Preparing for the Next Ebola

As horrific images of bodies piling up in West Africa and stories of children orphaned by Ebola filled American media over the summer and early fall of 2014, many feared someone with the virus would arrive undetected in the U.S. and spur a major outbreak. But experts considered the risk of that happening to be very low, says Kamran Khan, an infectious disease physician at St. Michael’s Hospital in Toronto and the founder of BlueDot, a social enterprise that uses big data to mitigate the impacts of global infectious disease. He and his colleagues modeled the global spread of pathogens via international air traffic and estimated that during the peak of the West African outbreak, just 2.8 travelers infected with Ebola would leave the affected countries every month on a commercial airliner. The U.S. receives only 2 percent of the air traffic from those countries. It seemed one of the wealthiest and most technologically advanced nations on Earth could handle 2 percent of 2.8 people a month.

Yet in October 2014, Thomas Eric Duncan was admitted to a Dallas hospital with Ebola shortly after arriving in the U.S. from Liberia. He had been turned away from an emergency department three days earlier, even though he had complained of Ebola-like symptoms. Over the course of those three days, he could have infected anyone who came in contact with his sweat or saliva.

That didn’t happen, but Duncan did quickly infect two of the nurses who were treating him. (The nurses would survive; Duncan did not.) Until that moment, health authorities believed most U.S. hospitals were prepared and equipped to handle an Ebola case. “We thought we knew a lot about Ebola and how it was transmitted, but there was clearly an underappreciation of what Ebola would do in a modern intensive care unit,” says Amesh Adalja, an infectious disease expert at the University of Pittsburgh Medical Center and a spokesperson for the Infectious Disease Society of America.

FULL COVERAGE: How 2015 Changed the Future

As a direct result of those events and of emergency funding by Congress authorized in December 2014, hospitals nationwide spent 2015 reorganizing, shoring up their facilities and know-how, building biocontainment units, training and retraining staff, and buying new laboratory equipment. Almost immediately after news broke about Duncan, many began scrutinizing their spaces and procedures and finding ways to improve them. The Johns Hopkins Hospital in Baltimore was one of many hospitals that had emergency preparedness plans in place but no biocontainment unit to isolate patients with highly infectious or deadly diseases. “The idea of seeing someone walk into the ER, and be faced with that scenario, changed our thinking,” says Lisa Maragakis, Hopkins’ senior director of healthcare epidemiology and infection control.

We need to make sure this is sustainable when it isn’t in the news as much.

Erica Shenoy, Massachusetts General Hospital

Johns Hopkins invested in the construction of a biocontainment unit, putting it in position to become an Ebola treatment center. The $5 billion in funding Congress appropriated following the scare over the infection of Duncan and of Dr. Kent Brantly and Dr. Craig Spencer, two U.S. residents who had treated Ebola patients overseas, went mostly to fight Ebola in West Africa. But $339.5 million was marked to revitalize and expand a nationwide network of hospitals that could safely diagnose and treat people with Ebola, and to prepare for other lethal outbreaks. Prior to Congress’ funding, only four biocontainment units in the U.S., with 22 beds among them, were ready to safely care for anyone exposed to a highly contagious and dangerous disease. The cash infusion has massively increased the number of hospitals and staff capable of meeting the challenge next time. A networked approach now exists in each state, with all acute healthcare facilities serving in one of three roles: frontline facilities that identify, isolate and evaluate possible cases of Ebola; assessment hospitals that can isolate a patient who might have Ebola and care for the patient for up to five days; and treatment centers for patients with confirmed Ebola.

A member of the CG Environmental hazmat team disinfects the entrance to the residence of a health worker at Texas Health Presbyterian Hospital who contracted Ebola.

To become Ebola treatment hospitals, state health departments and hospitals needed to patch up their systems. The hospitals had to develop plans with private medical transport companies, which operate many of the ambulances that might serve a given area, to safely bring infected patients in. Within the hospitals, they developed routes through unused corridors to the biocontainment units, which must be under negative-pressure ventilation to prevent any infectious particles from leaving the space. Hospitals were urged by the Centers for Disease Control and Prevention to create on-site laboratories and buy new machines so they could carry out certain tests without the risk of contaminating the hospital’s main laboratory.

The CDC also issued tougher guidelines for healthcare workers dealing with patients with Ebola. Each Ebola treatment hospital had to identify a task force of doctors, nurses, and support staff who would volunteer to care for patients. Workers were advised to wear full-face shields instead of goggles, two pairs of protective gloves instead of one, and fluid-resistant pants and shoe coverings. And they were never to work alone: All donning and doffing of the personal protective equipment is now to be done under the watchful eye of another team member peering through a window from an anteroom or corridor, so they will not spread the virus to other surfaces, including their own clothing or skin.

