2014-2016 Ebola Crisis: US Preparedness

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 The 2014-2016 Ebola Crisis and the Effects on U.S. Emergency Preparedness

The 2014-2016 Ebola crisis in West Africa proved to be a difficult lesson for the African countries affected as well as for the state of U.S. emergency preparedness when dealing with a relatively unknown infectious disease. Erupting from within a Guinean prefecture in December of 2013, the disease would spread through Guinea, Sierra Leone, and Liberia unchecked due to lack of awareness and emergency preparation due to the unfamiliarity of the disease (Baize et al., 2014). The World Health Organization, Doctors without Borders, and the Centers for Disease Control and Prevention, among others, would collaborate with regional government and public health officials to contain the disease, but the efforts would require extensive time, funding, education, and preparation, and would ultimately result in the loss of over 11,000 lives (Centers for Disease Control and Prevention, 2014, 2016). It would be the largest Ebola outbreak known to date. While U.S. public health agencies and military based support would play a crucial role in the end to the outbreak in 2016, the U.S. would have to come to terms with its own lack of planning and emergency preparedness when dealing with an imported infectious disease, and the fear and reservations that plagued its people and healthcare systems in its aftermath.

Emergency preparedness has been shaped by a myriad of natural disasters, epidemics, and pandemics that have sieged not only countries, but entire continents. It is the journey in discovering how to approach, contain, treat, and prevent these mass health crises from re-occurring in the future, that has given rise to the complex and unique strategies that keep the general population safe.  These advances in prevention and containment, uncovered particularly in the wake of epidemics and pandemics such as the plague, Spanish Influenza, SARS, and as highlighted in this report, Ebola Virus Disease, prove that the protective measures that responders on the front line must implement to keep disaster at bay, must remain adaptable and ever fluid.

The West African Ebola outbreak of 2014-2016 encroached upon the fears and concerns of continental Americans as never before in history. An elusive disease only known by most to be a worry of inhabitants of the sub-Saharan regions of the African continent, Ebola was now knocking on America’s doorstep.

  To understand and properly weigh the gravity of the Ebola outbreak, a general understanding of the virus and most recent outbreak is warranted. Ebola virus disease is one of two members of the Filoviridae virus family and is comprised of five differing variations within itself (Centers for Disease Control and Prevention, 2014).  First discovered within Africa in 1976 when two variations of the virus led to outbreaks, the Sudan viral strain, or SUDV within South Sudan, and the Ebola virus strain, or EBOV, in the Democratic Republic of Congo, were introduced (Cenciarelli et al., 2015). The spread of the virus among humans is via contact with infected bodily fluids such as blood, vomit, feces, sweat, and urine, or contaminated fomites (Centers for Disease Control and Prevention, 2014). However, the originating vectors are believed to be fruit bats, which are commonly hunted and eaten as wild game in some areas of Africa, and otherwise known as bushmeat (Saéz et al., 2014).  

Upon exposure to the virus, the incubation period prior to onset of symptoms ranges anywhere from 2 to 21 days, with symptoms tending to manifest by day 8 through day 10 post-exposure (Signs and Symptoms | Ebola Hemorrhagic Fever | CDC, 2014). It has been identified that infected individuals are not contagious while asymptomatic (Cenciarelli et al., 2015).   The tell-tale symptoms of Ebola virus primarily begin with fever, which progresses to onset of profuse diarrhea and vomiting usually after 3 to 5 days of fever (Chertow et al., 2014).  Accompanied with pain, lethargy, and secondary complications (including hemorrhaging) that occur if the patient is not given supportive treatment, the rapid deterioration in health that transpires due to hypovolemia, shock, or multi-organ failure, will ultimately lead to death (Chertow et al., 2014).  Survivors of the virus tend to improve near day 10 of active viral symptoms and are generally expected to live once they have made it to day 13 (Chertow et al., 2014). Those that do not improve and succumb to the virus tend to pass away between days 7 and 12 of viral infection (Chertow et al., 2014). The case fatality rates for the Ebola virus range anywhere from 50% to 90%, and to date there is still no definitive cure available (World Health Organization, 2018).

