Welcome to Stories of Care, a podcast from the American Medical Association and CDC's Project Firstline. In this episode, we are joined by Dr Jonathan Grein, an infectious disease physician at Cedars-Sinai Medical Center, as we consider some of the unique challenges that Ebola poses to health care professionals in the United States and how preparation for this rare but high-consequence event can strengthen responses to all pathogens.
When preparing to care for patients with various infectious diseases, we focus on doing what is right to keep the patients safe. But it's important to point out that those same measures work to keep all health care professionals safe, so they can continue to provide the lifesaving care that patients need.
Megan Srinivas, MD: So Dr Grein, thank you so much. I'm very, very excited to have you on the show and discuss this topic. First off, before we launch into everything that you're doing, can you give us an overall brief overview of what is the Ebola virus?
Jonathan Grein, MD: Sure. And thank you for having me. So, you know, just very briefly, Ebola virus is a part of a family of viruses typically called viral hemorrhagic fevers that can cause really serious and life-threatening infections. It's thought to live primarily in an animal reservoir. Nearly all outbreaks have occurred in Africa, in various parts of Africa. There have been multiple outbreaks identified since the seventies. And it really can cause a progressive illness that, in the more later stages, can lead to critical illness, sometimes bleeding and hemorrhaging from which the name comes from and can have a very high mortality rate.
Srinivas: So with the disease having been around for so long, since the seventies, it really got a lot of traction, more around 2014 when we really started to see it explode on the scene, and there was a lot more media around it. What was it that changed from the seventies to 2014 to even now?
Grein: Right. Well, you know, prior to the 2014 outbreak, you know, there certainly had been dozens of outbreaks reported in various parts of Africa, typically occurring in more rural parts of Africa where, you know, there, there wasn't as much of an opportunity for spread into large urban centers.
It is certainly a disease that can primarily impact caregivers, because of the close, you know, nature of the care that they're providing to patients that may be ill. But you know, prior to 2014, there were some larger outbreaks, but they were able to be contained, without as much international spread.
What we really saw change in 2014 was, that outbreak for a variety of reasons got into urban centers very early. And there was significant more, significantly more transmission and spread of the virus to other countries, and then ultimately in some instances outside of Africa as well. And so that was the, I think the big difference was the presence of the virus in much more urban settings.
Srinivas: It seems like with things like Ebola, things like COVID, there's so much personal risks that people take on when they're trying to decide whether they want to be involved in care or not. Did you find it hard to find a volunteer cohort when you were first setting this up at Cedars Sinai?
Grein: You're absolutely right. When this first began for us at least in 2014, we recognized, you know, fear was a big part of managing the response. And, you know, it's certainly understandable why healthcare workers will be intimidated, potentially scared, by this topic.
But I, I will say, we were so pleasantly surprised to find that as we began to prepare for this and put together an organized response and begin to develop, you know, protocols and a training program, there's a lot of health care workers that are really excited and energized by this work and find it fascinating and are really, you know, once they have some background, some training and get some exposure to this, you know, really are exceptionally motivated to do this work. And so, I think that's really the foundation of our team is we have a volunteer team that volunteers essentially in their off time to come in for additional training.
We put them through kind of an initial training and the periodic refresher training on Ebola PPE, on protocols. And, you know, we just have this wonderful group of health care workers. It's a very diverse group. Nursing-heavy as you might expect, but a diverse group of health care workers that have all volunteered to step up in the event we need to activate.
Srinivas: How did you first start recruiting this group?
Grein: Well, you know, it was a little bit out of necessity at first, right? I think we all recognized that, you know, there was a risk of, and certainly in 2014 as the news came out of Dallas about the first case of transmission to a health care worker. It was really born out of a need that we knew we needed to do something. We knew that we could manage patients safely if we put the right protocols in place and if we have team members that are trained and we can learn from others that have been doing this type of care, either in the field or at some other specialized centers.
And so, I think, to be honest, recruiting for the team particularly initially wasn't that difficult. There were a lot of people that approached us asking if they could participate. And then quite honestly, it, you know, it kind of happened organically and through word of mouth. We didn't have to do a lot of heavy recruitment, as you might expect. Now, you know, I think every center, you know, we're, we participate with the other regional centers across the country. There's now 13 in total. There were 10 for quite a while, and we work through an organization called NETEC (National Emerging Special Pathogens Training and Education Center). That has really helped us because it allows us to network with other people doing the same work. And we've all learned from each other and it's been a great collaboration.
Srinivas: And I know not just Ebola, most recently COVID and then actually monkeypox even after that, there was a whole discussion around, do we let pregnant caregivers, pregnant providers be a part of care? Did you have to face that in Ebola? What was the conversation around that?
