Combating Ebola at Home and Abroad
On the ground in West Africa and at home in the United States, Commissioned Corps officers of the U.S. Public Health Service worked to contain, and defeat, the worst Ebola outbreak in history.
By Lt. Diana Wong, Ph.D., M.SAME, USPHS
A U.S. Public Health Service flag flies above the Monrovia Medical Unit in Liberia. Commissioned Corps officers along with uniformed servicemembers and personnel from numerous U.S. government agencies served in the United States and deployed overseas to help contain and defeat the Ebola Virus Disease outbreak that ravaged West Africa in 2014. PHOTO BY LT. SHANE DECKERT, USPHS
The rain had stopped but everything remained wet, even as the hot, sweltering West African humidity lingered. The largest Ebola Virus Disease outbreak in history had been raging for months. It was September 2014, and the first U.S. Public Health Service (PHS) team had just arrived in Monrovia, Liberia, known as the wettest capital in the world, at the peak of precipitation and monsoon thunderstorm season.
The stifling discomfort was just the first of many challenges PHS officers faced, and overcame—both at home and overseas—in the international fight against Ebola.
ON THE GROUND IN LIBERIA
As PHS engineers reached the Monrovia Medical Unit (MMU), they were set to staff a standard military field hospital but the facility already was beginning to exhibit structural concerns. The floorboards of many tents were rotting with mold. A threat of the floor caving in was real before the PHS even received its first patients. Fortunately, in this instance the engineers located hand-me-down sledgehammers that had been left by the U.S. Navy Seabees and the rotted floorboards could be addressed. On a daily basis, key decisions continuously had to be made to prioritize which issues were the most urgent. Resources were a limitation and the team often had to be inventive.
Another type of challenge would emerge within the MMU treatment tents. A PHS safety team was charged with minimizing the hazards of the disease “hot zone” for those who were sent to battle it. Much time was spent meticulously spraying bleach and doffing personal protection equipment. Wearing non-breathable layers of plastic that left the wearer dehydrated in the African humidity fortunately was not the only line of defense for those who provided patient care. Safety team members implemented robust engineering controls into the facility, equipment and processes to minimize the risk of exposure.
The suspected ward of the Monrovia Medical Unit housed medical workers who were Ebola symptomatic and awaiting lab work to return. If they tested positive, they were then moved to the confirmed ward. PHOTO BY SGT. 1ST CLASS NATHAN HOSKINS, JOINT FORCES COMMAND-UNITED ASSISTANCE PUBLIC AFFAIRS
URGENT DOMESTIC RESPONSE
More than 5,000-mi away, at airports in major cities along the eastern half of the United States (Hartsfield-Jackson Atlanta International Airport, Washington Dulles International Airport, John F. Kennedy International Airport in New York, Chicago O’Hare International Airport, and Newark Liberty International Airport), hundreds of PHS officers stood on the front lines receiving travelers from Guinea, Liberia, Sierra Leone and later, Mali. These nations were ground zero of the Ebola outbreak.
In a multi-agency effort that involved Customs and Border Protection, the U.S. Coast Guard, and the Centers for Disease and Control and Prevention, the job at hand was to screen and educate. It was vital the travelers were screened by trained personnel before being allowed entry. In a given day, a typical case might be a man who did not appear to present symptoms, stated he was not a health care worker, and would say that he did not interact with one of his neighbors who might have been sick. In the most important part of the process, PHS officers had to make a decision. This often meant assessing that the visitor was not infected and most likely had low risk, but making sure to inform him of the disease, what symptoms to look for, and the crucial procedures to follow if he did develop symptoms. With his contact information logged, the visitor would receive an Ebola CARE (Check and Report Ebola) Kit, which reemphasized the necessary steps in case symptoms developed.
In Washington, D.C., the Department of Homeland Security’s Office of Health Affairs and National Biosurveillance Integration Center were providing situational awareness and decision support to department leadership and interagency partners in preparing for and responding to Ebola. PHS officers provided a gamut of information—including situation assessments, screening questionnaire recommendations, and analysis of air passenger data to support government decision-making.
While the responsibilities of PHS officers were different, they shared the same ultimate goal: to prevent the spread of Ebola beyond West Africa and protect the public health of the nation. The enemy the world faced was an invisible killer that only gave evidence of its presence when the hemorrhagic fever symptoms (fever, sore throat, muscular pain and headaches that painfully gave way to vomiting, diarrhea and possibly internal and external bleeding) manifested in its hosts, at which point the host may have already infected dozens of new ones.
