What’s needed to improve health sector resilience to serious infectious diseases? We asked people who responded to Ebola in four U.S. cities

In December 2013, what would become the largest Ebola epidemic ever recorded began in Guinea. The virus was transmitted from village to village and across country borders within West Africa, eventually reaching the United States in August 2014 in a limited fashion when two American health workers who had contracted the disease in Liberia were brought back to the U.S. for treatment.

Over the course of the domestic Ebola response, 11 people—including those two health workers—were treated for Ebola at five different health facilities across the country. Four of these facilities—the Nebraska Biocontainment Unit (NBU) at the University of Nebraska Medical Center (UNMC) in Omaha, the Serious Communicable Diseases Unit (SCDU) at Emory University in Atlanta, the Special Clinical Studies Unit at the National Institute for Health (NIH) in Bethesda, and the Special Pathogens Unit at NYC Health + Hospitals/Bellevue—had designated units for treating patients with high-consequence pathogens, as well as staff trained in the use of specialized personnel protective equipment (PPE). The fifth facility—Texas Health Presbyterian Hospital Dallas—treated the first domestically identified case of Ebola, a traveler from Liberia, and was the only facility that did not have an advanced treatment unit.

Additionally, numerous other healthcare facilities in the U.S. encountered individuals who had been in close proximity to someone with Ebola, or who had recently traveled to areas where it was being actively transmitted, illustrating the need for the entire health sector – hospitals, private practices, public health clinics and others - to be prepared to manage a high consequence infectious disease (HCID) event.

Everyone involved in the domestic Ebola response—including physicians, nurses, public health personnel, emergency medical services, emergency management, academics, media personnel, state and local government, and law enforcement—faced unique challenges and circumstances. Our Center, with support from the CDC, set out to gather lessons learned from this event, and help inform future responses to HCIDs such as Ebola.

After soliciting feedback and recommendations from 73 key informants who were intimately involved in the domestic Ebola response, we published “Health Sector Resilience Checklist for High-Consequence Infectious Diseases.” This checklist provides actionable recommendations and highlights topics that may need to be addressed during the response to a future HCID event. It is our hope that, by using this tool, state and local health sector leadership can help “improve the overall resiliency of their health sector and community to HCID events.”

Much of the research completed at the Center entails conducting semi-structured interviews—like was done for this research project—to gather lessons learned and important anecdotes that may benefit future public health endeavors. Our Center has a history of conducting this kind of work. Past examples include:

Our methodology typically involves identifying and interviewing those involved in public health  response efforts, documenting their experiences, and soliciting feedback/recommendations on a range of given topics that the Center regards as integral to health security and public health preparedness. These interviews are then analyzed qualitatively, focusing on common themes and recommendations conveyed by study participants. We find this methodological approach to be extremely important (and surprisingly under-utilized), as it helps improve preparedness and response efforts by providing insight and recommendations on how to overcome challenges that are all but guaranteed to arise during future responses.

For example, in the course of conducting research for our project on health sector resilience to HCIDs, participants revealed challenges that had likely not been considered by state and local health sector leadership. One common theme that arose at health facilities treating Ebola-infected individuals and persons under investigation was the resource-intensive nature of caring for these patients, particularly in terms of nursing coverage, which led to staff shortages throughout the facility. While facilities had anticipated that additional personnel would be needed, the requisite 21-day monitoring period for those who had taken care of infected patients led to protracted staff shortages, with those involved in the response not able to return to their home units even after patient care had ended. Additionally, hospitals that treated PUIs noted that these patients required nearly identical isolation and infection control precautions as confirmed Ebola patients, as the uncertainty about their infection status raised concerns about the risk they posed to clinicians and other patients.

Our hope is that this checklist will familiarize health sector leadership and personnel with the challenges experienced during the domestic Ebola response and improve future epidemic and pandemic response, thereby enhancing the resiliency of communities across the US to these types of events.

Tonight’s Top Story: Ebola and the News Media

When the first few cases of Ebola came to the US in 2014, it seemed as though it was impossible to watch or read the news and not hear about the disease.  At first, news coverage of Ebola rose in response to the return of media personnel diagnosed overseas.  Then news coverage increased greatly after the diagnosis of the first case on American soil in late September, 2014.

