Ebola Preparedness - Lessons Learned from 2014

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: public health on alert as the Ebola outbreak expands in Uganda; and lessons from 2014 when the Ebola virus made its way to Dallas, Texas.

DAVID LAKEY:
I remember very clearly getting the phone call from the local epidemiologist telling me, "Now, you've had several cases, but this guy's different. There's something different about him. This guy's sick, and there's this significant inflammatory response that's taking place."

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we're thinking about the Ebola outbreak that began in Western Africa nine years ago and the connection to a series of cases reported in Dallas in 2014. What can we learn from the Texas response as we watch what's happening today in Uganda?

Dr. David Lakey was commissioner of the Texas Department of State Health Services when Thomas Eric Duncan came to the state in 2014 after a trip to Liberia.

LAKEY:
He started feeling poorly about five days later, after his arrival to the state of Texas, and went to an emergency room up in Dallas Presbyterian Hospital, Texas Presbyterian Hospital. And after that evaluation, he was sent home.

In retrospect, he never told anybody—and I would say no one ever asked—whether he had recently traveled and whether he had any exposure. But he was sent home, and over the next several days started feeling worse.

And so, on the 28th of September, Mr. Duncan arrived by an ambulance to the same hospital, and at this time it was very clear that things were different. There was a variety of laboratory tests that were very clear that there was a significant inflammatory response occurring in his body. His liver function tests were very high. There was a variety of other signals. And at this time, they figured out that Mr. Duncan had been traveling and had come recently from Liberia.

And so, he was admitted to the hospital. And I remember very clearly getting the phone call from the local epidemiologist telling me, "You know, you've had several cases, but this guy's different. There's something different about him. This guy's sick, and there's this significant inflammatory response that's taking place."

And so, we've very quickly had samples—his blood samples—sent to both the CDC and to our public health laboratory. And over a matter of a couple of days, those tests came back positive and Mr. Duncan did indeed have Ebola. And that set off a cascade of events that occurred very quickly as we responded to this unique case in the United States—a very frightening case 'cause all of America has been watching these cases in Liberia and how deadly it had been, and a lot of angst and concern in the general population related to how we were going to respond to Mr. Duncan in a compassionate way that would also protect the health of the population.

JOHNSON:
So, you got a call saying this case was different. Did you have any idea then that you were dealing with Ebola?

LAKEY:
We were worried. You know, again, it's unique to think that you have the first case of Ebola or any other major consequential disease in your area of responsibility. But again, we knew that this could be coming and there were all these hallmarks related to his case. Again, the travel, the liver function tests, the high fever—a variety of things that told us that this was different and that we needed to be expecting that he indeed could have Ebola and be the first patient.

JOHNSON:
And then when the test results came back positive, what was your thinking at that point?

LAKEY:
Well, we realized very quickly that we had a major event on our hands. And you know, thank goodness this occurred near the end of my tenure.

I had been commissioner at that time for almost eight years and had significant ties with the CDC and the ASPR and a variety of other high-level officials that could help guide us through this event—maybe guide us as a little too strong of a word—that could work with us through an event like this.

Texas is a home rule state; and so, as a home rule state, the local jurisdiction is responsible for the management of any major event. But it was clear that Dallas County needed some additional help, and thus I became very involved. You know, I—basically the next day—was in Dallas for a press conference and that day helped set up an incident command structure in which I ended up being right in the middle of. And over the next month, basically lived in Dallas in hotel rooms—a variety of hotel rooms—as we managed this together with our local partners.

JOHNSON:
How important was coordination during all of this?

LAKEY:
Yeah, I think coordination is extremely important in any type of an event like this. And again, as I noted, by this time I had been involved in several events going from H1N1 to major hurricanes to a variety of other events.

And you really need to have a coordinated response or, you know, the left hand doesn't know what the right hand's doing and you fail the public because you have misinformation that is spread. And for an event like this where everyone is extremely nervous, where you basically have every media organization in the nation descending on Mr. Duncan's apartment and then the community, you have to be able to speak with one voice.

