Ebola Invades Texas: A Public Response to an Unfamiliar Threat
It was just like any other day in Dallas, Texas on September 19, 2014. Commercial air flights were coming and going. Little did anyone know that one flight passenger would introduce a microbe to Texas that would challenge the city of 1.32 million and the greater Dallas-Fort Worth metroplex of almost 6.97 million, test the public health infrastructure of Texas, grind the relations between multiple levels of government across the United States, and stir the fears of Texans and many Americans.
After arriving in Dallas, Eric Thomas Duncan made his way to the Ivy Apartments, located in North Dallas, to stay with his fiancé and her family. At this time, Duncan showed no signs of the Ebola virus despite his exposure to the virus in his home country of Libera. Four days passed before any symptoms of an illness began to manifest. On September 25th, Duncan and his family became concerned with his illness. The concern was enough that he presented at Texas Health Presbyterian Hospital in Dallas with a fever, dizziness, nausea and abdominal pain. He was examined by the medical staff at the hospital, prescribed antibiotics, and discharged. As the days passed, he did not become any better despite his treatment. On September 28th, having the same symptoms that he presented at the hospital with days prior but worse, he was transported by Dallas Fire and Rescue via ambulance from his apartment to Texas Health Presbyterian Hospital. Upon arrival at the hospital, he was evaluated to be in critical condition and placed in isolation in the intensive care unit. Being designated as a patient in isolation, he was treated by the staff in the hospital unit that followed CDC guidelines for personal protective equipment (PPE). The staff took blood specimens and submitted to the Texas State Public Health Laboratory in Austin. Two days later (September 30th), the Centers for Disease Control and Prevention Viral Special Pathogens Branch Laboratory confirmed Duncan was infected with Ebola Virus Disease (EVD). He became the first patient diagnosed with the virus in the United States.
Background: Ebola in Africa and Beyond
Beginning in March 2014, Africa began to experience, what would become, the largest Ebola outbreak in recorded history. Libera, Sierra Leone, and Guinea in particular experienced widespread coverage of the virus which killed thousands and interfered with the life of its citizens.
With limited healthcare infrastructure and case counts that were overwhelming, African countries began to request assistance from the World Health Organization and western countries. Liberian President Ellen Johnson Sirleaf said the fast-spreading disease overwhelmed her nation’s health care system, “The scope and scale of the epidemic … now exceed[s] the capacity and statutory responsibility of any one government agency or ministry.” Multiple accounts of resource exhaustion and viraemic spread of vast proportion propagated the global interest in containing the virus to keep it out of other countries. Despite response efforts, the virus found its way into seven countries across the globe aside from the three primary countries in Africa resulting in 36 cases and 15 deaths. In the three primary countries, there were a total of 28,616 cases and 11,310 deaths. In addition, “$2.2 billion in GDP was lost in Guinea, Liberia, and Sierra Leone in 2015, threatening not only macroeconomic stability but also food security, human capital development, and private sector growth.” Globally, there was $3.6 billion spent to combat the outbreak and develop response capacities for the next outbreak.
“The scope and scale of the epidemic … now exceed[s] the capacity and statutory responsibility of any one government agency or ministry.” — Liberian President Ellen Johnson Sirleaf
Ebola Invades Texas
With the flight to Texas, Duncan introduced the virus to Texas that had been
ravaging Africa. Immediately, questions arose regarding how Duncan made it into the country infected with the virus when there were efforts in place by means of passenger screening at ports of entry. After investigation into his personal story, it was discovered that he had assisted a pregnant friend infected with the disease when in Monrovia, Liberia before his travel to America. Duncan was not forthcoming when questioned about exposure in his native country.
