The Next Outbreak: Hantavirus, Ebola, and Hospital Readiness

00:00:00:06 - 00:00:18:22
Tom Haederle
Welcome to Advancing Health. The recent outbreak of the dangerous hantavirus infection on a cruise ship sent countries around the world, including the US, scrambling to bring their citizens home for quarantine and treatment. We learn more about America's ongoing response to the threat in today's podcast.

00:00:18:25 - 00:00:47:24
Chris DeReinzo, M.D.
Hi everyone! This is Dr. Chris DeRienzo, Thank you so much for joining us again on the Advancing Health podcast. I am incredibly excited to welcome to the podcast this week, Dr. Angela Hewlett. She is a professor of infectious diseases at the University of Nebraska's Medical Center, also called UNCW and the medical director of Nebraska's Biocontainment unit, which is not a thing that I imagine many of you know exists, and something that we're going to talk a little bit about over the course of our conversation today.

00:00:47:25 - 00:00:51:00
Chris DeReinzo, M.D.
Dr. Hewlett, thank you so much. Welcome to the podcast.

00:00:51:01 - 00:00:52:09
Angela Hewlett, M.D.
Oh, thanks for having me.

00:00:52:10 - 00:00:58:14
Chris DeReinzo, M.D.
Before we jump in, if you would tell us just a little bit about yourself and what brings you to the conversation today?

00:00:58:15 - 00:01:34:09
Angela Hewlett, M.D.
Well, I'm an infectious diseases specialist by training, and so I, I am originally hail from Houston, Texas, and did all of my training at University of Texas Medical Branch in Galveston, Texas, including an infectious diseases fellowship. And then I transitioned to Nebraska for my first so-called real job in 2009. And part of that package actually did involve the need for an associate medical director of the Nebraska Biocontainment Unit, which at the time I didn't really know existed, and like many people, but I was absolutely just floored by this facility when I visited this university.

00:01:34:09 - 00:01:54:12
Angela Hewlett, M.D.
And it really was part of the reason that I landed here in Nebraska in 2009. So I became associate director of the Nebraska Biocontainment Unit, at that time under the direction of Dr. Phil Smith, who was my mentor and the founder of the Nebraska Biocontainment Unit. And he was the director of the unit until 2016, when he retired.

00:01:54:12 - 00:01:59:00
Angela Hewlett, M.D.
And then I've been the director of the biocontainment unit since 2016.

00:01:59:06 - 00:02:23:08
Chris DeReinzo, M.D.
Wow. We've seen a lot in those ten years. But perhaps let's start the conversation with a little bit more about the role that that UNMC plays in the nation's critical medical infrastructure. Because truth be told, before I joined AHA three and a half years ago, I really had no concept of just how deeply integrated you are into how America manages emerging infectious diseases.

00:02:23:08 - 00:02:27:03
Chris DeReinzo, M.D.
So really, what is the biocontainment unit and what kind of work do you all do?

00:02:27:08 - 00:02:53:06
Angela Hewlett, M.D.
Well, here in Nebraska, we actually have two facilities that are designed for the care and monitoring of both patients and individuals who have either exposures to high consequence infectious diseases or are infected with high consequence infectious diseases. And we're part of a network called the National Emerging Special Pathogens Training and Education Center - NETEC. And this network was actually built after the 2014 Ebola experience.

00:02:53:06 - 00:03:18:01
Angela Hewlett, M.D.
And there are 13 regional emerging special pathogen treatment centers, or the RESPCs in the United States currently, as well as multiple level two facilities which are also designed for the care of high consequence pathogens. So those 13 facilities serve as the leads within their regions within the United States and here at UNMC Nebraska Medicine we are one of the originators, the founders of NITEC.

00:03:18:01 - 00:03:46:04
Angela Hewlett, M.D.
So one of the three facilities alongside Emory and Bellevue, New York City as well. And so we brought this network up, actually to enhance preparedness throughout the United States. But our facilities have actually are - the Nebraska biocontainment is actually been here since 2005. So this unit was dedicated in 2005. And our first official activation was actually in 2014, when we did care for three patients infected with Ebola virus disease.

00:03:46:04 - 00:04:07:27
Angela Hewlett, M.D.
But we do have two facilities here at UNMC that are designed strictly for this purpose. And the first facility is a national quarantine unit, which is actually the only quarantine unit of its kind in the United States. And it's a federally funded facility. It has 20 beds in the unit, and it's designed to monitor individuals that have exposures to high consequence infectious diseases.