Grein: Yeah, these topics were definitely discussed quite a bit. We discussed pregnant health care workers, we discussed trainees. We discussed health care workers that may have immunocompromising condition or impaired skin integrity.
You know, all of these were topics that were of much, you know, much discussion. And, you know, I'll say at the end of the day, it comes down to having confidence in your safety protocols. Knowing that PPE works. And also recruiting people that want to be there and want to do the right thing and work as a team to provide really safe and high level patient care.
I think by having a volunteer process for our team that really helps I think with that cohesion, the safety and that's the approach we've taken.
Srinivas: There aren't that many centers throughout the country. How many of you are there in total?
Grein: Right. So for several years there were 10 regional centers, one for every DHHS region across the country. The concept from a federal perspective was to have regional treatment centers distributed across the country from an equity perspective. Really also making sure that patients anywhere they present could get access to high quality special pathogens care. More recently, just within the last several months, three additional centers have come online. So now there's 13 in total, and I think that's fantastic. And, you know, the more, the more capacity we have as a country to care for these kinds of patients, I think that will bleed over to other benefits as well.
Srinivas: Definitely. Well, it's quite an honor then to have been selected so early on to be a part of such a small cohort. What was the process in getting involved and having Cedars Sinai be selected?
Grein: Yeah, there's, you know, going back to the initial phase where we were applying, you know, it really at the time, it required hospitals to have the capacity to to do the training, to have the supplies available. Importantly, to be able to manage the highly infectious waste that, the high volume of medical waste that comes out of these, the care of these patients. And also, very importantly, having the leadership support from the hospital to do this type of work. You know, we're very fortunate, at Cedars Sinai to have all of those elements. We have just tremendous team members. We have tremendous leadership support. You know, we've got a fantastic collaboration with our public health colleagues and other colleagues outside of our health system that we work with very closely. All of those things really have to line up to have an effective program. We've been very fortunate here.
Srinivas: Have you had to be activated in your role?
Grein: Well, yeah, so I'm very clear to say we have never taken care of a confirmed Ebola patient. So you know, there…
Grein: Knock on wood, yes.
There has not been a confirmed Ebola patient in California, or really on the West coast. And so, you know, to put that out there. But that being said, you know, readiness is crucial. We know there's, you know, major metropolitan hubs here, of course, Los Angeles being one. We have had to activate for a suspect case.
And you know, our example was, this was our first real life activation was in 2019, where there was a health care worker that had returned from an outbreak zone that developed some symptoms. We worked very closely with our health department colleagues, brought the patient in for evaluation and testing.
You know, very happy to say the patient tested negative. It was, however, a really I will say really good experience for our team to, you know, get that first real life activation scenario outside of a training or an exercise. And I, what really struck me about that, when we received that call and we made our, you know, a notification to the team that we needed to activate was how enthusiastic our team members were to respond. It was almost like we've been, you know, almost like people were waiting for something. So it was, it was fantastic. People, you know, stepped right up and said, we're here to help. What can we do? And we were able to, you know, to care for that patient, you know, successfully and safely discharge them home.
But it was just a really wonderful experience to see a lot of that training pay off.
Srinivas: And for those who don't have access to a center immediately in their background, what would you say are the big things that health care workers should keep in mind when they're facing patients, especially with everything else happening? I feel like Ebola has kind of fallen to the back of mind a little bit, but we did have that recent outbreak in Uganda. So what are some things that, that we who don't work in these centers should always think about?
Grein: Yeah, I think the first thing I would say is that, you know, the biggest risk comes to the patient that you don't think about that could have Ebola. So recognition is really first and foremost. And you're right, you know, the risk, unfortunately, the risk to U.S. health care workers for encountering a patient with Ebola is extremely low. But because it's such a low risk, it's not always at the front of people's minds.
The best thing people can do to prepare is to be mindful of what the events are happening in the world and to screen people, particularly people that may be presenting to health care settings with symptoms of an infection. Screening about where they've been, asking about travel history right up front, and identifying people that may be a risk as early as possible, because really the biggest risk in a health care setting is the presentation of the patient for which you don't suspect that they have something like this. And so, you know, the mantra that has been used has been identify, isolate, and inform.
That's a big part of what we do with our emergency department staff is really train that concept of identify people that may be at risk through travel screening upfront, isolating them quickly, and then informing, in our instance, our infection control group that will then work with public health to identify if it's truly somebody that warrants further investigation. So that I think is really where the initial focus should be in terms of preparing for a rare event like this.
Srinivas: And how does it work, if somebody's identified in a smaller town, hundreds of miles from a center, or maybe even further, who knows? How does that work in the care cascade?
Grein: Yeah. And, and this is a lot of the work we do. You know, in terms of collaborating with local and public health, state public health, developing those relationships for transport, working with our EMS colleagues, for example. You know, there's a lot of coordination that goes into this. You can't do any of that without first identifying the patient.
