not put those patients in a biocontainment unit.
43:29
I suppose you could if you wanted to, but that is not a particularly infectious
43:36
disease or contagious disease. It requires close body contact in order to contract it.
43:45
SARS-CoV-2 met the criteria early on in the pandemic. We'll talk about that
43:51
in a minute. We now have relatively effective countermeasures,
43:54
and obviously the horse is so far out of the barn there.
44:00
We don't have the beds to admit SARS-CoV-2 patients to biocontainment units.
44:05
I'll just say a little bit about children in biocontainment units.
44:10
The good news is we've never had to do that. We have not had a single admission
44:15
of a child to a biocontainment unit yet in this country.
44:20
We have put a lot of thought into it. This is a review of a lot of the issues.
44:27
That would come up when you consider managing children in a biocontainment unit.
44:32
If you're interested in that, you know, I would urge you to look this up or
44:37
I'm happy to send you a link to the paper.
44:40
There are some very troubling issues that would come up.
44:45
The presence of parents in the room with a sick child with Ebola,
44:51
for example, the wisdom of cohorting.
44:54
If you had two children in a family with Ebola, you know, would you cohort those
44:58
patients in the same room, et cetera, et cetera.
45:01
And time doesn't permit us to talk about the specifics of these today.
45:06
If you want to invite me back, Dina, we could talk, we could spend a whole hour
45:10
talking about, you know, how these issues apply to children in a biocontainment.
45:15
You know, suffice it to say, those are all problematic issues and there's not
45:19
unanimity of opinion as to how we would deal with that.
45:23
So let's move on to talk about isolation and quarantine specifically now.
45:28
So I just want you to be aware, these are two very different things.
45:31
The terms are often used inappropriately, but the CDC defines isolation as the
45:37
mechanism by which ill persons with a communicable disease are separated from those who are healthy.
45:43
And quarantine, on the other hand, separates well persons who may have been
45:49
exposed to a disease but have not yet become ill with it. And that's an important
45:54
distinction. We'll talk about that in a minute. So quarantine, I'll see you next time.
45:59
Happens all the time. It's usually under the radar. It usually happens at a
46:05
local level, and it's usually quasi voluntary.
46:09
So if you get exposed to measles and you're not vaccinated,
46:15
the local health department will likely tell if they become aware of your case,
46:20
they will likely tell you to stay home and don't go to school,
46:26
for the length of the incubation period.
46:29
Same with chickenpox. If you get exposed to chickenpox and you're not immunized
46:34
against chickenpox, the health authorities will tell you not to go to school
46:38
until you complete your incubation period.
46:41
This stuff happens all the time. It goes on all over the country.
46:45
Local public health departments deal with this, and it's usually dealt with under the radar.
46:52
But with that said, there are a small—and by the way, local health departments
46:58
and state health departments are free to,
47:02
prescribe which diseases they feel are worthy of quarantine.
47:08
But federal law establishes the diseases subject to federal quarantine.
47:14
And there are three executive orders written by President Bush and President
47:18
Obama that specify the diseases that are subject to federal quarantine.
47:23
So the federal government, the CDC, cannot order you into quarantine for other
47:29
diseases. States can add to this, to the list and do that.
47:34
And I like to divide these nine diseases into three categories of three each.
47:39
And I divide them based on what would happen if I put you in quarantine and
47:43
you actually got your disease. So remember, you're being quarantined because
47:47
you've been exposed to something. You're not yet sick.
47:49
And our hope is that if you're put into federal quarantine, you won't get sick.
47:54
You won't catch the disease that you were exposed to. But what happens if you do?
47:59
Well, if the disease in question is a certain viral hemorrhagic fever like Ebola,
48:06
then I'm going to put you in a biocontainment unit. Uh, I would do the same for SARS or MERS.
48:11
I'm lumping those two diseases together. Um, and I would do the same for smallpox.
48:16
And then there are diseases for which I would definitely not put you in the
48:21
biocontainment unit. And the three there are cholera, diphtheria, and yellow fever.
48:26
And those are, I think, on the list of federally quarantinable diseases,
48:29
mostly as an anachronism.
48:32
The fact that they're on that list dates to an earlier time in public health and stuff.
48:37
But clearly, diphtheria, we've got effective countermeasures.
48:40
Yellow fever, we've got an effective vaccine.
48:42
Yellow fever is not transmissible from person to person anyway,
48:46
except through the bite of a mosquito. So the only reason to put them in isolation
48:50
would be to protect the local mosquitoes.
48:52
So, again, those are diseases that are theoretically subject to federal quarantine.