The unfolding of the 2014-2016 crisis was fast, and the virus rampant by the time the nature of the culprit had been properly unmasked.   A sudden rash of illness exhibiting the characteristics of a filovirus, was first reported by health agencies within the Guéckédou and Macenta prefectures in Guinea in March of 2014, raising the initial red flag of outbreak (Baize et al., 2014).  A team of professionals was sent to the area in mid-March by Medecins sans Frontieres, also known as “Doctors without Borders”, and research began that same month to uncover the cause of the illnesses (Baize et al., 2014).   Coinciding with the beginning of surveillance and research of the outbreak of illness by Doctors without Borders in March of 2014, the Centers for Disease Control and Prevention, or CDC, also arrived on deck with a small team, lending an additional hand with research and guidance to the Guinean government. The CDC had already maintained a supportive presence in Guinea, Sierra Leone, and Liberia, due to the assistance that it offered in vaccination of the population, and other public health related programs including combating diseases such as malaria and polio (Bell et al, 2016).  Alongside the World Health Organization, UNICEF and International Federation of Red Cross partners, a structured, five-pronged investigation emerged, with the Guinean government primarily orchestrating the response efforts (Dahl et al., 2016). 

Extensive investigation and contact tracing led the researchers to surmise that the illness was in fact the EBOV, or Ebola virus, and that the suspected “patient zero” was a 2-year old from Meliandou in the Guéckédou prefecture (Baize et al., 2014). The toddler had succumbed to the virus in December of 2013, with the second through fourth victims passing afterwards the following January, all within the same prefecture of Guéckédou (Baize et al., 2014).  The agencies worked side by side with the Guinean Ministries of Health to get ahead of the outbreak, as surveillance methods in the region demanded strengthening to debilitate the spread of a disease known to have high case fatality rates, exhibiting at that time an initial 71% case fatality rate (Baize et al., 2014).

The CDC, alongside the other agencies worked to support the various villages, towns, and districts through continued tracing of contacts, providing education regarding contact precautions, safety when isolating those that were ill or potentially ill, as well as options for handling the deceased with care (Bell et al, 2016).  Researchers were able to discover that it was a healthcare worker, or the 14th victim, that initiated the spread of EBOV outside of the Guéckédou boundaries, with further incidences popping up in surrounding areas such as Kissidougou and Macenta (Baize et al., 2014). Research indicated that at the close of March, there were well over 100 potential EBOV cases in Guinea, with almost 80 dead (Baize et al., 2014).  

The voracity at which the disease spread would be fueled by unchecked traveling of contacts between Guinea and its surrounding countries, as well as individuals and healthcare workers in contact with the homes, surroundings, and families of those sick or becoming sick, unaware that the illness was in fact Ebola, and extremely infectious (Ebola in Sierra Leone: A slow start to an outbreak that eventually outpaced all others, 2015).  By April of 2014, the presence of Ebola had been officially confirmed in Sierra Leone and Liberia (Bell et al, 2016).  The first case of Ebola in Sierra Leone is believed to have been a woman that attended the burial of the “patient zero” in Meliandou in December of 2013 (Ebola in Sierra Leone: A slow start to an outbreak that eventually outpaced all others, 2015). The woman was apparently still in the home of the family of the first case when they too fell ill, and later returned to her home in Sierra Leone, where she subsequently became sick and passed away (Ebola in Sierra Leone: A slow start to an outbreak that eventually outpaced all others, 2015).  The Lofa County in Liberia, which skirts the Guinean border, was able to confirm its first cases of Ebola at the end of March 2014 (A timeline of the Ebola outbreak, 2014).