Most of us can agree that the intense public and media reaction to the limited number of cases in the US was unwarranted when considering the actual risks involved in the situation.   In fact, many actions were put forth, out of an abundance of caution, which were unnecessary and counter-productive, such as border closures and excessive quarantines. But what was the source of this reaction? Was the news media responsible for stoking people’s fears? What messages were people receiving about the risks of and policy responses to the occurrence of Ebola in the United States? 

To investigate this, colleagues and I set out on a news media content analysis, reading over 1,200 news articles from 12 news sources spanning the time frame from the beginning of July through the end of November 2014. Each time we read an article, we searched for a set of messages relating to risk and policy using a coding instrument that had been piloted on a separate set of articles. We used Paul Slovic’s risk perception framework to determine if some messages would likely have increased perception of risk or decreased perception of risk. Our methods and findings can be found here and here.

We found that nearly every article in our sample (96%) had at least one risk-elevating message while approximately half (55%) had at least one risk-minimizing message. However, although skewed towards risk elevating messages, news coverage from the main stream news sources we analyzed did not seem to report on Ebola in a hyperbolic or overly irresponsible manner – for instance, we found relatively few mentions of use of Ebola as a bioterror weapon or the suggestion that, once introduced, the disease could not be stopped in the US.  In fact, messages about the ability to interrupt transmission in the US were more frequent, when directly compared to messages about an inability to interrupt transmission. It may have been that the news media played a smaller role in hyping the Ebola outbreak than expected, and the nature of the disease itself played a stronger role than was originally recognized in increasing public concerns.

Perhaps most importantly from a risk communication perspective, it was clear that public health policy messages were frequently eclipsed by more controversial messages.  The most frequent policy messages we found were focused on isolation (47%) and quarantine (40%), which were often confused with each other (isolation is the separation of someone who is ill from those who are not sick while quarantine is the separation of someone who may have been exposed to a disease from those who have not been exposed). In contrast, one of the more central public health response policies – assigning different levels of risk and associated movement restrictions for potentially exposed individuals – was rarely found (5%). This difference could be due to the newsworthiness of controversial issues – quarantine was controversial while a measured public health approach was not.  As a result, Americans may have gained a skewed or incomplete understanding of the response activities that public health agencies were putting into place in the midst of the crisis.

At the end of the day, the news media played an important role in delivering messages about Ebola to the public and will no doubt perform a similar role in future outbreaks.  Although our study methodology prevents us from drawing conclusions about the public’s understanding of the risks posed by Ebola and associated response activities, it allows us to gain a more granular understand about the messages the public may have been exposed to via the news media. Although the news media frequently mentioned risk-increasing messages, some of the most inflammatory messages were not found as frequently as expected (though they may have been present in more “fringe” news sources that were not included in our analysis). However, we did find that communication of important scientific principles and policies can struggle to gain traction in the face of controversial issues. In the future, public health communicators should keep these factors in mind when communicating via the news media and emphasize the scientific underpinning of our understanding of the disease and appropriate responses. 

“Out of an abundance of caution” – An overused phrase

Last October, when fear about Ebola was at its height in the US, we saw the phrase, “out of an abundance of caution” being used to justify just about anything under the sun.  Want to ban kids from schools because they shared a continental land mass with Ebola victims?  Go ahead and do it out of an abundance of caution. Want to confine anyone who gets sick on an airplane to the bathroom for a whole flight?  Go ahead and do it out of an abundance of caution.  In fact, out of an abundance of caution, we should really plan to never read anything online again, so that we can be sure that the phrase never takes hold in our brains. 

Now that the fear around Ebola has died down, it’s a saner moment to think about what that phrase really does.  It allows businesses, schools, leaders in the government, and others in charge to enact policies that are scientifically unfounded but potentially irrational and, sometimes, to infringe upon the rights of others. We are hardly the first to complain about over-reaching policies set out of an abundance of caution, but it’s a recurring problem worth considering. 

Making decisions in a responsible way means weighing potential outcomes with the chances that those outcomes might occur.  The phrase, “out of an abundance of caution,” is often used when explaining an action that isn’t necessary, but is going to be done anyway because you want to be extra careful. Unfortunately, this throws the whole decision making process for a loop, because it assumes that there are no consequences for overly cautious and unnecessary actions.  Yet these actions always have a cost – in money, resources, time and, sometimes, civil liberties. 

