An Interim Examination of the US Public Health Response to Ebola

Abstract

From the summer of 2014 to the spring of 2016, the United States was involved in the Ebola response on both the national and international levels. The United States received 2 imported cases from West Africa and had 2 locally hospital‐acquired cases, which spurred a massive and unprecedented public health response. As the domestic response stabilized and the epidemic in West Africa slowed, the Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO), through a cooperative agreement with the Centers for Disease Control and Prevention (CDC), led an in-progress review to assess the national public health response to Ebola. The goal was to identify opportunities to improve the Ebola response and best practices to inform future responses. To inform the review, NACCHO and ASTHO relied on feedback collected from several sources, including a stakeholder meeting held in August 2015, a series of key informant interviews, ASTHO's and NACCHO's internal response assessments, and perspectives shared by state and local health department members and workgroups and national partner organizations. ASTHO and NACCHO engaged experts and practitioners in public health, health care, emergency management, laboratory sciences, environmental health, occupational health, homeland security, communications, and public works from US federal, state, and local governments, the nonprofit community, and private industry. This article summarizes feedback and lessons learned as shared by these sources. Additionally, this article presents recommendations for federal, state, local, and nongovernment partners to improve current and future preparedness and response efforts to infectious disease threats.

ASTHO and NACCHO led an in-progress review to assess the national public health response to Ebola. The goal was to identify opportunities to improve the Ebola response and best practices to inform future responses. This article presents recommendations for federal, state, local, and nongovernment partners to improve current and future preparedness and response efforts to infectious disease threats.

In December 2013, the index case of the 2014 Ebola epidemic appeared in Guinea, and the disease quickly spread to the neighboring countries of Liberia and Sierra Leone and eventually to Senegal, Nigeria, and Mali. By August 2014, the World Health Organization (WHO) had declared Ebola an international health emergency and threat to global health security.¹ In September and October 2014, the United States received 2 imported Ebola cases from West Africa, followed by 2 locally hospital-acquired cases. In addition, several healthcare workers who acquired Ebola in West Africa were transported back to the United States for treatment. The result was a massive and unprecedented public health response at all levels of government and with many nongovernmental and private sector organizations.

Federal agencies responded to the threat of Ebola in the United States by funneling travelers from Ebola-affected regions to 5 US international airports for enhanced entry screening and by developing new guidance to help state and local health departments monitor travelers and healthcare workers arriving from Ebola-affected countries. The Centers for Disease Control and Prevention (CDC) coordinated with other federal agencies to provide additional guidance on various topics dealing with Ebola, such as personal protective equipment (PPE) use and environmental cleaning and decontamination.² The Office of the Assistant Secretary for Preparedness and Response (ASPR) and CDC also developed a tiered national network of Ebola and other special pathogen treatment centers comprising 46 hospitals and 9 regional facilities to identify, isolate, assess, and care for suspected or confirmed Ebola patients.^3-5

State and local health departments played a leading role in preparing for and responding to potential Ebola cases in the United States.^6,7 In conjunction with healthcare systems, state and local authorities implemented the tiered hospital strategy and isolation and quarantine protocols. Public health staff at the state and local levels also monitored thousands of potentially exposed travelers and healthcare workers and ensured that symptomatic individuals were quickly isolated and transported to an appropriate medical facility. Additionally, they educated community stakeholders, including healthcare workers, law enforcement officers, emergency medical services personnel, and the public, on Ebola's risks and symptoms.

Many nongovernment partners also had a role in the response. For example, the Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO) provided technical assistance and resources to state and local health departments and helped to facilitate communications among federal, state, and local public health response partners. The partnership among CDC, ASPR, and national organizations—including ASTHO, NACCHO, the Council of State and Territorial Epidemiologists (CSTE), the Association of Public Health Laboratories (APHL), the American Hospital Association (AHA), and the National Association of State Emergency Management Services Officials (NASEMSO)—helped to facilitate sharing of concerns of state and local health departments during planning and implementation of a coordinated national response.

Methods

As the domestic response stabilized and the epidemic in West Africa slowed, NACCHO and ASTHO, in partnership with CDC, led an in-progress review to assess the national public health response to Ebola. The goal of the review was to identify lessons learned, successes, challenges, and recommendations for improving preparedness and response to Ebola and other infectious diseases at the federal, state, and local levels.

To inform the review, ASTHO and NACCHO used several methods to collect feedback, including a stakeholder meeting held in August 2015, a series of key informant interviews, ASTHO's and NACCHO's internal responses during the Ebola epidemic, and perspectives shared from ASTHO and NACCHO's state and local health department members. Through these mechanisms, ASTHO and NACCHO received input from more than 50 public and private organizations at the federal, state, and local levels representing various aspects of the response. ASTHO and NACCHO reviewed these sources of information to identify themes in the areas of strength and opportunities for improvement regarding the public health systems' response to Ebola. The themes, as well as recommendations for institutionalizing successes and addressing areas for improvement, are summarized in this article.

