While Ebola is not the same as coronavirus, a lot of the public health concerns, preparations, constraints and fears are very similar so my hope is that posting this summary of this Ebola crisis call from close to seven years ago helps people contextualize our current coronavirus concerns. Please don’t take any of this as professional public health advice- for that go to medical professionals. At some point this virus will go away. Hopefully it won’t be as bad as it could be but it’s not going to be fun for anyone and it will be awful for some. Which is one way of saying it’s never the wrong time to tell someone you love them!
All of these notes are specific to the 2014 Ebola crisis, but the last half, especially, are relevant to today’s challenges as people talked about personal protective gear for first responders, how to manage communications and so forth. To learn more about CDC’s response to the corornavirus, click here, to learn more about Massachusetts’ response click here and to check out Cambridge’s Public Health Department click here.
And for contextual, background, old Ebola information, read below:
Folks- I thought you might be interested in my notes from yesterday’s (Thursday, 16 October) conference call about Ebola preparations in Massachusetts. I don’t want to get people overly anxious about Ebola’s health threat but I want to do what I can to pass on useful information. I’ve mashed the notes around to read a bit better and I can’t claim to have captured everything with perfect accuracy, nor that what was said was necessarily accurate, but it is a pretty good summary of how things went up to the call’s last question (I had to hang up just before it ended). I’ve added links to sources (these were not referenced in the phone call) and supplemented my notes with info online that I thought relevant and reasonably dependable so don’t take these notes as a verbatim review of the call or the font of all knowledge concerning Ebola. But it’s a decent starting point.
The call had roughly 140 people participate, from Fire Chiefs to Mayors to public health officers. On the state level, senior DPH officials participating in the call included people from the State’s Bureau of Infectious Disease and the Executive Office of Health and Human Services.
For those who want to learn more, CDC has a lot of information on the web about Ebola.
Cambridge has its own Public Health Department with its own Ebola section (mostly links to other resources at this point).
State officials started out the call with a number of briefings
- As of the afternoon of 16 October, there were no known cases of Ebola in Massachusetts.
- While there were recently two high profile public events with folks who were being considered for rule “in/rule out” for Ebola, at least another dozen other people needed an epidemiological follow up based on symptoms, travel history and so forth to “rule out” their illnesses as being Ebola. Those instances just didn’t make the news.
- Ebolla was first described in the 1970s. Since then, there have been about 20 outbreaks in Afrcia. Most of these outbreaks were relatively small (in Central and Eastern Africa) and were contained or burned themselves out. But this is a new version of Ebolla, in West Africa, and has contaminated thousands of people in 3 countries, Liberia, Guinea and Sierra Leone. This outbreak is bigger than past ones and is being very disruptive in those countries where it is growing at an alarming rate.
- The Ebola virus belongs to family called viral hemorrhagic fevers and has up to an 80-90 mortality rate, between 50 and 90 typically. It is thought to originate in animals that are consumed by people which is how it originally enters the human transmission chain. Then it’s usually transferred via bodily fluids from victim to caretakers, to include funeral workers (it is rare that a disease is infectious after death), healthcare workers and so forth. It has not before entered large population areas like appears might be happening now in Lagos. While bodily fluids of all sorts (think blood, saliva, urine, feces) transmit the virus, it’s not airborne in the way that measles is. Nonetheless, CDC says it is possible to catch Ebola from someone who is sneezing or coughing, though those are not common Ebola symptoms. There is lots of evidence that it’s not regularly transmitted from virus on surfaces. Is not contagious before someone becomes symptomatic (that is, actually has a fever, starts vomiting and so forth), which usually happens in about 10 days but can take up to 3 weeks or start in as early as five days. In that pre-symptomatic period of time, there is no risk that these folks can infect others. That’s how we can control it. What controls the disease is public health measures. Isolate people who have disease and quarantine their contacts for the 21 day incubation period so these contacts can’t spread it. That’s how this outbreak in West Africa will be contained. There are no known vaccines for Ebola though there is some experimental stuff going on without certainty of how well it is working.
- Only one person with Ebola has ever left Africa unknown to have the virus and only two went to other countries in Africa. There have been folks who have come back from Africa with Ebola, to include doctor who has recovered, but we have known those people were infrected.
- Travel history is HUGELY important in figuring out who is at risk. If they have not been to Sierra Leone or other two countries or been in contact in those countries with folks who have EB, people are not at risk. Some people may have other diseases like malaria that can be found when we’re checking for Ebola. There is testing for Ebola virus but the state lab can only do that in limited quantities so we don’t want to overtest now in case the situation gets worse.
