The Outbreak in Context

Building on Bausch's description of the region in which the epidemic originated, where the borders of Guinea, Sierra Leone, and Liberia meet, Fair observed that these divisions were imposed by colonization on long-standing tribal territories that have far greater influence over routes of travel and trade. He also noted that the tri-state region is hyperendemic for Lassa fever, which has been the subject of ongoing disease surveillance in Sierra Leone funded by a consortium of U.S. government agencies.

Despite increasing awareness of Lassa fever in Sierra Leone, testing for other potentially confounding diseases, such as malaria, shigella, and typhoid fever, languished in the wake of recent civil war, Fair said. Indeed, many infectious pathogens are likely circulating undetected throughout the tri-state region, which has recently been ravaged by war and environmental upheaval, including the Ebola virus, based on enzyme-linked immunosorbent assay (ELISA) results from nearly a decade ago in suspected Lassa fever cases in Sierra Leone that turned out to be negative for that virus (Schoepp et al., 2014).

If Ebola was present in West Africa in 2006, why did it not spread as it did in 2014? Fair described several key developments in the region since then that encouraged Ebola transmission by enabling faster travel between rural areas and cities, along with major land use change associated with widespread slash-and-burn cultivation of cassava. By 2014, the tri-state region had become a local nexus of commerce and transport, he said.

In addition, over the past decade, civil conflict in Sierra Leone and Liberia produced mistrust of government authority, including public health messages about disease control—which, when they were issued to combat Ebola, were also unclear, according to Fair. Warnings about the lack of a treatment were widely interpreted as “There is absolutely nothing you can do for me,” thus, rather than report to a treatment center, many sick people hid. “They just came out of 10 years of civil war,” he explained. “Running and hiding was pretty much the only way to stay alive for a lot of their recent lives, and this is all part of their very recent memory. So in my own opinion I did think that influenced how the population behaved during this outbreak.”

Even worse, in Sierra Leone, the areas in which outbreaks occurred fell entirely in one territory of a deep national divide, Fair noted; the political party in power was opposed by the dominant party in the outbreak areas. Since the onset of the outbreak in Sierra Leone, there has been “a complete political breakdown and a very fragile political state, which greatly affected public health,” he observed—and it continues to do so. Meanwhile, rumors circulated in the outbreak area that the government was intentionally crippling its inhabitants to prevent them from voting in the next election.

While Sierra Leone's public health infrastructure in 2014 was “nascent,” by Fair's description, with only two physicians per 100,000 people, it was growing; it was also sensitized to Lassa fever, particularly in its three laboratories with virology capacity. These laboratories were quickly overwhelmed with samples to test when the Ebola epidemic ignited, he recalled. Similarly, the world—even the United States and other wealthy countries—proved inept at controlling Ebola, largely because there were no plans for addressing the disease on a regional or global scale, he concluded.

Now is the time to formulate policy and logistical contingencies for future Ebola outbreaks, Fair urged. “We need to make these plans while it is still really fresh in our minds what happened, what went wrong, and how can we fix this the next time—and actually do exercises to see if it works on a small scale,” he argued.

Fair observed that it took a multisectoral collaboration to gain control of Ebola in West Africa. Relationships that arose out of necessity between governments, academia, philanthropic and nongovernmental organizations (NGOs), and industry, should now be formalized and expanded, he advised. Combining these forces will not only improve global health security in the context of future pandemics, he predicted, but doing so will also specifically benefit each participating sector.

Getting to Zero

While the West African Ebola epidemic appeared to be on the wane at the time of the workshop, Fair (among others) reminded participants that much work remained before all transmission chains were extinguished. “In Liberia already there is complete complacency about Ebola,” he observed. “There are very few people, unless they survived it themselves or their family died, that are particularly worried about it right now,” he said. The outbreak has not been extinguished in Sierra Leone or Guinea, he warned; unless precautions are taken, it could reignite in Liberia just as easily as it began.

