Is the U.S. Ready for the Next Outbreak of Ebola?

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By Kathleen Marquardt

Some say those in charge of our medical emergency systems, the Centers for Disease Control and Prevention (CDC), Occupational Health and Safety Administration (OSHA), Department of Transportation (DOT), were not prepared for the Ebola outbreak in 2014, (and still aren’t). Others disagree, saying that, of course, not everything went smoothly but could we really expect even near perfection under such circumstances.

Thomas Eric Duncan, a Nigerian, was diagnosed with Ebola in September, shortly after arriving in Texas. Three people, two nurses who attended him and a health worker who handled his clinical specimens, contracted Ebola. One of the nurses became the first person diagnosed with Ebola on American soil. The Nigerian died, but the other three were eventually declared virus-free.

Earlier, in July 2014, a number of people returned to the U.S. and came down with the disease or came back after being diagnosed. They were treated at several hospitals – in Worcester, Massachusetts, Dallas, Atlanta, Omaha, and New York City. In those cases, the hospitals knew they were handling Ebola virus and were more careful handling the patients and their waste. But most of America knew only about Duncan and the three ancillary people who were infected. The others were not unexpected, giving those healthcare providers foreknowledge that made dealing with the virus easier.

Because some hospitals were dealing well with these patients, CDC Director Thomas Frieden showed a confidence that hospitals across the country were well prepared to deal with Ebola. And most of them probably would have handled Ebola patients well if they knew what they were dealing with from the beginning. The symptoms of Ebola are the symptoms of many other diseases. There is also the prospective problem that, while 80% of people entering the U.S. from the affected West African countries live within 200 miles of one of the designated Ebola treatment centers, (according to the CDC), there are another 20% who don’t and will be going to hospitals that are not on the alert for Ebola.

On July 17, 2019, the World Health Organization (WHO) finally declared the Ebola outbreak in the Democratic Republic of the Congo (DRC) was now a public health emergency of global concern. The catalyst was that Ebola was diagnosed in Goa, a city of two million, where people are crowded together, elevating the chance of the disease spreading. When they declared this emergency, Robert Steffen, chair of the emergency committee of WHO, asked that all countries, companies, and individuals support the DRC by not placing “travel and trade restrictions as a result of the declaration. Any border closures will have a ‘terrible impact’ on the economy of the affected region”. Complying with this, naturally, will allow the spread of the disease globally, so the U.S. has to be even better prepared than in 2014.

Ebola viruses are transmitted through direct contact with infected blood or body fluids/substances (urine, feces, vomit) or through exposure to objects (such as needles) that have been contaminated with infected blood or body fluids. The role of the environment in transmission has not been established. Limited laboratory studies under favorable conditions indicate that Ebola virus can remain viable on solid surfaces, with concentrations falling slowly over several days. Because of these factors, handling the waste is of utmost importance to control and eradicate the disease.

Many hospitals installed on-site incinerators starting in the 1980s, after OSHA and DOT began regulating medical waste. But when, in 2009, the Environmental Protection Agency (EPA) issued new standards to the Clean Air Act, of the 2,400 existing incinerators, only 22 commercial incinerators complied with the new regulations thus making 2,300+ incinerators obsolete without upgrades. Alice P. Jacobsohn, in the Jan-March 2015 edition of Healthcare Environmental Solutions, wrote, “Many hospitals tried to upgrade their incinerators to comply with the new requirements. Hospitals spent millions of dollars and their incinerators still failed to meet the standards, so they became gun shy about spending more money for on-site treatment. The incinerators were removed, and transporters were hired as an interim measure, but then transporting became permanent.”

The Affordable Care Act also acted to tighten hospitals’ purse strings, and many hospitals don’t have extra space for large equipment.

Today, only 20 percent of hospitals house onsite options, and many of these are not large enough to handle the volumes of waste from Ebola patients. The other 80 percent of hospitals contract with a medical waste hauling company to carry containerized waste to statepermitted disposal facilities.

Hospitals are working hard to be ready for the next outbreak. Because the waste materials from Ebola may be more contagious than contact with the patient, how to dispose of the waste is a critical issue that needs to be dealt with early.

Arthur McCoy, Sr. V.P. at San-I-Pak World Health Systems, noted, “hospitals that lack the infrastructure to autoclave their infectious waste on-site can become vulnerable quickly as was the case at both Emory and Bellevue Hospital. Other hospitals that have on-site autoclaves, i.e., Nebraska Medical Center, quickly realized their limiting factor for how many patients they can treat was based on their autoclave capacity to process the infectious waste. On-site waste sterilizers are a best practice for reducing the spread of such deadly diseases. Furthermore, without such infrastructure, hospitals can pay as much as $100K a day (i.e., Bellevue Hospital during the 2014 outbreak) to have this deadly infectious waste transported on public roadways to treatment facilities that are often hundreds of miles away.”

In December 2014, the World Health Organization issued guidelines that state, “It is not recommended to transport untreated infectious waste and therefore all waste should be treated on-site.” That is a good recommendation, but it won’t/can’t happen overnight. Hospitals had that ability with their incinerators, but since those were shut down by EPA standards, hospitals are inclined to be cautious about investing in high cost equipment. Today, most hospitals contract with waste management companies to dispose of their infectious waste.

Bob Spurgin, Medical Waste Consultant at Spurgin and Associates, noted that, “Medical waste is not and never will be federally regulated -- it’s left to the states. So rules vary, depending on where you are. Not to a great degree but still permits are very different in each location. What needs to happen is for these transporters and treatment sites to have consistent policies and procedures to handle the waste. DOT has taken care of that on the transport side, so those are uniform now. Commercial treatment sites have the ability to handle large quantities of material so it’s just the understanding of consistency for treatment and disposal. Guidance from the Centers for Disease Control and Prevention (CDC) in consultation with the service providers would help cement this.”

Many people, including former Senator, Joe Lieberman and former Secretary of Homeland Security, Tom Ridge, in a Chicago Tribune article, “Ebola is raging again - and the U.S. is not ready,” were concerned that, “Despite assurances that our country would be able to handle such a serious disease, our public health agencies and health care institutions made some serious mistakes.”

Not everything went perfectly, yet all situations were handled, and those entities concerned, the CDC, OSHA, and DOT, did what they were set up to do. These agencies do not overlap – they have their own jurisdictions. There is not one single control center. But, after 2014, corrections were made where necessary, and those agencies are much more ready to deal with an outbreak, according to Spurgin.

So, the answer to the title question is: the U.S. is seemingly more prepared than in 2014, but only time – and an outbreak – will tell if we are truly prepared.

A postscript on this: While only one person died and another had a relapse, there is now concern about life expectancy after recovering from Ebola. A study in Guinea revealed that 59 survivors died after discharge: “Five died within a month of hospital discharge, three within three months, four within 3-12 months after discharge, and four died a year after discharge. The exact date of death was not determined for the remaining 43 Ebola survivors who died,” wrote Jenny Lei Ravelo for Devex News. So, the goal must be to eradicate Ebola at its source, while countries are treating those infected.

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