Further, using the phrase undermines the science-based messages surrounding risk.  During the Ebola outbreak, public health officials repeatedly cited science-based messages that the disease could only be transmitted by people experiencing symptoms of the disease and that there was no science-based rationale for putting asymptomatic individuals in quarantine.  The Louisiana Department of Health and Hospitals highlighted these points in a manual on Ebola (the link to the document has since been removed from the website) then noted that quarantine would be used in Louisiana regardless of risk category.

What the phrase really suggests to the public is that these actions were actually needed, otherwise they wouldn’t be done.  Either something is necessary, and should be done, or is unnecessary and shouldn’t be done. One justification for acting out of an abundance of caution is calming public fears.  But do these actions actually calm public fears, or do they make a threat seem bigger than it really is? A better approach is to be transparent about what we know about risks, what science says we should do to minimize those risks, and maybe most importantly, be clear about what we don’t know. A transparent approach to communicating risk has been shown again and again to be more effective than trying to obfuscate the facts and make one sweeping decision “out of an abundance of caution.”

Using the phrase to justify our actions is tempting, especially when we are a little scared and not sure what to do. But let’s be honest with ourselves and others about the risks we face and act accordingly, rather than out of an abundance of caution. 

It would be crazy to think that thousands of Americans could be rounded up, out an abundance of caution, to spend the next few years in the middle of our country in internment camps.  Yet, that happened to thousands of Japanese-American citizens during World War II.  So let’s avoid falling into the “out of abundance of caution” mindset.  It’s often used to justify actions on the margins of advisability, and in reality it usually serves to signal a dangerous combination of fear and rashness. 

The Devil You Know vs. The Devil You Fear

During Ebola, a consistent concern was that healthcare workers could bring the pathogen home because of suboptimal infection control. This concern formed part of the rationale for sequestering patients with Ebola-like symptoms at designated facilities adept at infection control—a protocol I strongly endorse.

However, the idea that only headline-grabbing contagions can be transmitted by healthcare workers gives rise to a serious threat misperception. Consider these statistics:

It is not a stretch to assume that a proportion of healthcare workers are also colonized with carbapenem-resistant enterobacteraciae and multi-drug resistant Acinetobacter (which contaminated 9% of gloved healthcare workers hands in one study). And you know how well we all wash our hands.

These individuals serve as vectors for household and community transmission of these epidemiologically significant organisms that kill thousands annually. Yet when it becomes public knowledge that someone has cared for an Ebola patient, panic ensues, which results in political pressure to implement non-evidenced based interventions, like excluding the children of healthcare workers from school.

This kind of threat misperception hampers every outbreak response as public health authorities act increasingly to placate a panicked public and their elected officials, yet fail to place risk in its proper context.

In reality, the bigger threat to the human race is not Ebola or some exotic virus lurking on the hands of the nurse or doctor dropping off their child at daycare or school (which hopefully has high vaccination rates), but rather the usual suspects. that have proven, time and again, to be much more prolific threats to the human race.  While my aim is not to incite panic over what might be on healthcare workers’ hands, I do believe a little dose of reason goes a long way towards gaining a proper perspective of contagion risk. 

Not Every Model Can be a Supermodel

Infectious disease modeling is an important tool that can help predict the course of an outbreak and how specific interventions might fare. However, what is often lost in the course of the press reports of the model’s results and the simplified explanations given to policymakers, is the fact that this is a model and not in any way authoritative. All models are based on specific assumptions, which correspond to reality in varying degrees, as well as predictions about microbial transmission, human behavior, and other factors. All of these aspects of models lead to a degree of uncertainty in their predictions.

During the peak of the Ebola panic in the US, various modeling numbers, including one suggesting that there could be up to 1.4 million cases of Ebola, were in the press continually without the appropriate caveats such as the assumptions that formed the basis for the model that gave that result. Another important aspect of a model is whether it is deterministic and static or dynamic (stochastic). This is a vital distinction, as we know that during the course of an outbreak, things change. People modify their behavior, transmissibility changes, and countermeasures are deployed. Such facts severely limit the utility of static models as they are often unable to fully incorporate such dynamism. By contrast, stochastic models allow much more dynamism and therefore can be much more useful.

A new, somewhat technical, paper published in the Proceedings of the Royal Society B makes these important points using the Ebola outbreak as an example. In this paper, King et al. compared the results of using deterministic and stochastic models showing that deterministic models lead to an underestimation of uncertainty in prediction.

The points addressed in this paper are important to emphasize because in the midst of the complex decision-making that characterizes an outbreak response, understanding how uncertain or certain a possible scenario is can be vital. As such, highlighting the salient aspects of a model to policymakers and journalists can help ensure these high-consequence decisions are completely informed.   

