Engineering vs. Ebola
The work of engineers is vital in the fight against Ebola and general infection control.
BY MATTHEW McLAUGHLIN
The current outbreak of Ebola in West Africa is the largest and most complex since the virus’s discovery almost 40 years ago. Already it has killed more people than all other Ebola outbreaks combined, according to the World Health Organization.
The magnitude of the outbreak has been attributed to a lack of resources in the countries most affected—Guinea, Sierra Leone, and Liberia. This includes medical professionals but also many other human and infrastructure resources.
“We know there is a major shortage of doctors and nurses available to respond to the growing Ebola crisis in West Africa and we are urgently recruiting for these roles, but doctors alone won’t bring this crisis under control,” says Kevin Noone, International Medical Corps Executive Director for the UK. “The main risk we see undermining our efforts to bring the outbreak under control is a shortage of water and sanitation experts capable of training local staff and volunteers how to maintain clean, sterile conditions, and engineers capable of building the facilities in the first place. These [facilities] are the front line in our battle against Ebola.”
While it may be taken for granted in many countries, including the US, good engineering is an invaluable part of infection control, regardless of the contagion. In their article “Engineering Infection Control through Facility Design,” published in the Centers for Disease Control’s Emerging Infectious Diseases journal more than a decade before the current Ebola outbreak, Doctors Gary Noskin and Lance Peterson explore how health-care facility design can greatly influence infection control.
For example, including adequate access to clean water in a design may seem simple, but it’s extremely important for controlling infection in health-care facilities and isn’t necessarily the standard throughout the world. “Hand washing is the single most important method to prevent hospital infections,” Noskin and Peterson write. “Each patient room, examination room, and procedure room needs at least one sink.”
Engineering is so important in the fight against Ebola that even the World Food Program has been sending its engineers to design Ebola treatment units at the request of West African governments and the World Health Organization, a fellow United Nations agency. In October, the WFP built treatment units at two different sites in the Liberian capital of Monrovia capable of accommodating 400 patients.
The US Army Corps of Engineers also joined the fight against Ebola in October, when it deployed the main body of the Europe District’s Forward Engineer Support Team-Advanced (FEST-A) to the Liberian capital. The 13-member team includes two PEs and four EITs and will support the construction of multiple Ebola treatment units at locations chosen by Liberia’s Ministry of Health and armed forces. The team will also assist with the planning, surveying, and design of life-support and logistics facilities at base camps in both Senegal and Liberia for US, Liberian, and humanitarian workers coordinating virus-containment measures.
The FEST-A mobilization took just a few weeks, but all team members engaged in a series of medical checks, immunizations, individual training sessions, and team exercises to gain certification for the deployment.
“We’re as prepared as we can be,” says Maj. Michelle Dittloff, P.E., the FEST-A commander and a Europe District project manager. “That said, I think that you wouldn’t be human if there wasn’t a fear about this. That’s why I’m so proud of all these volunteers—everybody raised their hands for this mission, knowing the risks.”
While FEST-A will not be providing medical care or have direct contact with Ebola patients, the team will be given protective gear and continually trained in its use, should the need for it ever arise. To safeguard against exposure, the team will also follow all safety and health protocols set by the Centers for Disease Control and Prevention.
“This might be some of the best and most impactful work I ever do in my career, and I didn’t want to turn down the opportunity,” says electrical engineer Anton Klein, P.E. “Even though I’m a little scared of going, I know I’m going with a good team, and I know we’re going to take care of each other.”
For one of the team’s civil engineers, Milton Ricks, E.I.T., it was even more morally imperative he volunteer, having been born and raised in Monrovia before his family’s immigration to the US in the ’80s.
“It was personal, and moral, first of all,” says Ricks, who thought about his late father when he heard the Corps was deploying to Liberia. “If he was alive, he would be so proud that his son did this: ‘He lives in America, he’s got a comfortable life, but you know what, he’s a good man for doing this.’ That is my motivation.”
