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Public Health Resilience Checklist for High-Consequence Infectious Diseases—Informed by the Domestic Ebola Response in the United States

Sell, Tara Kirk, PhD; Shearer, Matthew P., MPH; Meyer, Diane, MPH; Chandler, Hannah, BS; Schoch-Spana, Monica, PhD; Thomas, Erin, PhD; Rose, Dale A., PhD; Carbone, Eric G., PhD; Toner, Eric, MD

Journal of Public Health Management and Practice: November/December 2018 - Volume 24 - Issue 6 - p 510–518
doi: 10.1097/PHH.0000000000000787
Research Reports: Research Full Report

Context: The experiences of communities that responded to confirmed cases of Ebola virus disease in the United States provide a rare opportunity for collective learning to improve resilience to future high-consequence infectious disease events.

Design: Key informant interviews (n = 73) were conducted between February and November 2016 with individuals who participated in Ebola virus disease planning or response in Atlanta, Georgia; Dallas, Texas; New York, New York; or Omaha, Nebraska; or had direct knowledge of response activities. Participants represented health care; local, state, and federal public health; law; local and state emergency management; academia; local and national media; individuals affected by the response; and local and state governments. Two focus groups were then conducted in New York and Dallas, and study results were vetted with an expert advisory group.

Results: Participants focused on a number of important areas to improve public health resilience to high-consequence infectious disease events, including governance and leadership, communication and public trust, quarantine and the law, monitoring programs, environmental decontamination, and waste management.

Conclusions: Findings provided the basis for an evidence-informed checklist outlining specific actions for public health authorities to take to strengthen public health resilience to future high-consequence infectious disease events.

Johns Hopkins Center for Health Security, Baltimore, Maryland (Drs Sell, Schoch-Spana, and Toner, Mr Shearer, and Mss Meyer and Chandler); Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Drs Sell, Schoch-Spana, and Toner, Mr Shearer, and Ms Meyer); and Office of Public Health Preparedness and Response, US Centers for Disease Control and Prevention, Atlanta, Georgia (Drs Thomas, Rose, and Carbone).

Correspondence: Tara Kirk Sell, PhD, Johns Hopkins Center for Health Security, 621 E. Pratt St, Ste 210, Baltimore, MD 21202 (tsell1@jhu.edu).

This work was supported by the Centers for Disease Control and Prevention (CDC) through research contract 200-2015-M-87759. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention.

The authors acknowledge Ryan Fagan, MD, and J. Todd Weber, MD, of CDC's National Center for Emerging & Zoonotic Infectious Disease (NCEZID) for their expert review and helpful input on this article.

The authors declare no conflicts of interest.

During the 2014-2016 West Africa Ebola virus disease (EVD) outbreak, patients with EVD were treated in 5 US communities.1–5 These communities represent the few locales that have experienced an active response to a high-consequence infectious disease (HCID) event in the United States. Although infectious disease events vary and present unique challenges, the lessons learned from the domestic response to confirmed EVD cases may improve preparedness and increase resilience to future HCIDs.

Beginning in August 2014, a total of 11 cases of EVD were treated in the United States. The first 2 patients were diagnosed overseas and returned to the United States for treatment in a specialized treatment and containment facility at Emory University Hospital in Atlanta, Georgia.3 Additional repatriated patients were later treated at Emory; the University of Nebraska Medical Center in Omaha, Nebraska; and the National Institutes of Health Clinical Center in Bethesda, Maryland.4 , 5 These facilities maintained specialized containment facilities established years previously. They provided treatment and supportive care since the patients they received were diagnosed elsewhere.

Two other communities—Dallas, Texas, and New York, New York—treated patients who were diagnosed locally. Texas Health Presbyterian Hospital Dallas was the first medical facility to treat a previously unidentified case of EVD.1 A number of resulting emergent issues provided important lessons for the future. NYC Health + Hospitals/Bellevue treated a patient who provided medical care to EVD patients in West Africa. Upon his return to the United States, he self-monitored for EVD symptoms and informed health authorities immediately upon registering a fever.2 Bellevue developed a special pathogens unit in preparation for the potential arrival of an EVD case in New York, but it did not have a unit specifically built for biocontainment purposes.6

Together, members of the health sector in these responding communities provide a unique perspective on the limited examples of resilience—that is, the ability to withstand, recover from, and evolve—in the face of HCIDs. Existing accounts of the domestic responses to EVD have shown the need for improvements to future HCID events.7–10 Researchers and medical teams have published a number of descriptions of hospital response to EVD.4 , 11 , 12 However, studies focusing on the implications of the response for public health are limited.13–15

This research was intended to gather important lessons from the communities that responded to confirmed cases of EVD and draw out recommendations for future HCID events. These recommendations have been developed into an evidence-informed checklist that outlines specific actions for public health authorities, in partnership with government, nongovernmental organizations, medical facilities, private industry, and other stakeholders, to strengthen resilience to HCID events. They are intended to complement, not replace, existing guidance developed and issued by the US Centers for Disease Control and Prevention (CDC).16 This article focuses on resilience of the public health sector and directly related entities only.