00:04:07:27 - 00:04:32:11
Angela Hewlett, M.D.
So this is not a patient care facility per se. It's more like more designed like a hotel. Because we know that our guests can potentially be with us for a prolonged period of time. And so we have things in the rooms like, you know, refrigerator and a TV with streaming capabilities and exercise equipment in every room just to try to make this kind of difficult quarantine as comfortable as we can be.

00:04:32:16 - 00:05:01:06
Angela Hewlett, M.D.
Our guests have access to, you know, in person and virtual behavioral health support, which is, I think, critically important. And a mission like this, where we have individuals who do stay with us for a prolonged period of time. We host a daily town hall meeting where our guests can communicate with our team and with each other, just to kind of interact and discuss the different scenarios and things like everything from testing plan to food to, you know, really anything else that they would like to discuss throughout the day.

00:05:01:10 - 00:05:22:04
Angela Hewlett, M.D.
Although that facility is designed sort of like a hotel, it also does have some interesting capabilities in that it is all negative pressure. We are monitoring these individuals, which should they become ill, we have negative pressure throughout our unit, as well as an autoclave that we could potentially use for waste disposal if necessary. So there are some more unusual aspects.

00:05:22:04 - 00:05:28:20
Angela Hewlett, M.D.
So it's not your typical hotel, but it was really designed to monitor individuals with those types of exposures.

00:05:28:21 - 00:05:48:28
Chris DeReinzo, M.D.
That is the understatement of the century. Not your typical hotel. Well, before we go one level deeper, you've used the term high consequence pathogen or high consequence infectious disease a couple of times. For a non ID doc, for our general listener population, what is a high consequence pathogen and what are the kinds of potential infectious diseases that folks would be exposed to

00:05:49:00 - 00:05:53:22
Chris DeReinzo, M.D.
where this would be a unit that we might send them to for the kind of monitoring you're describing?

00:05:53:24 - 00:06:33:22
Angela Hewlett, M.D.
So a high consequence infectious disease. And I will say there's been a lot of work on this because the terminology has changed quite a bit over the years. You may have heard highly infectious disease or highly hazardous communicable disease or a special pathogen. Those terms are all essentially interchangeable to really mean the same thing. And that is a disease for which there is a chance for transmissibility between humans, a disease that has potentially a high mortality rate or for which there are minimal or none as far as therapeutic agents or vaccines, and so typical diseases that fall in that category of high consequence infectious diseases include things like viral hemorrhagic fever.

00:06:33:22 - 00:07:05:25
Angela Hewlett, M.D.
So things like Ebola virus disease, Lassa fever, Marburg,  smallpox is in that category. Certain types of mpox potentially, depending on the facility, could be classified as that. So there are multiple types of diseases that could fall in that category. The most recent that we've been dealing with is the Andes virus, which is a hantavirus. But it's the only hantavirus known to be transmissible person to person and has all of the things that I mentioned as far as limited therapeutic options and no vaccine.

00:07:05:25 - 00:07:09:28
Angela Hewlett, M.D.
So we would classify that as a high consequence infectious disease as well.

00:07:10:01 - 00:07:30:25
Chris DeReinzo, M.D.
Well, let's spend a minute then on the subtype of the hantavirus, the Andes virus, it sounds like what it is called by those in the know. We know that that hit the news in a substantial way earlier this year. Help us understand the role that y'all played in Nebraska in the nation's response. And you know, where are we in the arc of that response right now?

00:07:30:27 - 00:08:06:02
Angela Hewlett, M.D.
Well, so the initial cases of Andes virus were actually reported off of the MV Hondius cruise ship. That was an expedition ship that was started in Argentina and made its way across the Atlantic to some very remote areas around the world, mostly territories, actually. So again, an expedition ship with a lot of very active outdoor exposures and other things that that occurred while unfortunately an individual on that on that ship became ill very quickly after boarding the ship in in early April and succumbed to his illness on board.

00:08:06:04 - 00:08:30:12
Angela Hewlett, M.D.
Subsequently, his wife became ill, as did another passenger. And so then there started to be some concern for is this disease that's transmissible human to human, what could this possibly be? And as more people got sick, eventually those individuals, when they were transferred off of the ship for medical care, eventually the diagnosis was made of a hantavirus and then eventually the Andes strain of hantavirus.

00:08:30:12 - 00:08:55:23
Angela Hewlett, M.D.
And so that occurred in all throughout April, essentially. In early May, you know, many of these people were still on the ship, and they had individuals who had become ill, who had been transported off of the ship, but also a fair number of people who had had various exposures during the cruise. And if you think about a cruise ship, there are potentials for lots of in-person contact with each other, lots of close contact potentially.