Ricks, who plans to retire to Liberia and still visits relatives there every year, also knew he would be able to help FEST-A with more than just engineering. “I know my way around, I know the culture, know the traditions,” he says.
Dittloff is confident the team will be highly effective in carrying out its mission and will be able to provide the joint task force commander with flexibility. “We have a unit that should be able to do just about anything,” she says.
The Home Front
Helping to stomp out Ebola at the source may be the surest way to prevent or limit the virus’s spread to countries like the US. In the rare instances when it does reach US shores, however, it’s engineering done right here at home that will help prevent it from spreading. According to Noskin and Peterson, engineers who design health-care facilities in the US protect the public from numerous infectious diseases.
There are four areas of focus crucial to designing health-care facilities to reduce the spread of infection: the overall process, systems, surfaces, and supporting facility operations.
According to Dale Woodin, senior executive director of the American Society for Healthcare Engineering, hospital construction involves an infection control risk assessment, a discussion between a design team and an infection prevention team made up of clinical personnel. “That discussion is held day one…to be able to really understand the type of patients that are going to be seen in this unit and what we need to design and build to prevent infection,” he says.
The infection control risk assessment guides the overall process of designing and building a health-care facility, helping to guide designers and builders through the other three areas of focus. Systems, such as ventilation systems, are designed to reduce the chances of infectious agents moving between different areas of a facility, and surfaces are designed to be as easy to clean as possible.
Design of a health-care facility should also support the facility’s operations, making it easier for health-care providers to carry out their work. Simple hand washing to prevent the spread of infections is one example. “It seems like the most basic thing of all,” Woodin says, “but part of it is how do we make sure we have hand washing sinks as well as alcohol hand wash in places where it’s very, very convenient for practitioners, family members, anybody to at a moment’s notice within a step or two clean their hands before they go to the next room or to see the next patient.”
With engineers designing for infection control, and response procedures and systems in place in the US, it is unlikely Ebola will be able to spread throughout the country, but not impossible. And there’s always room for improvement.
The International Council on Systems Engineering believes a systems approach could help stop the outbreak in West Africa and improve infection control in the US. INCOSE recently criticized the handling of Dallas Ebola patient Thomas Eric Duncan’s case. Duncan was seen and released from a Dallas hospital that did not accurately diagnose his symptoms in part because of communication breakdowns and flaws with electronic health records.
“A systems approach would have helped lessen or eliminate many of the issues in this case and the Ebola crisis in general, by ensuring that everyone involved in any part of the system was aware of the other parts of the system and that access to information was made available to everyone,” says INCOSE President David Long. “Engineering a coordinated system is key to ensure there are no missteps and each patient receives effective care.”
Bohdan Oppenheim, professor of systems engineering at Loyola Marymount University in Los Angeles, explains that systems thinking considers all systems that may be in play—doctors, patients, medical devices, waste disposal, and others—and considers how they interact together and as a whole. “The goal is to have all processes, people, and structures work together effectively,” he says.
“An engineer’s approach to this problem would ensure that no details are overlooked, and that actions are as effective as reasonably attainable,” adds Dr. Michael Appel, anesthesiologist and chief patient safety officer for the Northeast Georgia Health System. “Put another way, a mere flurry of activity will not solve this problem; only suitable actions will.”
Unfortunately, formal systems engineering is not yet used widely in health care, according to Oppenheim. But efforts are being made by INCOSE to change that.
“We need to understand and apply not only the medical aspects of Ebola—diagnosis, treatment, illness life cycle, medicines—but also illness containment along the entire timeline, from the first suspicion that an individual may be infected to…disposal of the body if the patient should die,” Oppenheim says. “This will involve the collaborative work of multiple parties—all sitting around the same table—systems engineers, doctors, nurses, the patient, emergency medical response teams, waste disposal teams, language translators, police, TSA, safety experts, the CDC, and FDA.”