Media transmitted graphic descriptions and images of patients and evoked worldwide fear. However, educating the population of what is known about Ebola, and how to mitigate and prevent infection, is by far one of the most important tools in reducing unnecessary panic and making sure it does not spread. Understanding that Ebola is not transmitted through respiratory means is relevant in knowing it will not spread as easily as influenza, for example. Effectively communicating that the disease spreads through direct contact with body fluids of an infected human or animal eventually held the key to discouraging locals from touching and washing the bodies of deceased and infected family members.
When the Ebola outbreak began in Guinea, in December 2013, it was surprising since Ebola had never been found in the region before. Through porous, easily crossed borders, the virus spread to Liberia and Sierra Leone. With increased air travel and globalized economies, the world realized the potential pandemic threat the disease posed. To prevent that from happening and to protect the citizens of the United States, numerous government agencies were mobilized. In addition to the efforts of the Department of Defense and Department of State, the Department of Health and Human Services and Department of Homeland Security took the lead on the clinical, public health and border security aspects of the Ebola crisis.
For PHS officers involved in the response, many either worked at various U.S. government agencies as their regular duty stations or deployed to support specific missions. This included 70 officers comprising the first of what would eventually be four PHS MMU teams that deployed to West Africa. The group trained in Anniston, Ala., before flying to Liberia for a 60-day deployment.
According to World Health Organization’s 2010 World Health Statistics there are no more than 10 physicians per 100,000 people in the affected region of West Africa. By comparison, there are 245 physicians per 100,000 people in the United States. Local health care workers were, and remain, essential to getting to the goal of zero new Ebola cases. There were too few of these fighters against the disease in the countries hardest hit. The PHS MMU teams were the only U.S. government entities providing direct patient care to this narrow but immensely critical line of defense.
U.S. Public Health Service officers reinforce flooring tarpaulin in the Monrovia Medical Unit’s confirmed ward. The medical facility was constructed to care for medical workers who became sick while treating Ebola patients. U.S. PUBLIC HEALTH SERVICE PHOTO
PROTECTING HEALTH AND SAFETY
For those PHS engineers working on infrastructure-related issues in Liberia, improvising work-arounds was a common requirement. Instead of replacing hospital floor boards in a “hot zone,” for instance, where a rusty nail puncturing personal protective equipment could have led to deadly infection, the team devised a plan to minimize hazardous exposure to staff and patients by overlaying plastic-wrapped, water-proofed floor boards. Additionally, when it was realized that road conditions on the 45-minute commute for the MMU team to travel to the hospital were too dangerous and filled with accident-prone drivers, which put the entire team at risk, PHS officers led construction of a new “tent city” living quarters that allowed the team to safely live right next to the hospital. This proximity was invaluable in giving the team more time and energy to accomplish the direct mission. Redirecting poor drainage of rain water and potentially biohazard wastes; building showers for patients; and jury rigging vital water storages to decelerate chlorine degradation were just some of the many projects executed in order to keep the MMU operating safely and effectively.
While the PHS MMU teams overseas focused on keeping Ebola at bay, at U.S. borders and airports, the Centers for Disease Control and Prevention, aided by Customs and Border Protection, enforced Code of Federal Regulations, Title 42–Parts 70 and 71. This empowers the agency to detain, medically examine, or conditionally release individuals reasonably believed to be carrying a communicable disease.
Because state and local authorities are the primary authorities to order and enforce quarantine and isolation, complex coordination between the federal agencies, airlines, local public health authorities and many other stakeholders was required to enhance entry screening. To aid with process and staffing needs, PHS officers were brought in at selected ports of entry to relieve Coast Guard corpsmen who had temporarily overseen the secondary medical screening. Daily inspections and educating travelers, along with rigorous analysis of entry data from West Africa in concert with public health engineering professionals across the Atlantic helped ensure Ebola did not progress stateside.
A GLOBAL FIGHT
Nearly a year after the peak of the Ebola outbreak, the numbers of new cases has finally began to diminish. Liberia saw a handful of new cases in June 2015 after being declared Ebola free in May. The virus is still a real threat in Sierra Leone and Guinea.
In the endless war against disease, a truly global fight, the PHS will be ready to stand on the front lines when needed again, having proven itself a unique and adaptive force “known the world around.”
Lt. Shane Deckert, P.E., M.SAME, USPHS, Indian Health Service, Lt. Jessica Sharpe, M.SAME, USPHS, National Park Service, and Lt. j.g. Michael Simpson, EIT, M.SAME, USPHS, Food and Drug Administration, contributed to this article.