The 2014–2016 West African Ebola virus disease (EVD) epidemic took the world by surprise. While 11 patients were treated in the United States, it challenged public health, health care, and emergency response infrastructures.1 The outbreak highlighted the need for robust systems of screening and care for patients with highly hazardous communicable diseases (HHCDs), especially because the outbreak showed how modern travel hastens international disease spread. The May 2018 EVD outbreak in the Democratic Republic of Congo reinforces this need and demonstrates the uphill battle against emerging and reemerging diseases.
In the beginning of the 2014 outbreak, most health care facilities in the United States were unprepared to identify, isolate, and provide care for patients who presented to their facilities with suspected EVD.1 Responding to this deficiency, the United States, led by the Assistant Secretary for Preparedness and Response and the Centers for Disease Control and Prevention (CDC), developed a tiered EVD care system that outlined the minimum expected capabilities for frontline hospitals, assessment hospitals, and Ebola treatment centers.2 Designated assessment hospitals and Ebola treatment centers collectively made significant modifications to their facilities to enhance infection control, purchased greater quantities of personal protective equipment, and enhanced staff training.3 In addition, the Assistant Secretary for Preparedness and Response designated and funded one hospital in each of the 10 Department of Health and Human Services regions as a regional Ebola and other special pathogens treatment center (RESPTC), requiring these facilities to make more upgrades than the other two tiers to receive designation as first-choice locations to provide care for patients with confirmed EVD. These efforts resulted in significant progress in our domestic capability to safely care for patients with EVD.1
CURRENT STATUS
After more than three years of efforts, and in light of the new EVD outbreak, policymakers and the public likely expect that the United States will sustain the new capabilities that it has paid for and developed to care for patients with EVD. It is also likely they believe this infrastructure can safely be used to accommodate patients during future outbreaks of other HHCDs, such as Middle East Respiratory Syndrome and other viral hemorrhagic fevers, such as Lassa. It is true that the upgraded facilities, personal protective equipment, enhanced trainings, and disease surveillance, in tandem with updated federal guidance, bolstered funding, and multisectoral collaboration, have improved our national abilities. However, there remain gaps in our nation’s ability to care for other non-EVD HHCDs such as ongoing costs and challenges associated with commonly occurring nosocomial infections that still lack robust prevention measures. Moreover, our newly developed system appears to be time-limited with supplemental funding mechanisms supporting these capabilities ending in 2020.
The national EVD infrastructure was created in Parts A and B of the Hospital Preparedness Program Ebola Preparedness and Response Activities, jointly funded by the Assistant Secretary for Preparedness and Response and the CDC.4 Part A of the funding mechanism supported “state- or jurisdiction-designated Ebola treatment centers, assessment hospitals,” as well as coalition activities, while Part B funded the development of a “regional network for Ebola patient care.”4(p4) Awardees who received funds through the Part B mechanism were obligated to receive and treat up to two patients with confirmed EVD and maintain 10 beds for enhanced airborne isolation for care of other diseases. While grant requirements obligate the 10 RESPTCs to accept and treat confirmed patients with EVD, it is unclear if there are similar stipulations for other funded facilities. Under Part A, funds were distributed through states to the assessment hospitals and Ebola treatment centers to prepare in the event of a patient with EVD, without a clear contractual obligation. Ambiguity remains about whether the acceptance of these Hospital Preparedness Program funds requires these facilities to activate for a patient with EVD or other disease and, if so, how long this obligation exists.
Programmatic activities, including development of state and regional concept of operations, were focused around the provision of care for patients with confirmed EVD. Although Hospital Preparedness Program supplemental Ebola funding mechanisms Parts A and B were preparedness funds, the program language stated that,
none of the funds made available in Part A of this [funding opportunity announcement] may be used to reimburse hospitals or entities for the costs associated with caring for persons under investigation for Ebola.4(p11)
This opens the question of who absorbs the cost burdens associated with treating persons under investigation or confirmed patients with another HHCD. Media estimated that the direct and indirect care costs of a single confirmed patient with EVD was in excess of $1 million5; however, there has been no public accounting of the costs of the 11 confirmed US patients with EVD, including the payee6; there is also no public record of the additional costs associated with treating US persons under investigation and expenditures associated with monitoring high-risk patients. As persons under investigation demand greater administrative controls and personal protective equipment usage than common infectious diseases until the HHCD is ruled out, it is likely that the costs associated with these patients are significantly greater and absorbed by those health care systems.
It is uncertain to what degree this infrastructure could or would be used for patients confirmed with other HHCDs. There is no commonly accepted definition of what constitutes either a special pathogen or HHCD, contrary to the specifications regarding microorganisms existing for laboratory biosafety levels. There is also limited surge capability in the current network. Without a clear definition of which diseases should or must be cared for within this network, in tandem with the lack of clear reimbursement mechanisms in the tiered health care facility network to evaluate persons under investigation or treat patients with a HHCD other than EVD, there is a potential financial disincentive to participate in response and care for any disease other than confirmed EVD.
During the EVD outbreak, several US states issued orders they believed to be in their state’s best interest—such as blocking transportation of Category A waste through their state even though it was the most direct route from the treatment facility to the disposal facility.7 It is possible that a current network facility or state government may bar the transfer of a non-EVD patient to a RESPTC during a new HHCD outbreak or a confirmed patient with EVD once the supplemental funding mechanism expires. The justification for such a move by a state could be based upon perceived safety concerns for their community or to avoid being caught absorbing the exorbitant cost of care. It remains unknown if a RESPTC or others in the tiered hospital network would be willing to receive a regional out-of-state patient, with no guarantee of cost reimbursement.
CONCLUSIONS
The tiered EVD response network has the potential to serve as the basis for the United States to address new cases of EVD and other HHCDs. The RESPTCs, in particular, could serve as the backbone of a new regional network of centers of excellence that could strengthen the nation’s overall preparedness. The systemic issues presented herein and other critical questions must be addressed, so when this network is needed for the next HHCD outbreak, these uncertainties are not barriers to participation and response.
ACKNOWLEDGMENTS
We acknowledge the National Institute of Environmental Health Sciences Worker Training Program Ebola Biosafety and Infectious Disease Response Training UH4 grant UH4ES027055; although the grant funding did not contribute to this work, the program did highlight the need. We acknowledge that both Nebraska Medicine–Nebraska Medical Center and Massachusetts General Hospital were funded through US Department of Health and Human Services Hospital Preparedness Program Ebola Preparedness and Response Activities (EP-U3R-15-002); although the grant funding did not contribute to this work, the program did highlight the need.
We also thank our consortium members in the Biosafety and Infectious Disease Training Initiative at the University of Texas Health Science Center at Houston School of Public Health—Janelle Rios, PhD, MPH, Robert Emery, DrPH, and Scott Patlovich, PhD—and Leighton Jones, MLA at Harvard T. H. Chan School of Public Health for their partnership.
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