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Methods

Review of traditional media, available after action reports, and peer-reviewed literature was performed to orient the research, identify prospective interview participants, and inform interview themes (eg, risk perception; health care; and local, state, and federal response). Key informant interviews were conducted between February and November 2016. Purposeful sampling was used to select and identify individuals who were especially knowledgeable about the Ebola response. Inclusion criterion was participation in EVD planning or response in Atlanta, Georgia; Dallas, Texas; New York, New York; or Omaha, Nebraska, or had direct knowledge of response activities. After identifying an initial set of interviewees, snowball sampling, in which study participants identified other responders who could provide a rich description of the Ebola response, expanded the sample. The sample was evaluated periodically to ensure a range of perspectives from each locale. A subset of the authors reached consensus on the addition of each interviewee. A total of 181 individuals were contacted via e-mail or telephone, and 73 individuals (Atlanta—17, Dallas—22, New York—13, Omaha—18, and CDC—3) were interviewed via telephone (Figure). Participants represented health care; local, state, and federal public health (including CDC and Federal Bureau of Prisons); law; local and state emergency management; academia; local and national media; individuals affected by the response; and local and state governments in communities that responded to confirmed cases of EVD. A semistructured interview outline was developed on the basis of literature and prior knowledge of the research team. Interviews were recorded, transcribed, and qualitatively coded using NVivo qualitative analysis software.17 In addition, 2 focus groups with previously interviewed individuals were conducted in Dallas (N = 4) and New York (N = 7) in December 2016 and January 2017, respectively, to investigate interview themes from each locale in more depth. Study results were vetted by an expert advisory group, assembled in January 2017, consisting of infectious disease subject matter experts (N = 12) and select study participants (N = 5). Study participants offered a range of comments, including accounts from the EVD response and recommendations for future events (Table 1). Results from each phase of the study were used to inform the development of checklist items. This methodology has been used previously to study other public health threats.18 , 19

FIGURE

FIGURE

TABLE 1

TABLE 1

This research was designated “exempt” under §45 CFR 46.101(b)(2) by the University of Pittsburgh institutional review board and determined to be “nonresearch” by the CDC Human Research Protection Office. This study was supported by federal funding through contract 200-2015-M-87759 “Health Sector Resilience Checklist for Highly Infectious Diseases.” Study findings related to health care and emergency medical services are described elsewhere.20 , 21

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Findings

Governance and leadership

Across all 4 communities, participants noted that the response chain of command (eg, via the incident command system), with a single designated leader at each level (eg, facility, local, state) was critically important to ensure that responders, the public, and the media knew who was in charge. Participants further indicated that strong coordination and communication between health care and both local and state health departments was vital for the response. Participants also stressed that senior local government officials should be prepared to play a visible role in the response even if they are not the Incident Commander, since they considered the personal relationships, influence, and understanding of available resources to be invaluable. Further highlighted as an important ingredient for success was a clear understanding of relevant federal, state, and local roles that ensures the inclusion and integration of all stakeholders, including public health, in a unified cross-sectoral response effort.

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Communication and public trust

Many participants noted that fear of the unknown, particularly when coupled with changing or conflicting information, may trigger unintended responses from the public. Interviewees reflected that the political, social and traditional media, and social environment in which the domestic Ebola response occurred required robust information campaigns and public outreach by trusted and influential community leaders and experts to mitigate acute fear, rumors, and stigmatization of some affected populations (eg, patients, clinical staff, and their families). Participants commented that efforts to communicate transparently and build trust through multiple communication approaches were important in improving the response, even if not always completely successful.

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Programs monitoring potentially affected individuals

Because of the pathology, symptomology, and epidemiology of EVD, many individuals identified as being at risk for exposure to Ebola virus were monitored by public health for the onset of EVD symptoms and to reduce the need for quarantining these individuals. Multiple study participants reflected on the fact that the monitoring programs used during the domestic Ebola response required extensive resources to implement. Study participants stressed that successful monitoring programs require the development of a relationship between public health and the person under monitoring. They noted that initial face-to-face meetings facilitated the development of trusted relationships, and provided an opportunity for public health officials to explain monitoring requirements and for monitored individuals to ask questions. Although considered an appropriate and beneficial approach for successful monitoring, participants explicitly noted the incredible burden this process placed on their limited time and resources. Participants noted that although funding restrictions often limit the number of staff that can be made available for monitoring and for a large public health response, surge capacity and the ability to track resource use are vital.