“If you don’t have the staff in there that are going to do it that way every time, and staff that are going to hold them accountable, then it’s not going to work,” says Sharon Vanairsdale, a nurse and program director for the Emory University Hospital disease unit that cared for four patients with Ebola in 2014. “It can be intimidating to hold someone accountable who is more senior or who is a renowned physician. A nurse has to feel comfortable to say, ‘I’m not sure, Doctor, but I didn’t see you wash your hands. Would you do it again?’ ”

The CDC recommends that Ebola treatment hospitals have enough personal protective equipment on hand for at least seven days of patient care. A team of doctors and nurses can go through as many as 20 suits a day caring for a single patient, says Vanairsdale. Earlier concerns about shortages have been offset by increasing the number of PPEs available at the Strategic National Stockpile, a national repository of medical equipment and supplies at an undisclosed location, and at state and local health departments.

Dr. Kamran Khan. (Photo: Courtesy St. Michael's Hospital)

Even with the upgrades, some of the designated Ebola treatment hospitals have little more than a taped-off area within the anteroom and the patient’s room for staff to remove their protective gear. “The existing biocontainment units—they didn’t have sufficient space,” says Maragakis. “Taking off PPE was identified as one of the ways that health care workers were infected with the disease.”

The units designated as Ebola treatment centers had to spell out how they would deal with the enormous amount of biohazardous waste produced from caring for a patient with Ebola. According to a Los Angeles Times story, treating one patient with Ebola generates an average of eight 55-gallon barrels of medical waste each day. “We spent a lot of time figuring out what to do with the waste disposal—it’s a huge issue that all institutions taking care of patients had to deal with,” says Erica Shenoy, the assistant chief of the infection control unit at Massachusetts General Hospital in Boston.

Once a facility has been set up, the CDC sends a team of experts for a daylong visit to assess the hospital’s ability to meet a minimum set of requirements. But it is up to the state health department to make the final decision about whether a facility is prepared to treat a case of Ebola or a similar public health emergency, says Ryan Fagan, a medical officer in the CDC’s Division of Healthcare Quality Promotion. Fagan says the most common gaps in readiness are related to laboratory testing. Facilities may not have the right type of equipment on hand—and near the biocontainment unit—or laboratory staff with the appropriate training to handle Ebola specimens.

By all accounts, U.S. hospitals are in a better position today to receive the next patient who arrives at an emergency department with Ebola or another dangerous pathogen. Nine health departments and associated partner hospitals have been designated regional Ebola treatment centers that are part of the national network of 55 Ebola treatment centers. These regional centers can care for at least two patients at a time, can isolate at least 10 patients with a dangerous disease, such as a deadly influenza that easily infects humans, and treat pediatric patients, among other things. They are assessed annually on staff preparedness and training. Each is receiving approximately $3.25 million over five years. Some, like Johns Hopkins and Mass Gen, renovated old spaces into new biocontainment units. “You’re evaluated to make sure you can meet the criteria on an ongoing basis,” says Shenoy.

The new 7,900-square-foot unit at Johns Hopkins opened in April. Funded in part by the state of Maryland and the Office of the Assistant Secretary for Preparedness and Response, part of the U.S. Department of Health and Human Services, the facility has three patient rooms, an on-site lab, a waste management system, two large autoclaves that sterilize medical waste using high-pressure steam, and systems that disinfect patient rooms with a vaporized hydrogen peroxide solution.

But perhaps the most coveted feature at the Johns Hopkins Hospital are the anterooms, adjacent to each patient room. Healthcare workers can remove their personal protective equipment under the eye of a coworker, and the layout allows staff to flow in one direction into and out of a patient room to reduce the risk of contamination.

Although Congress’ funding did not meet the Obama administration’s request to designate at least one treatment center in every state, the location of the units put more than 80 percent of all travelers who might arrive from countries affected by Ebola within 200 miles of one of the centers.

Training for the next outbreak is ongoing. “We need to make sure this is sustainable when it isn’t in the news as much,” says Shenoy. U.S. hospital staff learn best practices for treating patients with Ebola and other emerging threats through a recently launched National Ebola Training and Education Center, co-led by Emory, the Nebraska Medical Center, and Bellevue Hospital Center in New York City. By July 2015, the center had provided in-depth training in Ebola clinical care to more than 460 heath care workers from 87 health care systems. “We sent three groups of people to learn from the Nebraska biocontainment unit for three days and then down to Emory as well,” says Shenoy.

High-risk, low-probability events are challenging for hospitals to prepare for because taking over rooms and doing drills pulls resources from the day-to-day hospital needs. “Ebola is the poster child for the kind of pathogen these units are designed for, because it takes so few of the virus particles to infect someone,” says Maragakis. “But the units also prepare us for highly lethal forms of respiratory viruses like SARS or MERS.” The changes will make hospitals better prepared for both rare and common infectious diseases, like MRSA or the flu, which kill thousands of Americans each year, or for the next dangerous outbreak—whatever it is.

“Preparing for one infectious disease will prepare you for other infectious diseases,” says Adalja. “We are so much better prepared today for a disease like Ebola than we were.”