And so, we set up an incident command structure where we worked in partnership with the local leadership. The mayor of Dallas, Mayor Rawlings, the county judge Clay Jenkins, and myself as a team put a incident command structure in place so we knew who was going to speak to the media, how we were going to speak, what was our talking points as we're also making sure that we were coordinating with our partners.

Making sure that we very quickly figured out how to relocate the people that were living with Mr. Duncan. How do you identify all the contacts that Mr. Duncan has had—over his initial part of exposure, and then with the ambulance ride and all the healthcare workers—identifying all those individuals.

Getting the paperwork done related to decontamination—you have a large number of items in an apartment that have to be disposed of properly, you have to get the right paperwork, you have to identify entities that will take care of that. The stuff—you know, again, that can range from clothing to couches to just a variety of things—all has to be disposed of properly.

Figuring out what kind of medicines, what do the best scientists in the nation think are possible medical options for Mr. Duncan. You know, how do you—how are you going to take care of his body if he dies? You know, how are you going to cremate the body? 'Cause you know, we felt very passionate that we didn't want a body with Ebola in it accessible to anybody. And so, how do you work through the processes of cremation? Just a variety of factors.

And I'm not going through all of those right now, but it's very complex and you have to have an organized structure, make sure you know who's going to speak what, how we're going to do that in a coordinated fashion.

And actually one of the things we had to stop early on was that there were people in the EOC that wanted to tweet out, you know, different decisions at different times. And we had to stop that because that was causing confusion, and we needed to work through and have coordinated speaking points, coordinated message at any time.

You know, part of that was on a daily basis. We'd have meetings with the leaders here, plus the CDC. We would have daily briefings with the national media and we needed to make sure, again, that we were organized in all those communications.

JOHNSON:
So, here we are again—cases now being reported in Uganda and concern about Ebola traveling outside the country, off the continent of Africa.

What came to your mind when you heard about this latest round of infections overseas?

LAKEY:
It was very reminiscent of 2014. Again, watching what was going on in another continent, that feeling that that's very far away; but then knowing that just one flight can bring somebody that doesn't know that they're exposed or knows that they're potentially exposed but that won't tell you—that individual can be in the United States within 24 hours and disappear into a local community very, very quickly.

So, the issues of making sure hospitals are prepared: those questions about travel history are really important, and measuring a temperature for somebody that has recently traveled is really important.

And one of the things we did during the response was, you know, we were initially not screening anybody nationwide unless they had a temperature of over 101.5. And we decided, you know, that was too high in the midst of this event. And we started screening anybody with a blood test, anybody that had the criteria that had that temperature of over 100.5. You know, I think you have to become a little bit more diligent related to those screening protocols.

I think it's important that people map out how they are going to get blood tests to their laboratories and make sure their laboratories are able to do this. Understand that there's going to be a lot of patients with malaria, again, a lot of patients with other medical conditions that are going to be a lot of rule outs. But you have to have a pretty stringent filter right now to make sure you don't miss one of these cases 'cause they're very intense to take care of.

Because, as I noted earlier, you know, some of that public messaging in 2014, in the summer, was that any community hospital can take care of a patient with Ebola. I think that's false. You know, we learned that it was false 'cause this was a very good hospital and people forget that hospitals in the United States are very different in what we can do than in African hospitals—the central lines, the innovative treatment that takes place.

And Mr. Duncan had a tremendous amount of diarrhea and a variety of other body fluids that were released, and with that the potential for exposure was significantly higher. We had two nurses that ended up being infected—and they were wearing the proper PPE, but something happened where they got exposed.

I think that was another thing that potentially we did right, is that, you know, we watched all the healthcare workers very closely and as soon as any of them that had potentially been exposed had any temperature—and these two nurses only reached 100.5—we got them in, isolated them, and started the best medical therapy possible on those individuals early. And they did well, those two nurses survived. And again, there's a lot of media about them, but they did well.