By the end of April 2014, there were well over 200 cases across the region, however it appeared that the amount of cases was stabilizing, and on the decline in areas such as Liberia (Briand et al., 2014, Centers for Disease Control and Prevention, 2016). However, after the next two months of apparent stability, reporting indicated a renewed upward trend in Ebola cases, and the fresh report of confirmed Ebola cases in the city of Monrovia, the heavily populated capital of Liberia, unveiled an exploding time bomb of infection (Liberia: A country-and its capital-are overwhelmed with Ebola cases, 2015).

Even with the best efforts of all participating agencies, it had become elusive to keep up with the massive chains of potential contacts, and with the disease now appearing in Monrovia, Liberia, the city was found to be ill-prepared to deal with such a contagion, allowing it to spread like wildfire (World Health Organization, 2015). It is notable to mention that West Africa had not experienced an Ebola outbreak of any measurable magnitude, and the experience and lessons in containing the disease were bestowed upon those countries such as the Democratic Republic of Congo, and Uganda (World Health Organization, 2015). Monrovia’s major health center was in desperate need of repairs and had limited resources, in turn opening the door for widespread infection of healthcare personnel on top of the patient care load (Liberia: A country-and its capital-are overwhelmed with Ebola cases, 2015).  With the onset of July, cases of Ebola doubled in Liberia, and a rising trend of infection persisted in Guinea and Sierra Leone (Centers for Disease Control and Prevention, 2016). This rash of new cases that now plagued the region prompted the CDC to employ an Emergency Operations Center, or EOC, on July 9th, 2014 (Dahl et al., 2016). The engagement of this operation led the CDC to forward task an increased presence of personnel to directly assist the regional governments, supplying epidemiologists, laboratory scientists and a plethora of supportive staff (Dahl et al., 2016). WHO, UNICEF, and Doctors without Borders remained prominently active during the amplification of support, and with the increased presence of American aid, all agencies worked tirelessly with the local government leaders and Ministries of Health to establish a much-needed emergency management plan capable of supporting and withstanding the outbreak (Dahl et al., 2016).

As the supportive efforts amongst first responders and the new cases of Ebola both drew to a fervor in the early summer of 2014, American citizens and other countries became aware of the uniqueness of this Ebola outbreak.  Word spread globally of the first case of Ebola transported into Nigeria in July of 2014 (Fasina et al.,2014). Flying from Liberia to Nigeria after exposure to the disease, the individual was symptomatic in flight, and succumbed to the illness just 5 days after the flight into Nigeria (Fasina et al.,2014). The individual was Patrick Sawyer, an American citizen from Minnesota (Man Who Died of Ebola in Nigeria Was American Citizen: Wife, 2014). A native of Liberia, but an American citizen, Mr. Sawyer had been working and living in Liberia, while his wife and children continued to reside in the United States (Minnesota Man Who Died of Ebola in Nigeria Was American Citizen: Wife, 2014).  On July 31st, 2014, a few days after the death of Patrick Sawyer, the Centers for Disease Control and Prevention issued a class 3 travel warning, advising against travel to the affected region, and highlighting measures being taken to screen travelers leaving the region to ensure that they are not infected (Centers for Disease Control and Prevention, 2014). Along with this advisory, the CDC also reported an additional advisory issued to U.S. healthcare workers, to address protocols to be followed when addressing the possibility of encountering potentially infected patients (Centers for Disease Control and Prevention, 2014). As confirmed cases throughout the affected region peaked to over 1300, with over 700 dead, the CDC announced in the July 2014 advisory that the United States would continue to work with international partners over the next several years to help strengthen and enhance emergency response efforts in the region, with the president of the United States aiming to dedicate $45 million dollars towards the cause (Centers for Disease Control and Prevention, 2014, 2016). 

The steps that the United States would need to take to ensure its own readiness to handle Ebola would soon be put to the test, when around the same time that the CDC issued its health alert and travel advisory, it was announced that two American healthcare workers had contracted Ebola while stationed in Monrovia, Liberia (CBS/AP,2014). In late July of 2014, Dr. Kent Brantly, a doctor employed in a post-residency position with the aid group Samaritan’s Purse, became infected with Ebola while serving as a medical director in relief efforts in the area (CBS/AP,2014).  Nancy Writebol, an aid worker with the group called Serving in Mission, had also contracted Ebola in the same timeframe while working as a hygienist in the Samaritan’s Purse Ebola care center (CBS/AP,2014). Plans immediately commenced to arrange for the workers to be transported back to the United States to continue supportive care (Achenbach, Dennis, & Hogan, 2014).

