Perspectives on the Management of Children in a Biocontainment Unit: Report of the NETEC Pediatric Workgroup
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During the outbreak of Ebola virus disease that struck West Africa during 2014-2016, a small handful of expatriate patients were evacuated to specialized high-level containment care units, or biocontainment units, in the United States and Western Europe. Given the lower mortality rate (18% versus 40% for those treated in Africa) among these patients, it is likely that high-level containment care will be used in the future with increasing frequency. It is also likely that children infected with Ebola and other highly hazardous communicable diseases will someday require such care. The National Ebola Training and Education Center convened a pediatric workgroup to consider the unique and problematic issues posed by these potential child patients. We report here the results of those discussions.
It is likely that high-level containment care will be used in the future with increasing frequency and that children infected with Ebola and other highly hazardous communicable diseases will someday require such care. The National Ebola Training and Education Center convened a pediatric workgroup to consider the unique and problematic issues posed by these potential child patients.
High-level containment care, often referred to as biocontainment, can be differentiated from traditional means of hospital infection prevention and control by its use of a broad array of administrative and engineering controls and security measures, as well as by the use of unique staffing models, specialized training, specific waste handling procedures, robust personal protective equipment ensembles, and myriad other safety features not typically found in “conventional” isolation settings.
An evolving appreciation of the need for specialized high-level containment care capability has taken place over the past several decades, and efforts to construct dedicated high-level containment care units trace their beginnings to a confluence of events in 1969. Among these events was the first lunar landing, which, because of concern for the potential importation of microbes from space, prompted the construction of the first biocontainment units at the Johnson Manned Spaceflight Center in Houston and at a military facility at Fort Detrick, MD. These efforts ultimately led to the opening of civilian high-level containment care units at Emory University and the University of Nebraska. The wisdom of employing such units in the management of patients infected with highly hazardous special pathogens was validated during the 2014-2016 outbreak of Ebola virus disease (EVD), when expatriate patients were evacuated from West Africa and successfully cared for in these 2 facilities, while additional patients were successfully managed at New York City Health and Hospitals–Bellevue and at the National Institutes of Health in units adapted to provide high-level containment care.
In response to the 2014-2016 Ebola outbreak, the Department of Health and Human Services' (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) and the Centers for Disease Control and Prevention (CDC) funded the development of the National Ebola Training and Education Center (NETEC) with the goal of improving the national capacity and capability for managing patients infected with Ebola and other special pathogens. As a component of this effort, CDC and ASPR developed a 3-tiered system of hospitals designed to care for patients with certain highly hazardous communicable diseases. Under this system, high-level containment care capability would be developed in tertiary care facilities known as Ebola treatment centers (ETCs). Approximately 55 facilities initially applied for such designation and funding; among them are 10 categorized as regional referral centers by HHS (1 in each of its 10 geographic regions).
Although no pediatric patients with confirmed EVD were cared for in high-level containment care units in the United States, children did constitute 18% of EVD patients in Guinea during the 2014-2016 outbreak, and high-level containment care units must be prepared to care for pediatric patients in the future. In addition, at least 89 children were evaluated in the United States for possible EVD during the first 6 months of the outbreak.6 Planning for the provision of such care, however, presents some significant challenges, with the question of parental presence at the bedside of an ill child among the most problematic. The American Academy of Pediatrics (AAP) recently addressed this issue,7 providing guidance applicable to the initial evaluation of a symptomatic child, as well as to the inpatient care of a child with confirmed or suspected infection (person under investigation, or PUI). While the authors of this guidance concluded that “the optimal way to minimize risk is to limit contact,”some allowed for parental presence under certain circumstances, recommending that parents (or other caregivers) should be evaluated for their ability to “follow instructions” (eg, regarding donning and doffing of personal protective equipment) and advocating for the exclusion of parents at increased risk for poor outcomes (such as pregnant women).
Despite the AAP guidance, parental presence remains a controversial issue among biocontainment experts and high-level containment care personnel, with many stating that they would prohibit the entry of parents into a high-level containment care unit under nearly all circumstances. Others, however, have raised the possibility of altering this exclusionary approach based on the infectious agent in question, the clinical status of the child (“wet,” or patients with significant vomiting, diarrhea, or hemorrhage, versus “dry”), their age or developmental status, and other factors.
Beyond the issue of parental presence, several other vexing issues confront high-level containment care units preparing for the eventuality of pediatric patients. Among these are concerns about breastfeeding, cohorting (ie, permitting infected children to room with their infected parents or siblings), staffing and support, and school and social reintegration. In this article, we attempt to advance the work of the AAP and others and further our understanding regarding these challenging issues. The scope of this document is limited to children with proven infections caused by special pathogens who are cared for in high-level containment care units; the guidance published herein is not intended to apply to persons under investigation at emergency departments, primary care clinics, or other assessment facilities.