Some health experts say the USA hasn't learned key lessons from Ebola experience

One year after doctors diagnosed the first Ebola patient in the USA, some experts question whether the country is prepared to deal with the next outbreak of a serious infectious disease.

Ebola’s appearance in Dallas last year was a “wake-up call” to the health system, showing that the United States was far more vulnerable to the disease than most people assumed, said Stephen Morse, founding director at the Center for Public Health Preparedness at Columbia University’s Mailman School of Public Health in New York.

While the number of Ebola cases in West Africa has dropped dramatically, the world still faces a number of dangerous infectious diseases, including bird flu and MERS, or Middle East Respiratory Syndrome, said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy.

“The next outbreak won’t look like the one we prepared for with Ebola,” said Jeffrey Duchin, health officer and chief of communicable disease, epidemiology and immunization for Seattle and King County in Washington state. “It could be much worse."

The Ebola experience exposed a number of weaknesses in the country’s ability to respond to a public health emergency, said Lawrence Gostin, director of the O'Neill Institute for National and Global Health Law at Georgetown University in Washington.

Doctors and nurses don't always communicate. They don't always ask the right questions, such as whether patients have traveled recently. Hospitals don't do enough to prevent infections from spreading from patient to patient. Health departments often lack the money and staff they need to do their jobs. Many communities have never developed plans for dealing with epidemics; even fewer have tested those plans.

Responding to a respiratory illness such as MERS or bird flu would likely be far more difficult than dealing with Ebola, said Amesh Adalja, a senior associate at the Center for Health Security at the University of Pittsburgh Medical Center.

"Although Ebola is scary and deadly, it's not a very contagious disease," Adalja said.

Ebola more complicated than many doctors realized

Ebola is relatively hard to transmit, spreading only through direct contact with bodily fluids and only after patients have developed symptoms. MERS and flu spread easily through coughing and sneezing, Adalja said. Although studies show an experimental vaccine effectively prevents Ebola, there is no vaccine against MERS, which is currently spreading in Jordan and Saudi Arabia.

“A lot more hospitals are prepared to isolate a patient with Ebola than a year ago,” Bruce Ribner, medical director of Emory University Hospital’s serious communicable disease unit in Atlanta, which treated four Ebola patients last year. “If someone from Saudi Arabia comes in with a respiratory infection, I’m not sure if they’d be prepared.”

No one has performed a careful, wide-ranging analysis of what went wrong with the USA's response to Ebola, what went right and what needs to change, said Wafaa El-Sadr, a professor of epidemiology at the Columbia University Mailman School of Public Health.

“I’m not sure we’ve learned enough from the last incident to better prepare for the next one,” El-Sadr said.

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The Dallas experience

Texas Health Presbyterian Hospital in Dallas, which treated the first Ebola patient diagnosed in the USA, recently released an independent investigation into its care of that patient, Thomas Eric Duncan. The outside panel that wrote the report found a number of problems with the hospital’s care.

Duncan, 42, went to the Dallas hospital Sept. 25, 2014. He told an emergency room nurse that he’d recently arrived from Liberia. He complained of dizziness, stomach pain, nausea and headache.

During his stay in the ER, his fever spiked to 103 degrees. Although the nurse recorded Duncan’s travel from Liberia in his electronic medical record, the nurse didn’t mention it to the doctor who treated Duncan. The doctor didn’t ask Duncan about recent travel, either, according to an investigation of the case by outside experts.

In spite of widespread publicity about the Ebola outbreak in West Africa – and symptoms that were consistent with the virus – hospital staff released Duncan with medication for a sinus infection.

Three days later, an ambulance crew was called to Duncan’s apartment. By then, Duncan was feverish, with nausea, vomiting and diarrhea. The ambulance crew alerted hospital staff, who isolated Duncan and alerted both the Dallas County Health and Human Services and the Centers for Disease Control and Prevention. Doctors diagnosed Duncan with Ebola. He died Oct. 8.

Some experts say they've seen little improvement in the way hospital staffs communicate. "I definitely think it could happen again," said Adalja, noting the quality varies greatly among U.S. hospitals. While some large hospitals are well-prepared to fight infectious diseases, staff at some small hospitals "might not even know what MERS is."

Before Duncan was diagnosed, CDC officials had said that any hospital could safely treat an Ebola patient by using standard infection-control measures. That advice changed after Duncan infected two nurses in the intensive care unit. Both nurses were transferred to larger hospitals – Emory and the clinical center at the National Institutes of Health – and survived. One of the nurses, Nina Pham, sued Texas Health Resources, the Dallas hospital’s parent company, charging that it failed to properly train and equip nurses to treat Ebola patients.

The CDC now says that while all hospitals should be able to screen and isolate patients with Ebola, only specially equipped facilities should treat them. In June, the Health and Human Services Department designated 55 hospitals as capable of caring for Ebola patients, with nine regional facilities able to provide the highest level of care.

