With its diverse population, significant West African community, and large number of international travelers, it was highly probable that New York State (NYS) would be affected by the 2014-2015 Ebola virus disease (EVD) epidemic that struck Liberia, Sierra Leone, and Guinea. New York City alone is home to approximately 14,000 residents born in these West African countries. 1 In this article, we look at preparedness activities at state and local health departments, in particular the New York City Department of Health and Mental Hygiene (NYCDOHMH), as well as health care facilities in NYS, and examine lessons learned for future emergency preparedness efforts. The efforts of NYS are a blueprint for other states to follow.
MAKING PREPARATIONS
New York has a long history of all-hazards preparedness planning. Strong responses to health crises such as the events of 9/11 and the subsequent anthrax attacks, the 2009 H1N1 influenza pandemic, and Superstorm Sandy in 2012 relied on the collaborative partnerships among state and local health departments and the emergency response and health care communities. State and county health workers in the aftermath of Superstorm Sandy spoke of the importance of good communication and routine practice drills, which were applied in the Ebola preparations.Reference Shipp Hilts, Mack and Li 2 Events such as the SARS outbreak and the state’s smallpox vaccination initiative to preempt bioterrorist threats, which both took place in 2003, compelled the New York State Department of Health (NYSDOH) to fully flesh out our isolation and quarantine protocols for exposed or ill persons, which we modified and relied upon during Ebola. The state also issued infection control guidance during SARS and the 2009 H1N1 pandemic, which helped hospitals get comfortable with handling these issues. During the anthrax attacks of 2001, the state learned how to coordinate clinical laboratory submissions between the NYCDOHMH and the NYSDOH. Although NYCDOHMH did their own Ebola testing, our 2 labs were able to successfully coordinate our activities, based in part on this prior experience.
These relationships, and the underlying health care emergency management expertise, enabled the state to respond proactively and effectively to EVD. The most notable relationship was with NYCDOHMH. The agency played a pivotal role owing to its oversight of the state’s most populated and ethnically diverse city that also contains an international airport and multiple hospitals. But the reality was that any traveler could get to any other part of the state, making New York’s preparations for EVD a statewide event.
On August 8, 2014, the World Health Organization declared EVD a public health emergency of international concern. 3 Shortly after, the NYSDOH began increasing its own emergency stockpile of personal protective equipment (PPE) to supplement hospital stockpiles. NYSDOH also conducted regional and statewide conference calls and held meetings with public health and health care providers. In preparation for treating a patient, NYSDOH asked all hospitals to stage mock surprise drills in their emergency departments to assess facility preparedness and identify gaps in their systems. These drills were modeled after those previously conducted by hospitals preparing to care for a patient with an emerging infectious disease. In conducting these drills, the state was able to advance the readiness of the state’s entire pre-hospital and hospital systems. Discussions also occurred with emergency medical services (EMS) providers, funeral directors, medical examiners, and local health departments.
ACHIEVING READINESS: A TWO-TIERED SYSTEM
In mid-October, with the West African epidemic worsening and the death of an Ebola patient in Texas, then acting Health Commissioner Howard A. Zucker, MD, JD, issued a Commissioner’s Order that enabled immediate action to address existing or imminent threats to public health. 4 This order codified existing recommendations from the Centers for Disease Control and Prevention (CDC) on how to identify and manage patients with suspected or confirmed Ebola. It was targeted to all general hospitals, diagnostic and treatment centers, off-campus emergency departments, ambulance and advanced life support first-response services, and funeral establishments.
The Commissioner’s Order required regulated health care facilities to arrange an isolation room, screen travel history at initial triage, and have protocols for handling a suspect Ebola patient, plans for transport, and dedicated EVD 24/7 contact, among other things. The order also detailed protocols for the rapid identification, isolation, and evaluation of symptomatic travelers from Ebola-affected countries at all reception points in hospitals and regulated clinics. In addition, the order specified requirements for isolation and treatment rooms, safe laboratory testing, and staff training, including PPE usage and waste management. Working with statewide partner organizations the Healthcare Association of New York State (HANYS) and the Greater New York Hospital Association (GNYHA), NYSDOH ultimately designated 11 hospitals to provide care for suspected or confirmed Ebola patients in advance of any federal system or designation. The Commissioner’s Order created a two-tiered system with regional tertiary care medical centers serving as designated Ebola treatment centers (ETCs) and other hospitals and regulated clinics serving as frontline (or nondesignated) hospitals being prepared to quickly identify, isolate, stabilize, and transfer a patient suspected of having Ebola. Each designated hospital had at least 2 full-day site visits by NYSDOH, where all aspects of preparation for Ebola patients were reviewed. Although the CDC visited all ETCs, the CDC ultimately designated 5 of them federal ETCs 5 before the CDC discontinued its designation process.
To further ensure readiness, NYSDOH conducted site visits to every single hospital and regulated clinic in the state to review Ebola plans, provided technical assistance where needed, and assessed compliance with the Commissioner’s Order. The department worked with hospitals and EMS providers to create plans to transport patients from their homes to nearby facilities for assessment and the movement of EVD patients from frontline hospitals to a designated ETC in a way that was safe for the patient and transport personnel. CDC staff accompanied NYS on site visits to designated hospitals; their expertise was invaluable in helping hospitals prepare for the demands of safely treating an Ebola patient. These early experiences in NYS helped the CDC develop its hospital assessment form for designated hospitals nationwide.
