How to Discuss Ebola and Enterovirus with your Patients

steve_alder2 by Steve Alder

The continued emergence and reemergence of infectious diseases is in stark contrast to the optimism that existed a few decades ago as we saw great leaps forward in our preventive and therapeutic measures against the morbidity and mortality caused by these agents.  2014 is turning out to be a banner year for infectious diseases as headlines alternate between Ebola (or formally, Ebola virus disease [EVD] and the associated Ebola hemorrhagic fever [EHF]) and Enterovirus D68 (or EV-D68) – however, the memories of recent global outbreaks such as Sudden Acute Respiratory Syndrome (SARS) and H1N1 influenza remain fresh.

A primary public health and primary care challenge with these headlining infections is misperceptions held by the general public regarding their true nature.  For instance, the strain of Ebola circulating in Guinea, Liberia, and Sierra Leone is highly preventable given that it remains transmissible only by direct contact with the bodily fluids of infected individuals rather then through airborne mechanisms.  However, once contracted, the resulting disease comes with a high probability of mortality.  Enterovirus D68 is also highly contagious and is linked to severe respiratory challenges yet does not have the lethality of Ebola.

When assessing risk, the concept of virulence may be confused with infectiousness.  Clarifying in simple terms the nature of the organism that causes the disease, including its type, how it is detected, how infection can be prevented and how to determine if seeking care (for either diagnosis or treatment) is needed.  A few years ago, I led a study that looked at the issue of overprescribing of antibiotics to children with respiratory illness.  One of the primary reasons reported for overprescribing was that parents felt insecure, so were seeking something they felt they could count on to help their child feel better.  An effective ‘antidote’ to antibiotic seeking was improving communication – however, we focused communication interventions exclusively on parents of these patients.  We found that if parents had the answers to 4 simple questions, they felt much better about the interaction with their child’s provider and their expectation of antibiotics was also reduced.  The questions, adapted from other research, included:

  1. What is causing my child’s illness?
  2. How long will it last?
  3. What can I do at home to help my child feel better?
  4. How do I contact you [my provider] if they don’t start feeling better?

What was remarkable from this study was that many providers felt they were (and in cases where we checked, actually were) providing answers to these questions in the course of the clinic visit, yet the parents of these patients were not receiving the communication.  However, when the parents were given a short training and practice session on asking these questions, then were able to initiate them in the course of the interaction with their child’s provider, they were able to receive these messages much more effectively.

Currently, it appears that the spread of both EVD and EV-D68 is continuing to accelerate.  Exacerbating the concerns about these diseases is the impressiveness of the experience of those infected – such as the bleeding consistent with hemorrhagic fever or the severely challenged breathing associated with respiratory distress.  Principles of risk communication suggest that the most effective ways to help people get a realistic sense of their true vulnerability is to:

Provide factual information that is at a level of sophistication appropriate for the audience.

  1. Be realistic and blunt about the actual risk and anticipated consequences.
  2. Clearly communicate what information is currently unknown, and provide an estimate of when that information will be available.
  3. Provide sources for reliable information (such as the CDC website http://www.cdc.gov/) that will also be updated as more information is available.

And finally – it is always helpful to provide clear, direct guidance on specific behaviors that will reduce the chance for acquiring the infection and similarly clear behavioral guidance on what to do if the infection is acquired.   Helping people know what they can do is reassuring.

The greatest capacity we have to address these emerging infections often is through effective public health and primary care measures.  With the dynamics of healthcare transformation motivating more integration of these two health fields, our capacity to prevent the diseases caused by these old and new nemeses and to catch them early if they are acquired is expanding.  One only needs to look to the current Ebola outbreak to recognize the kind of costs that can be avoided as we become more effective and adept at detecting and stopping these outbreaks.

Steve Alder, Ph.D. is the Chief of the Public Health Division within the Department of Family and Preventive Medicine at the University of Utah.

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