As part of the CDC’s recent health alert, healthcare agencies within the United States were advised to inquire of patients if they have recently traveled to or from the West African region within the prior 21-day timeframe (Centers for Disease Control and Prevention, 2014). The CDC stressed the importance of healthcare provider awareness of the signs and symptoms of Ebola, as well as activation of isolation and contact procedures immediately upon any suspicion of the disease (2014).

Just as West Africa had never experienced an Ebola outbreak, the CDC was also aware that U.S. healthcare facilities had never dealt with the Ebola disease head on, and problems could arise if facilities were not properly equipped to handle infected patients (Morbidity and Mortality Weekly Report (MMWR), 2017).  Thus, in planning for the transport of Dr. Brantly and Mrs. Writebol, plans were cemented to arrange for their arrival at Emory University Hospital in Atlanta (Achenbach, Dennis, & Hogan, 2014). Emory University Hospital is one of four facilities across the United States that can treat patients diagnosed with highly infectious diseases (Courage, 2014). The two-room isolation unit housed within Emory Hospital, and constructed in hand with the Centers for Disease Control and Prevention, provides an optimal environment for healthcare personnel and patients when managing infectious diseases (Courage, 2014). Touting state of the art digital pressure monitoring, negative air pressure and HEPA filtration, a safe zone workspace and prep area, contained bathroom facilities, and specialized laboratory space, workers can essentially care for a patient without risk of any contact with the remainder of the facility (Courage, 2014). Regarding medical waste, which is a key concern when dealing with highly infectious cases, the hospital dilutes all bodily waste in toilets with bleach for a set period prior to flushing, and all other items to include personal protective equipment from staff, and other solid items are sanitized and then incinerated (Courage, 2014).

 The remaining three facilities across the United States with comparable biocontainment facilities include the National Institutes of Health’s Special Clinical Studies Unit located in Bethesda, MD, the University of Nebraska Medical Center’s Biocontainment Patient Care Unit, and Saint Patrick Hospital in Missoula, MT (Courage, 2014).  As Dr. Brantly arrived at Emory University Hospital at the end of July 2014, followed by Mrs. Writebol in the first week of August, President Obama addressed the United States regarding the outbreak, assuring the American public that screening precautions in airports were in effect in West Africa and in the United States to reduce the risk of infected individuals entering the country  (Achenbach, Dennis, & Hogan, 2014).

By the 8th of August in 2014, the West African Ebola Virus epidemic had become extreme enough for the World Health Organization to make an international announcement, that the situation had now become an emergency detrimental to public health (Cenciarelli et al., 2015.)  By this time, the total cases over the region equated to just over 1700, with deaths rising to near 1000 (Centers for Disease Control and Prevention, 2016).  The numbers of cases and deaths associated with the current outbreak exceeded the worst Ebola outbreak previously documented in Uganda in the year 2000, where there were 425 cases and 244 deaths (Bell et al., 2016). The implementation of this Public Health Emergency of International Concern, or PHEIC, by the World Health Organization, is a deliberate tool meant to be used when disaster calls (Briand et al., 2014).  Meant to put emergency plans into action with the assistance of international partners, the beginning of collaborative efforts would begin to aid in mitigating the toll that the virus has taken on the affected countries. 

In response to the emergency declaration by the World Health Organization, the CDC would in turn increase the amount of personnel that it had deployed to the area (Dahl et al., 2016). The White House followed suit with an official press release detailing the U.S. response to the crisis. On September 16, 2014, the White House relayed the expansion of funding and support to the evolving outbreak (The White House Office of the Press Secretary, 2014). Along with supplying additional U.S. funding to bring a total of almost $175 million invested collectively towards various supportive efforts, the White House also activated a cell of U.S. Africa Command personnel to provide on ground support in Liberia to arrange operational oversight of the U.S. based activities aligned with response efforts (The White House Office of the Press Secretary, 2014). The press release also entailed the deployment of additional personnel through the U.S Disaster Assistance Response Team, or DART, as well as the supply of care kits, training, and the institution of additional Ebola Treatment Units, as well as laboratory support (The White House Office of the Press Secretary, 2014). 

The latter only briefly touches on some of the response efforts engaged by the U.S. in support of the affected region, however the need for effective emergency management measures would hit home, when just days after the White House press release, a man whom had recently traveled from Liberia to Texas to attend his son’s graduation, would arrive at the emergency room of Texas Health Presbyterian Hospital in Dallas, TX (Chevalier et al., 2014, VOA News, 2014).

Texas Health Presbyterian’s ER would send Thomas Duncan home after treating him for what was believed to be sinusitis (Chevalier et al., 2014). Presenting to the ER with a fever, headache and stomach pain, Mr. Duncan had informed the staff that he had recently arrived from Africa, and while this information was documented in his record, the ER physician at that time somehow overlooked it, and did not conclude that Ebola virus disease should be suspected (Dallas News, 2014). The hospital would later acknowledge this oversight, as three days later, Mr. Duncan would be transported to the Texas Presbyterian Hospital’s ER, this time via ambulance, with an exacerbation of symptoms to include vomiting and diarrhea (Dallas News, 2014, VOA News, 2014). This time, Mr. Duncan’s recent arrival from Liberia would be accounted for in his medical assessment, and subsequent testing would conclude that he was in fact infected with Ebola (Dallas News, 2014). 

Further exposing the fissures within the handling of this case, the hospital’s holding company later acknowledged that the clinician training regarding the Ebola virus had been available but was not required of staff at the time when Mr. Duncan presented to the facility (Dallas News, 2014).  The facility was also aware of the CDC health alert from July of 2014 that stressed the possibility of an infected traveler arriving in America due to the magnitude of the outbreak, and the need for American healthcare facilities to be on the lookout for the very symptoms Mr. Duncan presented with on September 25th, 2014 (Dallas News, 2014).  As a result, numerous people would need to be traced and evaluated relating to their contact with Mr. Duncan during his travel and after his arrival to Dallas, TX.  As Texas responders and the CDC personnel worked to trace the 48 potential contacts for Mr. Duncan, the man would eventually succumb to the disease on October 8th, 2014, becoming America’s first death from Ebola Virus Disease (VOA News, 2014.)

 Some experts say that the initial misdiagnosis of Mr. Duncan is due to human error, since travel should have been an essential question asked of the patient upon assessment by the physician (Dallas news, 2014). However other experts acknowledge the difficulty of identifying a disease that has never been diagnosed on American soil (Dallas news, 2014). It was more than likely a combination of these factors that led to the results of Mr. Duncan’s case, and while Texas health officials dealt with the missteps of the event, just 3 days after Mr. Duncan’s death, one of the nurses that participated in his care would be diagnosed with Ebola, with a second nurse testing positive 4 days after the first (McCarty et al., 2014). The second nurse diagnosed with Ebola after taking care of Mr. Duncan, reported that she had traveled to Ohio from Texas prior to her diagnosis (McCarty et al., 2014).

 Enlisting the CDC to support in guidance and training, Ohio public health officials began the process of tracing contacts (McCarty et al., 2014).  Learning through first-hand experience how to identify and monitor individuals that may have interacted with the infected nurse, as well as how to prepare local health facilities regarding ability to properly triage, isolate, and safely transport infected patients, Ohio officials hoped to avert a crisis while assuring the protection of healthcare staff and the general population (McCarty et al., 2014). The total effort in Ohio was extensive and required cooperation from a considerable portion of the state’s counties, with 164 contacts to follow (McCarty et al., 2014). While most of the facilities were determined to be ready to act in the event of an active case of Ebola, the transportation plans and other points of coordination such as transfers between various agencies needed to be established, and the information gleaned from this real-world scenario exemplified the necessity for healthcare facilities to have these forms of emergency preparedness already in place (McCarty et al., 2014).