Stakeholder Meeting

The stakeholder meeting was held in August 2015. Individuals were invited by ASTHO and NACCHO to participate in the meeting. To identify participants and plan the meeting, ASTHO and NACCHO established a planning committee of 11 representatives from APHL, ASPR, CDC, CSTE, Dallas County Health and Human Services, the Montgomery County Maryland Department of Health and Human Services, NASEMSO, the Nebraska Department of Health and Human Services, the New York City Department of Health and Mental Hygiene, and the Texas Department of State Health Services. The committee considered the role of the organization in the Ebola response, the level at which the organization operates (eg, national, state, local), and geography when inviting participants to attend the stakeholder meeting. Individuals attending the meeting represented their organizations. NACCHO and ASTHO, with support from the CDC, provided travel scholarships to state and local health department participants. Overall, more than 90 individuals representing 44 organizations participated in the meeting, including federal, state, local, and private organizations representing public health, health care, public works (eg, water, waste management), environmental health, transportation, homeland security, emergency management, diplomacy, and law enforcement (see Figure 1 for list of In-Progress Review Stakeholder Meeting Participating Organizations).

Figure 1.

Organizations Participating in In-Progress Review Stakeholder Meeting

During the 2-day stakeholder meeting, participants shared their experiences and observations through facilitated large group and small group exercises, as well as a series of group rotations and report-outs. While participants represented their own organizations, they were asked to share feedback on both what was going well and how to improve the response to date. The meeting focused on the public health system's response to Ebola, though consideration was given to the intersection between public health and many other disciplines, including health care, environmental health, and transportation. Discussions were organized around 4 tracks: administrative preparedness; public health preparedness systems; epidemiology, infection control, and laboratory systems; and communications.

Key Informant Interviews

ASTHO and NACCHO then conducted 8 key informant interviews and small meetings with representatives directly involved in domestic Ebola cases from the American Hospital Association, ASPR, the Association of American Medical Colleges, APHL, the Association of Public Health Nurses, CDC, CSTE, Dallas County Health and Human Services, and the Texas Department of State Health Services. The purpose of these follow-up interviews and meetings was to further detail lessons learned, challenges, and recommendations identified at the review meeting with subject matter experts who were either unable to attend the meeting or whose expertise was helpful in exploring the feasibility of specific recommendations.

Participants were selected for interviews by ASTHO and NACCHO. Consideration was given to the organization's representation at the stakeholder meeting, their role in the Ebola response, their anticipated role in implementing the recommendations resulting from the stakeholder review, and areas of expertise.

ASTHO and NACCHO staff conducted the interviews. Feedback shared in the interviews was documented in summary notes and organized into major themes. Findings from the key informant interviews were incorporated into the recommendations and a summary report.

Ebola In-Progress Review Report

ASTHO and NACCHO staff analyzed feedback shared by participants from the stakeholder meeting, key informant interviews, and other sources to identify overarching themes regarding the strengths and areas for improvement in the public health systems' response to Ebola in the United States. Using input from these sources, ASTHO and NACCHO also identified recommendations for improving federal, state, and local responses to Ebola and other emerging infectious diseases.

ASTHO and NACCHO summarized feedback, key findings, areas for improvement, and recommendations in a final report. The in-progress review and report were supported by funding from CDC. Through the in-progress review planning committee, CDC provided guidance and input for the development of the report. The final report and its contents were also reviewed by the in-progress review planning committee and finalized by NACCHO and ASTHO to reflect input and comments from planning committee members.

Limitations

ASTHO, NACCHO, and the planning committee made every attempt to ensure participants in the stakeholder meeting and key informant interviews represented the full range of disciplines involved in the Ebola response. Given the diversity of organizations involved at various stages of the Ebola response, as well as time, budget, and logistical constraints, however, the results of the in-progress review may not represent all disciplines involved in preparing for or responding to Ebola in the United States. For example, ASTHO and NACCHO invited organizations representing the healthcare industry to participate in the meeting and key informant interviews, but some were unable to do so because of time and resource constraints.

ASTHO and NACCHO did not independently verify the content of the information shared by participants. Since areas of strength and improvement were identified based on themes communicated by multiple sources, the potential for inaccurate information or bias from a single organization to have significantly influenced the findings and recommendations summarized in this article is thought to be low. Nonetheless, as meeting participants and interviewees represented organizations with interests in the outcome, there is a potential for bias in the themes. To help manage this source of bias, ASTHO and NACCHO worked with an external consultant to develop questions and prompts for the discussion that would encourage critical discussion and focused on themes that were communicated by multiple sources throughout the review when identifying the findings and recommendations in the final report.

