Designing Medical Facilities to Care for Patients with Highly Hazardous Communicable Diseases

  • Mark G. KortepeterEmail author
  • Elena H. Kwon
  • Theodore J. Cieslak


Certain highly hazardous communicable diseases (HHCD), including viral hemorrhagic fevers, the Middle East respiratory syndrome coronavirus (MERS-CoV), and severe acute respiratory syndrome virus (SARS), have caused nosocomial outbreaks in unprepared facilities. Consequently, biocontainment units have been constructed to protect caregivers, patients, and family members, in addition to providing optimal care of the infected patient. Biocontainment units have adopted many of the design features originally found in biocontainment laboratories and can serve as national referral facilities for the most severe and highly hazardous infections.

Although a patient with a HHCD can show up at any healthcare facility unannounced, not every hospital can or should attempt to establish a biocontainment unit. Nevertheless, there are design features or management principles found in biocontainment units that can be adopted in most facilities. Awareness of the potential risk, in addition to adopting structural and policy control measures, can do a lot to prepare a facility for the next unexpected infectious disease outbreak.


High-level containment care Highly hazardous communicable diseases Biocontainment Viral hemorrhagic fevers Biosafety level SARS MERS Ebola Marburg Lassa 


  1. 1.
    World Health Organization. Health worker Ebola infections in Guinea, Liberia and Sierra Leone, Preliminary report. Found at 20 Jan 2017.
  2. 2.
    World Health Organization. Ebola health worker infections. Found at 24 Apr 2017.
  3. 3.
    Kortepeter MG, Kwon EH, Hewlett AL, Smith PW, Cieslak TJ. Containment care units for managing patients with highly hazardous infectious diseases: a concept whose time has come. J Infect Dis. 2016;214:S137–41.CrossRefGoogle Scholar
  4. 4.
    Kortepeter MG, Smith PW, Hewlett AL, Cieslak TJ. Caring for patients with Ebola: a challenge in any care facility. Ann Int Med. 2015;162:68–9.CrossRefGoogle Scholar
  5. 5.
    World Health Organizations. Ebola haemorrhagic fever in Zaire, 1976. Bull World Health Organ. 1978;56:271–93.Google Scholar
  6. 6.
    World Health Organization. Ebola haemorrhagic fever in Sudan, 1976. Report of a WHO/International Study Team. Bull World Health Organ. 1978;56:247–70.Google Scholar
  7. 7.
    Tucker JB, Mahan ER. President Nixon’s decision to renounce the U.S. offensive biological weapons program. Washington, DC: National Defense University Press; 2009.Google Scholar
  8. 8.
    Crichton M. The Andromeda strain. New York: Centesis Corporation; 1969.Google Scholar
  9. 9.
    Crawford DH. The invisible enemy: a natural history of viruses. Oxford: Oxford University Press; 2000.Google Scholar
  10. 10.
    Covert NM. Cutting edge: a history of Fort Detrick, Maryland. 3rd ed. Fort Detrick: Public Affairs Office, Headquarters U.S. Army Garrison; 1997. p. 79.Google Scholar
  11. 11.
    Hill EE, McKee KT. Isolation and biocontainment of patients with highly hazardous infectious diseases. J Army Medical Dept. 1991;PB8–91-1/2:10–4.Google Scholar
  12. 12.
    Cieslak TJ, Christopher GW, Eitzen EM. The “slammer”: isolation and biocontainment of patients exposed to biosafety level 4 pathogens. Clin Infect Dis. 1999;29:1083.Google Scholar
  13. 13.
    Kortepeter MG, Martin JW, Rusnak JM, et al. Managing potential laboratory exposure to Ebola virus by using a patient biocontainment care unit. Emerg Infect Dis. 2008;14:881–7.CrossRefGoogle Scholar
  14. 14.
    Pigott DC. Hemorrhagic fever viruses. Crit Care Clin. 2005;21:765–83.CrossRefGoogle Scholar
  15. 15.