00:08:55:23 - 00:09:18:13
Angela Hewlett, M.D.
And this was a special voyage. It wasn't your typical kind of large cruise line. This was very much an expedition where they had a lot of close contact with each other. It was a small ship, but still a lot of prolonged contact with other people on the on the boat. And so because of that, that introduced the possibility of transmission of Andes hantavirus, which is what was occurring on the ship.

00:09:18:13 - 00:09:44:03
Angela Hewlett, M.D.
So when the ship eventually docked, all of the individuals on the ship had potential for having exposure just due to the number of cases of hantavirus that individuals that became ill on the on the ship, including the ship's physician, actually. And so after that happened, then each individual country flew a plane essentially to, to the area and actually which was the Canary Islands at the time and actually then took their citizens back to their home country.

00:09:44:03 - 00:10:05:27
Angela Hewlett, M.D.
So this happened all over the world. This was a cruise that had many countries involved from all over the world. And those countries actually were came back and essentially, you know, picked up their exposed individuals and took them back home for quarantine. And so here in the United States, because we have the national quarantine unit here on our campus, that was our job is to monitor those individuals.

00:10:05:27 - 00:10:28:10
Angela Hewlett, M.D.
And, you know, should they become ill, then we have the possibility of transferring them into the Nebraska Biocontainment Unit, which is our patient care unit. We originally accepted 16 individuals that had exposure to Andes hantavirus on the cruise ship. Later we received an additional two individuals and so we had a total of 18 when we started this on May the 11th.

00:10:28:10 - 00:10:54:28
Angela Hewlett, M.D.
And so we're still currently monitoring eight individuals. We since that time, some of our individuals have actually been transferred home for home quarantine. So they're still they're still under quarantine for 42 days total, which is the maximum incubation period of Andes hantavirus. The average incubation period is around 18 days. And we have definitely surpassed that. And so we are definitely past the average incubation period, but not completely out of the woods with our individuals yet.

00:10:54:28 - 00:11:01:03
Angela Hewlett, M.D.
We're very fortunate to have PCR testing capability here on campus, which is a very unusual entity.

00:11:01:08 - 00:11:19:04
Chris DeReinzo, M.D.
Especially for such a for such a rare virus. In order to be able to test for it, you truly have to be in, in like the top leading center in the country, which what you all are. And it really sounds like the connection there between the quarantine unit and the bio containment unit make it a potentially seamless experience.

00:11:19:04 - 00:11:31:12
Chris DeReinzo, M.D.
So it sounds like I think I heard you say we're not out of the woods yet, but in terms of timing here, we're on hopefully the back end of what could have been much more significant kinds of exposures.

00:11:31:16 - 00:11:57:25
Angela Hewlett, M.D.
Yeah, absolutely. And I think just to highlight the reason that the national quarantine Unit is here on our campus is because of the Nebraska Biocontainment Unit, which is our patient care facility. So that is where as in all ages, all hazards unit, we can provide a full spectrum of clinical care in the Nebraska Biocontainment Unit, everything from typical supportive care to critical care modalities like mechanical ventilation, dialysis, ECMO, really the full spectrum of clinical care.

00:11:57:25 - 00:12:20:21
Angela Hewlett, M.D.
And that unit is also negative pressure throughout with the gradient. It has HEPA filtration of all of our exhausted air. We have dual autoclaves for waste management. We have an in-house laboratory as well as laboratorians who train with us on our team and come in and process specimens for us right inside the unit. We have a large trained team of healthcare workers that includes physicians from multiple different specialties.

00:12:20:21 - 00:12:44:21
Angela Hewlett, M.D.
And I mentioned all ages unit. We have pediatricians. We have pediatric infectious diseases specialist, peds critical care docs, neonatologist. We have a cadre of surgeons actually on our team as well. We have a CT surgeon who's actually part of our team as well as obstetricians. You know, there's a chance that we could need you need to care for a pregnant individual and potentially a neonate as well.

00:12:44:21 - 00:13:03:09
Angela Hewlett, M.D.
So all of our team members, including the physician groups as well as the nursing team, which comprises a variety of different specialties of nurses. We have respiratory therapists on our team. We're an all volunteer team, actually, so none of our health care workers are compelled to do this type of work. We have a lot of team maintenance activities.

00:13:03:09 - 00:13:24:01
Angela Hewlett, M.D.
We have ongoing training that we're required to participate in, as well as drills and exercises and team building events and things like that that really enhance our teams. So, you know, again, these two facilities are an unusual entity. And the fact that they're co-located on our campus makes us sort of the spot to be, if you will, for individuals who require quarantine.