The findings and recommendations summarized here represent themes shared by participants in the stakeholder review meeting, key informant interviews, and other sources. It is not intended to be a comprehensive list of all activities and processes that were successful or could be improved, and ASTHO and NACCHO acknowledge there may be additional considerations not represented in this review. Additionally, this review is a summary of the proceedings; it is not necessarily a product of formal consensus, but rather a synthesis of major themes, impressions, observations, and in some cases recommendations that seemed to strongly resonate with many, if not all, participants and were found to be reasonable and generally accepted.

Findings

The in-progress review and interviews helped to identify several overarching themes regarding the response's areas of strength and areas for improvement, which are described below.

Areas of Strength

National calls were useful sources of information. Regular federal national calls were held to coordinate efforts and maintain situational awareness across public health stakeholders. Federal partners also regularly used national association partners such as APHL, ASTHO, CSTE, and NACCHO to organize conference calls, disseminate information, and provide bidirectional communication.

The airport screening strategy was effective in monitoring movement of incoming travelers. Federal agencies responded to the threat of Ebola in the United States by funneling travelers from Ebola-affected regions to 5 US international airports for enhanced entry screening. On October 11, 2014, formal entry screening procedures were established at Hartsfield-Jackson Atlanta International Airport, Newark Liberty International Airport, Washington Dulles International Airport, John F. Kennedy International Airport, and Chicago O'Hare International Airport. This process, along with notification to state and local public health entities of travelers' destinations, enabled the public health system to monitor travelers' health.

Laboratory infrastructure rapidly confirmed or ruled out possible cases of Ebola. On August 5, 2014, after the Department of Homeland Security determined that Ebola presented a material threat to national security, the US Department of Health and Human Services issued an emergency use authorization (EUA) for in vitro diagnostics to detect Ebola.⁸ The EUA authorized the release of Ebola detection test kits through the Laboratory Response Network (LRN) to state and local laboratories across the country to support rapid Ebola detection. Labs then worked with healthcare providers and CDC to appropriately collect and test specimens for Ebola. Participants praised the speed at which LRN labs tested specimens and communicated results. Stakeholders attributed this success to the laboratory capacity that has been built over time, thanks in part to federal preparedness funding.

The incident command structure (ICS) was an effective mechanism for state and local health departments and their partners to organize response operations. Use of the standardized approach of the ICS enabled coordination and communication within and across agencies. Participants observed there may be opportunities, however, to strengthen the integration of core public health functions, such as epidemiology and infection control, into the ICS of future responses.

State and local health departments quickly redirected resources to stand up monitoring systems for active and direct active monitoring. After the first domestic case of Ebola surfaced in Dallas, the federal government put a monitoring plan into place.^9,10 The purpose of this system was to ensure that if people with epidemiologic risk factors became symptomatic, they were identified as soon as possible after symptom onset so they could be rapidly isolated and evaluated. Review participants noted the success of ramping up the monitoring system, but also the high resource burden it placed on state and local health departments. Participants expressed concerns about the negative impacts on other infectious disease or preparedness programs as staff were redirected to support Ebola-specific requirements. While most participants noted the that monitoring system has useful application for other infectious diseases (eg, tuberculosis, MERS-CoV), they were quick to emphasize the significant resource burden on public health departments and commented that a better understanding at all levels of what can be realistically achieved within the constraints of existing and available surge capacity would be necessary to scale for another event.

Federal partners, through national associations, rapidly disseminated information and guidance to their members, enabling broader situational awareness. CDC partnered with national organizations, including ASTHO and NACCHO, to help coordinate preparedness and response efforts with state and local health departments across the country. National organizations were well positioned to share information and collect feedback directly from their members (eg, state and local health departments) through existing communication channels. This information helped to inform national preparedness and response guidance and efforts.

Areas for Improvement

Housing for isolation, quarantine, family, and pre- and post-hospital patient care was difficult to secure and fund. Many participants felt the US public health system at all levels had not sufficiently planned or exercised implementation of isolation and quarantine authorities on the scale required for Ebola. As a result, there was confusion across federal, state, and local authorities on roles and responsibilities for securing housing and providing food and other sustenance for quarantined individuals and families. Resource requirements were also not well-defined. This led to challenges at the state and local levels in identifying facilities willing and able to accept people under investigation or a patient's family members. This challenge was exacerbated by the stigma associated with Ebola and the intense media scrutiny. Over time, costs associated with housing and basic amenities to isolated and quarantined individuals and their families strained local and state resources. Furthermore, partners who cared for suspected or confirmed Ebola cases cited similar challenges securing and financing housing and other resource needs.