    Borchert M, Mutyaba I, Van Kerkhove MD, Lutwama J, et al. Ebola haemorrhagic fever outbreak in Masindi District, Uganda: outbreak description and lessons learned. BMC Infect Dis. 2011;11:357.CrossRefGoogle Scholar
  16. 16.
    Smith PW, Anderson AO, Christopher GW, et al. Designing a biocontainment unit to care for patients with serious communicable diseases: a consensus statement. Biosecur Bioterror. 2006;4:351–65.CrossRefGoogle Scholar
  17. 17.
    Banniser B, Vincenzo P, Fusco FM, Heptonstall J, Ippolito G, EUNID Working Group. Framework for the design and operation of high-level isolation units: consensus of the European Network of Infectious Diseases. Lancet Infect Dis. 2009;9:45–56.CrossRefGoogle Scholar
  18. 18.
    U.S. Department of Health and Human Services. Biosafety in microbiological and biomedical laboratories. 5th ed; 2009. Atlanta: HHS Publication No. (CDC) 21–1112.Google Scholar
  19. 19.
    Cieslak TJ, Kortepeter MG. A brief history of biocontainment. Curr Treat Opt Infect Dis. 2016;8:251–8.CrossRefGoogle Scholar
  20. 20.
    Reynolds G. Why were doctors afraid to treat Rebecca McLester? New York Times, 18 Apr 2004.Google Scholar
  21. 21.
    Kim KH, Tandi TE, Choi JW, Moon JM, Kim MS. Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in South Korea, 2015: epidemiology, characteristics and public health implications. J Hosp Infect. 2017;95:207–13.CrossRefGoogle Scholar
  22. 22.
    Poor planning, communication lead to missteps in care of Ebola patient. ED Manag. 2015;27(11):121–6.Google Scholar
  23. 23.
    Jahrling P, Rodak C, Bray M, Davey RT. Triage and management of accidental laboratory exposures to biosafety level-3 and -4 agents. Biosecur Bioterror Biodef Strat Pract Sci. 2009;7:135–43.CrossRefGoogle Scholar
  24. 24.
    Beam EL, Boulter KC, Freihaut F, Schwedhelm S, Smith PW. The Nebraska experience in biocontainment patient care. Pub Health Nurs. 2010;27:140–6.CrossRefGoogle Scholar
  25. 25.
    Lowe JJ, Jelden KC, Schenarts PJ, Rupp LE Jr, Hawes KJ, Tysor BN, Swansiger RG, Schwedhelm SS, Smith PW, Gibbs SG. Considerations for safe EMS transport of patients infected with Ebola virus. Prehosp Emerg Care. 2015;19:179–83.CrossRefGoogle Scholar
  26. 26.
    Hewlett AL, Varkey JB, Smith PW, Ribner BS. Ebola virus disease: preparedness and infection control lessons learned from two biocontainment units. Curr Opin-Infect Dis. 2015;28:343–8.CrossRefGoogle Scholar
  27. 27.
    Wadman MC, Schwedhelm SS, Watson S, Swanhorst J, Gibbs SG, Lowe JJ, Iwen PC, Hayes AK, Needham S, Johnson DW, Kalin DJ, Zeger WG, Muelleman RL. Emergency department processes for the evaluation and management of persons under investigation for Ebola virus disease. Ann Emerg Med. 2015;66:306–14.CrossRefGoogle Scholar
  28. 28.
    Courage KH. Inside the 4 U.S. biocontainment hospitals that are stopping Ebola. Scientific Am 2014. Found at 24 Mar 2017.
  29. 29.
    Johnson DW, Sullivan JN, Piquette CA, Hewlett AL, Bailey KL, Smith PW, Kalil AC, Lisco SJ. Lessons learned: critical care management of patients with Ebola in the United States. Crit Care Med. 2015;43:1157–64.CrossRefGoogle Scholar
  30. 30.
    Lowe JJ, Gibbs SG, Schwedhelm SS, Nguyen J, Smith PW. Nebraska biocontainment unit perspective on disposal of Ebola medical waste. Am J Infect Control. 2014;42:1256–7.CrossRefGoogle Scholar
  31. 31.
    Lowe JJ, Olinger PL, Gibbs SG, Rengarajan K, Beam EL, Boulter KC, Schwedhelm MM, Hayes AK, Kratochvil CJ, Vanairsdale S, Frislie B, Lewis J, Hewlett AL, Smith PW, Gartland B, Ribner BS. Environmental infection control considerations for Ebola. Am J Infect Control. 2015;43:47–9.CrossRefGoogle Scholar
  32. 32.
