State, local authorities in the driver’s seat for much of the Ebola response

When it first became clear that a hospital in Dallas, TX, had initially missed the diagnosis of Ebola virus disease (EVD) in a patient from West Africa, criticism was swift, not only of the hospital, but also of public health authorities such as the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The heat on federal health agencies grew even more intense when it took days for a clean-up crew to arrive at the patient’s home, and for the loved ones of the patient to be relocated to a safe location while they remained in quarantine for 21 days. However, much of this criticism stemmed from a lack of understanding of how the health system is set up in this country, according to Mark Rothstein, JD, director of the Institute for Bioethics, Health Policy and Law at the University of Louisville in Louisville, KY.

"Public health response is mostly a matter of state law," observes Rothstein. "The CDC has limited jurisdiction. It provides guidance, consultation, laboratory services, and other things, but the CDC is limited to preventing the importation of infectious diseases and the interstate spread of infectious diseases. Everything else is the primary responsibility of the state and the localities."

Further, even within a particular region, there is a variety of different players and actors involved with public health response, including EMS personnel, county public health officials, law enforcement, epidemiologists, and others, notes Rothstein. "The thing that the Dallas episode really demonstrated is that it is unfortunately easy to drop the ball, and the consequences can be very grave," he explains. "We need systems in place and redundancies to make sure [these mistakes] don’t happen again. And I am not necessarily sure that all of the players nationwide would necessarily do better in the next case, and that is a great concern."

Laws differ from state to state

Emergency personnel have an obligation to identify someone who presents with EVD, isolate the person, and immediately notify public health authorities, but then local and state public health authorities need to take the next steps, explains Rothstein. "They have to engage in contact tracing, perhaps with the help of the CDC; they then need to make sure that people who need to be quarantined are in fact quarantined, and to obtain orders to quarantine if people indicate that they are not going to obey the quarantine," he says.

It is also the responsibility of state or local authorities to arrange for a bio-hazard crew to clean up an area that may put the public at risk, to arrange for the monitoring of people who are under quarantine to ensure that someone who shows signs of having EVD is immediately identified, and to make sure that people who are under quarantine receive needed food, medicine, or other services, explains Rothstein. "There are a lot of details that need to be worked through, but these are not the responsibility of the hospital or the ED after they do those first basic steps," he says.

Still, each state has different laws governing how and when emergency personnel should contact public authorities. "For instance, in some states there is an obligation to report all gunshot wounds. In every state there is a responsibility to report cases of suspected child abuse. When you get to infectious diseases, the schedule for how soon you have to report them depends on what the disease is," says Rothstein. "With something that is so contagious or where mortality is so high [such as with EVD], immediate notification should be second-nature to emergency folks."

The patchwork of differing state laws has become particularly evident with the range of policies being employed with respect to the quarantining of health care workers returning from West Africa. Some states, including New York, New Jersey, and Connecticut, are requiring 21-day quarantines for all returning health care workers, regardless of whether they have any potential symptoms of EVD. Such policies go well beyond what federal health authorities recommend. In fact, officials are concerned that such policies will discourage health care workers in this country from volunteering their time to fight the epidemic in West Africa, thereby increasing the risk to Americans. Further, health care workers themselves are strongly critical of such measures.

In an effort to make such policies more uniform and consistent with the science regarding EVD, the CDC has unveiled guidance for the "Monitoring and Movement of Persons with Ebola Virus Exposure" that is based on five risk categories, but as Rothstein explains, the agency cannot force states or localities to follow the recommendations. (See CDC’s guidance for returning health care workers here: http://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html.)

Dallas episode offers lessons

While it is clear that the public health response to the initial case in Dallas was not optimal, other communities can learn from these early missteps. "I am hoping that the experience with the Dallas situation is the alarm bell that other folks around the country are hearing," observes Rothstein. "Sometimes you need something like this to shake the complacency of the system."

The lessons should apply well beyond the current Ebola outbreak, but Rothstein is concerned that the focus on preparedness will fade when the public health risks from EVD in this country subside. "In 2004, my institute and I were asked to do an assessment of the lessons learned from the SARS [Severe Acute Respiratory Syndrome] epidemic, and we concluded that we were just not ready for this. We don’t have in place the necessary surge capacity in hospitals," he says. "If we had a pandemic flu situation, which would require many more hospitalizations than Ebola is likely to require, many more people would be needing respirators, and they just weren’t there."

During the 2004 exercise, investigators found that hospitals in some other countries had entire floors equipped with beds and equipment that they were not allowed to use unless there was a declaration of an emergency, at which point administrators could just turn on the lights, explains Rothstein.

"We don’t have that. We’ve got lots of hospitals, but they are 70% occupied, so it is not clear that we have all the facilities ready to go, and it’s certainly not clear that the needed coordination is in place," says Rothstein. "The greatest challenge of the American health care system is that it is very fragmented and legal responsibility rests with the federal government, the state governments, the county governments, municipal governments, and then in various agencies across the board. It is not always clear who is calling the shots. If we work it out, that would be the best response that we could have to this Dallas episode."