Study participants commented that some individuals under monitoring may require assistance to participate in required check-in activities. They reflected that, while cell phones provided to monitored individuals during the domestic Ebola response were costly, many individuals under monitoring, particularly those without a strong local network of family and friends, needed this resource to successfully report to local public health authorities. Study participants cited online systems, phone applications, video chats (eg, Skype and FaceTime), and other technology-enabled monitoring systems as ways to reduce the workload on public health. In addition, interviewees noted that these mechanisms can limit intrusion on monitored individuals' lives and provide them with a sense of greater control. Several also commented that safeguards are required to ensure data security, particularly for medical data and personally identifiable information, and to prevent false reporting of data by monitored individuals.

Study participants noted that monitoring programs during the domestic Ebola response required significant coordination with federal partners and neighboring jurisdictions. Travelers crossing into and between jurisdictions required local, state, and federal authorities to coordinate closely to identify monitored individuals and transfer appropriate data and responsibility. Furthermore, monitored individuals occasionally resided outside of a typical community setting (eg, homeless and incarcerated populations), requiring coordination with a variety of nontraditional public health partners. For instance, participants commented that incarcerated individuals who required monitoring posed unique challenges due to their prolonged close contact with others, potential lack of cooperation by inmates, limited on-site clinical and isolation capabilities, and requirements for patient escort (potentially including armed escort). In addition, a few participants noted that corrections officers have little or no training in infection control practices, and they noted that officers may be unwilling to interact with monitored or symptomatic individuals. Close coordination with local emergency medical services and health care facilities was also needed to facilitate transfer to appropriate medical facilities as necessary.

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Quarantine and the law

Participants highlighted the importance of understanding the scope and limitations of quarantine laws as well as the processes and mechanisms for implementing and enforcing these laws prior to the onset of an event. Participants also noted that scalability is a major challenge for quarantine operations since public health officials often assumed responsibility for the care of affected individuals while in quarantine. They noted that individuals subject to quarantine require food and drink, clothing (appropriate for varying religions and personal needs), shelter, privacy and security, the ability to communicate with family and friends, and mental health support, and they may additionally require clinical care for unrelated medical conditions, recuperation of lost wages, assistance with child/elder/pet care, and/or legal counsel.

Interviewees also indicated that the use of quarantine requires coordinated planning and response across multiple entities outside the traditional scope of public health. For instance, interviewees reported that local law enforcement was often required to provide security, both to ensure compliance with quarantine orders and to protect individuals under quarantine. In addition, they noted that coordination with emergency medical services and the health care system was also necessary in the event that a quarantined individual became symptomatic and required transport to a treatment or assessment facility.

Several participants commented on the importance of due process with respect to quarantine activities and explicitly noted that caution should be taken to avoid unnecessarily infringing on individuals' civil rights. Although public health provided a range of support services, a limited number of participants indicated that it was difficult for quarantined individuals to challenge quarantine orders expeditiously. Participants noted the need for legal expertise, both to support public officials in the implementation and enforcement of quarantine laws and policies and to ensure that appropriate legal counsel is available to quarantined individuals. This counsel was envisioned to protect the rights of affected individuals throughout the quarantine process and ensure that they are afforded due process, including their right to challenge issued orders.

Several study participants described the use of “voluntary” quarantine as a means of avoiding the use of mandatory quarantine orders. While some participants highlighted this approach as a way to expedite and simplify quarantine processes for public health officials and model a cooperative approach to epidemic control, some drawbacks were noted. For instance, 1 quarantined participant noted that for an individual who consents to voluntary quarantine but later believes the quarantine to be unjust, the process by which to challenge the “voluntary” quarantine without significant stigma and public backlash is unclear.

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Environmental decontamination

Environmental decontamination of buildings and objects that had potentially been contaminated with Ebola virus also proved difficult for public health during the domestic Ebola response. Participants noted that in situations in which scientific evidence surrounding transmission and safety may not be clear, expenditures on decontamination can become extraordinary and the number of willing and decontamination-qualified contractors scarce. They highlighted the importance of pre-event planning, recognizing that authorities and contractors must continually seek out the authoritative guidance for different pathogens and be alert for potentially changing guidance during an event. Many participants commented that the decision to engage in decontamination activities should be based on scientific evidence and that overly aggressive actions taken “out of an abundance of caution” can undermine science-based policies in the rest of the response.