State and local health departments were not always sufficiently involved in development of guidance and response strategies. CDC coordinated with other federal agencies to provide guidance on topics such as patient care, PPE use, environmental cleaning and decontamination, and handling of laboratory specimens. The ever-changing landscape of the response and knowledge of Ebola created some challenges in providing up-to-date and specific guidance and response strategies, however, including the meaningful collection, consideration, and integration of feedback from key stakeholders. Participants suggested development of a fast-track or streamlined process in the future to better engage state and local public health departments in the development of guidance and response strategies.

Guidance for external partners was not adequately tailored to the audience, particularly for law enforcement, EMS, transportation, and waste management/public works. Participants noted healthcare facilities, EMS, and other stakeholders often turn to public health departments for infection control needs, and it was important for health departments to have resources to address those needs, such as training for appropriate PPE use and guidance on hospital waste disposal.¹¹ In the absence of adequate expertise and resources, it was difficult for health departments and their healthcare partners to address infection control issues as they arose. As a result, many state and local health departments were unable to identify EMS providers willing to transport suspected Ebola patients and specimens. Additionally, lack of timely federal guidance and inadequate coordination among public health departments, healthcare facilities, EMS sectors, and public works departments resulted in insufficient ability to address actual and perceived waste management concerns. Clear national guidance regarding waste management and decontamination was initially slow to be released, resulting in uncertainty among key responders and lack of coordination, particularly with transportation and waste management partners. Health departments with strong, existing relationships with EMS and public works agencies, including waste, water, and local infrastructure, helped to mitigate some of the issues related to waste disposal during an infectious disease event, but participants stressed the need for earlier guidance and clearer communication materials to aid in coordinating safe disposal of medical waste.

Risk communications to the public, while available, did not sufficiently address popular misconceptions about the risk of contracting Ebola. A great deal of misinformation was regularly spread, leading to public and political pressure and strong stigma against people under investigation, confirmed patients, infected healthcare workers, recent travelers to affected and even non-affected areas, and against affected West African diaspora community members. Regular public health engagement with schools, daycare centers, people with limited English proficiency, and people from Ebola-affected countries should be a critical component of the response.

Politics and public perceptions made it difficult to implement a strategy based on science about Ebola transmission for decreasing the level of screening and monitoring of incoming travelers from Ebola-affected countries. Review participants felt strongly that the political backdrop created an environment where individuals in leadership positions were pressured to make decisions based on misperceptions, resulting in fear and public opinion sometimes trumping science. Many participants felt this led to a disconnect between official guidance and what the public was seeing on television and in educational materials and fact sheets, including the strained transition to a rollback strategy for screening and monitoring of incoming travelers from Ebola-affected countries.

Public health, healthcare, and EMS sectors were not adequately prepared to manage the special level of infection prevention and control for Ebola. Meeting and interview participants identified infection control as a major challenge during the Ebola response across various stakeholders and noted outstanding gaps in infection control expertise and resources as barriers to preventing and controlling Ebola and other healthcare-associated infections. Implementing the tiered hospital strategy and infection control measures for Ebola generated questions that reflected gaps in community and healthcare infection control preparedness. The transmission of Ebola within a US healthcare facility further signaled the need for additional support in applying adequate healthcare infection control measures.

The tiered hospital strategy is not sustainable in its current capacity. ASPR and CDC developed a tiered hospital strategy consisting of a national network of hospitals designated to address Ebola, which relied on other healthcare facilities to quickly identify, isolate, and, in some cases, begin testing of potentially exposed patients. The strategy designated hospitals in 3 categories: (1) treatment centers with the ability to treat Ebola-infected patients for the duration of their illness; (2) assessment centers with the ability to isolate and care for possible Ebola patients for a limited amount of time until an Ebola diagnosis is confirmed or ruled out; and (3) frontline hospitals and acute care facilities that are responsible for rapidly identifying, triaging, and isolating (if needed) individuals with Ebola exposure and symptoms.¹² This network included 9 regional Ebola and other special pathogen treatment centers and 46 additional hospitals with the capability to treat Ebola patients.

Meeting and interview participants identified challenges in implementing the strategy, particularly with designating Ebola treatment and assessment centers. Review participants cited challenges with trying to organize hospitals into the 3 tiers of the strategy that did not necessarily align with existing healthcare capacity and capabilities in a jurisdiction. Additionally, the referral and triage system set up with the tiered strategy did not necessarily align with established regional healthcare triage and referral patterns within healthcare networks. Healthcare and public health participants said it was also challenging to navigate the politics of implementing the strategy, which occurred at the same time as many states' gubernatorial elections. Media attention surrounding the elections brought added scrutiny that, when combined with the potential for federal funding and other resources, created an external political environment that at least partly influenced the designation of treatment and assessment centers in some states. Additionally, some jurisdictions had difficulty encouraging healthcare facilities to self-designate as either a treatment or assessment center, as those facilities became increasingly concerned about the high costs associated with adequately preparing their facility and the stigma associated with being designated as an “Ebola hospital.” These factors contributed to inconsistent implementation of the strategy across geographic locations, with participants commenting on what seemed to be too many treatment or assessment centers in some geographic locations and too few in others.