After it was confirmed that Duncan was infected with Ebola, the Texas Department of State Health Services requested assistance from the CDC. Ebola was an unfamiliar pathogen to state and local officials, and the need for expert assistance was immediately identified. October 1st, Governor Rick Perry met with local, state, and federal officials to discuss the level of emergency, or if there was one, that Duncan’s case of Ebola presented to the state. At this point, it was clear that the response would be a prolonged incident; the incubation period for Ebola is 21 days. This meant that the individuals exposed to Duncan would have to be monitored for that period of time to make certain none of them became symptomatic. It was determined there were a total of 15 individuals in close contact with him. At this time, the CDC’s guidance stated that Ebola was not airborne and the only way one could contract the disease from an infected individual was through bodily fluids. Dallas County employed a team of nine epidemiologists, who were led by a young doctor named Wendy Chung. The group of epis were responsible for monitoring the individuals identified as contacts. Chung had attempted to get the CDC to facilitate testing of Duncan prior to his confirmation, but they wouldn’t agree to the need, “The CDC was actually not real keen on testing; there was no indication he’d been to a funeral, no evidence he’d eaten bushmeat, no evidence of Ebola exposure. All he was was a gentleman form Liberia with a fever.” In short, he met no clinical definition nor had any document travel exposure that met CDC guidelines for testing. Chung continued to try and convince the CDC and other officials of the need, but it only led to irritation. Chung described her thoughts when she got the news of Duncan’s positive Ebola lab, “It was almost that feeling of incredulousness. Is this real?”
The Response
The next issue of concern centered on the question of who or which government — local, state, federal — would be in charge of the public response to the United States’ first positive Ebola case. “The CDC, they’re a government agency, but they have no authority,” stated Jennifer Gates, the councilwoman for the area where Duncan stayed. “There was this assumption they would take over. And they didn’t.” Clay Jenkins, the Dallas County Judge, expected the CDC’s director Tom Frieden to take over as well, “My hope talking with Frieden was ‘Hey, big man, you’re freaking in charge of this.’” Dallas Mayor Mike Rawlings, a former Pizza Hut C.E.O., conveyed his concern to Jenkins, “I am freaking out…” Rawlings knew that he was ill prepared to respond to such an event. Jenkins assured Rawlings he would sort out the issue of command and control. At the time of the outbreak, there were no specific command and control rules for these types of outbreaks. It was left up to the local officials to respond as the jurisdiction deemed appropriate and refer to state and federal subject matter experts for guidance.
“I am freaking out…” — Dallas Mayor Mike Rawlings
Later, Texas Governor Rick Perry held a press conference in an attempt to assure the public of the efforts of the state and local governments’ control of the incident, and after Governor Perry’s press conference, Dr. David Lakey, Commissioner of the Texas Department of State Health Services, Frieden, and Jenkins had a teleconference. Lakey urged an incident command structure to command the incident. Jenkins knew this kind of approach would put one person at the helm of the entire crisis. He had experienced it a few years prior with a West Nile Virus outbreak. Jenkins inquired of Frieden, “Well, who’s going to be in charge?” Frienden replied, “You would be in charge, Clay.” Jenkins thought it would be advantageous for a doctor to lead the response, but Lakey and Frieden declined the role. After the teleconference, Jenkins met with Rawlings to try and explain to incident command system, but Rawlings response to Jenkins was contentious, “I don’t give a fuck about that…Who’s in charge?” Jenkins relayed the remainder of the earlier conversation to Rawlings, and sarcastically he replied, “Oh, good.” Both Jenkins and Rawlings were keenly aware of their inability to lead a response to something as threatening as Ebola, but what were they to do when the state and federal officials refused?
Later, Lakey issued a Control Order to Duncan’s fiancé and three other family members. Lakey exercised his authority under Texas Health and Safety Code, § 81.083(b). This statute states that “DSHS has the authority, with reasonable cause to believe an individual has been exposed to or infected by a communicable disease, to order the person to submit to control measures.” The Control Order mandated that they stay home and not allow visitors in their home without going through DSHS to document and get approval. Jenkins wanted to approach the order with care, “What we were doing was something no one was really comfortable with. We were signing an order that abridged people’s ability to move about. We knew we were leaving ourselves open to criticism.” Also, the aspect of the Control Order introduced a new set of problems. The family would need to receive food, hygiene, and other consumable products, and the apartment was contaminated by Duncan’s volatile vomiting and diarrhea. Confining the family to the apartment would further expose them to the virus and prohibit the decontamination of the apartment. Louise Troh, Duncan’s fiancé, became angry with the conditions in which the DSHS expected her to wait out her monitoring period, “we can’t wait to be over with everything.” She also advised that she had to sign paperwork that stated, “if we step outside, they are going to take us…to court [because] we will have committed a crime.” She confirmed that no food was brought to them on the Thursday after the confinement order was issued, and there were four people in the house with no ability to get food. The electricity to the apartment was in and out due to a thunderstorm that had passed through the area. The state advised Troh that she could not dispose of any linens or other household objects that could have been contaminated with Duncan’s bodily fluid without first getting state approval. The question of how to properly dispose of the contaminated objects would materialize into a perplexing problem for officials. The issue of disposal of contaminated items extended to the hospital as well. The “hospitals [said] they face a major challenge disposing of waste generated in the care of Ebola patients because two federal agencies [had] issued conflicting guidance on what they should do.” As a result, the linens and other waste posed the problem of staking up.
