On the Front Lines: A Look at How States are Preparing for an Ebola Response
Before Ebola dominated U.S. news media or the first American citizens contracted the disease in West Africa, state and territorial health departments were mobilizing to respond to imported cases. For months, they've been creating Ebola guidelines and algorithms for their healthcare facilities and providers, collaborating with their West African populations, and communicating with the public about the disease and how to prevent an outbreak.
States have been building their public health preparedness capabilities for years thanks to investments made in the area since 9/11, according to Connie Jorstad, director of emerging infections at ASTHO. Many health departments run drills for pandemics, which provide lessons for other outbreak responses.
Texas is the first state to receive an imported case. On Sept. 30, CDC announced that Thomas Eric Duncan, a Monrovia resident who was visiting family in Texas, had been diagnosed with Ebola in a Dallas hospital. Duncan passed away on Oct. 8. Although he was initially released from the hospital after his first visit, the hospital alerted the Texas Department of State Health Services (TX DSHS) about his symptoms and travel history during his second visit.
After TX DSHS learned about Duncan, it tested him and confirmed that he had Ebola. It then began contact tracing, using disease detectives who identified everyone who came into contact with Duncan when he was contagious and determining the likelihood that they had been exposed to Ebola. They initially screened 100 people in early October and by Oct. 13, had narrowed down the list to 11 people who had definitely been exposed to Ebola and 38 who had possibly been exposed. In addition to monitoring those total 48 contacts for the 21 days during which Ebola can develop, TX DSHS ordered Duncan's family to stay home in quarantine. Because Ebola patients are especially contagious after death, the state health department coordinated his cremation according to CDC procedures to prevent further infections.
A nurse who treated Duncan became the first case of Ebola transmitted in the United States. The transmission's causes are being investigated, and updated protocols on how hospitals should treat infected patients are being developed and communicated.
"This is a serious issue, but the risk of a widespread Ebola outbreak in the United States remains very low," says James Blumenstock, ASTHO chief program officer of public health practice. "Healthcare and public health are in this fight together. We will continue to anticipate, learn, and adapt, and we are committed to protecting healthcare workers and the public."
In states and territories that haven't yet received an imported case, health departments are readying their healthcare partners and building their Ebola response capacity. The New York State Department of Health and New York City Department of Health and Mental Hygiene worked together to produce Laboratory Guidelines for Handling Specimens from Patients with Suspected or Confirmed Ebola Virus Disease. The Guam Department of Public health and Social Services and Guam International Airport Authority are planning to convert one of the airport gates into an isolation unit in case the territory receives potential Ebola cases. The Tennessee Department of Health sent a letter to universities and colleges on how to address possible Ebola cases among students, as well as published several tabletop exercises for healthcare providers and facilities on its Ebola resource page.
These preparations have been especially critical in states with large West African populations, such as Minnesota and Rhode Island, where residents often travel back and forth between their homelands. Both states have set up incident command systems, an organizational system approach designed to help manage emergency responses.
"We have a Liberian population of about 15,000, so we watched Ebola closely as the situation evolved," says Michael Fine, director of the Rhode Island Department of Health (RI HEALTH). "I've also spent some time in Liberia, so I understand the situation on the ground—the health infrastructure—and that probably made me conscious early on of what was coming at us."
RI HEALTH is working closely with its Liberian community to prevent Ebola transmission in the state and back in Liberia. On Oct. 5, Fine met with hundreds of Liberians in a town hall-style meeting in a local church. During the event, he answered questions about Ebola, collaborating with the pastor and deacons—some of whom have lost family members to the disease. He also encouraged attendees to talk to their loved ones back in Liberia about the disease.
To help further educate Liberians about how to avoid Ebola, RI HEALTH has partnered with its local United Way and Fox News affiliates to start a campaign that allows members of the Liberian community to call friends and family members in Liberia to teach them about Ebola. This accomplishes two goals, according to Fine: (1) some Liberians are skeptical of health workers and are more likely to take advice about the disease from someone they trust; and (2) when members of Rhode Island's Liberian community learn these messages and share them, it also ensures that they retain them.
"We have been expecting some imported cases of Ebola into the United States, but we are ready," Fine told a local news station earlier this month. "We've been working on this since the summer. Our hospitals are ready, our primary care physicians are ready, our EMS is ready. Everybody's been looking out, paying attention, and being aware."
Four Tips on Ebola Preparedness for Health Departments from Rhode Island Department of Health Director Michael Fine:
- "Make sure that you know your West African community," says Fine. "We know people, we know places, we know where the community is, we know the churches." These are potential outlets for communicating with at-risk populations.
- Develop detailed information for the practicing community, including emergency dispatch, EMS, primary care and health centers, and hospitals. If your department needs assistance, Fine says that they can refer to RI HEALTH's materials.
- Study Ebola situation maps. "We look at WHO's maps almost on a daily basis. Most of the risk in the United States will be a function of the situation in West Africa. As numbers grow, the population pressure will increase," says Fine.
- Pay attention to airports and other ports of entry, including migration by sea. Thanks to RI HEALTH's close ties with its Liberian community, it's aware of incoming flights and a bimonthly cargo ship that arrives at a port in the state every two weeks.
The department has also been communicating about Ebola with the state's healthcare facilities and providers for three months. In July, it began disseminating information about Ebola through its electronic publication, which reaches about 50,000 healthcare workers. In August, it released a health advisory for EMS workers who have come into contact with a possible Ebola case, advising them to make sure they take travel histories, learn to recognize symptoms, use personal protective equipment, and alert hospitals during transportation about a possible incoming case.
Like Rhode Island, the Minnesota Department of Health (MDH) has been holding public information meetings to address Ebola concerns. Minnesota also had the opportunity to test its hemorrhagic fever preparedness in March when it received an airplane passenger who had Lassa fever, which spreads similarly to Ebola. The patient was treated at a Minnesota hospital and no one else was infected.
"This is what public health does whether there's an Ebola outbreak or not," says Kathy Talkington, ASTHO's senior director of immunization and infectious disease. "No matter what the outbreak of the day, this is why it's so critical to have public health infrastructure to work with the private sector, communicate with healthcare and public, and conduct contact tracing and monitoring."
ASTHO has an information page on Ebola geared specifically to states and territories that can be found at www.astho.org/Ebola.