Cross-Cutting Recommendations

The Ebola in-progress review resulted in the identification of several broad, recurring recommendations for improving our national capacity to respond to Ebola and future infectious diseases. In some cases, these recommendations cut across multiple sectors or levels of government. These cross-cutting recommendations are described below and a full list of recommendations is presented in Table 1.

Table 1.

Summary of Recommendations

Topic	Recommendation	Intended Audience
Funding	1. Establish a new mechanism and/or authorize funding for the public health emergency fund that can be drawn down quickly during an emergency.	• Assistant Secretary for Preparedness and Response (ASPR) • CDC • State and local policymakers, eg, governors and other high-level state officials
	2. Update PHEP, HPP, and ELC annual cooperative agreement/grant language to make the programs more responsive and flexible.	• CDC • ASPR
	3. Increase and accelerate funding to end-users.	• ASPR • CDC • State and local policymakers, eg, governors and other high-level state officials • State, local, and territorial health departments • National associations, eg, ASTHO, NACCHO, National Governors Association (NGA) • National associations • State, local, and territorial health departments • State and local policymakers, eg, governors and other high-level state officials
	4. Build and expand nonfederal sources of preparedness and response funding.	• State, local, and territorial health departments
	5. Improve pre-response communication and concurrence processes to ensure transparency and collaboration and increase effective and timely use of funds.
Isolation and quarantine	6. Strengthen isolation and quarantine preparedness planning.	• ASPR• CDC• DHS• Department of Homeland Security (DHS)• State, local, and territorial health departments• State and local policymakers• Partner organizations/stakeholders, eg, National Association of State EMS Officials (NASEMSO), law enforcement
	7. Identify, develop, and share promising practices and resources for isolation and quarantine.	• State, local, and territorial health departments• National associations• CDC• ASPR
	8. Collect and share promising isolation and quarantine practices, including those used for other infectious diseases with state and local health departments and partner organizations.	• National associations• State, local, and territorial health departments
Screening and monitoring	9. Explore and improve use of available and allowable tools and technology, such as social media, to conduct monitoring.	• ASPR• CDC• State and local policymakers• State, local, and territorial health departments• National associations and other partner organizations, eg, National Public Health Information Coalition (NPHIC)• IT/software developers
Screening and monitoring	10. Improve and increase sharing of global disease surveillance information.	• CDC• ASPR• DHS• State, local, and territorial health departments• Hospitals/healthcare systems• Healthcare coalitions• National associations and other partner organizations, eg, NPHIC• IT/software developers
Healthcare preparedness and infection control	11. Support and maintain the regional network of special pathogen treatment centers.	• United States Congress• ASPR• CDC
	12. With public health partners, convene healthcare stakeholders to assess the healthcare response to Ebola and identify lessons learned and recommendations for federal, state, and local public health, healthcare, and other relevant partners to improve responses to future infectious diseases.	• ASPR• Occupational Safety & Health Administration (OSHA)• State, local, and territorial health departments• Hospitals/healthcare systems• Healthcare coalitions• Law enforcement• PPE manufacturers• Healthcare supply managers• Transportation companies• Waste management• Public works• National associations and other partner organizations, eg, American Hospital Association (AHA), American Public Works Association (APWA), National Association of State EMS Officials (NASEMSO)
	13. Build and sustain infection prevention and control expertise in state and local public health.	• OSHA• ASPR• CDC• State, local, and territorial health departments• Hospitals/healthcare systems• Healthcare coalitions• National associations and other partner organizations
	14. Better integrate public health and healthcare preparedness by aligning and leveraging existing resources and strengthening relationships across sectors.	• CDC• ASPR• State, local, and territorial health departments• Hospitals/healthcare systems• Healthcare coalitions• Healthcare supply managers• Emergency medical services• Transportation companies• Law enforcement
Transportation	15. Improve guidance for 9-1-1 and EMS providers to support Ebola and other emerging infectious disease response operations.	• ASPR• CDC• DOT• OSHA
	16. Ensure that EMS workers receive appropriate training and are knowledgeable and competent in infection control practices for all communicable disease, not just Ebola.	• State, local, and territorial health departments• National associations and other partner organizations, eg, NASEMSO
	17. Further integrate transportation, including EMS and 9-1-1 dispatch, into preparedness and healthcare planning for infectious disease threats to address policy and logistical challenges.	• State and local policymakers• State, local, and territorial health departments• Hospitals/healthcare systems• Healthcare coalitions• 9-1-1• Emergency medical services• Transportation companies• Law enforcement