Jenkins, was not happy with the control order confining the family to the contaminated apartment. He wanted them relocated to another location. He advised national media, “I would like to see those people moved to better living conditions. We are working on that. I would like to move them five minutes ago.” With media attention on the apartment and the family, it seemed Jenkins was concerned with the political ramifications of inaction.
“What we were doing was something no one was really comfortable with. We were signing an order that abridged people’s ability to move about. We knew we were leaving ourselves open to criticism.” — Dallas County Judge Clay Jenkins
Also, on October 1st, Duncan’s condition was upgraded to serious. This change in condition was a welcomed improvement, but the officials knew the fatal nature of the disease. Even if Duncan recovered from the virus, the question of how the hospital neglected to field the appropriate questions about travel and exposure to the virus with him being a Liberian national would be topics of investigation for the DSHS and the CDC. Furthermore, Duncan had advised the nurse screening him at the hospital that he had traveled from Libera and had a fever of over 100 degrees; she neglected to probe further or contact the health department for guidance. Also, the public began to question how Duncan made it into the United States without being screened at Dulles Airport. When questioned about this, Frieden “defended the lack of a more robust screening process at airports in the United States, saying the costs would not be worth the potential benefits, ‘Like any intervention, there are upsides and downsides. There are a lot of downsides. You slow travel. You end up costing people money. Who’s going to get screened? Who’s going to train them? If you have a positive, where are you going to bring them to? The plain truth is we can’t make the risk zero until the outbreak is controlled in West Africa. What we can do is minimize that risk, as is being done in Dallas.’”
As soon as the media became aware of Duncan’s residence, they invaded the Ivy Apartment complex. All of them wanted a photo and camera shot of Apartment 614, Duncan’s apartment. They were handing out $20 bills to anyone that would afford them a good view and were pulling anyone aside that would talk about the Ebola case. Problems and issues for the officials were greatly exacerbated by the fear that the media was spreading regarding the Ebola case.
It was determined the next day that potentially, 80 people had contact with Duncan or associates of Duncan that could have been closely exposed to him. Out of the 80 individuals, there were five school children that were added to the list. The key to containing the spread of the illness was to monitor the contacts and document any development of symptoms, and since the five children were in school, it was clear that the state and local health departments would have to work with the schools or exclude the children from attending school altogether. Either way it would certainly create a public information issue with parents wanting to ensure the safety of their children in school with the monitored children, or the school would have to facilitate three weeks of education for the children outside of the classroom. “Mike Miles, the superintendent of the Dallas Independent School District, said that attendance at the schools [was] about 86 percent, down from about the usual 96 percent.” Royale Hollis, a 15 year old freshman at Emmett J. Conrad High School described his experience with the Ebola risk, “my mom, she recommended that I not touch a lot of kids at school. I haven’t been shaking hands, just bumping elbows.” One thing was certain, the community’s perception of the Ebola risk was going to be an issue that public officials would have to address and provide some public information to counter the exaggerated information. As a result of the rapid expansion of the monitoring and the potential for additional contacts to be discovered by the public health professionals, the City of Dallas, Dallas County, and the Dallas County Health and Human Services each opened their emergency operations centers to begin to effectively respond to the incident.