To prevent this from happening, Fair urged the reestablishment of baseline diagnostics for febrile diseases in Ebola-vulnerable countries, as well as testing for malaria, human immunodeficiency virus (HIV), and other major infectious diseases. He also encouraged ongoing, extensive community engagement. “When these outbreaks are over we typically leave,” he said, but that would not be wise, given the magnitude of this public health disaster and its certain ongoing impact on the population. It will also be important to maintain active surveillance for Ebola—as well as other diseases with similar presentations, such as Lassa and yellow fever—after the epidemic is declared to be over, but it is uncertain who would fund such an effort, he noted.

Typically, one country's engagement with another to protect global health security is viewed as a contract, Fair observed, but this goal would be better served in the context of friendship. For example, he noted, programs focused on pathogens from the standpoint of biodefense should also address significant public health threats in the countries where they are being conducted. While impoverished countries understandably benefit from the influx of money that such engagement brings, they also value the commitment of expertise and resources for disease prevention and treatment, he said.

To this end, Guinea and Sierra Leone will be included in a laboratory network established by the Fondation Mérieux USA in partnership with the French Development Agency, Fair announced. Called RESAOLAB (the French acronym of its title, the West African Bio-Laboratory Analysis Network), it links laboratories within several countries with the goal of establishing standardized diagnostics, improving staff training and management systems, and obtaining funding for and strengthening governance of laboratory systems.

RESAOLAB is part of the GABRIEL (Global Approach to Biological Research, Infectious Disease, and Epidemics in Low-Income Countries) Network, which encourages the sort of international health collaboration that will be necessary to address epidemic and pandemic diseases, Fair explained. By maintaining lines of communication and data sharing in real time, network participants should be better prepared to cooperate effectively in a global health emergency, he suggested.

Patient Care in Liberia

Patients arriving at the ETU were triaged according to a simple algorithm that determined “who stays, who gets admitted, and who goes home,” Bucks said. The treatment protocol they used—and which was typical of other ETUs across West Africa—was based on one for sepsis, a similar syndrome (Bray and Mahanty, 2003) and consisted largely of supportive measures focused on fluid replacement,² along with anti-infectives for malaria, which frequently accompanied Ebola. The collected data from all such ETUs might someday suggest which interventions, at which stage of infection, were most effective, he noted; in the meantime, there are protocols to follow, which clinical staff tried their best to adapt. Most importantly, he emphasized, “everything hinges on infection control.”

The ETU staff applied a range of tools and approaches beyond PPE to meet this goal, Bucks explained. The unit was designed and constructed to simplify infection control in all activities, including moving patients, staff, and materials, providing water, and disposing of waste. Vigilance, checklists, and mutual responsibility reduced human error. “We stayed healthy,” he reported, but he warned that deadly mistakes are bound to occur, given enough time.

Bringing It Home

Bucks then turned to the challenge of translating successful elements of West African Ebola care to hospitals such as his home facility in the United States. Unlike the ETUs, U.S. hospitals provide treatment for a broad spectrum of health problems, into which Ebola care would need to be integrated, he noted. “There are tons of rules about how we will be trying to do this,” he observed, expressing his thankfulness for such guidelines. While recognizing the potential of Western health care to provide a higher level of care to Ebola patients than has been previously attained, he reminded the audience that the priorities of Ebola care are universal.

The prospect of treating Ebola patients caused staff and administration at Buck's hospital to review their pandemic plan for the first time since 2009, and to operationalize it to address Ebola, he reported. To navigate the complex regulatory milieu that governs pandemic preparedness—which encompasses disaster planning, infection control, federal and state law, and union contracts—he found useful guidance in the CDC's Detailed Hospital Checklist for Ebola Preparedness.³ Indeed, he noted, its opening message could be applied to hospital preparations for any emerging infection:

Every hospital should ensure that it can detect a patient with Ebola, and respond in a coordinated fashion. Many of the signs and symptoms of Ebola are nonspecific and similar to those of many common infectious diseases, as well as other infectious diseases with high mortality rates. Transmission can be prevented with appropriate infection control measures. . . . [E]nsure [that] your hospital is able to detect possible Ebola cases, protect your employees, and respond appropriately.