    Jelden KC, Gibbs SG, Smith PW, Schwedhelm MM, Iwen PC, Beam EL, Hayes AK, Narion N, Kratochvil CJ, Boulter KC, Hewlett AL, Lowe JJ. Nebraska biocontainment unit patient discharge and environmental decontamination after Ebola care. Am J Infect Control. 2015;43:203–5.CrossRefGoogle Scholar
  33. 33.
    Leligdowicz A, Fischer WA, Uyeki TM, Fletcher TE, Adhikari NKJ, Portella G, et al. Ebola virus disease and critical illness. Crit Care. 2016;20:217–31.CrossRefGoogle Scholar
  34. 34.
    Garibaldi BT, Reimers M, Ernst N, Bova G, Nowakowski E, Bukowski J, Ellis BC, Smith C, Sauer L, Dionne K, Carroll KC, Maragakis LL, Parrish NM. Validation of autoclave protocols for the successful decontamination of Category A medical waste generated from the care of patients with serious communicable disease. J Clin Micro. 2017;55:545–51.Google Scholar
  35. 35.
    Centers for Disease Control. Interim guidance for U.S. hospital preparedness for patients under investigation (PUIs) or with confirmed Ebola Virus Disease (EVD): a framework for a tiered approach. Found at 20 Jan 2017.
  36. 36.
    Herstein JJ, Biddinger PD, Kraft CS, Saiman L, Gibbs SG, Le AB, Smith PW, Hewlett AL, Lowe JJ. Current capabilities and capacity of Ebola treatment centers in the United States. Infect Cont Hosp Epi. 2016;37:313–8.CrossRefGoogle Scholar
  37. 37.
    Siegel JD, Rhinehar E, Jackson M, Chiarrello L, the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Found at Jan 2017.
  38. 38.
    Beam EL, Schwedhelm SS, Boulter K, Kratochvil C, Low J, Hewlett A, Gibbs SG, Smith PW. Personal protective equipment processes and rationale for the Nebrask biocontainment unit during the 2014 activations for Ebola virus disease. Am J Infect Control. 2016;44:340–2.CrossRefGoogle Scholar
  39. 39.
    Lenaghan PA, Schwedhelm M. Nebraska biocontainment unit design and operations. J Nurs Admin. 2015;45:298–301.CrossRefGoogle Scholar
  40. 40.
    Risi GF, Bloom ME, Hoe NP, Arminio T, Carlson P, Powers T, Feldmann H, Wilson D. Preparing a community hospital to manage work-related exposures to infectious agents in biosafety level 3 and 4 laboratories. Emerg Infect Dis. 2010;16:373–8.CrossRefGoogle Scholar
  41. 41.
    Moore D, Gamage B, Bryce E, Copes R, Yassi A. Protecting health care workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines. Am J Infect Control. 2005;33:88–96.CrossRefGoogle Scholar
  42. 42.
    Gershon RR, Karkashian CD, Grosch JW, Murphy LR, Escamilla-Cejudo A, Flanagan PA, et al. Hospital safety climate and its relationship with safe work practices and workplace exposure incidents. Am J Infect Control. 2000;28:211–21.CrossRefGoogle Scholar
  43. 43.
    Timen A, Hulscher MEJL, Rust L, van Steenbergen JE, Akkermans RP, Grol RPTM, van der Meer JWM. Barriers to implementing infection prevention and control guidelines during crises: experiences of health care professionals. Am J Infect Control. 2010;38:726–33.CrossRefGoogle Scholar
  44. 44.
    Brett-Major DM, Jacob ST, Jacquerioz FA, Risi GF, Fischer WA 2nd, Kato Y, Houlihan CF, Crozier I, Bosa HK, Lawler JV, Adachi T, Hurley SK, Berry LE, Carlson JC, Button TC, McLellan SL, Shea BJ, Kuniyoshi GG, Ferri M, Murthy SG, Petrosillo N, Lamontagne F, Porembka DT, Schieffelin JS, Rubinson L, O’Dempsey T, Donovan SM, Bausch DG, Fowler RA, Fletcher TE. Being ready to treat Ebola virus disease patients. Am J Trop Med Hyg. 2015;92:233–7.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Mark G. Kortepeter
    • 1
    Email author
  • Elena H. Kwon
    • 2
  • Theodore J. Cieslak
    • 1
  1. 1.The Nebraska Biocontainment Unit, Department of Epidemiology, College of Public HealthUniversity of Nebraska Medical CenterOmahaUSA
  2. 2.Division of MedicineU.S. Army Medical Research Institute of Infectious Diseases (USAMRIID)Fort DetrickUSA

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