The DSHS’s Community Preparedness Section immediately recognized the level of concern that the African Ebola outbreak presented and would be causing for Texas and the United States’ public health and healthcare systems. With this in mind, the Section made the decision to survey and assess the capabilities of the hospitals throughout the state to effectively deal with an Ebola patient should another one present at an emergency room or other clinic setting seeking medical attention. The central issue at hand was to determine the preparedness level of the hospital community across the state.
On October 3rd, the DSHS initiated full activation of the State Medical Operation Center. The decision was made by DSHS to offer support to the local officials in Dallas County, but it also became apparent that the event was going to require the coordination of many sections of the state health department; integration between state agencies and the health department would require a concerted effort by the department and state. Additionally, there needed to be a center for information regarding the response to be synthesized and passed on to the CDC and other federal entities that would be addressing the unfolding public health emergency. However, good news presented on this day as well — the number of closely monitored individuals decreased to 50 with only ten being at high risk for contracting Ebola due to the close nature of their contact with Duncan.
The issue of getting Troh’s apartment decontaminated and the family moved remained issues for officials. Jenkins’ aides tried contacting numerous hotels, apartment complexes, and shelters, and none of them were willing to provide a relocation site for the family.
The uncertainty of Ebola made these entities fear offering assistance. Rawlings was desperate for a job to do beyond his continuous press briefings; so, Jenkins tasked him with finding a new location for the Troh family. Jenkins expressed his exasperation with the apartment task to Rawlings, “Find me a freaking place for Louise to go.” What Rawlings perceived to be a 15 minute job turned into two hours when he reported back to Jenkins that it was a much harder task than he originally thought. After a few more hours of searching, Rawlings determined to use a bungalow that his son was renovating in the Oak Cliff neighborhood of Dallas. Jenkins was elated to hear of Rawlings’ solution; however, Rawlings’ Chief of Staff Adam McGough was not as excited as Jenkins, “I was worried about the media and the neighborhood. The whole place would go crazy: what did it mean for the neighbors?…Property values. Would [Rawlings’ son] even be able to sell his house one day?” Rawlings’ wife Micki did not like the idea either, “You can’t do this to Gunnar [the Rawlings’ son].” The decontamination also proved to be a chore as well. McCallum’s Cleaning Guys was selected to provide the service, and R.J. Schwartz was selected to be the incident commander for the decontamination. Originally, the clean-up was described as deconning the apartment and disposing of one mattress and some clothes, but this was not all that had to be done. Schwarz, referencing the description of the job, “That was a bunch of horseshit, whoever told us that;” there turned out being eight mattresses, a set of metal folding chairs, a 60-inch television, and a PlayStation. The amount and size of the contaminated items greatly magnified the scope of the job and the materials required to accomplish it.
The next day Duncan’s condition worsened to critical. The condition update presented bad news to officials. They were now back to their original concern regarding the possible death of Duncan. Just like before, the officials were keenly aware of the negative affect an Ebola death in the U.S. would have on the public and the public’s perception of the government and protection.
Later that day, County officials were successful in finding an alternate location for Troh and the other family members to complete the remainder of the Control Order. The final location was provided by the Dallas Catholic Bishop who allowed the use of a church owned house. Jenkins didn’t want the media to record the movement of the family, and according to sources, he requested the White House close the airspace over Dallas because he didn’t want an O.J., white bronco scene to transpire. The reported response from the White House was to get it done in 17 minutes. The White House didn’t want the perception of federal manipulation. Also, Jenkins wanted the media to record him personally escorting the family out of the apartment. Rawlings’ aides described this as a political move by Jenkins. Jenkins was photographed entering and exiting the contaminated apartment without personal protective equipment; this ignited a media firestorm. In addition to the Troh family issues, there was a second Control Order issued for another close contact of Duncan on that day.
Texas State Government Acts
In trying to ensure adequate response to the unfolding Ebola incident in Dallas and ensure Texas maintained a capacity for response to infectious disease in general, Gov. Perry issued Executive Order 79, “Relating to the creation of the Texas Task Force on Infectious Disease Preparedness and Response.” The Task Force was compromised of many state agencies and academia. According to the Executive Order, the Task Force was given the following duties:
“Provide expert, evidence-based assessments, protocols and recommendations related to the current Ebola response and a strategic emergency management plan for the incident command team and their partners at the state and local level of government.