	18. Analyze state-specific and interjurisdictional barriers to efficient transportation, such as restrictions on crossing state lines with PUIs or lab specimens, to identify policy or procedural recommendations.	• ASPR• CDC• DOT• State and local policymakers, eg, governors and other high-level state officials• State, local, and territorial health departments• State and local laboratories• Hospitals/healthcare systems• Healthcare coalitions• Emergency medical services• Transportation companies• National associations and other partner organizations
	19. Before an event, designate EMS providers for high-visibility and high-pathogenic events and engage those providers to create specimen and PUI transport plans.	• State, local, and territorial health departments• Emergency medical services
	20. Ensure that EMS workers are trained and have the necessary funding to purchase appropriate specific PPE for emerging infectious diseases.	• ASPR• CDC• OSHA• Emergency medical services• National associations, eg, NASEMSO
Waste management	21. Convene all federal and national stakeholders to develop a framework that supports state and local jurisdictions in creating waste transport policies and guidance that facilitates efficient and proper waste disposal.	• CDC• ASPR• DOT• National associations, eg, American Public Works Association (APWA)
	22. Further integrate waste management and public works into preparedness planning, exercises, and drills.	• State, local, and territorial health departments• Waste management companies• Public works• Hospitals/healthcare systems• Healthcare coalitions• National associations and other partnerorganizations/-stakeholders, eg, AHA, APWA
	23. Provide education about infectious waste to waste disposal and public works partners.	• ASPR• CDC• OSHA• State, local, and territorial health departments• Waste management companies• Public works• National associations, eg, APWA
	24. Regularly include waste management and public works in emergency response planning discussions and exercises.	• State, local, and territorial health departments• Hospitals/healthcare systems• Healthcare coalitions• Waste management companies• Public works
Laboratory testing	25. Clarify guidance on decontamination in laboratory settings.	• ASPR• CDC
Laboratory testing	26. Include laboratory representatives in preparedness planning committees and healthcare coalitions.	• ASPR• CDC• State and local laboratories• State, local, and territorial health departments• Hospitals/healthcare systems• Healthcare coalitions• National associations, eg, Association of Public Health Laboratories (APHL), AHA
Operational coordination and communication	27. Improve speed, clarity, and background of guidance.	• ASPR• CDC
	28. Centralize communications through an information-sharing platform managed by ASTHO, NACCHO, Council of State and Territorial Epidemiologists (CSTE), and APHL so their members can provide bidirectional communications with federal partners.	• ASPR• CDC• State, local, and territorial health departments• National associations, eg, APHL, ASTHO, NACCHO, CSTE• Other partner organizations
	29. Coordinate a “partner ConOps integration” among public health organizations preparing for and responding to disease threats.	• ASPR• CDC• State, local, and territorial health departments• National associations, eg, APHL, ASTHO, NACCHO, CSTE• Other partner organizations
	30. Create resources that describe the capabilities, triggers, procedures, flexibilities, benefits, and drawbacks of emergency or public health declarations at the federal level and within each state, and include summary of gubernatorial and state health official authorities.	• ASPR• CDC• Governors and state health officials• State, local, and territorial health departments• National associations, eg, APHL, ASTHO, NACCHO, CSTE, NGA
Risk communications	31. Tailor risk communication and educational materials to specific audiences and include input from state and local health departments.	• ASPR• CDC• State, local, and territorial health departments• Other partner organizations, eg, faith-based organizations, community organizations, schools, daycares, etc.
	32. Regularly brief governors and other high-level state officials on state ICS procedures and policies using real-world scenarios.	• State, local, and territorial health departments• Governors and other high-level state officials• National associations and other partner organizations, eg, National Governors Association (NGA)
	33. Include destigmatizing messaging in communication and educational materials to mitigate potential negative impacts on affected people, families, and communities.	• ASPR• CDC• State, local, and territorial health departments• Other partner organizations, eg, faith-based organizations, community organizations, schools, daycares, etc.

All levels of government should work together to increase and accelerate preparedness funding to public health and healthcare end-users, including EMS, by expanding funding sources, improving flexibility, and identifying opportunities to improve efficiency in administering funds at all levels. Although state and local health departments appreciated federal efforts to secure the supplemental federal funding, delays in funding awards created additional challenges for the Ebola response. Stakeholders recommended Congress and federal entities collaborate in establishing a public health contingency or emergency fund that does not require separate congressional approval and can be used quickly during an emergency. State, local, and territorial health departments and national associations can support this effort by continuing to advocate for and educate state and local policymakers on the benefits of a public health and healthcare contingency or emergency fund as part of annual appropriations, as well as the importance of preparedness and response funding in general.