While that’s a big increase from a year ago, when Ebola patients were sent to just four hospitals equipped to deal with the most dangerous viruses, Ribner notes that federal officials haven’t yet designated a regional Ebola center for California.

Many hospitals today have no interest in providing specialty care for Ebola, Ribner said, given the hazards to their staff and patients, as well as the considerable expense. Both Emory and Omaha’s Nebraska Medical Center -- which treated three Ebola patients -- say they have yet to be  fully paid for caring for Ebola patients.

Duncan’s case also shows how important it is for doctors and nurses to ask about patients’ recent travels – and to share that information with other hospital staff, Duchin said. Some doctors haven’t learned that lesson, Duchin said.

“I’m constantly asked by my colleagues at the hospital, ‘When can we stop asking about travel history?’” Duchin said.

The independent panel that investigated Duncan’s care also faulted the CDC, noting that the first CDC adviser didn’t arrive at the Dallas hospital until three days after Duncan’s second ER visit. The CDC also failed to update its guidance about handling Ebola-contaminated waste, leading to delays in getting permits from the Department of Transportation to dispose of it, the report said.

CDC director Thomas Frieden said the agency’s advice changed as new information became available. Although CDC advisers can assist in outbreak investigations, they don’t take over for hospitals or health departments, Frieden said.

“You don’t expect science to be omniscient; you expect science to learn,” Frieden said. “You have to act with the best information that you have today and you have to be open to new information.”

Authors of the report on Texas Health Presbyterian, who include Denis Cortese, emeritus president and CEO of the Mayo Clinic, also noted a lack of coordination between staff at the hospital, the CDC, Texas transportation department and city, county and state health officials.

Dallas officials also appeared unsure what to do with Duncan’s family after his hospitalization, Gostin said. Public officials first quarantined Duncan’s family in a contaminated apartment, before eventually relocating them. In New Jersey, Gov. Chris Christie quarantined a nurse returning from Sierra Leone even though she had no symptoms of Ebola.

“It was a chaotic situation,” Gostin said. “Each state and locality should have an epidemic response plan. What happens when you fail to plan is that you get caught up in the hysteria, and then politics rules.”

Health system remains vulnerable

Adalja worries that the USA hasn't learned one of the key lessons from Ebola: Infectious diseases are unpredictable. And they take advantage of complacency.

South Korea’s recent MERS outbreak was, in many ways, a repeat of what happened in Dallas, but with even greater loss of life, Adalja said.

A large MERS outbreak this summer began with a man who had recently traveled to the Middle East. He sought care at two hospitals and two outpatient clinics in Seoul before being diagnosed with MERS nine days later. By that point, the man had infected dozens of people. A total of 186 people fell ill and 36 died, according to the World Health Organization.

According to the WHO, the man who started the outbreak “provided no history of potential exposure to the virus.” To Ribner, that suggests nobody asked him.

With MERS spreading in Saudi Arabia -- where 2 million travelers have gathered for the annual Hajj pilgrimage this week -- a traveler with MERS could very easily arrive in the USA, Osterholm said.

“The likelihood that this virus will move around the world to another health facility is very real,” Osterholm said.

Yet hospitals today struggle to control even common infections, said Sean Kaufman, a biosafety consultant who previously worked for the CDC and has conducted training at the agency.

According to the CDC, one in 25 patients comes down with an infection while in the hospital. These health care-acquired infections sicken 722,000 Americans a year and kill 75,000.

Georgetown’s Gostin said communities haven’t made much progress in working together. States aren’t required to develop or test disaster plans. Even when such plans are in place, officials feeling political pressure can simply disregard them, Gostin said.

Congress could change that by requiring states to develop and test epidemic plans in order to receive federal dollars, Gostin said.

Many health departments across the USA are struggling with reduced budgets and staffs , Gostin said. While many metropolitan health departments are robust, some in rural areas get by with only a one half-time worker, Gostin said.

Local health departments have lost 51,700 jobs since 2008, according to the National Association of County & City Health Officials.

The Obama administration is spending $351.5 million to help public health agencies and health systems prepare for Ebola.

Hospitals with experience treating Ebola are now training doctors and nurses around the country, said Nicole Lurie, assistant secretary for preparedness and response at the Department of Health and Human Services. Emory and Nebraska Medical Center have each trained hundreds of clinicians.

Lurie worries that the country will forget about Ebola now that the disease has disappeared from the headlines.

“These things recede from the public memory really quickly,” Lurie said. “But if we let our guard down, we’re going to be in big trouble.”

Funding for Emory’s biocontainment unit was in doubt before the Ebola outbreak, Ribner said. “We had a lot of years where it was difficult to come up with enough funding to maintain the unit, especially if we went years without activating it,” Ribner said. “If Ebola had not come along, there is a good chance that I would have had to close my unit this year.”