Hospitals as the epicenters of infectious disease outbreaks

You probably shouldn’t be surprised that a hospital would be the epicenter of an outbreak of an infectious disease. After all, hospitals are where people who are really sick go to. Things like influenza, MERS, or multi-drug resistant bacterial infections make you very sick, so you need to go to a hospital. Working in the hospitals are healthy people with lives outside the hospital. Between hospital employees and visitors of the sick people, really infectious diseases are hard to contain.

Still, containment is not impossible. There are plenty of rules to follow in order to keep the staff and visitors to hospitals safe from infectious diseases, but those rules need to be followed by people. People are fallible.

Take, for example, what recently happened in South Korea. A man who had traveled to the Middle East returned to Seoul and started to feel sick. He went to a hospital to seek care and was sent home with a diagnosis of a viral syndrome. He didn’t feel better, so he went to another hospital. They also sent him home. By the time someone figured out that he was really, really sick and asked him for his travel history, it was too late. He had already infected others at the other hospitals. There were over 180 cases and over 30 deaths. The outbreak is waning, but it is not over.

A hospital in Seoul, South Korea. (I'm not implying this hospital was involved in the outbreak. It's just for illustrative purposes.)
A hospital in Seoul, South Korea. (I’m not implying this hospital was involved in the outbreak. It’s just for illustrative purposes.)

Now, there is another outbreak of MERS, this time in Saudi Arabia. There, like in Korea, a hospital has been shown to be the “epicenter” of the outbreak:

“Peter Ben Embarek, PhD, who leads the WHO’s MERS response, told CIDRAP News that the vast majority of recent and current cases are related to one hospital, a national guard hospital in Riyadh. He added that there is a small outbreak at another hospital involving five cases, as well as sporadic cases not linked to the main hospital.

Ben Embarek said the smaller hospital outbreak is under control.

King Abdulaziz Medical City has about 690 beds and was established in 1983 to care for National Guard soldiers and their families. The government-funded hospital was combined with many other medical centers and inaugurated as a “medical city” in 2001.”

Last year, during the height of the Ebola panic in the United States, a man by the name of Thomas Eric Duncan was sent home with a diagnosis of a viral syndrome even though he had been in an Ebola-affected country and had symptoms of a viral infection. He would later return to that hospital and, sadly, die a few days later. The hospital officials say that Mr. Duncan was asked if he head been in Africa, which he answered in the affirmative. But, for some reason, no one told his attending physician that. At least that’s the story.

Then we have the numerous other stories of other cases of infectious diseases like measles and tuberculosis kicking off outbreaks at hospitals. The reasons why this happens are clear and preventable. The right questions are not asked, or, if they are asked, the information is not passed on to the right people. Even worse, the person may not want to answer a question out of fear. (Just look at how a nurse was treated by the government of the State of New Jersey when she was isolated in less than humane conditions.) If that is the response a person is going to get, it’s no wonder that they would be dishonest in their answers to questions.

We can train hospital staff every which way we can and equip them with millions of dollars worth of technology, but hospitals will continue to be the epicenters of these things because the systems we have put in depend heavily on human interaction. We can tell triage nurses to ask questions, but that requires them to remember to ask the question on top of everything else they have to do and that the patient answer the questions truthfully on top of all the worries about their illness. (Of course, there can and will be patients who are too sick to answer the questions.)

We can also give guidance to providers on how to screen for infectious disease, and what to do when they find a candidate for isolation. But that requires them to be astute enough to ask those questions and order those lab tests. Again, the plan requires humans to be at their best. When that fails, no amount of isolation technology can save us. Even when the plan has tried to take humans out of the equation, humans find a way to muck it up.

For example, in order to contain influenza outbreaks inside and outside of hospitals, many hospitals are requiring their employees to be vaccinated against influenza on a yearly basis. Some hospitals are going as far as to terminate non-complying employees. But there have been legal challenges to these terminations, and some state legislations are being pressured into “protecting” non-complying healthcare workers. Other workers, as I and others have seen in online discussion groups, have considered falsifying vaccination records. (Silly humans, right?)

The list goes on and on of how human nature gets the best of us and leads to hospitals becoming the source of an outbreak. Healthcare providers may find personal protective equipment (PPE) too cumbersome to use. Non-providers — like clerks and housekeeping staff — may not fall within the plan for containment of such diseases.

When I was working at an urgent care center, I got to see some technology that made me think about way to prevent these things from happening. In the particular center where I worked, patients would come in and register through a touch-screen computer at the front desk. The system would ask them for basic information. I was thinking that such systems could be used to make sure that all the questions are being asked based on the patients’ chief complaints. Modern technology is allowing us to better communicate with computers. I imagine a system that allows a patient to enter a description of their signs and symptoms and for the system to accurately ask all pertinent questions. Then, once the patient is being seen by a provider, the same system would prompt the provider to make sure that all questions are asked, answered, and that the proper laboratory analyses are ordered and done. There is still a human factor in there, but it is backed up by an automated system. Of course, the flip side to automated systems is that they may not be able to think on their own and respond to things as they happen.

All around the world, hospitals are the places where we go to try and get relief from what ails us. Unfortunately, in the United States and in many other parts of the world, hospitals are filled to the limit with people seeking one form or another of care. In that mass of humanity, someone with an infectious disease can go and sit and be unrecognized for enough time to infect many people and get an outbreak going. It has happened in the past with measles and other vaccine-preventable diseases in the era before vaccines. Today, it happens with emerging infections like SARS, MERS, and the resistant bacteria. Even well-known diseases like influenza can gain a foothold on a population if they are allowed to enter and spread in a hospital.

We have technology today that can help us prevent all this, but there is always going to be one big loophole in all our automated systems: human nature. Good luck finding a solution for that one.

I'm a doctoral candidate in the Doctor of Public Health program at the Johns Hopkins University Bloomberg School of Public Health. All opinions posted here are my own, of course, and they do not necessarily reflect the opinions of my school, employers, friends, family, etc. Feel free to follow me on Twitter: @EpiRen

3 thoughts on “Hospitals as the epicenters of infectious disease outbreaks

  1. The touchscreen idea has merit in a good way and a deleterious way.
    The good way is, as you described, patient enters their information, symptoms, travel history, etc and that helps the physician by collecting that information in advance.
    On the deleterious side, a patient has an illness, for this thought exercise, norovirus. Now, the touchscreen is a data collection tool and a fomite.
    Even with a disinfection policy, barrier protection with screen covers that are changed between patients, etc, the human factor remains. One forgotten disinfection, disease spreads.
    Of course, the furniture in the waiting area, door knobs, push plates, etc are also fomites in any facility and nearly impossible to keep disinfected for any realistic amount of time.
    Which is why I chose norovirus, a virus so infectious that many a medical facility was closed to the public and new patients until the virus was brought under control.

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    • Well, the kiosk would be cleaned after each patient by a hard-working immigrant lady in full PPE. You’re right about Noro. That bastard is infectious as I’ll get out.

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      • As I recall, it’s somewhere around 6 – 8 viral particles result in infection with Noro. Thankfully, it’s largely a self-limiting illness. Want nightmares? Think of more virulent influenza strains being that infectious and durable.

        Oh, the other day, I read a notice in the PROMED list about the ebola vaccine. 100% efficacy for those receiving VSV-EBOV, using rink vaccination. Those who received it on a delayed, random fashion did not fare very well, resulting in dropping the random portion and going 100% of those at risk.
        Hopefully, protection will be smoothly be ramped up.

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