Restrictions in the supplemental funding also made it difficult for state public health department awardees to effectively spend funding received late in the response. The federal government can increase flexibility in supplemental and emergency funding by phrasing guidance to focus on expected outcomes instead of specific activities. Similarly, language in future Public Health Emergency Preparedness (PHEP), Hospital Preparedness Program (HPP), and Epidemiology and Laboratory Capacity (ELC) for Infectious Diseases annual cooperative agreements could be updated to allow the use of funding for response purposes.

Additional delays were caused by state and local regulations and processes for accepting and receiving funds. Except for 4 cities that receive federal funding directly, these delays are even more pronounced at the local level, since funding must first go through state health departments and intermediaries.

To improve effective spending of grant funds, stakeholders stressed the need for increased pre-response communication and transparent concurrence processes between state and local health departments. With the assistance of federal entities and national associations, a reassessment of state and local laws, regulations, and processes could identify opportunities and methods to improve the efficiency of fiscal and administrative processes for accepting, obligating, and expending grant funds. Furthermore, national associations can contribute to expanding nonfederal funding sources by identifying existing funding models and sharing innovative and promising practices, such as public/private partnerships.

Diversify, strengthen, and formalize partnerships at all levels, including waste management, transportation, and other nontraditional partners, to improve guidance and preparedness planning. The lack of timely guidance, sufficient knowledge about Ebola and infection control, and adequate coordination and pre-planning with nontraditional partners resulted in confusion on roles and responsibilities and hesitance to support the response. State and local health departments can improve preparedness and healthcare planning for infectious disease threats by establishing and fortifying relationships with hospitals, healthcare coalitions, laboratories, 9-1-1 departments, transportation companies, waste management companies, and other partners prior to an event. Federal, state, and local engagement of nontraditional partners in the development of policies, guidance, and plans, as well as in drills and exercises, will create a stronger public health system that is better prepared to address future infectious diseases.

Transition from Ebola-specific guidance and protocols to broader infection control improvements to strengthen health systems and improve integration of preparedness and infection control. Infection control was a major challenge during the Ebola response. The federal government developed several iterations of guidance based on lessons learned from treating Ebola patients, including training videos and infographics tailored to specific audiences (eg, healthcare workers, EMS, law enforcement). Challenges and considerations used to develop guidance and resources for Ebola and other infectious disease threats should be assessed for application to other highly pathogenic diseases and incorporated into ongoing infection control efforts. Ensuring that response partners are knowledgeable and competent in infection control practices for communicable diseases will also prepare them to effectively carry out their critical roles in the health system.

Identify promising practices and tools developed or used during the Ebola response that could be used for existing or emerging infectious disease threats, such as Zika, and improve mechanisms for sharing with appropriate stakeholders. Many health departments and response organizations developed or adapted tools, resources, and training to monitor and respond to the threat of Ebola. National associations and federal partners (eg, ASPR TRACIE¹³) can serve as resources to collect, evaluate, and disseminate information about promising practices and tools to address stakeholder needs for future emerging infections.

Leverage national associations to improve operational coordination and streamline bi-directional communication among federal, state, and local partners. For the purposes of the review, operational coordination and communication included all efforts to communicate and coordinate across various sectors and jurisdictional or state boundaries, such as those required to move people with suspected or confirmed Ebola to assessment or treatment facilities, share information about the monitoring and movement of people potentially exposed to Ebola, and implement guidance across public health and health care. In addition to fostering more streamlined and centralized communications among federal, state, and local partners, national associations can also improve operational coordination by better aligning their concept of operations and crisis and emergency risk communication plans.

Build awareness of and educate policymakers and political leaders at all levels on the ICS and public health preparedness and response systems. Review participants felt the stigma associated with Ebola and intense public scrutiny and media coverage created an environment in which individuals in leadership positions were pressured to make decisions based on misperceptions. State health departments and national associations can preemptively prepare governors and other high-level elected officials to make informed decisions through regular briefings from scientific experts, subject matter experts, and preparedness officials on incident command system procedures and policies. Educating policymakers and political leaders could potentially influence them to use their authority to create and improve policies to address the challenges experienced during Ebola, such as the interjurisdictional transportation of people under investigation, medical waste, and laboratory specimens.