DPH’s Planning and Outreach around Ebola
The state started monitoring for Ebola in early August as the issue grew in importance. They also started developing guidance for clinicians who were asking questions, passing out CDC info and so forth. They put together an Ebola webpage with links to CDC and WHO (more info on what’s going on in West Africa). As more info became available and infected health care workers came back to US, they’ve pushed more info from Mass DPH and CDC to individuals. They are holding conference calls both statewide and aimed at specific communities such as public safety, hospitals, municipal leaders, EMS, etc. Weekly statewide conference call this week had 1100 lines which allows them to answer questions for everybody. They are working with the MEMA, fire services and so forth to develop SOPs and pass out information on Ebola. The Bureau of Infectious Diseases has done outreach to West African communities to educate them about Ebola, the risks and so forth. In addition to the Department’s static webpage they have list-serves for local officials, ambulance services, etc. They also have the health and homeland alert network to reach these same groups. Plus they work with MEMA. They have protocols so that if the epidemiologist on call gets information it goes to the right place. Some organizations and communities are going through senior leader tabletop exercises using Ebola as a situation. This helps people develop common practices for other response actions as well and DPH is happy to help develop scenarios to work through these issues with communities, hospitals, etc. The intersection of public health, health care and emergency management is an important one to understand.
Public Health Support
State officials are there to help us all coordinate in these fast changing situations. They want to protect public, health care providers and so forth and it is important to be alert to risk of Ebola but not to raise undue concerns. Professionals also need to protect patient confidentiality and not stigmatize sub- groups, locations and populations. Plus, it is important not to waste local public health and safety resources. We want to make sure they’re being effectively used. There is 24/7 availability with an epidemiologist on call at all times to help locals answer questions and conduct appropriate assessments. After hours that call goes to an answering service that collects the information and then relates it to the epidemiologist on call and the caller will get contacted in no more than 10 minutes. And it’s not not just for Ebola-this person can screen for over 90 diseases the Department worries about. Sick people can have symptoms, but the travel history and ambiguity of contact might indicate the person does not have Ebola. Connecting at the start with the epidemiologist on call can downgrade needed response resources if it’s not Ebola.
Public Safety Preparedness
Braintree and Logan Airport events were possibly suspect cases that came to the attention of the health care system from a 911 call. So it’s quite possible that local public safety may have the first contact with a person who is suspected of maybe having Ebola. It’s important that we ensure our First Responders are informed, equipped, trained and ready to deal with someone who might have Ebola and is evidencing flu like symptoms. And First Responders need to do that while keeping themselves and their communities safe. MEMA and Executive office of Public Safety have been collaborating efforts with other departments to focus efforts to prepare First Responders. First they circulated CDC and DPH information to First Responders and emergency managers through various associations, direct emails, etc. They do that as new stuff comes up. They brought in First Responders (Fire, EMS and hazardous materials experts) to ask what needed to be done to prepare for this issue. Training enhancements around quick risk assessments about folks with Ebola symptoms, make a risk based assessment of what Personal Protective Equipment (PPE) to use and how to use it to protect First Responders. Beyond that, transportation of potentially contaminated waste is something they are working on. They’ll continue to meet, develop info and push it out to folks. They’re expanding the group next week to bring in law enforcement and emergency management staff for the same review of capabilities, gaps and needs. They are providing 24/7 expertise to incident commanders & dispatch centers for the folks out on the street who are dealing with a patient. They would call MEMA communications who would stand up a conference call bridge to connect the on-scene guy to DPH, MEMA and hazmat experts.
(I think this was when it started)
- If folks are sick, they need to be clinically evaluated but on-scene questions can give you a very good analysis of Ebola probability. If there are still questions about Ebola, the First Responders are to call the local health care providers (such as a hospital) to warn them someone who might have Ebola is on their way but they should also call the 24/7 support. The more hospitals know before people show up, the better even if there is no Ebola risk.
- State is working on a checklist with questions, protocols, POCs, etc. Will be one page and very available very soon.
- Right-to-privacy does impact what officials can say about who might have what. Patient ID is completely private. But it is thought that in Dallas, when they decontaminated the health care workers’ homes, that the authorities told the neighboring apartments what was going on. In more spread out areas there would not be that need to pass on the information. If Ebola has been confirmed, the DPH folks will tell people that they may have been exposed but they really need to protect patient ID. They rely on individuals to trust the public health system to not make their information public. (Basically, you don’t want sick people getting sicker, and possibly infecting more people, because they’re afraid to tell people they’re sick).
- Facilities in the state are ready to treat an Ebola case. DPH is training staff and reviewing what hospitals need to handle the risk. That may be an issue if more people from West Africa return to US for treatment, though Massachusetts does not have a facility identified for that purpose.
- CDC has issues guidance on the issues involved with handling bodies. State’s Chief Medical Examiner was at last meeting about Ebola.