00:13:24:02 - 00:13:33:06
Angela Hewlett, M.D.
Also keeping in mind that that's the reason that these facilities are here is so that should we need to care for someone with an infection, we're able to do that readily.

00:13:33:10 - 00:13:57:03
Chris DeReinzo, M.D.
Well, they truly sound like a one of the kind duo. And you know, you mentioned back in the 2014-15 Ebola virus disease response, the unit was active. I got to be honest, in 2026, the recurrence of Ebola virus in the conversation globally was not on my dance card. But we know that there's one of the most significant Ebola virus disease outbreaks going on in history right now.

00:13:57:07 - 00:14:12:01
Chris DeReinzo, M.D.
What are you all seeing again? We know you are as plugged in as any unit could possibly be in the global conversation. Where are you seeing that outbreak trending at the moment? And what, if anything, should hospitals be doing in preparedness?

00:14:12:03 - 00:14:36:10
Angela Hewlett, M.D.
I'm really concerned about what's going on in the Democratic Republic of the Congo and Uganda. You know, there have been a large number of cases and deaths associated with this outbreak, which actually is reminiscent of the earlier days of the 2014 outbreak, which occurred in a different part of Africa. So in West Africa, but still just the large number of cases and the ongoing increase in case counts that we're seeing on a daily basis.

00:14:36:13 - 00:14:56:21
Angela Hewlett, M.D.
The 2014 outbreak resulted in around 28,000 cases and about 11,000 deaths. And I'm really hopeful that we won't see that number of cases with this outbreak. But I'm very nervous about that, just given the kind of volatile situation that's occurring, particularly in this area of the Democratic Republic of the Congo, which has a history of outbreaks in the past.

00:14:56:21 - 00:15:17:15
Angela Hewlett, M.D.
So this is not the first time that they have seen Ebola virus disease, but they also have a very mobile population in that area, limited access to health care, which subsequently results in limited access to testing, as well as a history of conflict in the area, which really makes this scenario very difficult. And so I'm definitely concerned about what is going on overseas.

00:15:17:19 - 00:15:41:03
Angela Hewlett, M.D.
You know, as far as preparedness locally, we should all be aware of what's going on throughout the world because these outbreaks are occurring regularly, and they're also something that we need to take note of because, you know, there could always be imported cases of any infectious disease with travelers who either are from the United States and go travel abroad and return, or travelers from other countries who are coming to the United States.

00:15:41:03 - 00:16:01:28
Angela Hewlett, M.D.
And a great example that is occurring right now is the World Cup. Just in the fact that there are a lot of people who a lot of fans who are coming to the United States and traveling to other parts of the world for these games. And so facility preparedness is, is incredibly important. And I think infectious diseases, we use a mantra that we call identify, isolate and inform. Facilities -

00:16:02:00 - 00:16:22:22
Angela Hewlett, M.D.
regardless of the size of your facility - it could be the smallest kind of critical access hospital or a clinic or the emergency department or a large academic center. People can present to any of these settings, and so even the smallest hospital needs to be ready to at least identify, isolate and then inform appropriate authorities should there be concern for high consequence infectious diseases.

00:16:22:22 - 00:16:53:26
Angela Hewlett, M.D.
And the way to do that is to make sure that you have protocols in place that can identify symptoms that are appropriate and concerning, as well as a history of travel, which we actually have frontline in our facility. We utilize our electronic medical record, and we ask patients a set of questions on intake, whether they're coming into our emergency department or to any clinic setting, and then that the answers to those questions sometimes lead to the isolation of that individual or further questioning or, you know, the activation of some of our protocols.

00:16:53:26 - 00:17:04:13
Angela Hewlett, M.D.
So I would just emphasize that it's really important that every facility is prepared, and it doesn't matter the size of your facility, because people definitely will present. And so we need to be ready for that.

00:17:04:14 - 00:17:25:12
Chris DeReinzo, M.D.
Dr. Hewlett, that is the perfect note to end today's conversation on. You hit the nail on the head. I've been to every conceivable kind of hospital in America, and none of them, except UNMC, have your unique combination of the national quarantine unit in a biocontainment unit. But every hospital can follow those kinds of steps in every clinic and every outpatient center.

00:17:25:14 - 00:17:40:27
Chris DeReinzo, M.D.
Those steps really are sort of the foundational baseline of us being prepared. And that's what today's conversation has been all about. Thank you so much for joining the podcast. This has been a fascinating conversation, and I certainly wish you all the best as the summer goes on.

00:17:41:02 - 00:17:43:18
Angela Hewlett, M.D.
Thank you so much. I appreciate you having me.

00:17:43:20 - 00:17:52:13
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.