Poorly understood emerging diseases, especially lethal ones such as Ebola, can place unusual stresses on clinical caregivers, especially if they are not fully prepared. The University of Chicago Medicine has a real advantage as US hospitals continue to prepare for potential cases. In 2009, the institution opened the Howard T. Ricketts Laboratory at Argonne National Laboratory. Ricketts was designed and built to study organisms that cause infectious disease. Teams in the laboratory develop and test drugs, vaccines and diagnostic devices to counter bioterrorism and study pathogenic microorganisms, including emerging pathogens. A primary focus in designing and building the laboratory was safety.
Science Life spoke with the University’s vice president for research safety, Joseph Kanabrocki, PhD, professor of microbiology, the biological safety officer for the University, and director of the biosafety programs at Ricketts. Kanabrocki is a member of the National Science Advisory Board for Biosecurity, chair of the Biological Safety Examination Board for the American Society for Microbiology National Registry of Microbiologists and a former member of the Recombinant DNA Advisory Committee (RAC) and the Scientific Advisory Board for National Biosafety and Biocontainment Training Program for the National Institutes of Health.
In a situation like this, what does a biosafety office do?
The first step is to identify the potential risks. The next step is to figure out how to mitigate those risks. Then we train people to execute that.
That sounds simple and straightforward in theory. How does it work in practice?
This is biology; it is dynamic and there is always complexity, variation, diversity. People imagine biosafety as being all about compliance and rigorous enforcement of standard rules, but one of the things I find exciting about this specialty is that nothing is standard. You almost never see two identical situations. You have to look carefully, be precise how you assess the challenges and address real risks. Only then can you think through the whole process and come up with a sensible, systematic approach. Enforcement follows.
Was that what happened when you were asked to help prepare our volunteer caregivers for potential Ebola cases?
Not quite. It’s never that neat. At first we were asked, “Just give us the Ricketts SOPs.” Our team handles many select agents, such as the bacteria that cause anthrax and the bubonic plague. It’s true that our Standard Operating Procedures provide a great place to start, but every situation is unique. In this case it involved adapting techniques established and tested in a carefully controlled laboratory setting to a clinical environment, with actual patients. That’s very different.
How long does that take?
It took us almost two weeks to simply modify the written procedures we use at Ricketts to draft a written procedure to be used in a clinical isolation ward. Then, when you analyze any system, and start to test it, you always find something that needs to be modified. We were thoughtful about where we started and meticulous about finding possible problems and making improvements. Our processes are pretty well honed at this point, but it has taken more than a month of dedicated teamwork to get to this point. We believe that we are further along than most places.
So, you are done here?
Well, no. Even though we are weeks into this exercise our SOPs are still living documents. That’s how it should be. No one has more experience with high-containment work than the Centers for Disease Control and Prevention, and just like ours, their Ebola-care SOPs are all marked “Interim.” That likely won’t change.
How do the lab culture and the clinical medicine culture fit together?
At first I had the sense that at least some people on the clinical side were a little uncertain about how we could help. The general opinion was that application of standard, established infection-control practices would be sufficient. But as we worked together, mutual respect emerged. Each team brought different talents and backgrounds. The Dallas experience may have sped that up.
How does dealing with patients differ from the laboratory setting?
A research laboratory, such as the BSL3 labs at Ricketts, is a highly controlled environment. A clinical situation is less controlled. When you introduce something like Ebola, where you are trying safely to care for people who may be delirious, angry, upset, frightened and suffering from a disease that causes massive fluid loss—the words projectile and explosive often come up here—then biosafety becomes orders of magnitude more difficult, and more crucial. Having these basic biosafety techniques and activities nailed down in advance is really important. That allows the caregiver team to think about providing clinical care and not to worry about their safety.
Does practice matter?
It’s huge. People should practice as much as possible, even seemingly simple things like donning and doffing the protective equipment. There are multiple steps; they have to be done in a certain way and in the correct order. The more you practice that routine, the more accustomed you get, the more it becomes part of muscle memory. Solid established habits are big advantage.
What else is important?
One subtle thing is having a buddy. We do that at Ricketts and we’ve adopted that here. In the isolation environment we have one physician, two nurses and one observer, an infection-control practitioner. We use two nurses so that they always have a buddy, one person enters the patient’s room and the other one helps out with supplies and specimens, and monitor safety issues, especially when they take off their protective gear. That concept came from the laboratory and is critical. It’s one of the things that the CDC recommends as well.
How does the animal-care facility here play into this?
As I have already said, the lab is a highly controlled environment. When you introduce animals into the equation, the situation is instantly more complex. We learned how to move the agent around, perform animal care, clean spills and dispose of waste, amongst many other relevant lessons.
The BSD animal facilities also bring resources. One of our veterinarians, Lois Zitzow, DVM, is a key crossover player. She is a skilled professional in animal health and care as well as in biocontainment practices and principles, but she also knows how to do clinical procedures—everything from installing a central line to surgery.
This unique skill set brings an added component to our training. Most hospitals that are preparing for an Ebola patient train on the fundamentals, things like basic biosafety, PPE donning and doffing, cleaning up spills, movement and packaging of waste. That’s day one of our two-day training program. Lois is central to day two, which focuses on clinical care, in containment, with full PPE. That’s something that I don’t think anyone else is getting, anywhere else in the country.