Acceptance of the CDC guidelines for Ebola treatment was strongly encouraged by Medicaid and Medicare, which provide significant funding for hospitals, Bucks pointed out. Similar guidelines were imposed on emergency physicians under the Emergency Medical Treatment and Labor Act (EMTALA). He said he welcomed this guidance, given the “lean, just-in-time, profit-driven environment” that is the U.S. health care system. This carrot-and-stick approach encourages hospitals to provide for the public good in a crisis without regard for profit, he concluded.

Specific preparations for Ebola care in hospitals—just as in an ETU—include protocols for patient isolation and planned movement of patients, staff, and materials. In addition, hospitals must be able to address Ebola in the context of labor and delivery, pediatrics, and other special populations. Staff must volunteer to work with Ebola patients, Bucks noted. “We need a PPE plan that meets all the guidelines and recommendations,” he continued, and a simulation facility where staff can be trained in these techniques. There must be protocols for safe waste disposal, as well as for both public and internal communications.

“Just like an ETU, you want as few people doing as much of the work [as possible], working like a team,” Bucks advised. They should be intensively trained in PPE and actively observing each other to ensure safety, and they should strive to minimize their exposure (in terms of both numbers and time) to patients in order to reduce the number of potential contacts, he said. In addition, the team should use dedicated equipment and follow guidance for its safe disinfection or disposal. “Whether it is housekeeping, nutrition, changing the beds, administering medications, or doing clinical assessments, you are all working together,” he emphasized. “Working as a team is absolutely essential, as is having a defined set of protocols.”

While complex, the Ebola-appropriate PPE developed by Bucks and his Stanford colleagues is far cooler than the outfit he wore in Liberia, he said, but still uncomfortable—largely due to the necessity for full face coverage during doffing. The expense of PPE is a substantial component of the costs of Ebola preparation, which he estimated at $500,000 for his hospital. This will not be a hardship for a large institution, he noted, but on a nationwide scale, it represents a considerable expenditure, and one that is unlikely to be efficient.

Clinical care guidelines for Ebola treatment in the United States would do well to follow those set out by Canada (Canadian Critical Care Society et al., 2014), according to Bucks. They incorporate interventions unavailable in African ETUs, such as continual infusion, transfusions, mechanical ventilation, hemodialysis, and experimental antivirals—any of which (individually or in combination) could make a difference to patient outcomes, he said. He also noted the contrast between standard emergency medical protocol, driven by the adage that “time is tissue” for conditions such as heart attacks and gunshot wounds, and emergency care for Ebola and other emerging infections, in which infection control is the first priority, and the clinician's first step is the time-consuming donning of PPE. Knowing this, and recognizing that there is no cure for Ebola, emergency physicians must reset their expectations of what they can accomplish for patients, he said, recognizing that those expectations could change if a cure became available.

Applying Lessons Learned

Evoking the memory of severe acute respiratory syndrome (SARS), Bucks remarked that the 2003 epidemic offered lessons that could have been applied to better address Ebola, and that should be applied to all emerging diseases. In particular, he—echoing other workshop participants—argued for the establishment of infection control standards for people and institutions that treat emerging infectious diseases. To illustrate this point, he compared the SARS experience in Toronto, where the first imported cases to enter a hospital were not immediately isolated and a major outbreak ensued, and, simultaneously, in Vancouver, where such a case was quickly isolated and infection control stepped up, extinguishing transmission.

Similarly, PPE developed to address Ebola should be adopted as a general standard for emerging infections, Bucks argued. “Let's test it and make it good and fit it into our infection control procedures,” he said. Moreover, he added, “If every hospital in the country is required to have this, we should create the economies of scale so this is affordable in developing nations.”

