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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
2. Yacisin K, Balter S, Fine A, et al Ebola
virus disease in a humanitarian aid worker—New York City, October 2014. MMWR Morb Mortal Wkly Rep. 2015;64(12):321–323
3. Lyon GM, Mehta AK, Varkey JB, et al Clinical care of two patients with Ebola
virus disease in the United States. N Engl J Med. 2014;371(25):2402–2409.
4. Johnson DW, Sullivan JN, Piquette CA, et al Lessons learned: critical care management of patients with Ebola
in the United States. Crit Care Med. 2015;43(6):1157–1164.
5. Matlock AM, Gutierrez D, Wallen G, Hastings C. Providing nursing care to Ebola
patients on the national stage: the National Institutes of Health experience. Nurs Outlook. 2015;63(1):21.
7. Gostin LO, Hodge JG Jr, Burris S. Is the United States Prepared for Ebola
? JAMA. 2014;312(23):2497–2498.
8. Smith CL, Hughes SM, Karwowski MP, et al Addressing needs of contacts of Ebola
patients during an investigation of an Ebola
cluster in the US—Dallas, Texas, 2014. Morb Mortal Wkly Rep. 2015;64(5):121–123.
9. Miles SH. Kaci Hickox: public health and the politics of fear. Am J Bioeth. 2015;15(4):17–19.
10. Spencer C. Having and fighting Ebola
—public health lessons from a clinician turned patient. N Engl J Med. 2015;372(12):1089–1091.
11. Hewlett AL, Varkey JB, Smith PW, Ribner BS. Ebola
virus disease: preparedness and infection control lessons learned from two biocontainment units. Curr Opin Infect Dis. 2015;28(4):343–348.
12. Cortese D, Abbott P, Chassin M, et al The Expert Panel Report to Texas Health Resources Leadership on the 2014 Ebola
Events. Arlington, TX: Texas Health Resources; 2015.
13. Tate A, Ezeoke I, Lucero DE, et al Reporting of false data during Ebola
virus disease active monitoring—New York City, January 1, 2015-December 29, 2015. Health Secur. 2017;15(5):509–518.
14. Sell TK, McGinty EE, Pollack K, Smith KC, Burke TA, Rutkow L. US State-level policy responses to the Ebola
outbreak, 2014-2015. J Public Health Manag Pract. 2017;23(1):11–19.
15. Kraemer JD, Siedner MJ, Stoto MA. Analyzing variability in Ebola
-related controls applied to returned travelers in the United States. Health Secur. 2015;13(5):295–306.
16. Hageman J, Hazim C, Wilson K, et al Infection prevention and control for Ebola
in health care settings—West Africa and United States. MMWR Suppl. 2016;65(3):50–56.
17. NVivo Qualitative Data Analysis Software. Version 11. Doncaster, Australia: QSR International Pty Ltd; 2015.
18. Toner ES, McGinty M, Schoch-Spana M, et al A community checklist for health sector resilience
informed by Hurricane Sandy. Health Secur. 2017;15(1):53–69.
19. Adalja AA, Watson M, Bouri N, Minton K, Morhard RC, Toner ES. Absorbing citywide patient surge during Hurricane Sandy: a case study in accommodating multiple hospital evacuations. Ann Emerg Med. 2014;64(1):66–73.e1.
21. Meyer D, Sell TK, Schoch-Spana M, et al Lessons from the domestic Ebola
response: improving health care system resilience
to high consequence infectious diseases. Am J Infect Control. 2017. doi:10.1016/j.ajic.2017.11.001.
22. Sell TK, Boddie C, McGinty EE, et al Media messages and perception of risk for Ebola
virus infection, United States. Emer Infect Dis. 2017;23(1):108–111.
23. Steelfisher GK, Blendon RJ, Lasala-Blanco N. Ebola
in the United States—public reactions and implications. N Engl J Med. 2015;373(9):789–791.
24. Seeger MW. Best practices in crisis communication: an expert panel process. J Appl Commun Res. 2006;34(3):232–244.
25. Schoch-Spana M, Franco C, Nuzzo JB, Usenza C; Working Group on Community Engagement in Health Emergency Planning. Community engagement: leadership tool for catastrophic health events. Biosecur Bioterror. 2007;5(1):8–25.
26. Stehling-Ariza T, Fisher E, Vagi S, et al Monitoring of persons with risk for exposure to Ebola
virus disease—United States, November 3, 2014–March 8, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(25):685–689.
27. Chung WM, Smith JC, Weil LM, et al Active tracing and monitoring of contacts associated with the first cluster of Ebola
in the United States. Ann Intern Med. 2015;163(3):164–173.
28. Shaw FE, McKie KL, Liveoak CA, Goodman RA; State Public Health Counsel Review Team. Legal tools for preparedness and response: variation in quarantine powers among the 10 most populous US states in 2004. Am J Public Health. 2007;97(suppl 1):S38–S43.
29. Hodge JG Jr, Penn MS, Ransom M, Jordan JE. Domestic legal preparedness and response to Ebola
. J Law Med Ethics. 2015;43(suppl 1):15–18.
30. Hodge JG, Gostin LO, Hanfling D, Hick JL. Law, medicine, and public health preparedness: the case of Ebola
. Public Health Rep. 2014;130(2):1–4.
31. Lowe JJ, Gibbs SG, Schwedhelm SS, Nguyen J, Smith PW. Nebraska Biocontainment Unit perspective on disposal of Ebola
medical waste. Am J Infect Control. 2014;42(12):1256–1257.
Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Ebola; infectious disease; resilience