48:56
I can't imagine they ever would be ordered into federal quarantine,
49:01
but they certainly wouldn't need to go in a biocontainment unit.
49:04
And then there are the three in the middle, the maybes. So XDR-TB,
49:08
a particularly nasty strain of extremely drug-resistant TB, I might put them
49:13
in the biocontamnative unit.
49:15
Pneumonic plague, we already talked about, and certain strains of highly pathogenic
49:21
avian influenza, maybe.
49:23
Okay. Now this whole notion of quarantine, um, is, uh, built upon the fact that
49:30
we're going to put you into a situation, um, until your incubation period has passed.
49:38
But the dirty little secret is that if I trust you, uh, for the vast majority
49:44
of diseases, you, we probably don't even need to do that.
49:47
If I can trust you to take your temperature and watch your symptoms and report
49:55
to medical authorities as soon as you become sick, then I don't need to put you in quarantine.
50:00
I can let you go home and go about your lives. And that would be true for Ebola.
50:04
So if I could trust you, if you got exposed to Ebola and I could trust you to
50:08
let me know as soon as you develop the temperature, you don't need to go in a quarantine unit.
50:13
And there really are only very few diseases that become contagious before they're symptomatic.
50:20
And you can see those five here, flu, yellow fever, chickenpox, measles, and COVID-19.
50:26
So those are the diseases where you may feel well, but you could actually be,
50:32
walking around in public spreading the disease. Ebola is not one of those.
50:37
So let's talk about our quarantine unit a little bit. This is outside of the
50:41
Davis Global Center at the University of Nebraska.
50:44
Beautiful building and the quarantine facility occupies one floor of this building.
50:49
The rest of it's training and education center.
50:52
So I ran this quarantine unit and we've activated it three times.
50:56
So the first was in December of 2018 and we had a high risk Ebola exposure.
51:04
And this person was a physician named Patrick. He's given me permission to tell his story.
51:09
He's interesting because he's also been put into quarantine a second time during
51:14
the current Ebola outbreak. He's a Christian missionary working in Democratic Republic of Congo.
51:20
So he was working one day and a woman was wheeled into his clinic in extremis.
51:29
She was delivering a dead fetus.
51:32
She was bleeding all over. He reached out to help her, examined her quickly
51:38
before they realized she probably had Ebola. So he had a very high risk exposure.
51:44
Again, if I trust him, I can let him self-quarantine. I certainly trusted him.
51:49
He was a physician, but there was a lot of political unrest in Congo at the time.
51:55
There were threats made against this Ebola treatment center.
51:58
He was due to come home for rest and relaxation anyway, but he didn't have a
52:02
home to come home to because he lived permanently in the Democratic Republic of Congo.
52:08
So we thought it was best to put him into the federal quarantine unit.
52:13
Incidentally, he was the first person ordered into federal quarantine since
52:18
smallpox roamed the earth in 1963.
52:21
When I say ordered, he came voluntarily. But when I picked him up at the airport,
52:25
we had an order in my back pocket in case he objected to it. He didn't.
52:31
And he never caught his disease and walked out the front door to go back to
52:36
Congo eventually. Then in early.
52:41
February and March of 2020, in the very earliest days,
52:45
of the COVID pandemic, we started to get patients being repatriated from China.
52:52
So in early February, shortly after the pandemic was diagnosed,
52:59
we had a plane flight, a voluntary,
53:03
repatriation of 57 US citizens from Wuhan.
53:08
Our quarantine unit, which had just recently opened, was 20 beds.
53:13
So right out of the gate, we exceeded the capacity of our quarantine unit.
53:18
And so we moved them to a place called Camp Ashland. I'll talk about that in a second.
53:22
And then we got 15 Diamond Princess cruise ship passengers.
53:28
You probably remember the story of the Diamond Princess cruise ship was stuck in a harbor in Tokyo.
53:33
The passengers spent weeks confined to their, uh, staterooms on that cruise
53:40
ship, uh, in the earliest days of the COVID pandemic before a plan was finally
53:45
arranged out to move some of them back to.
53:48
Uh, to the quarantine unit here in the United States.
53:51
And then more recently, and I was not involved with this, but,
53:53
uh, got this information, um, from my colleagues there.
53:58
Uh, we had some of the patients from the MV Hondias cruise ship that were exposed to, um, the COVID.
54:05
Andy Spires. So this is the aircraft that brings them to Omaha.
54:10
We were very, very fortunate when we got these passengers because we had an
54:15
empty DHL warehouse at the airport.