What surprised you about working with the clinical teams?
I was surprised by how new some of our processes were to clinical staff, except for those who specialize in infectious disease. It appears that there’s a pretty wide gap between the way we train scientists for research and clinicians for patient care. Before training, for example, we noticed in some a lack of sharps awareness, a critical and basic concept. People get used to something, even HIV, and become overly familiar. There is greater awareness now. At this point, knock on wood, no one is overly familiar with Ebola.
Have we gotten better as a result?
The way the medical center pulled together for this has been remarkable. People recognized that this was important and that they had a role. It’s been a pleasure to see how people consistently stepped up.
At first, the dogma was that every American hospital had the skills and the equipment to take care of an Ebola patient. Has that changed?
In principle, that’s true, but the Dallas experience put everyone on alert that it may not be entirely true in practice. One problem is that few hospitals have been trained on this level of clinical care and none have really practiced. We have. And we had a successful and informative trial run with a suspected patient in October; the patient ultimately tested negative, which was an ideal way to test the system.
Do different institutions choose different approaches to personal protective equipment?
There are a variety of approaches. There’s no one right way to go. Most of the PPE that we’ve chosen was based on our experience at Ricketts, where we’ve tested the different equipment for years. For head gear, we’ve chosen to wear PAPRs—powered air purifying respirators. They make it easier to breathe. Air is pumped in. You can work a lot longer with a PAPR than a negative-pressure respirator. They are much more comfortable, although more expensive.
What does a typical set of PPE cost?
One set of gear costs somewhere around $750, less than $1000. Most of that expense is attributed to the PAPR, which costs about $600; those get re-used. We buy the Tyvek suits and the other pieces in bulk. (It would have been a good idea to invest in Tyvek a couple months ago.) We’ve been using the PAPRs at Ricketts for years.
Those look kind of awkward. How comfortable are they?
Not bad. The only real problem is the noise. The motor is in the helmet, which makes it difficult to hear your colleagues. It may be a little top heavy, too, but you can adjust it to fit your head. But, yes, if you are inside one, they are noisy.
What if we never see a real Ebola patient? What will we have gained from this effort?
I think that by focusing our clinical care from a biosafety, infectious-disease perspective, we are finding little things we can improve. The people we train suggest imaginative ways to apply these techniques to patient care involving common pathogens, those that we see all the time. It’s being appreciated, understood and valued.
What part of our Ebola preparations and response are you most proud of?
I’m proud of all of my staff. Their efforts toward planning and developing procedures and training activities, which are led by John Bivona, have been invaluable. The way they have been calmly committed to this, putting aside what they were working on yet keeping those balls in the air, while focusing on Ebola preparedness. It’s been a juggling act.
I’m proud of the way the all the teams, laboratory staff and clinical staff and volunteers have worked together and put aside fiefdoms. Mutual respect has blossomed, all the way around. The laboratory team has been impressed by the nurses. How dedicated they are. How quickly they assimilated new practices and mastered the PPE. They’ve even made suggestions based on their extensive clinical experience, things we hadn’t thought of: for example, what’s the gentlest and safest way to turn a patient? That sounds trivial, but with an Ebola patient, that’s a high-risk situation.
I’m also proud of how medical center leadership has made this a priority, recognizing our responsibility to the city and to the public health of the community. They’ve made it possible. Think of all the staff time and all the PPE we’ve gone through just in training.
What upsets you, keeps you up at night?
You would think that a high-containment laboratory, like the Ricketts Lab, or a high-intensity clinical setting, like an Ebola isolation unit, would be my biggest worry. But those are staffed by a limited number of trained, capable, focused people, whom we now know personally. It’s not that difficult, with first-rate people, to get such a team to a consistently high level.
It’s the lower-containment settings, with less apparent risk, that leave me dyspeptic. Places where people may not fully appreciate the risks. A colleague points out that if you exclude major maritime catastrophes, like the Titanic hitting an iceberg, then the vast majority of people who drown manage to do so in shallow water. They aren’t paying attention. They don’t swim, but since they are in shallow water, no one is watching. Then they make a mistake.
I should note that we’ve had no trouble finding solid, capable volunteers willing to care for patients with Ebola. There’s something noble about that. And believe me, they focus. They pay attention. When they are donning their protective equipment, they do it with reverence. They go in, do their thing in a thoughtful, compassionate, attentive way, then come out. They take off the gear with even greater care, under the guidance of a designated buddy. They may not all be completely comfortable yet, which is fine, but they are focused. They are on their toes.
Why is our biocontainment facility called Ricketts?
The Ricketts Laboratory was named for the University of Chicago’s Howard Taylor Ricketts (1871-1910), who discovered the organism that causes Rocky Mountain spotted fever. He also discovered the organism that causes typhus—which killed him. There’s a lesson there.
Well, that’s motivating. Any final piece of advice?
For managers: when people work in a stressful or potentially hazardous setting day after day, they should be able—every once in a while—to say “You know what? I’m just not on my game today. I don’t think I should go in.” And that should be permitted, even encouraged. There’s always something else that may need attention.