Develop a comprehensive plan to ensure Texas is prepared for the potential of widespread outbreak of infectious disease, such as the Ebola virus and other emerging infectious diseases, and can provide rapid response that effectively protects the safety and well-being of Texans.
Serve as a reliable and transparent source of information and education for Texas leadership and citizens.”
By October 7th, the Texas State Legislature held a hearing regarding the Ebola virus case. Senate Health and Human Services Committee Chairman Charles Schwertner scheduled the hearing.
He said lawmakers want an overview of the local, state and federal response to handling Ebola and preventing the spread and wanted to hear if the legislature needed to make legal changes to how the state responds in a health crisis. During the hearing, the Committee invited Dr. Gary Weinstein, the head of critical care at Texas Health Presbyterian Hospital, to provide testimony on why the hospital failed to adequately screen Duncan and ask pertinent travel questions to identify the possibility of Ebola. Dr. Weinstein declined to provide specific answers to the Committee’s questions regarding the hospital’s failure. However, he did assure the committee that the misstep was being “thoroughly reviewed” and the results would be announced, “With regards to our specific hospital’s response to this first case of Ebola virus disease, the events preceding his current admission are being thoroughly reviewed,” Weinstein said. “The results of that review will be made available once they’re compiled.” There was no timeline provided to the Committee. Initially, the hospital cited a glitch in their software which didn’t allow the emergency room physician to see Duncan’s travel history, but that explanation was retracted and no other explanation provided. Dr. Weinstein did not address this issue before the Committee. He also provided comments that medical workers’ efforts were being interfered with by the number of governmental agencies involved in the case. Health and Human Services Commission executive director Kyle Janek testified that the state’s response system was capable of preventing an Ebola outbreak, but the possibility of human error and mistake could prevent the response system from operating as designed, “Texans should be confident of our ability to get our arms around the virus.”
“Texans should be confident of our ability to get our arms around the virus.” — Kyle Janek, Texas Health and Human Services Executive Director
The Mistaken End
On October 8th at 7:51 a.m., Duncan was pronounced dead. After his death, his remains were cremated, but Jenkins had to track down Duncan’s 19 year-old son to sign authorization papers, “David Lakey said we couldn’t take the risk of the body being dug up. We had the power to just take the body and burn it, but we thought it was important that people be given power over their own decisions,” Jenkins stated. This development introduced new issues to the event. Public concern would elevate with the death of America’s first Ebola patient. The U.S. healthcare system would be questioned based on the death of an individual in a “developed” healthcare system. Furthermore, questions would begin to develop of his level of care being based on his race, nationality, and country of origin as if he received substandard care based on those factors; Jesse Jackson, with some of Duncan’s family, even held a press conference in Dallas questioning discrimination and Duncan’s treatment based on his race.
At this point, the number of hospital staff Duncan encountered during his treatment was detailed at 76 doctors, nurses, and staff. The next day, a Dallas County Sheriff’s deputy reports symptoms of Ebola after he was exposed to Duncan’s apartment. This brought additional attention to the risk that the community had been exposed. The deputy was merely serving a quarantine order, and now the man was symptomatic. Dallas officials began to identify the need for a public education campaign to help ease the fears of the general public. This plan was initiated by the Dallas EOC.
New Challenges
After Duncan expired, it seemed to officials that the worst of the Ebola incident was over. The patient was the only one to die as a result of the disease and, to this point, the hospital had contained the deadly threat; however, the monitoring period for the contacts was not over. The main issue to be tackled at this point was the hospital not fielding the appropriate travel questions and the federal government failing to identify patients from the African outbreak countries at ports of entry. The latter question was partially addressed by the chairman of the Liberian national airport authority, Binyah Kesselly. “Kesselly said that Duncan, who was screened before boarding and did not have a fever, answered ‘no’ to a question whether he had had contact with any person who might have been stricken with Ebola in the past 21 days.” Even after the information from Kesselly, this generated the issue of the U.S. exploring additional screening at the airports and other ports of entry into the country. Aside from this, new issues in the Dallas Ebola incident was about to be introduced to officials.