As the number of Ebola cases continued to escalate in the West African region, with confirmed diagnoses reaching over 8,000 into the first couple weeks of October 2014, and deaths numbering over 4,000, the American public attempted to process that two of its own had contracted Ebola on U.S. soil (Centers for Disease Control and Prevention, 2016).  Fear pervaded the comfort zones of many Americans. Some protested allowing anyone from the African continent to travel to the United States, while others feared encountering individuals that had been anywhere near Africa (Sanburn, 2014). During the various stages of emergency preparedness in Ohio after the turn of events surrounding Mr. Duncan, one business closed when it was learned that an employee was a contact of the Ebola-positive nurse from Texas (Sanburn, 2014). The fear of infection also hit healthcare workers particularly hard. As the investigation ensued into how the two nurses in Texas acquired the Ebola virus, despite employing protective measures, the uncertainty regarding the reliability and proper use of personal protective equipment (PPE) against Ebola, was compounded with the question of whether training among healthcare personnel was effectively being implemented (Fernandez, 2014).  Both nurses recovered from the disease, and the biocontainment ready facilities in Nebraska and Atlanta would carry on to successfully treat up to 11 total Ebola-positive patients transferred from the West African region by April of 2015 (Hewett, Varkey, Smith, & Ribner, 2015).  The successful treatment and ability to prevent cross-infection of other healthcare workers proved that the U.S. could properly manage an uncommon infectious disease abroad and at home. However the initial problems that led to the fear and uncertainty of the aftermath of Ebola virus disease within the United States, point to unfamiliarity with the disease in general, as well as lack of preparedness at a level that allowed for proper management of a highly infectious patient from the moment they present to a healthcare facility to diagnosis and commensurate care (Hewett, Varkey, Smith, & Ribner, 2015). Management of Ebola virus demands an intricately woven web of planning and preparation that not only carries the foresight of how to identify potential cases, but how to prepare healthcare staff to properly protect themselves and use PPE, how and when to arrange the transport of a patient while preserving a chain of clean and safe hand-off with all involved agencies, and how to conserve the safety of all personnel throughout (Hewett, Varkey, Smith, & Ribner, 2015). This lesson hearkens to the explosion of the outbreak in West Africa as well. Unfamiliar with Ebola virus, many care centers in the affected region attributed initial cases of Ebola to more familiar diseases endemic to the area, such as malaria and yellow fever (World Health Organization, 2015). A combination of initial misinterpretation of disease, lack of effective protocols that would have prevented the continuous spread of cases in both the healthcare facilities and in the civilian sector, populations were simply unaware of the gravity of the situation until it was too late (World Health Organization, 2015).

The 2014-2016 Ebola outbreak highlighted the need within the United States to filter more time, attention, and funding into research and planning to deal with unique public health emergencies such as Ebola virus (Gostin, Hodge, & Burris, 2015). U.S. assistance via the CDC, U.S. public health affiliates and aid organizations, in hand with military support, was crucial to the eventual containment of the Ebola crisis in West Africa. Clinical trials would lead to the implementation of a promising vaccination against Ebola known as ZMapp, however a cure remains out of reach to date (U.S. Department of Health and Human Services, 2016). As the outbreak finally died out in 2016, with over 28,000 cases and over 11,000 deaths collectively, a haunting reminder of mistakes and lessons learned would follow all agencies and countries involved (Centers for Disease Control and Prevention, 2016).  The phoenix that would arise from this event is the understanding that the United States would be required to fortify its public health awareness and planning, along with tightening emergency preparedness protocols to remain ahead of the inevitability that one day, another infectious disease may find its way to America’s doorstep.

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