Conclusions

A limitation of in-progress reviews is that they represent a specific snapshot in time. This review of the public health response to Ebola is no exception. Since the time of the in-person meeting and key informant interviews, the national response to Ebola has ended and many process improvements from the Ebola response have already been translated to Zika preparedness and response efforts across the nation. As seen during Ebola, supplemental funding was granted to PHEP awardee jurisdictions for Zika-specific activities. Communication from federal partners has been consistent and significantly more unified during Zika. During Ebola, seemingly unrelated partners worked together to plan response activities such as waste removal and lab sample transportation. Now, during Zika, national associations are working to disseminate timely information quickly and efficiently to a cohesive and yet again unique group of partners, including epidemiologists, preparedness directors, physicians, public health officials, vector control professionals, and maternal and child health experts. The close proximity in time between the Ebola and Zika responses has been beneficial in applying lessons learned without losing knowledge and experience gained in the previous response.

It is our intention to share the distinct perspectives of state and local public health and response partners as reflected in the summer and fall of 2015 and build recommendations from their collective thoughts. The goal of capturing this information is to provide the public health community with information to spur additional conversations and action to improve future responses to infectious disease threats. Findings and recommendations from the review will be shared with stakeholders and accessible to the public via NACCHO's and ASTHO's websites. We applaud the efforts at the federal, state, and local levels to improve preparedness and response efforts since the in-progress review period and look forward to advancing best practices as we respond together to the next national disease threat.

Footnotes

Acknowledgments

This project, report, and article were supported by the Centers for Disease Control and Prevention through the following cooperative agreements: ASTHO: 3U38OT000161-02S2, 3U38OT000161-03S2; NACCHO: 3U38OT000172-02W1, 3U38OT000172-03S2. ASTHO and NACCHO would like to thank all the in-progress review participants, planning committee members, our federal partners, and CSTE and APHL for their time, effort, and contribution to the report and this article.

References

World Health Organization. 2014 West African Ebola outbreak: feature map. WHO website. March 23, 2014. http://www.who.int/features/ebola/storymap/en/. Accessed August 18, 2017.

Centers for Disease Control and Prevention. The road to zero: CDC's response to the West African Ebola epidemic. July 9, 2015. https://www.cdc.gov/about/pdf/ebola/ebola-photobook-070915.pdf . Accessed August 18, 2017.

Centers for Disease Control and Prevention. Hospital preparedness: a tiered approach. CDC website. Updated February 20, 2015. https://www.cdc.gov/vhf/ebola/healthcare-us/preparing/current-treatment-centers.html. Accessed August 18, 2017.

Centers for Disease Control and Prevention. Interim guidance for U.S. hospital preparedness for patients under investigation (PUIs) or with confirmed Ebola Virus Disease (EVD): a framework for a tiered approach. CDC website. Updated August 28, 2015. https://www.cdc.gov/vhf/ebola/healthcare-us/preparing/hospitals.html. Accessed August 18, 2017.

U.S. Department of Health & Human Services. HHS selects nine regional Ebola and other special pathogen treatment centers [news release]. June 12, 2015. https://www.hhs.gov/about/news/2015/06/12/hhs-selects-nine-regional-ebola-and-other-special-pathogen-treatment-centers.html. Accessed August 18, 2017.

Association of State and Territorial Health Officials. State and territorial health departments working overtime to prepare for Ebola [press release]. ASTHO website. October 14, 2014. http://www.astho.org/Press-Room/State-and-Territorial-Health-Departments-Working-Overtime-to-Prepare-for-Ebola/10-14-14/. Accessed August 18, 2017.

Bevington

, Kan

, Schemm

, Aldridge

. Ebola as a case study: the role of local health departments in global health security. J Public Health Manag Pract, 2015; 21(2):220-223.

U.S. Department of Health and Human Services. Declaration regarding emergency use of in vitro diagnostics for detection of Ebola virus. Fed Regist August 12, 2014. https://www.federalregister.gov/documents/2014/08/12/2014-19026/declaration-regarding-emergency-use-of-in-vitro-diagnostics-for-detection-of-ebola-virus. Accessed August 18, 2017.

Centers for Disease Control and Prevention. State and territorial Ebola screening, monitoring, and movement policy statements—United States, August 31, 2015. MMWR Morb Mortal Wkly Rep, 2015 Oct 16; 64(40):1145-1146. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6440a4.htm. Accessed August 18, 2017.

10.

Centers for Disease Control and Prevention. Notes on the interim U.S. guidance for monitoring and movement of persons with potential Ebola virus exposure. CDC website. Updated February 19, 2016. https://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html. Accessed August 18, 2017.

11.

Lowe

, Gibbs

, Schwedhelm

, Nguyen

, Smith

. Nebraska Biocontainment Unit perspective on disposal of Ebola medical waste. Am J Infect Control, 2014; 42(12):1256-1257.

12.

13.

Assistant Secretary for Preparedness and Response, Department of Health and Human Services. Technical Resources, Assistance Center, and Information Exchange (TRACIE) Healthcare Emergency Preparedness Information Gateway. ASPR website. Updated August 18, 2017. https://asprtracie.hhs.gov/. Accessed August 18, 2017.