Igniting the incident on October 10th, Nina Pham, who cared for Duncan while he was in the intensive care unit, developed a low grade fever. She reported her fever to her assigned epidemiologist and reported to Texas Health Presbyterian Hospital. When she arrived at the hospital, staff placed her in isolation and took a lab specimen. Officials had changed the status of the State Medical Operations Center (SMOC) to “virtual level” after the death of Duncan; Pham’s condition alerted officials of the need to elevate the SMOC level, but they were waiting for a confirmed lab before a decision would be made. With this new issue, the SMOC was reactivated, and then the Texas Department of Emergency Management’s Disaster District (DDC) 4 in Garland was activated. These activations clearly indicated the concern of officials.
Also occurring at this time but not identified as a concern to officials, Amber Vinson, another nurse who treated Duncan, was asymptomatic, but took a flight to Cleveland, Ohio to visit family, and on October 12th, a Dallas lab supervisor who handled Ebola specimens boarded a cruise ship in Galveston and left the country.
As a result of Pham’s condition, the Texas Health Presbyterian Hospital decided to go on “diversion,” meaning all incoming ambulances would be diverted to other hospitals and take as few new patients as possible. Rachelle Cohorn, a local health care vendor described the hospital, “It feels like a ghost town. No one is even walking around the hospital.” The hospitals E.R. wait time went from the typical 52 minutes to “no wait time.” Even the health clinics around the hospital felt the effects of the incident. Dr. Dan Varga, the chief clinical officer of Texas Health Resources, told a media outlet, “We’ve been in communication with our doctors that have their private offices in our professional buildings around the campus who are getting 40, 50, 60 percent cancellations just for fear of being somewhere in the geography of the hospital where Ebola is treated.” Local healthcare services were adversely affected.
Pham’s lab test was confirmed on the 12th, and her positive Ebola lab test introduced a new question to officials; what should be done with Pham’s dog while she was isolated? Officials made arrangements for the dog to be kept in isolation, and in addition, her apartment and vehicle were placed under a protective order. Officials went to great lengths to accommodate Bentley, the one-year-old King Charles Spaniel belonging to Pham.
Much of their efforts were fueled by a similar incident that happened in Madrid with an Ebola stricken nurse’s dog, Excalibur. Excalibur was euthanized by Madrid’s regional government based solely on an unknown risk of Ebola to animal transmission. Bentley was relocated to a decommissioned naval air base, Hensley Field, and supplied with bedding and toys. Rawlings assured the public city officials would do everything possible to take care of Bentley. The care afforded Bentley did not come at a small price for the City of Dallas. According to a Twitter post made by the City of Dallas (Exhibit B), the total cost of Bentley’s expenses was $26,884.16. The bulk of the cost, $17,057.46, for Bentley was expended to make the facility ready to accommodate the dog and the security required at the facility. The issue of Bentley stirred up animal rights activists and taxpayers alike.
October 13th, Vinson returned to Dallas from Cleveland, but her temperature was 99.5 degrees the morning of the flight. Being a nurse, Vinson realized the importance of her elevated temperature so she notified the CDC before boarding the airplane. The CDC allowed her to fly back to Dallas. After returning to Dallas, Vinson’s temperature remained elevated, and she presented at Texas Health Presbyterian Hospital on her own. Vinson was tested for Ebola and October 15th, it was confirmed that she was infected with the Ebola virus. The hospital staff placed her in isolation and she was transported by EMS to the airport. From the airport, she was flown to Atlanta to be treated in the bio-containment unit of Emory University Hospital.
October 16th, Pham was also flown, by private aircraft, out of Texas to be treated at the National Institutes of Health hospital in Maryland. As a result of Vinson’s Ohio air flight, an additional 160 air passengers would have to be monitored and tracked by health officials until their monitoring period expired on November 7th.