And so, you need to sharpen your game, figure out where are you going to care for these individuals. All hospitals have to be ready to screen. Once the screen comes back positive, where are you going to treat these individuals? Do they have the equipment, the personnel, the expertise to do it right? Because you really don't have an opportunity to make a mistake because other individuals will get infected if you do.

JOHNSON:
What advice do you have for your colleagues in public health about preparing in the event one of these cases in Uganda ends up here?

LAKEY:
Well, I think their role is to make sure the hospitals are preparing and making sure the laboratory is ready. Think through who's going to be communicating this information and making sure that the governor's office is not going to get surprised with the response.

And make sure that your emergency managers know what the role of public health is versus emergency management. Again, this is different than the hurricane response and some of those other type of responses I was involved in, and this was a major public health response. And you need to be ready to be all in and be able to mitigate the potential for the virus to be spread to others.

Again, I think making sure that there's coordination across your hospital to make sure they know what their responsibility is and what it's not—and that's going to vary from one state to another. But if somebody comes down with Ebola, how are you really going to care for that individual? And not ivory tower talk, you know, not hypothetical talk—how are you really going to do this? And who's going to be the spokesperson? What are your messages? How are you going to communicate? All those things need to be mapped out now.

JOHNSON:
And you would be doing all of this, even though what we've heard so far is the cases are contained in Africa?

LAKEY:
I think you need to be ready. And so, you have to have somebody that knows the details and is following it very closely, that knows all the variables you need to be ready for.

We thought we were ready. But again, there's nothing like actually doing it to realize that there's a lot of little nuances that you need to be ready for. How are you going to decontaminate an apartment? How are you going to relocate a family to some place when every apartment, everybody doesn't want that individual in their house 'cause they're afraid of the media and everything else that's going on?

The stuff that's going to be decontaminated—if it's going to be burned, where are you going to burn it? And I bring that up because that was a big deal for us and it was for the hospital. They had a plan on how, you know, these big barrels of stuff—again, it's clothing, cushions, et cetera—where it was going to be incinerated. And the entity that was going to do that for them said no, and so we needed to scramble around and find another entity, which ended up being one of the University of Texas institutions, UTMB, and they incinerated that.

But it was interesting as we watched the other cases. This wasn't the only case, this was the first case. But those other cases in the United States, they actually had their stuff, these barrels incinerated here in Texas at UTMB because they couldn't find anyone else in the United States that would do that. And so, it became a big scene of following these trucks across convoluted lines across the United States, 'cause some states wouldn't let the barrels pass through their states and others would.

And there's all these type of nuances that you need to start thinking through and game out, so to speak, to make sure that you're ready and know how you'll take care of the event.

JOHNSON:
Last question. How would you characterize this moment in your career as a public health professional?

LAKEY:
Well, it was clearly the most visible role that I had. I knew things had changed when, at the end of one of our long days, I walked into a McDonald's to grab something to eat late with a group, and the people standing in line looked at me and knew who I was and asked me if I was David Lakey.

And so, things elevated very, very quickly and that's different than many of the other events that I had had been involved in. A lot of people have asked about, like we're doing today, to talk about the event.

It got a lot of publications. You know—as I joke during games with other people of True or Not True—when I tell them that I was, you know, in a picture in Vogue Magazine, no one believes that. But actually it happened, and several of the epidemiologists in Dallas were, too.

It's just, and I only say that to say that it was a different level of just scrutiny and visibility than anything else I had really been involved in, including Hurricane Ike and H1N1. It just... it was extremely intense and you just need to be ready for that and figure out what you can say yes to and what you can say no to as you tried to really manage it.

You know, during that time period, I could have been on radio stations or national news pretty much consistently every day because of the intensity, and we just said, "No, we can't do that." 'Cause we needed to take care of business and have other people do that while we made sure that the people of Texas were safe.

JOHNSON:
Thanks for listening to Public Health Review.

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This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.