In closing, Bucks offered an analogy between controlling Ebola outbreaks and wildfires, from the perspective of his experiences in both activities. In the early, exciting days of fighting a wildfire, “Some of us are just hanging on by the seat of our pants,” he observed. “Firefighters are praying for rain at this time, but they are also gathering good stories and lots of lessons.” Then, as a fire comes under control, a process called mop-up begins:

Mop-up is tough; it takes a long time. At times, you take off your gloves and you crawl in the ashes and use your hands to find hot spots that still need to be dug out and then you put them out. If you don't put them out, that fire can come raging back in a week. It is certainly not glamorous at all, and the newspapers don't cover this. There are no video crews there. People lose attention. But if you don't do this work diligently, then you lose everything that you started with. You cannot get to the big work of recovery and rebuilding unless you do the mop-up safely.

As the West African Ebola epidemic approached the mop-up stage, Bucks expressed hope that lessons learned then, as well as in the heat of raging outbreaks, could be applied to improve the preparedness of U.S. hospitals to face the next emerging disease.

The CDC's Domestic Response

Anticipating the possibility of Ebola importation into the United States, and in response to the infection of two nurses who cared for an Ebola patient in a Dallas hospital, the CDC acted to educate U.S. health care workers about isolating Ebola patients and preventing infection, tightened previous infection control guidance for health care workers caring for such patients, and updated PPE guidance, Damon stated. Fifty-five hospitals, located within 200 miles of more than 80 percent of travelers arriving from West Africa, have been designated as Ebola treatment centers/assessment hospitals, she added. However, any hospital in the United States that receives an Ebola patient will be assisted by a CDC Ebola Response Team comprising 10 to 12 epidemiologists and clinicians who have experience with Ebola, along with sanitation workers and surveillance officers, she said.

The CDC has also provided more than $145 million to support state emergency preparedness programs through public health emergency preparedness cooperative agreements, Damon stated. In addition, the agency and its partners have provided training in infection control to health care systems and public health systems, reaching more than 800,000 health care workers online and 6,500 in person.

Finally, Damon described the CDC's enhanced entry screening and graduated follow-up procedures for travelers determined to be from low to high risk for the disease, established at the five U.S. airports where travelers from the three Ebola-affected West African countries enter the United States. All such travelers receive “check and report” Ebola kits with information on the disease, tools to help check their temperature and symptoms for 21 days, and information on who to call if they develop symptoms, she said. The CDC designates a person who has both consistent signs or symptoms of and risk factors for Ebola as a person under investigation, who is actively tracked in cooperation with state and local health departments.

Preparedness for Infectious Disease Care

Because of its proximity to both the CDC and the world's busiest airport, Emory University Hospital began planning to accommodate patients with serious communicable diseases in 2001, giving it a considerable head start on other such institutions, Ribner noted. “We realized that if any of these individuals, either travelers or CDC employees, acquired a serious communicable disease, there was really no place in our city to treat them”—a conclusion shared by the CDC, he recalled.

The two institutions began a dialog that led to the creation of biocontainment units: treatment areas for the safe delivery of effective medical care for patients with a known or anticipated communicable disease (Fairley et al., 2016; Smith et al., 2006). Additional biocontainment units were subsequently established at the University of Nebraska in Omaha, and at the NIH in Bethesda.

“We had SARS in 2003; we had the H1N1 outbreak in 2009; we have MERS [Middle East respiratory syndrome], which started in 2012; we have the H7N9 influenza virus; and, of course, the virus which has brought us all here today, the Ebola virus,” Ribner recounted. “As each one of these outbreaks presented, we adjusted our policies and procedures to make sure they were, in fact, the best we could find available to treat patients with these infectious diseases.” Among the adjustments the Emory team made was to select a dedicated staff of 19 nurses and 5 physicians for the three-bed biocontainment unit, and to schedule them continuously, in order to limit response time to less than 1 hour, he said. They also chose to work with a single ambulance company, training a select group of emergency medical technicians (EMTs) who were always on call, and modifying an ambulance so it could be decontaminated. This model of specialized expertise has since been adopted (after some debate) by the CDC for Ebola care, he noted.