The CDC, based on the experience with Vinson, reevaluated their temperature guidelines for monitoring. It was certainly clear based on their experience that a lower grade temperature could be indicative of the virus. By lowering the temperature guideline from 101.5 to 100.4 degrees, there would be a higher likelihood that the epidemiologists doing the patient under monitoring (PUI) to identify symptomatic individuals and order the Ebola testing on a quicker timeline; this would better protect the public, but the continual modification of CDC guidelines brought additional public scrutiny to their expertise and to the response in general.
In their effort to contain the virus, Dallas County Commissioners planned to pass a disaster declaration for the county during an emergency meeting on October 16th. The purpose of the declaration was to restrict the travel and public exposure for people being currently monitored. However, the declaration was tabled. Commissioner John Wiley Price explained their rationalization, “A declaration, in and of itself, would not accomplish what we think it would. With what’s happening locally, we need to move cautiously with a declaration. It may be premature.” The consensus was the declaration would have the potential to hurt Dallas more by portraying an embellished risk to the public. Initially, Commissioner Mike Cantrell expressed interest in a declaration to help offset the cost of the incident and reduce the financial burden of the county. The Court ultimately proceeded with caution.
The state’s Ebola problems also extended to sea. October 17th, the Dallas lab worker that handled Duncan’s lab specimens was voluntarily quarantined on the cruise ship that had departed days earlier from Galveston. The concern was the lab worker could have been exposed to Ebola, and now the worker was contained on a ship that held 5,000 passengers thus exposing them to the risk. Additionally, there would have to be a plan of action for the ship passengers when they disembarked from the cruise ship. The capacity to test all 5,000 for Ebola did not exist. Numerous government agencies including Health and Human Service, Coast Guard, and other state and federal agencies worked together to devise a plan for the cruise ship passengers. On the 18th, a Coast Guard helicopter transported a tropical disease doctor to the cruise ship to take blood samples from the lab worker, and then the sample was transported to Austin. On the 19th, the cruise ship made port, and there was no incident with the passengers; however, the lab worker ultimately tested negative for Ebola.
The same day, Lakey issued a “Movement of Persons with Possible Exposure to Ebola” letter to the 76 workers who had come in contact with Duncan, and on this day the Texas Task Force on Infectious Disease Preparedness and Response presented its initial recommendations to Governor Perry. The initial guidance was comprised of four topics and recommendations and included the following:
1. State Designated Hospitals for the Treatment and Care of Diagnosed Ebola Patients
2. Evaluation of, or Interactions with, Patients with Suspected Ebola Infection
3. Federal Hospital Preparedness Program
4. Education of Institutions, Health Care Providers, First Responders and other Stakeholders
The Task Force met three more times before their recommendations were submitted by Governor Perry to DSHS for implementation. Their final recommendations and report consisted of 17 items to better position the State for the next public health infectious disease event (Exhibit C). “The recommendations contained in this report represent a major step forward in protecting the people of Texas in the event of an outbreak of Ebola or other virulent disease,” Governor Perry stated. Brett Giroir, the director of the Task Force and the chief executive officer of Texas A&M Health Science Center, said health professionals responded “rapidly and heroically.” The report also described findings regarding the federal response, “Federal authorities have failed to supply actionable information during the Ebola emergency in Dallas. At best, information — when available — was piecemeal, abstract, incomplete, and contained little actionable information such as where and how to get the therapeutic.”
As the event unfolded, the CDC continually modified their guidance to state and local health departments regarding the guidelines for effective use of personal protective equipment (PPE) and training and supervision for preventing infection of disease while interacting with an Ebola patient. This happened again on October 20th. This was the cause of much confusion and irritation to local and state officials. Departments were expending funds for Ebola PPE and then the CDC changed the recommendation which resulted in wasted funds and unneeded supplies. Regarding the CDC’s role in the response, world-renowned risk communication specialist Peter Sandman commented, “There’s no question that the CDC’s overconfident, over-reassurance exacerbated the American public’s adjustment reaction, its temporary overreaction to Ebola. When the CDC changed its guidelines it made the initial recommendations look ‘insufficiently cautious’ and incompetent” thus contributing to confusion and public fear.