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Waste management

During the domestic Ebola response, participants highlighted waste management as one of the most vexing and difficult problems to overcome. Care for Ebola patients generated enormous amounts of hazardous sewage and solid waste that was difficult to dispose of under preexisting plans and procedures. Participants noted that although hospital facilities have a primary role in determining how to manage this waste, public health plays an important role in planning for waste handling, transportation, and storage. When interstate transportation of waste was required, multiple states, the Environmental Protection Agency, and other organizations needed to be involved to coordinate response operations. Participants noted that, in the case of the Ebola response, communicating about these plans, including hospital wastewater sanitation, with the media and the public was necessary to address public fears.

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Discussion

This research was performed to inform the development of a resilience checklist for state and local public health entities with the responsibility for preparedness and response to an HCID event.8 Checklist recommendations relevant to public health are described in Table 2.

TABLE 2

TABLE 2

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Governance and leadership

Response to an infectious disease outbreak is greatly influenced by the governance structure of a specific municipality or state, and these differences often determine lines of communication, authority, and responsibility. Public health has an important role to play in the management of an HCID, as do local leaders. Checklist items in this section reflect participant statements highlighting a need for clear leadership and coordination across a range of stakeholders.

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Communication and public trust

Public trust is key to a successful infectious disease response, but it can be easily lost due to poor communication. Ebola virus disease generated a high level of attention from the news media and concern among the public.22 , 23 Often, the most effective responses to such events involve organizations and officials who have built up stores of public trust through “good neighbor” policies in advance of an event and thus can retain public confidence and receive the benefit of the doubt by the community.24 , 25 In this instance, 2 of the studied facilities with biocontainment units had engaged the local community and media prior to the Ebola response and, as a result of this prior open relationship, enjoyed better support during the response. Checklist items in this section are geared toward practices that increase public trust through improved communication and engagement.

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Programs monitoring potentially affected individuals

Monitoring efforts proved to be a significant burden on public health officials and reflect existing accounts of the response.26 , 27 Although these endeavors may reduce the need for quarantine, they are time consuming and difficult, requiring the effort of many individuals who may have other responsibilities, especially during a large-scale infectious disease event. In a future HCID event, monitoring programs are likely to be implemented and, as a result, checklist items in this section are geared toward improving and streamlining future practices.

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Quarantine and the law

During the domestic Ebola response, quarantine was used in an attempt to reduce potential risks to the public. However, the use of quarantine was a nuanced practice that was often situation dependent. Public health laws are the foundation for quarantine and isolation orders, but these laws are complex and differ among jurisdictions.28–30 In addition, the provision of services to individuals in quarantine may be manageable when overseeing the quarantine of a few individuals, but they may quickly exceed local capacity as a greater number of individuals are placed under quarantine. Furthermore, comments from a few participants highlight the need for additional research on the practice of using mandatory quarantine versus voluntary quarantine. Checklist items in this section are intended to ensure consideration of public health laws, the needs of public health practitioners, the desires of the public, and the experiences of those who are quarantined.

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Environmental decontamination

Environmental decontamination was an important component of the public health response to EVD. However, with little guidance in existence, environmental decontamination practices grew costly and some may have been unnecessary. Private citizens and business owners may engage in additional decontamination efforts on their own, but public health and government should not take responsibility for activities that go beyond decontamination efforts supported by science. Checklist items in this section aim to support a measured approach to environmental decontamination in the event of an HCID.

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Waste management

Waste management represents an area that previously received little recognition as a potential concern; yet, in the Ebola response, waste management was a concern in some cases. Checklist items relate to a need for careful planning around HCID waste management and reflect existing accounts of the Ebola response.11 , 31

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Limitations

Although efforts were made to ensure robust and generalizable results, included locales may not be representative of other settings. In addition, the period of time (1-2 years) between events of interest and research interviews may introduce recall bias. Furthermore, the study sample was designed to achieve a range of differing viewpoints but not a statistically representative sample of those involved in the domestic Ebola response. Participants were skewed toward high-profile responders, identified through our literature review; however, snowball sampling helped expand the sample. Snowball sampling may have introduced additional biases, including overrepresentation of some interviewee opinions or personality types. Finally, recommendations target improving preparedness for an HCID event at the state and local levels; additional federal activities are beyond the study scope.

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Implications for Policy & Practice

  • This research provides a unique perspective on the limited examples of resilience in the face of HCIDs and identifies important lessons from the communities that responded to confirmed cases of EVD.
  • Recommendations for future HCIDs, developed into an evidence-informed checklist, outlines specific actions to strengthen resilience to HCIDs.
  • As preparedness for the future encounters with HCIDs continues, these findings, recommendations, and checklist will help public health entities improve response activities and avoid potential pitfalls during future responses.
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References

1. Chevalier MS, Chung W, Smith J, et al Ebola virus disease cluster in the United States—Dallas County, Texas, 2014. MMWR Morb Mortal Wkly Rep. 2014;63(46):1087–1088.
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Keywords:

Ebola; infectious disease; resilience

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