Emory's biocontainment unit also features high-level PPE—which at first was criticized for evoking panic in the general public, but was eventually accepted as a standard for safe Ebola care, Ribner observed. Health care workers in the unit receive repeated training and testing in the performance of all Ebola-related practices and procedures, and specifically in the donning and doffing of proper PPE, he reported (Wu et al., 2015).

“Running a program like this is very expensive,” Ribner observed, noting that his budget had declined steadily since the biocontainment unit's inception. Were it not for the West African Ebola epidemic, he said, the program would likely have been disbanded in 2015. Instead, federal funding has been granted to support one regional ETU for each U.S. Department of Health and Human Services region, and ancillary facilities will be designated to care for patients in the event of an overflow. All such treatment units will be equipped and staffed such that there is no disruption in overall hospital operations if a patient with a serious communicable pathogen such as Ebola is admitted, he added. “Regional centers will get $2.25 million for the first year, mainly for renovation, which I think is fine for most of us,” he said, but he also noted that funding for subsequent years has been cut to a level below which many such units will be able to sustain operations.

Screening and Follow-Up

Ribner then turned to the management of potential Ebola patients: travelers and medical personnel returning from West Africa, including possible asymptomatic cases. This issue is of particular importance at Emory, owing to its proximity to both a major international airport and a medical nerve center. Because rules regarding the screening of travelers for disease are largely determined at the state level in the United States, there have been wide disparities in how asymptomatic travelers from Ebola-affected countries have been managed, Ribner stated. While one northern state confined a returning health care worker in a tent in the middle of winter, others have allowed travelers to simply go home, no matter how distant from a treatment center, he observed. However, as time has passed, states have become increasingly consistent in their approach to asymptomatic travelers from high-risk regions.

Recognizing that patients presenting with fevers of unknown origin that are under investigation for Ebola are also at risk for malaria, typhoid, or influenza—diseases that can kill quickly—hospital laboratories must be equipped to diagnose these conditions quickly, and not wait until Ebola has been ruled out, Ribner insisted. Emory's unit “can tell whether a patient is viremic within an hour or two of identifying them as a person under investigation,” he noted—which, while it does not rule out Ebola, vastly simplifies safe testing for other confounding, life-threatening infections. Unfortunately, such rapid testing is not available in most U.S. hospitals, he added.

Emory's outpatient management program is also expensive. Even in their relatively efficient, time-tested system, ruling out Ebola in a person under investigation costs as much as $2,500, Ribner estimated—yet, he remarked, third-party payers are unwilling to pay for more than a clinic visit in these cases. “I have been very fortunate in that our administration has underwritten this project for untold dollars,” he said, noting that few community hospitals are likely to possess such resources.

Inpatient Care

Ribner noted that Ebola care protocols in U.S. hospitals are much like those in Germany (see next section, “Preparedness for an Ebola-Like Disease”). While typical intensive care units at Emory have one nurse for two patients, within the ETU, there are three nurses per patient in order to avoid mistakes due to time pressure, he explained.

Many hospitals have elected not to become ETUs for two main reasons, according to Ribner: it could drive away patients who fear Ebola, and the significant expense of providing (and even offering to provide) Ebola care. “Third-party payers are not interested that we need extensive nursing care, that we need dedicated doctors,” he complained—and certainly they do not compensate for the considerable costs of ancillary services such as medical waste disposal. Again, while Emory's administration has underwritten these expenses, other hospitals are unlikely to receive that level of support, he predicted.

Future Constraints

Ribner's response to his rhetorical question as to whether support for infectious disease emergency preparedness will outlast the Ebola outbreak was pessimistic, as befits his experience. “I can only guess how long funding is going to persist if we have no major outbreaks over the next year or two, or if we are fortunate enough to control this Ebola outbreak over the next 6 to 12 months,” he remarked.

Likewise, Ribner observed that, although significant resources have been allocated for infectious disease preparedness, none have been earmarked for the very expensive treatment of people with dangerous infections. Our fee-for-service health care system is not designed to support outpatient evaluations of people with possible serious communicable disease, or to reimburse hospitals for the high cost of caring for such patients, he concluded.