Ebola-Free Texas
In terms of monetary cost, “Dallas-area tax payers paid more than $825,000 in Ebola costs.” Dallas County paid the majority of the expenses, approximately $623,000, and “the city of Dallas paid more than $160,000 in direct costs, including the expense of hazardous response teams and supplies. The rest includes some school districts paying for hazardous materials responses and cleaning.” As a result of the incident, Congress and the Texas State Legislature appropriated funding to better prepare the state for another Ebola incident. Texas’ portion of the Congressional appropriation was $22.4 million (Exhibit D), and the State Legislature appropriated “$13.3 million to prepare for [Ebola] and other infectious diseases through laboratory response, training exercises, and coordination.”
After a week of treatment, on October 22nd, Vinson finally tested negative for Ebola and was released from isolation at Emery University Hospital. Her full release would come on October 28th. Pham would later be released from the National Institutes of Health hospital after being treated for eight days and testing negative. Overall, there were a total of 177 individuals that were monitored by DSHS because of exposure to Duncan, Pham, Vinson, or medical specimens, and by November 7th, all monitoring had concluded with no additional positive Ebola cases. By early January of 2015, Lakey resigned his position from DSHS to pursue new opportunities.
Exhibit A
Exhibit B
Exhibit C
Exhibit D
Teaching Notes
Target Audience
Professional Use — Public officials, emergency management officials and professionals, public health officials and professionals, emergency first responders, hospital administrators and emergency room staff
Academic Use — Undergraduate students
Case Summary
The Dallas Ebola incident of 2014 was an effect of the largest recorded African Ebola outbreak. The unexpected infected Liberian national uncovered the cracks in the United States’ public health, healthcare, and emergency response system. The incident also highlighted the unforeseen effects of the public’s reaction to fear and unknowns. Each level of government relied on another to lead a response to a deadly situation, and none of them were fully prepared to meet the issues that a high consequence infectious disease presented. The local mayor, county judge, state health commissioner, and director of the CDC would be required to work together with different concerns in mind and standards guiding decisions. Although Ebola only infected two individuals, aside from the index patient, the number of individuals exposed and that required government monitoring taxed the public response system. The main issues of concern were the coordination of response by officials, lack of information clarity to the public, unexpected expenses, decisions that were politically charged, and fluid governmental expert guidance. In short, public health emergencies provide unfamiliar situations that can have unforeseen reactions; infectious disease events can be neglected in the emergency management and political sectors.
Learning Objectives
As a result of the Dallas Ebola incident, federal, state, and local governments have worked proactively to draft and refine the public health and emergency management systems to respond more effectively to high consequence infectious diseases and provided supplemental funding. Public information strategies and campaigns were refined, planning has become more robust with newly identified considerations, and adequate political attention has been afforded to public health emergency preparedness. More specific objectives:
· The media will capitalize on sensational stories and this contributes to public fear and misunderstanding
· Public health events present unique concerns such as disease communicability and individual repudiation regarding infection
· Local officials do not always understand emergency management protocols and operating processes
· Politics play a role in public decision-making even during an emergency
· Decisions have the potential to be financially costly — directly and indirectly
· Officials need to be prepared to make decisions without relying on other officials or government agencies
Teaching Strategy
Break the incident down into an event timeline by drafting one or utilizing the patient and monitoring timeline provided as an exhibit and fill in any pertinent information that is missing. Based on the events highlighted, identify the core decisions that were made regarding the highlighted events, and draft potential problems based on communication, public reaction, operation and response, politics, financial impact, and/or other concerns. This case provides a multitude of issues for discussion and speculation and provides a general overview of issues and problems that can be encountered in an emergency situation and response; it stimulates the identification of real issues and considerations.
Questions for Discussion
· Identify all the pertinent players in this case. How did each interact and relate?
· What errors were made? Include the error and the perpetrator.
· Identify the effects of the Ebola incident. What were the direct and indirect effects?
· Did politics play any role in the decisions that were made or the considerations of the officials, or was there the possibility?
· What decisions or actions could have contributed to the public’s perception? Identify the good and bad decisions and actions. What are some remedies for the bad decisions and actions?
· What are some ways that procedures and plans could be modified to better address the challenges in this incident?
· Overall, what were the issues and/or problems presented by this public health emergency?