So that identify, isolate, inform is first and foremost. But then through notification of public health, the idea would be, the concept would be that as quickly as possible, to identify a trained transport team that could essentially transport that patient from where they present to a regional center, such as ours or another local regional center, that has the capabilities to care for those patients.
And all of that work requires prompt notification and really strong communication across public health and across the health system as a whole. And that's where a lot of the preparation goes in, kind of in the background, that people don't hear about, I think, in the absence of an outbreak.
Srinivas: How do you make sure that you stay tuned in to what's going on in the sense of making sure that your protocols are up to date, that everybody's kind of ready to go? Do you do practice activations?
Grein: All the time. Yeah. So we do, our team, you know, and actually is a part of our grant for the program, we are required to do four exercises a year, quarterly exercises, in addition to the training we do. We learn so much from those. We really get a lot out of each exercise we do. We also frequently collaborate with other regional centers. We steal heavily from other protocols that we like. We all steal from each other in terms of good ideas and different ways of doing things. And I think that's really encouraged.
We also work with other local hospitals that aren't necessarily regional treatment centers, but also many hospitals have maintained some level of preparedness for this, for at least a temporary activation. And so a lot of the work we do, you know, particularly here in LA County, is collaborating with our wonderful colleagues that we do exercises with them as well. And, you know, things, for example, is transporting a patient between hospitals, or even just tabletop exercises where we'll go through communicating various things. So that's all an important part of this, of this readiness.
Srinivas: And with what you were saying, just in the sense of where Ebola has been, the fact that we're doing well now, fingers crossed, no current outbreaks. What is the discussion around the future of Ebola? Is there a concern that it'll evolve further, become more virulent, change in the way that it presents?
Grein: Yeah. That's the million dollar question, isn't it? I don't know that anyone knows. I think as we've seen over the last decade or more, we don't anticipate Ebola or these other viral hemorrhagic fevers going away. If anything, outbreaks have perhaps become more, more frequent. We've seen some larger outbreaks. For example, the Uganda outbreak recently, a fairly large outbreak. Of course there was the West African outbreak that was massive. You know, the outbreaks aren't going to go away. And, also, international travel is only expanding.
So the reality is, whether we like it or not, we need to maintain a level of preparedness, not just for viral hemorrhagic fevers like Ebola, but for other emerging pathogens. So this type of preparation we think is really critical from a health system perspective, from a health security perspective. And I will say, I think we've seen some of the benefits of the preparation for Ebola and how that translated to COVID response as well as more recently the mpox outbreak, that we've recently had. A lot of the protocols that we developed for Ebola were adapted to manage these other outbreaks.
And so, you know, I think sometimes people wonder why do we put so much effort in preparing for Ebola. And I always say, if you can prepare yourself and your hospital for Ebola, you can prepare yourself for just about anything. And I think we definitely saw the benefits of that with our initial response to COVID and to mpox.
Srinivas: One of the things that we often see talking about kind of our response to COVID as well as mpox, is some of the issues that arise in geographic inequities as far as resource distribution, and honestly even specialist distribution. If you don't have exposure to someone who's ever discussed this topic with you, it's kind of hard for many people to even identify it. What are some of the things that, that you're facing in Ebola preparation regarding those inequities?
Grein: Well, I think you're right, that the challenges are a patient with a disease like this can really present anywhere. And how do you provide the same level of care for a patient presenting in a, for example, a more rural setting than might perhaps present in a setting with more resources. And, you know, that is the ongoing challenge.
It's something that we can utilize some of the tools we've learned through COVID to help us with through telemedicine and other things that I think we've all gotten much more comfortable with. But you're absolutely right that that is an area of ongoing focus in terms of how can we make sure, you know, a patient presenting anywhere can get access to high level care as quickly as possible. And getting them into a treatment center as quickly as possible is really a top priority for us. So, you know, that's an ongoing challenge, and an area of a lot of work at the moment.
Srinivas: Have you seen any solutions? You mentioned telehealth. Has telehealth been really applied to this aspect of potential Ebola preparation for smaller rural areas as much?
Grein: Yeah. Well, telehealth is a big part of our, even just internally with our program, a big part of our response. So, you know, we take a lot of measures to minimize the number of people, for example, that's in the room with the patient.
So telehealth has been incorporated into our protocols really from the beginning. And I think the idea would be in the event of an activation, outside of our setting, that absolutely telehealth would be a big component of at least that initial care until we can get that patient transported to an area that may have the resources to manage them.
Srinivas: Other solutions that you've been seeing applied to this, this problem so far?
Grein: I think there's a lot of work now at the federal level looking at a national special pathogens system of care. And really trying to move beyond Ebola readiness specifically and more to special pathogens readiness more generally across the country. And developing a more tiered response to caring for patients that have a wide variety of special pathogens. So that work is underway, to really have a more sustainable approach that's not disease-specific that will provide that broader safety net across the health system.