54:19
Just happened to be empty, happened to be in good condition, reasonably clean.
54:23
And so we were able to triage the patients here in this facility and not have
54:28
to take them all to the medical center.
54:30
Again, the first wave exceeded our capability. We were lucky again in that the
54:37
Nebraska National Guard had a facility 20 miles west of Omaha, which was empty.
54:43
They use it for training and there just didn't happen to be a training audience
54:47
there at the time. So we were able to house these patients in the barracks at Camp Ashland.
54:53
Same was not true with the Diamond Princess cruise ship when we got 15 patients.
54:58
From there. So 13 of these patients were actually positive for COVID, SARS-CoV-2.
55:06
Back then, if you'll recall, we didn't know what that meant.
55:08
We didn't know how long a positive test was relevant.
55:15
You know, did that indicate active infection? Did that indicate residual bits
55:21
of DNA that were harmless, et cetera, et cetera? But we had a tiger by the ears.
55:26
Once we had these patients in quarantine, it was going to be difficult to let them go.
55:31
And eight of them remained positive for more than a month, the longest for 43 days.
55:39
The two who were negative were discordant spouses.
55:42
So they had spent a month with their positive spouse in the same room and yet never caught COVID.
55:49
And we still don't know why that is, but we suspect they had some preexisting
55:53
T cell immunity, probably as a result of some coronavirus infection earlier in life.
56:01
So this is what the quarantine unit looks like. It's very unimpressive.
56:05
It looks more like a holiday inn than a hospital facility. Okay.
56:11
So I'm moving ahead quickly because I know I'm running out of time.
56:14
We learned a lot of lessons by putting these 15 Diamond Princess cruise ship
56:18
passengers in the quarantine year. First of all, people rally when they need
56:21
to. These people, it was an honor taking care of them. They were great.
56:26
Note that none of them were children, and I'm a pediatrician.
56:29
It's probably a bad idea for me to take care of them. But again,
56:33
I was more a hotel manager than I was a clinician.
56:35
And anybody that got sick was quickly transferred to my adult infectious disease colleagues.
56:41
We learned a lot about PCR and how it can be too sensitive because we were getting
56:47
positive test results long after these patients were well and ready to go home.
56:54
I say act as if the media are everywhere. They are one of our patients,
56:58
a couple, a husband-wife couple from the cruise ship, actually owned a radio
57:02
station in Santa Clarita, California.
57:05
And they were broadcasting live via their iPad every day from our quarantine
57:09
unit. So that was at first a little unsettling to know that every decision you
57:13
made clinically was being broadcast to the country.
57:17
But we got to be friends with them and it actually turned out pretty well.
57:21
I'll just close by saying, you know, we've talked about isolation.
57:24
We've talked about quarantine.
57:25
There is kind of a gray zone between isolation and quarantine that we call recovery care.
57:31
And that's what leprosaria and sanitaria are.
57:34
And the facility there in the upper left is actually our very own Texas Center
57:40
for Communicable Diseases down on the south side of town. A lot of ethical issues
57:45
obviously raised by quarantine.
57:47
One of my colleagues, Rachel Lookadu at Nebraska, has written a legal and ethics
57:52
reference guide, if any of you are interested. Yeah.
57:57
We also have an isolation and quarantine manual that goes over all the ins and
58:02
outs of isolation and quarantine.
58:04
Happy to send you one of these if you want. Just feel free to email me,
58:08
and I'll be glad to get the book to you.
58:12
So I said in the beginning that there are five criteria we use to decide when
58:16
a patient needs to go into biocontainment. I showed you the first three,
58:20
infectivity, communicability, and hazard.
58:22
Then we talked about the fourth, and that's the presence or absence of countermeasures.
58:26
And then finally, the fifth and final one, is there a heavy metal band named
58:32
after it? So you can see here diphtheria, anthrax, Ebola, and plague.
58:36
Those are all real punk rock bands.
58:39
It was only a matter of time, but there's now a band called Coronavirus.
58:44
And then finally, there's just a generic band called Virus. But I'd heard,
58:48
last I heard, they were actually thinking of changing their name to Andes virus. So there you have it.
58:55
These are some of our Nebraska patients finally getting to go home after 28
58:59
days, leaving at the Omaha airport, not turning back to look at us with the camera.
59:06
But anyway, thanks. Thank you for your attention. I apologize for going up to
59:10
the very, very last minute.
59:12
Okay, thanks, Dr. C. Slack. And thank you guys for attending Grand Rounds today.
59:16
We will resume next week And I appreciate everybody being here Thanks a lot.