- State is working with Public Health authorities to prepare a checklist that would be appropriate for communication centers that receive 911 calls to help guide conversations with appropriate questions for person calling. The 911 center can then pass appropriate info on to officers on the scene. One fear is that if the First Responders get exposed then need to be quarantined for 21 days, even if they’re not infected they’ll still out of action for that time. (And their equipment- ambulances, cruisers, buildings- may also be off-line unless deconned and that can be expensive)
- Massachusetts is working on creating guidance on PPE and training on how to use it as safety officials transport victims. EMS providers know what they should have and folks are doing inventories now and will procure supplies as needed. There do not seem to be shortages of PPE equipment.
- This is the flu season and that has its own problems. The state figures that most EMS providers have appropriate training and equipment for this sort of thing under current standards of practices. But there are still nagging concerns about Is the N95 a good enough mask, do they need Tyvek suits on the ambulances, new gloves, etc. The state has a working group to figure this stuff out and issue clear and consistent guidance across the state.
- Might Ebola virus mutate to infect differently? Official says there is no evidence that it’ll become transmissible from a different route.
- Another PPE question- if First Responders and others use PPE on responses but the Dallas nurses used PPE and they knew they had patients with Ebola but still got infected, how safe should people feel using that PPE? State says they’re investigating that- what kind of equipment did the nurses have, was it used correctly, how might the transmission have occurred. CDC may come out with new guidance based on the findings there. With new guidance, you need new training on how to use PPE, take it off, put it on, etc. Health professionals deal with sick people constantly and don’t know, as the nurses DID know, who has Ebola. Level of training is different across facilities and providers regardless of guidance. Especially things like gowning and ungowning needs to be practiced and observed. So the state will start to go out and do surveys to see what people are doing in the ‘field’ and see what best practices are and so forth.
- More PPE concerns from a fire department. Some folks are using close to Level I hazmat suits for transport and actions like cleaning but we’re thinking just N95 face masks? So what is the appropriate PPE level for responders? And how do we keep the interior of the ambulance from getting contaminated. And this stuff is gonna be expensive!!! State says this issue is being raised repeatedly; part of the answer is that people with the training to use higher levels of PPE and have access to that equipment are choosing to use it although they don’t need to. High risk patients may make the care provider, like an ambulance service, more likely to make that extra effort. The state has started a subcommittee that is meeting to talk about this on Tuesday, ww October. The extra high levels of PPE some people use raises concerns from people who aren’t in that level of protection. And hospitals may have different protocols for accepting patients from ambulances that differ from each other and from the ambulance’s protocol.
- CT declared a public health emergency to allow folks, if needed, to be quarantined. But in Massachusetts the state and local authorities can quarantine and isolate with that under state law.
- Cambridge Health Alliance has a robot that might kill Ebola with UV light to decontaminate Ebola virus is pretty easy to kill with regular hospital disinfectants says state.
- The hope is that folks who are sick will contact health care providers. That seems to make sense to state officials. People are being screened and interviewed and given instructions if they become symptomatic in the five airports which serve 95% of folks these three countries (Boston is not one of those airports). No one Massachusetts hospital has been identified to handle Ebola patients. Mostly infected people go to GA or Nebraska right now and the CDC is looking for more hospitals. If folks are critically ill in Mass they’d get transferred.
- Concern that restocking PPE can take 2-8 weeks. And moving patients around, downstairs and around corners and so forth, can require more robust gear. CDC is looking into that at this time as well.
- Hospitals have NOT been identified in MA as specialty centers for Ebola care. NY has 8 hospitals for that. But none of our hospitals have said we’re not prepared for Ebola and the state expects them to be so. State is working with hospitals to provide checklists, visiting them, having plans in place for infection control, etc.
- Some concern that the medical clinic into which a person might walk, as happened in Braintree, should have the appropriate numbers and a quick response from the folks giving the 24/7 response. And then Braintree had to sideline a vehicle while they deconned it and so forth. This is getting expensive. Will the state help out? Not clear what state will do, it’s too early to tell since there’ve been only two large scale response actions. And you need to make sure these vehicles and people don’t become victims as the public gets scared.
- As we roll into flu season, the symptoms of a normal flu may have folks worried that they, or someone they have contact with, have Ebola when that isn’t the case. It is important to try to minimize the fear of Ebola while being clear about and addressing the real risks.
- More questions about PPE even under non-Ebola circumstances. Folks are running low and would like updated lists of what is appropriate and make that available even if it is to just make the First Responders more comfortable when there isn’t much risk.
- People want more communication out from DPH/state, especially to mobile devices as not everyone has ready access to computers.
- Another PPE question about backlog and market forces leading to supplies drying up. People want equipment on hand and think it would be a good idea for the state to cache stuff. The state is just starting down this path and has a PPE subcommittee that is meeting on Tuesday.