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 Even before Sunday's news that a health worker who treated the
Dallas case had herself contracted the disease, officials
acknowledged they need to do more.
Reuters checks with health departments in six states and cities that
have large West African communities, Philadelphia, Boston, New York
City, Minnesota, New Jersey, Maryland and Rhode Island, show that
they are scrambling to adapt those generic plans to Ebola.
If they are not able to stay one step ahead of any cases, then
lapses that characterized Ebola patient Thomas Eric Duncan’s
treatment in Dallas could recur. In the Texas case that led to
unnecessary exposure to the victim.
“To think the first patients would go flawlessly are an
overestimation of our systems,” said Dr. Craig Smith, medical
director for infectious disease at University Hospital in Augusta,
Georgia. “I would expect there would be a few stumbles.”
As it turned out, those stumbles included infection of a Texas
health worker who treated Duncan. The infected worker, identified as
a woman but not named by authorities, is believed to be the first
person to contract the disease in the United States.
In terms of preparedness around the United States, there is a lot to
do: hospital drills, 911 emergency operator guidelines, quarantine
rules, even details such as checking that plastic body bags meet the
minimal thickness - 150 micrometers - recommended by the U.S.
Centers for Disease Control and Prevention.
“It takes a certain amount of reverse engineering to get the plan to
where it can respond to new, emerging threats,” said political
scientist Chris Nelson, an expert on public health systems at Rand
Corp.
While departments contacted by Reuters said they were confident they
would be able to identify, treat and contain Ebola, "nobody is
charged with reviewing all 2,800 departments' plans," said Jack
Herrmann, chief of public health programs at the National
Association of County & City Health Officials.
Among the lapses in Dallas, even before the case of the infected
health worker, were the hospital's failure to admit Duncan when he
first went to the emergency room and told staff there of his recent
arrival from Liberia, delaying his treatment by at least two crucial
days. It took almost a week to clean the apartment where he stayed.
And health officials briefly lost track of a homeless man who they
were monitoring for Ebola symptoms.
“We're learning from what's going on in Dallas, too," said Dr. Jay
Varma, a deputy commissioner at the New York City Department of
Health. "We have a plan that we think is strong but we don't have
the final answers to a lot of questions."
While the CDC advises states on 15 “preparedness capabilities” they
need to respond to public health emergencies, the list was last
evaluated in 2011 and is fairly general— “emergency operations
coordination” and “information sharing”.
Local health departments have varying capabilities, preventing the
CDC from crafting a single national plan, so it provides guidelines.
Thus local authorities decide what is an “adequate” stockpile of
protective gear, and which community and other “partners” need to be
involved.
That reflects the common view that states and localities should lead
health emergencies as a matter of right and responsibility, said Dr.
Michael Osterholm of the University of Minnesota, an expert on
infectious disease.
There is no detailed national plan or protocol for Ebola, he said,
and "some states are much, much better prepared from a public health
perspective to handle (an outbreak) than others."
The closest things to nationwide plans are those developed for
pandemic flu and for so-called "all-hazards emergencies," said
Herrmann.
Still, it would be difficult if not impossible for those preparing
for a health emergency to learn separate protocols for every
individual contingency.
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The generic plans cover obvious needs such as calling in additional
staff to handle a flood of patients. There are also less obvious
needs: if schools are closed, hospitals will need to provide daycare
for their workers’ children, said Jeff Levi, executive director of
the private non-profit Trust for America's Health, a research and
advocacy group.
HOSPITAL DRILLS
Even top hospitals are learning that a plan for dealing with
infectious disease outbreaks may still leave them exposed to Ebola.
Vanderbilt University Medical Center recently ran an Ebola drill
with a pretend patient arriving at the emergency room, being
admitted and placed in an isolation unit.
During the drill, when doctors and nurses removed gowns, masks and
other protective equipment "they wanted to get out of that stuff and
do it quickly," Dr. William Schaffner, chairman of the Department of
Preventive Medicine, told an audience at the Woodrow Wilson
International Center for Scholars on Tuesday.
Moving quickly raised the risk of accidentally touching fluids on
clothes, a likely reason for infection of healthcare workers in West
Africa and possibly Spain, Schaffner said. All staffers have since
been instructed to remove protective gear with a partner, "to count
to 10" during each step "and do it slowly."
According to National Nurses United, 76 percent of nurses surveyed
say their hospital has not communicated to them any policy regarding
potential admission of Ebola patients, 85 percent say their hospital
has not provided education sessions where nurses can ask questions,
and just over one-third say their hospital has insufficient supplies
of face shields and impermeable gowns.
Dr. Leon Yeh, director of emergency medicine at Saint Francis
Medical Center in Peoria, Illinois, said, "It's happened so fast we
haven't drilled specifically on Ebola."
That patchiness characterizes other elements of Ebola preparedness:
New York City 911 dispatchers have been asking callers with Ebola
symptoms about their travel history for about a week, but in Ohio's
Cuyahoga County, which includes Cleveland, they have not.
Some blame lack of funds.
The CDC’s budget for Public Health Emergency Preparedness fell from
$1.1 billion in 2006 to $698 million in 2010 to $585 million last
year. From 2008 to 2013, local health departments lost 48,300 jobs
to layoffs and attrition, or about 15 percent. "Those job losses
absolutely eroded the capabilities that would be needed if we had to
deal with Ebola," said Herrmann.
In New York City, several hospitals have run drills with actors
portraying Ebola patients. Nurses, doctors and lobby security guards
- who might be the first people a patient encounters – are put to
the test.
"It's the nitty-gritty details that we're now trying to work out,"
Varma said, including how to dispose of waste generated by an Ebola
patient and who would provide food for people under quarantine.
(Additional reporting by Julie Steenhuysen, editing by Michele
Gershberg, Peter Henderson and Frances Kerry)
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