Srinivas: That's really exciting to hear about. One thing that I had talked about with a previous guest when we were discussing some of the other special pathogens happening in the U.S., not Ebola, was just how sometimes we focus so much on those giving direct care that we forget about people like the environmental services and the exposures that they may have. Has there been a special focus in ensuring that we also include them, in protecting them and how they can also help with care of these patients?
Grein: Oh yeah. Absolutely. And I'll say that our, the team members, part of our volunteer team, are across multiple specialties. And so we involve, it's not just nurses, not just physicians, it's our respiratory therapists. It's our imaging staff. We do have a component of our environmental services staff as well, that all go through the same training, that are all a part of this volunteer team to care for these patients. And so, yeah, absolutely. I think it really does take a village. I've always said that having a special pathogens program is essentially like building a hospital within a hospital. And that, that's kind of what it is.
Our approach is to section off a portion of our hospital, provide some privacy barriers, and then essentially set up a care area and a lab that are really completely separated from the rest of the hospital. You know, that is kind of, in order to do that, you've got to have your laboratory technicians, you've got to have your, you know, all your subspecialists, all kind of ready to go in that area. And that's kind of what that looks like.
Srinivas: Wow. And where do you see this, this protocol development going in the future, especially with the broadening up to all special pathogens? Do you see you guys expanding your efforts to a broader sense of diseases?
Grein: Yeah, I think there's certainly an effort for outreach and to engage really essentially all hospitals, all health care systems in at least some level of preparedness. We saw that recently with the Uganda outbreak, is that there's a need to go out and remind people of some of the protocols that may have been put into place back in 2014 that have gotten dusty now on the back shelf. It was a reminder that we have to maintain some level of preparedness and every hospital has to, you know, be prepared to, as we said at the beginning, identify, isolate, and inform. Have at least some basic protocols in place. At least have a plan in place so that, you know, if this happens at two in the morning on a Saturday, as it may, that you know, at least we know where to go. We know where to start. We know who to call.
Srinivas: That's awesome. And I have to say, one of my friends, but when I told him I was doing this episode with you to discuss Ebola, he said to me, isn't Ebola gone? Why are we even worried about it? So maybe one message from you on why do we need to be ready and have this preparation done ahead of time for special pathogens in general?
Grein: Yeah. And, you know, unfortunately as we've seen over the last few years, with Ebola, with COVID, with mpox. You know, emergence of these high consequence infections, for lack of a better term is going to be with us for some time.
We're going to need to, as a health system, as a health system across the country, be prepared for these emerging kinds of threats. And they can catch us off guard. So, you know, as I said before, when you prepare yourself for Ebola, you really are providing yourself a buffer against a wide variety of potential threats.
You can tailor your Ebola plans for other emerging pathogens. And I think the message I would have is that special pathogens preparedness remains critical. It is true that this may be a rare event for many hospitals, but it's a rare event with high consequence. And so, by preparing for, using Ebola as one example, you're also strengthening your response to things that we don't even know about yet.
And I think that's really the key message in terms of why this is important.
You know, that being said, preparation is key. What's the saying, an announce of prevention's worth a pound of cure? And it's really true in the world of special pathogens preparedness that having a plan, training with a team, walking through these protocols in advance, takes you so far.
Because people feel comfortable with the protocols, they feel safe. And when people feel safe, that's when they can provide high quality care. And at the end of the day, we have patients to take care of. And I think one thing that's easy to forget, as you're planning and and caring for patients with Ebola or what have you, is that, you know, those patients are likely just as scared as everyone else, and they're people as well. And, and we've got to make sure we're doing the best for them as well as keeping ourselves safe. And you have to keep that perspective in mind.
Srinivas: Any final messages you want to give to our audience about equity and preparing for illnesses that we need to, to be safeguarded for the future?
Grein: You know, the world is a big place, but it's getting smaller every day. We see, you know, and now as things have opened up through the pandemic, we're seeing travel really returning. We see, we're seeing, there's the potential for additional emergence of other things that we need to be able to pivot to and respond to quickly.
And so, you know, maintaining that awareness of what's happening in our world, maintaining some level of readiness that you can respond to something that may show up unexpectedly remains just as important as ever. And I think we can use those skills that we've learned from that effort and apply it to other challenges that we're seeing and, be it COVID or mpox, we, you know, we are much better prepared when we have that preparation in place.
Srinivas: Thank you so much Dr Grein. Your insights are so invaluable. As much as I hope we didn't need to use them, I think we will eventually. So it's great to have you share your wisdom and your experience.
Grein: I really appreciate the time and I hope this was helpful and thank you for having me.
CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
If applicable, all relevant financial relationships have been mitigated.