Bioethics and Ebola

In December 2014, Presidential Commission for the Study of Bioethical Issues requested public comments on the complex ethical landscape of U.S. public health emergency response to the Ebola virus disease (EVD). Specifically the Commission sought comment on the following 7 topics:

  1. Ethical and scientific standards for public health emergency response;
  2. Ethical and scientific standards that guide the use of quarantine or other movement restrictions during public health emergencies;
  3. The impact of quarantine or other movement restrictions on the availability or willingness of health workers to volunteer to contain the epidemic in disease-affected areas;
  4. The impact of quarantine or other movement restrictions on public fear and anxiety about potential threats to public health;
  5. How U.S. public policy and public health response to the current EVD epidemic might or should affect public attitudes to, and further U.S. policy and public health response to, other current and future public health issues and emergencies;
  6. Ethical and scientific standards for placebo-controlled trials during public health emergencies;
  7. Ethical and scientific standards for collection, storage, and international sharing of biospecimens and associated data during public health emergencies.

The UPMC Center for Health Security submitted comments on each of these topics, which are available here.  The following are our comments on the first 2 topics. The Commission issued its final report on February 26, 2015.

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1) Ethical and scientific standards for public health emergency response

There is a set of ethical norms and procedural principles that should guide all preparedness and response actions in public health emergencies including the Ebola response. First among the norms is a commitment to fairnesspolicies and actions that:

  1. Balance the potentially competing duties to care and steward resources (see below);
  2. reflect the specific values and needs of the affected communities;
  3. address the potentially differing viewpoints of patients, clinicians, government authorities and the general public;
  4. are evidence-based (see below); and
  5. are carefully considered and vetted in advance by a broad cross-section of relevant stakeholders.

Duty to Care - Clinicians have a well-recognized duty to provide medical care to the sick and injured especially when the needed care is urgent, such as in an epidemic like Ebola. This duty to care is complicated by the risk that is posed to care providers by the virus. The risk of exposure to the clinician must be weighed against the duty to care, and balancing the two is not easy. Clinicians should not be expected to take extraordinary risks for a patient with no chance of survival. On the other hand, patients should not be abandoned because of a fear of contagion.  

Duty to Steward Resources - The duty to care is also complicated by the potentially competing need of the individual patient and the population.  Clinicians, healthcare facilities, and public health organizations have a duty to steward limited resources in order to do the greatest good for the greatest number. In a crisis such as Ebola, health professionals and policy makers must constantly make difficult allocation decisions based a commitment to doing the most good.  

Evidence-base - In crises like the Ebola epidemic, scientific certainty is hard to come by. Rigorous studies (e.g., epidemiologic, virologic, clinical and therapeutic) that might help answer critical clinical and public health questions  have not been conducted in the past and likely are very difficult to conduct during the ongoing crisis. Nonetheless, clinicians, public health officials, and policy makers have a responsibility to make difficult decisions even in the absence of hard facts and therefore should do all that is possible to secure the best information possible, even if it is only a consensus of experts.

Among the process and procedural principles that should guide actions in preparing for and responding to a crisis are:

  1. Transparency in planning and decision-making
  2. Consistency in application among individuals and across populations
  3. Proportionality - the actions taken must be commensurate with the scale of the emergency and degree of scarce resources
  4. Accountability of governments and policy makers for making reasonable and just policies and clinicians and healthcare facilities for implementing such polices in good faith with reasonable judgment 

2) Ethical and scientific standards that guide the use of quarantine or other movement restrictions during public health emergencies

The use of quarantine and travel restrictions is premised on the assumption that they will reduce the likelihood of disease spread. If this were true, they maybe ethically permissible as a means of preventing harm to many even while imposing limited hardship on a limited number. The problem with this argument is that there is no evidence to support these assumptions.   There is no data or historical evidence to shows that quarantine and travel restrictions significantly slow disease spread, and the hardship imposed maybe substantial and counterproductive.  For example, in the Ebola outbreak, large scale quarantine contributed to areas of hunger and economic crisis in West Africa and made people fearful to report disease.  For these reasons, we conclude that larger scale quarantines and travel restrictions are misguided policies that could worsen rather than improve outbreak control and are therefore both ethically and scientifically unsupportable.   Limited forms of quarantine of specific individuals who have known high risk exposures to a highly contagious disease might be justifiable in certain circumstance but the degree of sequestration of the individual must be commensurate with the risk of exposure and the risk of subsequent transmission, scientifically sound, and the least restrictive possible.

