As an Ebola virus outbreak continues in the Democratic Republic of Congo, healthcare workers in the United States remain at risk of an infected traveler presenting to their ED for care.

Recent trends show the outbreak may be worsening, raising the likelihood that cases may come into the U.S. During the previous Ebola outbreak in West Africa in 2014-2016, two nurses who treated a dying patient at a Dallas hospital contracted the virus but survived. (See Hospital Employee Health, December 2015.)

That outbreak was characterized by a lot of confusion about personal protective equipment (PPE), particularly the finding that healthcare workers frequently contaminated themselves doffing their PPE.

“We learned after Dallas the critical importance of effective PPE,” says Lauren Sauer, MS, deputy director of critical event preparedness and response at Johns Hopkins Hospital in Baltimore. “It’s not just about having the right PPE — it’s about safely putting it on and taking it off. Taking it off is really high-risk, so we need to make sure all providers know how to do that safely and routinely.”

There was the expectation by the CDC, at least at the onset of the last Ebola outbreak in 2014, that individual U.S. hospitals could safely isolate these patients. The CDC went to rapid response teams after the nurse infections in Dallas. National facilities with biocontainment units handled the known incoming cases, which were primarily U.S. caregivers infected in West Africa.

In the aftermath of that Ebola outbreak, the U.S. adopted a tiered healthcare response system, going from frontline hospitals, assessment facilities, and designated treatment centers.

“The idea is that each of these hospitals has different capacities,” explains Jennifer Andonian, MPH, an epidemiologist and program manager of the Biocontainment Unit at Johns Hopkins.

The vast majority of U.S. hospitals are considered “frontline” — which, according to the Department of Health and Human Services,1 means they should be prepared to:

  • rapidly identify and isolate a suspected Ebola patient;
  • notify appropriate facility staff and public health authorities;
  • contact an assessment hospital or Ebola treatment center to coordinate patient transfer;
  • have enough Ebola PPE for at least 12 to 24 hours.

At the next level above frontline facilities, there are 217 Ebola assessment hospitals with the lab capabilities and network contacts to test for the virus. They also are required to have enough PPE for up to 96 hours of patient care in isolation, along with waste-handling capabilities for highly infectious agents. Beyond that, the Ebola hospital network has 63 designated treatment centers, which have the capability to care for at least two Ebola patients for their duration of illness.

In essence, the basic principles of “identify, isolate, and inform” apply from the frontline community hospital to facilities with sophisticated biocontainment units, Andonian says.

“The only way we are going to be able to ensure the safety of our healthcare workers is to start with the initial identification of these patients,” she says. “The [hospital network] system has been in evolution and has really been designed to support that. The general premise is that we all need a baseline level of preparedness.”

A primary reason for this is that infectious diseases have an infamous disregard for borders, international or otherwise. “In today’s interconnected world, diseases can spread from an isolated, rural village to any major city in as little as 36 hours,” the CDC warns.2

“The goal isn’t necessarily just to take care of a single Ebola patient but to protect the healthcare system from that initial impact,” Sauer says. “People should definitely be asking travel screening questions. We have implemented that in our emergency department. There are several high-risk outbreaks right now that warrant travel questions — even if Ebola was not occurring.”

For example, the WHO recently reported another hospital outbreak of Middle East Respiratory Syndrome (MERS) coronavirus in Saudi Arabia that totaled 39 cases and resulted in four deaths.3 Nine healthcare workers were infected with the emerging respiratory virus as a result of exposures in the ED and an ICU in the same hospital. None of the dead were healthcare workers.

“There is Crimean-Congo hemorrhagic fever in Pakistan and a Lassa fever outbreak in Nigeria and a couple of other countries,” Sauer says. “Travel is a really helpful tool when you are intaking a patient.”

The Front Door Is Open

Johns Hopkins is one of 10 designated Ebola treatment centers across the U.S. with “enhanced capabilities” such as designated biocontainment units and other control and treatment measures. Although such facilities are designed in part to accept transferred patients with highly infectious diseases, they also must prepare for a suspect case walking in off the street. In a recent drill at Johns Hopkins, Andonian included the ED and biocontainment unit.

“Realistically, patients don’t show up looking for a biocontainment unit,” she says. “They present through the front door to the emergency department, so we really have to have those ‘identify, isolate, and inform’ processes in place.”

The basic PPE needed is considerable, even for frontline hospitals that will be looking to quickly hand off a patient to one of the Ebola assessment facilities.

The CDC recommendations for possible cases of Ebola in frontline hospitals include such PPE as disposable fluid-resistant coveralls and gowns; a single-use full-face shield; and two pairs of gloves that include one with extended cuffs.4 More extensive measures are recommended if a suspected or confirmed Ebola patient is bleeding or vomiting.5

“PPE is absolutely important as healthcare facilities in the U.S. brace themselves for infectious diseases, whether that is Ebola, viral hemorrhagic fevers, or talking more broadly about airborne transmissible pathogens,” Andonian says.

The repetition of PPE training is a critical aspect of drills, Sauer notes.

“We find with this enhanced PPE we are really retraining our staff’s muscle memory,” she says. “We are training staff so they are confident in their PPE and understand the nuances and the body mechanics of it. Then they will be confident in their ability to work in the PPE and in this environment without contaminating themselves.”

Trained observers assist healthcare workers in correctly removing the PPE.

“If a healthcare worker was to become contaminated, we have training and protocols in place to remediate that depending on the severity,” Andonian says.

For example, healthcare workers involved in the care of Ebola patients can communicate via a mobile phone app to report any symptoms.

“That allows us to send text message prompts for symptom monitoring,” Andonian says. “That is something we do for any healthcare worker who comes into contact with the patient themselves. We apply similar principles if someone had an exposure, depending on how high-risk.”

In addition to a focus on donning and doffing PPE, the Hopkins drill emphasized the importance of avoiding contaminating the patient care area and the surrounding environment in general. The central question, Sauer says, was “How do we remediate and reduce that bioburden in the environment?”

A lot of this is spatial awareness when working within patient rooms, including establishing clean spaces and using mechanical disinfection systems or surface wipes, Andonian says.

Setting up protocols and practicing such measures will bolster treatment and response for pathogens more common than Ebola, she adds.

“These practices really transcend beyond high-consequence pathogens,” Andonian says. “These principles can help identify patients with measles, chickenpox, or tuberculosis. If we can do the basics really well, we should have better systems in place to identify these high-risk but low-probability cases.”


  1. Department of Health and Human Services. Regional Treatment Network for Ebola and Other Special Pathogens. November 2017. Available at:
  2. CDC. Global Health. Available at:
  3. World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV) – The Kingdom of Saudi Arabia. Feb. 26, 2019. Available at:
  4. CDC. Interim Guidance for Preparing Frontline Healthcare Facilities for Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD). Available at:
  5. CDC. Guidance on Personal Protective Equipment (PPE) To Be Used By Healthcare Workers during Management of Patients with Confirmed Ebola or Persons under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE. Available at: