Frontline defense: Public health system prepares for battle against Ebola

Vital Signs » Fall 2014
photo of the ebola virus

The largest Ebola epidemic in history began with the death of a small boy named Emile in southern Guinea near the borders of Sierra Leone and Liberia in West Africa.

Just two years old, the toddler fell ill with a fever. He died two days later on December 28, 2013. The mysterious disease soon claimed his three-year-old sister, Philomena, his mother, Sia, and his grandmother, Koumba. Mourners at his grandmother’s funeral and a health care worker are believed to have carried the virus to nearby villages, where it spread rapidly. By March 20, 2014, 59 Guinea residents had died of the fever, which Guinea confirmed as Ebola. By the end of March, two cases were reported in Liberia, and in May, Ebola reached Sierra Leone.

On September 20, Thomas Duncan flew from the capital of Liberia, Monrovia, to Dallas, Texas. On September 30, he became the first person to be diagnosed with Ebola in the U.S. He died a week later in a Dallas hospital. Within days, two nurses who had cared for him tested positive for Ebola.

By the end of October 2014, the World Health Organization (WHO) reported a total of 13,567 suspected cases and 4,960 deaths. Almost all of the cases were in the three countries of Guinea, Liberia, and Sierra Leone.

Could an Ebola epidemic happen here?

The United States is not immune to Ebola. The death of Thomas Duncan, and the infection of the two nurses who treated him, have brought Ebola to the forefront of the national discussion. From news shows to water cooler discussions, Americans are asking whether an Ebola epidemic could happen here.

Fortunately, the United States has a frontline defense against an uncontrolled outbreak of a deadly disease such as Ebola: a strong public health system.

According to James Gross, M.P.H, the health commissioner for Public Health—Dayton & Montgomery County (PHDMC), the U.S. public health system differs from other health systems because it involves local public health departments, hospitals, clinics, health professionals of all types and every level of the local, state, and federal health agencies.

“The U.S. public health system also monitors what is going on regarding the different diseases,” said Gross, who also is a graduate of the Wright State University Master of Public Health (M.P.H.) program. “It monitors how they are being identified, how they are being treated, and the success of stopping their spread. It’s an integrated system that needs all parts to work together.”

That’s not the case in parts of West Africa, Gross said. “The medical care is spotty, the number of facilities is quite limited, and people involved in health care are often not as well trained as they are in the United States,” he said.

Furthermore, the degree of communication from various areas, the labs for medical testing, and the overall quality of care lags behind that found in the United States. “Relatively poor countries cannot match the quality of care found in first world countries,” said Gross, who has served as the PHDMC health commissioner for seven years and serves on the voluntary faculty of the M.P.H. program.

Like PHDMC, public health organizations throughout the United States work to prevent the spread of disease, protect the population against health threats in air, food, and water, promote healthy behaviors, reach out to vulnerable populations, mobilize community action through partnerships, prepare for and respond to public health emergencies, and serve as a public health information resource to physicians and other health care workers.

Infection control practice is key

Thomas Herchline, M.D., professor of internal medicine at the Boonshoft School of Medicine, is an infectious disease expert and also serves as medical director for PHDMC. He explained that much of the spread of Ebola in Africa has been within hospitals or within the homes of families providing care for very ill individuals. In the United States, these patients would have been hospitalized.

“Infection control practices in the United States are dramatically different than in the affected African countries and would be much more effective at preventing spread of the Ebola virus,” said Herchline, who has lectured for the medical school’s Master of Public Health Program, has been a preceptor for M.P.H. students doing their practice placement at PHDMC, and has been an adviser for M.P.H. students completing the culminating experience research project.

Herchline explained that contact tracing, as was done for the Ebola patients in the United States, is key to preventing the spread of disease.

In neighboring Greene County, home to Wright State University, the Greene County Combined Health District (GCCHD) is monitoring the situation through communication with federal, state, and regional partners. It is working closely with area hospitals and monitors hospital data continuously. The public health staff distributes information about personal protective equipment, answers questions, and remains on call to conduct an epidemiological investigation, implement case contact tracing, and arrange for specimen collection to state and federal health diagnostic laboratories.

“While the probability of an outbreak is low, there is the possibility of a case occurring here or elsewhere in the United States,” said Melissa Howell, M.S., M.B.A., M.P.H., R.N., R.S., health commissioner of the Greene County Combined Health District. “There is a possibility that a person could be infected, not yet ill, and travel, unrestricted and unknowingly, to areas where the disease has not yet spread.”

The GCCHD is vigilant in scanning available information for unusual activity. She explained that detection requires trained communicable disease staff and epidemiologists to know what to look for—fever, travel history consistent with the virus, and information that can be ignored. “This level of training to discern and sound an alarm cannot be replaced by computerized decision models,” said Howell, who graduated from the medical school’s M.P.H. program in 2007.

The GCCHD has issued press releases regarding Ebola and has been on several conference calls with the Centers for Disease Control and Prevention (CDC) and the Ohio Department of Health to receive updates. It has provided guidance to those entities that have international travel concerns and disseminated Information to hospitals and health care providers.

“While most Americans know public health is important to them, they aren’t always sure about what is being done to protect them behind the scenes,” she said. “Outbreaks such as Ebola raise awareness of how important it is to have a public health system that works.”

Even without a vaccine for Ebola, public health departments can implement nonpharmaceutical interventions to stop the spread of disease. These include quarantine, isolation, cordon sanitaire (cordoning off areas stricken by the disease), school closures, social distancing measures, targeted pharmaceutical intervention, and social media messaging.

Dallas death a wake-up call

Along with local and state health departments, the U.S. health system has been preparing since late March for the possibility of Ebola in the United States. What happened in Dallas was a wake-up call for hospitals nationwide, said James Ebert, M.D., M.B.A., M.P.H., F.A.A.P., Oscar Boonshoft Chair and director of the Center for Global Health and the Master of Public Health program, and associate professor of community health and pediatrics.

“Health issues anywhere in the world can potentially affect other points in the world quickly due to high speed transportation and shipment of goods,” he said. “However, people can survive Ebola through IV fluids, ventilators, and antibiotics used to address secondary infections.”

In spite of their best efforts, the response of U.S. public health officials to the Ebola threat was not without controversy. After the two Dallas nurses were exposed to Ebola, it seemed as if things were changing every few hours. Thomas Frieden, M.D., M.P.H., director of the CDC, was interviewed daily by the media and testified before the U.S. Congress. On October 17, President Barack Obama appointed Ron Klain as the nation’s Ebola “czar” to manage federal efforts to monitor the deadly virus.

The CDC issued tighter guidelines for health care workers caring for patients with Ebola. Those guidelines address rigorous and repeated training, skin exposure, and supervision by a monitor.

System is working

Public health officials argue that the nation’s local, state, and national public health systems are working to protect Americans from an Ebola epidemic. According to the Ohio Department of Health, the CDC has protocols, professional staff, and a strong network of partners to protect against further spread of disease. When one of the Dallas nurses traveled to Ohio and later developed Ebola, the Ohio Department of Health worked with local health officials in Summit County, Ohio, to identify people with whom the nurse may have had direct contact. Epidemiological staff helped state and local health care officials conduct contact tracing, identifying people the patient may have contacted. To date, no one in Ohio has contracted the Ebola virus.

In the Greater Dayton area, public health officials, with ties to the Boonshoft School of Medicine Master of Public Health program, are behind the scenes working with local hospitals and health providers to provide the public with information.

Public Health—Dayton & Montgomery County provides information about Ebola to local TV stations, newspapers, radio stations, and social media. Gross said the likelihood of an outbreak in Dayton is the same as with any other community that has individuals routinely coming in from West Africa. “Remember, the disease is spread by coming in direct contact with bodily fluids from someone who has Ebola and is showing symptoms,” Gross said. “It is not easily contagious like the flu.”

Ebert explained that the CDC plays a vital role in public health efforts to contain a disease outbreak. “Providing correct timely information helps dispel unnecessary fears,” Ebert said. “The Centers for Disease Control and Prevention is the national leader in public health. Policies should come down from the CDC. The CDC communicates closely with the World Health Organization.”

The threat of Ebola continues to present new challenges, such as weighing the liberty of returning health care workers and public safety. In late October, New York and New Jersey grappled with whether to quarantine returning health care workers. Nurse Kaci Hickox, who was quarantined in New Jersey in an isolation tent after treating patients from Sierra Leone, defied a quarantine in Maine, arguing that she had no symptoms of the disease and tested negative twice. The CDC updated its Monitoring and Movement Guidance, defining risk levels for people who may have been exposed to Ebola. The guidance recommends stricter actions for higher levels of risk.

Crisis focuses national attention

Despite the much greater number of deaths from complex health threats such as obesity, diabetes, and heart disease, the public tends to focus on national health issues more when a crisis hits. “Outbreaks capture the concerns of Americans like no other topic,” Howell said. “Fighting infectious disease requires vigilance on the part of public health to scan for threats, respond early and with enough force to counter the spread of disease, and continue to promote the science of public health in the face of mass concern.”

As for Ebola, she believes the United States is prepared to stop the deadly virus. “President Obama and Thomas Frieden, the director of the CDC, have made this a national priority,” she said. “We are subject to attacks from disease-causing agents, but the U.S. public health system is quick to respond and implement interventions to stop the spread of disease. The public health system is critical to the welfare of people in the United States.”

Despite our worst fears, there have only been two deaths from Ebola in the U.S. since the outbreak began. The public health system has done what it was designed to do. As the battle against Ebola continues, the CDC and the public health system will continue to implement lessons learned and adjust guidelines to better protect Americans.

—Heather Maurer

Last edited on 09/22/2015.