Travel restrictions- The World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) have opposed imposing travel bans during the Ebola crisis because there is no scientific evidence that bans have ever been effective at limiting the spread of contagious diseases. At best, modeling studies of Ebola, influenza and other contagious diseases suggest that highly effective travel restrictions (which are probably impossible in the real world) would delay cross-border disease spread by a matter of only 1 or 2 weeks.  Unless there were a vaccine or other intervention that could suddenly be deployed in this short timeframe, this delay is insignificant. But is comes at substantial cost. It interrupts essential trade and causes significant damage to the economies of the affected countries. It also drives travel underground. If people cannot travel legally, they will travel illegally.

Geographic Quarantine- Geographic quarantine, what used to be called cordon sanitaire, involves sequestering a population who may (or may not) have been exposed to the contagious disease but who are not yet ill. Often this means confining people who are not infected along with those who are; thereby greatly increasing the risk of infection to the not-yet-infected. Furthermore, such geographic quarantine often leads to food and water shortages and cut off of basic medical care to the sequestered group. Such “collateral damage” might be ethically justifiable if these measures effectively reduced disease spread, but time and time again we see that many people escape quarantine or flee in anticipation of it and thus the imposition of quarantine promotes rather than hinders disease spread. 

Limited individual “quarantine”- Some forms of limited quarantine (work/home quarantine) and other related forms of movement restriction or monitoring of specific individuals with known or suspected high risk exposures are ethically justifiable if they meet the tests of being scientifically sound, proportional, and consistent. Authorities must also ensure adequate support (e.g., medical, food, emotional, financial) to those whose movement is restricted. Authorities involved should be transparent in their decision-making and accountable. For many people and many diseases that are not transmissible until the onset of symptoms, self-monitoring and active public health surveillance are reasonable courses of action.  

Reforming WHO in a Time of Ebola

As a prelude to the 136th World Health Organization (WHO) Executive Board session (January 26-February 3, 2015), 36 countries and the EU member states drafted recommendations based on the WHO efforts in the ongoing Ebola epidemic in West Africa.  While the majority of the resolution affirms or reaffirms institutional dedication to addressing and managing the international response to the Ebola crisis in West Africa, several  recommendations and their corresponding deliverables, indicate a commitment to building an improved, more responsive WHO.  What follows is a summary of some of the most notable recommendations put forward to the Executive Board.

As noted in OP 39, the WHO acknowledges that “short-comings in…human resources systems and processes slowed down the Ebola response,” and this theme permeates many of their recommendations.  This draft resolution seems designed to prompt organizational change that will facilitate more efficient coordination, both within the WHO and with external stakeholders.  From developing mechanisms to increase emergency response workforce and capacity to implementing better screening and training processes for country representatives to independent review of the Ebola response, the language of the draft resolution indicates that organizational change may be forthcoming at all levels of the WHO.  Specifically, OP 2 clearly states the need to “accelerate ongoing reform of the Organization.”

Under the umbrella of improving leadership and coordination, several measures are recommended to provide the Director General with additional support to deal with large-scale response issues.  OP 5 recommends that the Director General consider appointing a Special Representative [1] to direct coordination at the county, regional and global levels and direct WHO response for the Ebola epidemic.  Additionally, OP 54 suggests establishing an advisory group “composed of operations experts from relevant stakeholders…to provide advice on administrative and logistical support” for future incidents.  The magnitude of the Ebola epidemic posed considerable challenges that the drafters determined to be beyond the capacity of the Director General to handle directly.  The resolution recommends that additional support to address response coordination from the outset of an incident would be beneficial, both in the context of the current Ebola response as well as for future public health emergencies. 

Another priority identified in the draft resolution is bolstering communication and information sharing capabilities. OP 9 specifically mentions the need for the WHO to “improve communication, coordination, and information sharing” with the UN Mission for Ebola Emergency Response (UNMEER) in order to support engagement by Member States. The resolution also requests that the Director General develop and improve mechanisms for international sharing of information on “diagnostic, preventive and therapeutic products” in order to improve the ability to rapidly employ them during an emergency.  In order to facilitate this, the resolution calls for creation of a global database of identified and stockpiled medical assets at the national and regional level (OP 32).  In light of the ongoing Ebola epidemic, it is recommended that the initial population of this database begin with hemorrhagic fevers.

Some of the suggestions reiterate previous recommendations from the 2011 International Health Regulations (IHR) Review Committee to strengthen the worldwide public health response workforce.  Specifically, OP 42 advocates developing a plan to establish and maintain “comprehensive emergency response teams” that can be deployed and sustained to support emergency response activities.  In particular, the recommendation lists three required capabilities of this surge program:

1.  Recruiting and training personnel to provide “internal surge capacity”

2.  Improving and expanding cooperation with organizations such as the Global Outbreak Alert and Response Network and Global Health Cluster to increase local public health capabilities

3.  Enhancing coordination with other United Nations agencies to provide scalable response

Additionally, OP 48 calls for the establishment of a contingency fund to respond to “the need for adequate resources for the preparedness, surveillance and response work of the [WHO].”  A report by the Director General to the 68th World Health Assembly will outline options for the scope, potential funding sources and other aspects of the contingency fund plan.  In addition to the 2011 recommendations, the resolution charges the Director General with formalizing agreements to provide use of existing surge capability and regional humanitarian aid, sharing available resources in order to decrease response time in future emergencies (OP 23).

As mentioned above, the WHO acknowledges that its internal processes hindered the progress of Ebola response in West Africa, and several of the recommendations call for review of some internal processes as well as the response effort as a whole, specifically citing a need for increased “transparency and reliability of health-related needs-assessment processes” (OP 10).  First, OP 52 recommends commissioning an independent assessment by a panel of experts on “all aspects of WHO response, from the onset of the current [Ebola] outbreak.”  This recommendation specifically calls out resource mobilization—a process, in particular, that delayed the initial WHO Ebola response—as requiring an investigation.  OP 53 requests that the Director General direct an internal review of the IHR with respect to “prevention, preparedness and response to the Ebola outbreak and the effectiveness of the IHR in facilitating that response.”  Of specific concern are the measures recommended by the 2011 IHR Review Committee that were and were not implemented and identifying future measures to “improve the functioning, transparency, and efficiency of WHO’s response…in future outbreaks.”  In addition to reviewing internal response policies and mechanisms, the resolution calls out the “selection, training and performance review” processes for Country Representatives (OP 40).  This recommendation even goes as far as to provide explicit support to the Director General in the use of her authority to “add or change staff…at the country or regional level,” indicating again a commitment to organizational change on multiple levels.

In addition to organizational reform designed to increase efficacy and efficiency of emergency response, the WHO affirms its role in guiding research and development of pharmaceuticals.  With respect to Ebola, the draft resolution calls for the Director General to maintain sustainability for the therapeutic drug and vaccine clinical trial working groups. Of specific concern are providing proper regulation under emergency conditions to ensure patient safety and developing “quality, safe, effective and affordable vaccines and treatments” (OP 33).  Furthermore, OP 34 addresses establishing priorities for Ebola-related research and appropriately utilizing data from clinical trials. This data will be valuable in determining the efficacy and safety of therapeutic drugs and vaccines; however, special consideration must be given to the limitations of studies conducted under current conditions.

There are many additional recommendations (57 OPs, in all); however, those listed above all bear the burden of specific deliverables. Many of them require some form of report, either to the 138th Executive Board or to the 68th World Health Assembly.  By delineating methods to ensure accountability, the WHO again illustrates its commitment to change and improvement. The outcomes of these recommendations will likely take months or years to come to fruition, and the magnitude of necessary changes and reorganization are not specified. It seems at this point, however, as though the WHO has good intentions in reviewing their actions and coordination over the course of the Ebola epidemic and implementing measures to improve future response.

 

1. On February 3, 2015, Dr. Bruce Aylward was named as the WHO Special Representative for Ebola Response.

Cleaning Up is Hard to Do

When Dr. Craig Spencer became ill with Ebola in New York City following his return from West Africa, the City government was faced with difficult decisions about whether to decontaminate the now famous bowling alley, where the doctor bowled a few games before he felt feverish. Available scientific evidence suggests that remediation was probably unnecessary -- once Dr. Spencer became symptomatic, he isolated himself and reported to the New York City health authorities. Yet, the decision was made to retrace Dr. Spencer’s steps in the days before he became ill and to inspect and decontaminate the places he visited, including the bowling alley.

He’s not a bioremediation expert, but he plays one on TV

Enter Sal Pane and his company Bio-Recovery Corp–contracted by the City to carry out decontamination of the bowling alley and Dr. Spencer’s residence. Upon receipt of the contract to decontaminate, Mr. Pane proceeded to grant interviews to major media outlets, touting his decades of experience and presenting himself as a kind of Harrison Ford of bioremediation. Unfortunately, as reported in a recent BuzzFeedNews article, Sal Pane’s confident claims about his qualifications and certifications as a bioremediation consultant are now being called into question. On paper, Bio-Recovery Corp had the appropriate experience in biological assessment and cleanup, as it had contributed to the post-anthrax 2001 clean-up operation (under another company name and owner) before coming under the direction of Mr. Pane. In reality, BuzzFeedNews reported that while the company “claimed to have certifications from EPA and the New York Department of Environmental Conservation,” BuzzFeedNews “could not find any evidence of this.” In addition, BuzzFeedNews found that Bio-Recovery Corp’s “state permit to haul medical waste expired in 2012, before Pane was associated with the company.” So, now it is unclear whether the work this company did was effective (regardless of whether it was necessary in the first place).

This is not to suggest that the midst of the crisis was the time for the City to be tracking down and verifying the bonefides of remediation companies. I am sure that the City relied on the information it had at hand, which indicated that Bio-Recovery Corp was legitimate–a reasonable approach in an emergency. I do find it disheartening, however, that we are still caught off guard when biological decontamination issues arise.

It’s not as though we didn’t know this could be a problem. In 2001, anthrax spores from the Amerithrax letters contaminated media office buildings in New York City. At that time there were no guidelines available for the cleanup process and no registry of reputable companies qualified for remediation work. And, in 2010, I worked with the US Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism to revisit this issue and research federal progress in preparedness to decontaminate after a bioterrorism attack on a US city. Again, and we found major gaps in preparedness, including gaps in determining safe levels of contamination and in vetting and engaging remediation companies.

For me, this incident illustrates that there are two major outstanding questions which we need to address:

First, what is our process for assessing the risks from biological contamination and making decontamination decisions?

The decision to decontaminate public spaces in NYC was incongruous with the public health messaging that Ebola transmission does not occur unless a person is symptomatic. Based on public health and medical evidence and on CDC guidance, decontamination of public spaces was not necessary in the case of Dr. Spencer, and yet it was still carried out.

Now, the science we have on Ebola is not perfect–there is still some uncertainty about Ebola transmission, and there was also some uncertainty about when Dr. Spencer started feeling ill. This uncertainty, along with a desire to reassure the public, may have influenced the decision to decontaminate, and rightly so. Science cannot be the only factor considered in response to complex situations.

However, the decision to decontaminate, and the public way it was carried out under Mr. Pane, resulted in mixed messages that were intended to reassure the public, but instead confused the issue. What we really needed in this situation was open communication on what we know about the risks to public health, the uncertainties about the science that informs risk, the options we have to manage the risks, and the social, political, and economic consequences of the risk-based decisions we make.

Second, what systems should we have in place decontaminate when it is necessary?

There are many companies that do biological remediation, most of which are legitimate, and some of which have the requisite knowledge, certifications, and skills to perform remediation in a bioterrorism event or other bio-contamination emergency. There are major differences between the routine remediation of medical settings, and the skill-set that will be needed following a large-scale incident. It is likely that snake oil salesmen will try to take advantage of an emergency situation, so how does the responsible local official tell the difference? The key will be to think through these issues and vet companies prior to an emergency. A registry of companies maintained by the state or federal government would be a good start.

Fortunately, despite this example, progress has been made in other areas on this issue since 2010. DHS, in partnership with the DoD, sponsored two major projects on response and recovery for biological terrorism: the Integrated Biological Restoration Demonstration (IBRD) project in Seattle, and the Wide Area Recovery and Resilience Project (WARRP) in Denver. These projects brought the federal government together with state and local officials to develop and pilot remediation plans in those cities. The work resulted in a number of planning documents that may be useful to other cities, research on remediation, and a research agenda for the future. Also helpful was  the 2013 White House Biological Response and Recovery Science and Technology Roadmap, which calls attention to the issues of biological remediation, and lays out a research agenda which DHS has begun to address.

It’s clear that our ability to remediate following a biological contamination emergency remains incomplete. I am hopeful that we are moving the right direction, but let’s not forget that cleaning up is hard to do.