Most hospitals designated as ETCs had to build treatment isolation units to achieve that status. These biocontainment units had to have a room in which to isolate a patient, provide space for staff to don and doff PPE, provide point-of-care laboratory testing, and safely store and manage patient waste without jeopardizing the safety of staff and the care of other patients in the facility. The Commissioner’s Order required at least one isolation room to have negative pressure (or that could be converted to negative pressure). NYSDOH created an expedited review and approval process for designated ETC construction and renovation projects, which are normally subject to a lengthier state approval and review. This enabled work to proceed efficiently.
Being a designated hospital also involved extensive training of staff in the donning and doffing of PPE as well as proper waste management, laboratory worker training, environmental cleaning, and team-based simulation training in the isolation room. All policies, procedures, and activities were carefully reviewed. Deficiencies noted during site visit assessments were relayed to the hospital and followed up at the next site visit with discussion and assistance provided in the interim. The order also required hospitals to do monthly drills.
In order to achieve readiness in designated ETCs, the department worked with local health agencies, including NYCDOHMH, to arrange regular statewide conference calls to provide information and assist health care sites. Throughout the fall, 2 conference calls were held each week with clinicians and administrators from the NYS designated ETCs. Two in-person meetings with GNYHA and HANYS were also held to improve EVD readiness, one for designated hospitals and the other for all hospitals. These meetings focused on a multitude of issues related to identification, isolation, and treatment as well as ethical issues and post-care monitoring of hospital staff and included expert presentations on the preparation for and care of patients with EVD. GNYHA maintains 11 checklists on Ebola preparedness on its website. 6
LAB GUIDANCE
A key step toward greater preparedness was the development of clinical laboratory guidance for the safe handling and testing of specimens from persons under investigation for Ebola. 7 The arrival of Ebola prompted New York to develop guidelines for procedures, policies, and safe practices for hospitals on how to best deal with highly pathogenic agents within their facilities.
With the threat of Ebola, NYSDOH developed several sets of guidance for laboratory testing. First was a series of documents on recommended safe practices for performing routine laboratory tests, other than for Ebola, on suspected cases. Subsequently, additional guidance advised on the minimum recommended testing that needed to be in place for these patients.
While this can be performed in routine core laboratories using standard precautions, instrument decontamination became a major concern and potential obstacle. Therefore, guidelines also included recommendations for tests and instruments in a point-of-care laboratory dedicated for that purpose. The guidelines required the availability of tests such as basic blood chemistry, hematology, and malaria. Developing these guidelines involved comprehensive reviews of the literature on laboratory-transmitted Ebola and similar viral hemorrhagic fevers, as well as consultation with national experts including infectious disease physicians, laboratory directors, scientists with expertise in highly pathogenic agents, and epidemiologists. HANYS and GNYHA were also consulted to ensure recommendations were feasible for hospitals. The process resulted in the development of comprehensive guidance documents for both designated and nondesignated hospitals. The documents were frequently referenced by the CDC during national conference calls, and the guidance steered the preparedness of NYS laboratories and hospitals, as well as those in other states that adopted them.
PEDIATRIC AND OBSTETRIC READINESS
In formulating its clinical management and infection control strategies, New York worked with clinicians from designated hospitals to discuss unique considerations for vulnerable populations, such as children and pregnant women. The NYSDOH and NYCDOHMH collaborated to form a NYS pediatric/obstetric workgroup and hosted meetings to discuss the challenges specific to these groups that informed preparedness activities. The workgroup discussed issues such as changes in the composition of the care team for these populations, caregiver visitation, clinical protocols, and ethical considerations for patient management.
EMS
Under the Commissioner’s Order, designated hospitals also had to work with ambulance services and advanced life support first-response services. NYS comprises 18 EMS regions, ranging from extremely urban—including the largest city in the United States—to very rural. Regional needs and access to resources vary widely, and regions with fewer resources worked collaboratively with neighboring regions with more available resources.
In responding to Ebola, many EMS providers found it appropriate to develop a regional approach for emergency medical response and interfacility transportation. Such an approach maximized the efficacy of locally available resources and ensured the safety of EMS providers in response to a person under investigation or a confirmed case of EVD. EMS personnel and vehicles are limited, and the regional approach allowed the use of the more robust services, which have more staff and vehicles available to dedicate to EVD responses or interfacility transfers. In addition, some regional plans limited EMS exposure to EVD to those with more frequent training. EMS providers frequently worked with designated hospitals in their region to develop protocols for decontamination after a transport.
Depending on the resources and the region’s needs, one or more lead agencies were identified and asked to staff and otherwise operationally support a regional team. Agency participation was voluntary. Establishing an effective and safe transport system in each region occurred because of the cooperation and support of all EMS agencies and their medical directors.
COMMUNITY OUTREACH
In early November 2014, the state Office of Minority Health & Health Disparities established the New York State West African Health Collaborative to respond to the needs of West African communities around EVD. The collaborative convened several agencies as well as more than 60 leaders from the New York City’s West African community with the goal of engaging in a dialogue about the impact of EVD on NYS and the city’s West African communities. Palm cards educating the community about Ebola were distributed. While the focus of the gathering was on educating the community about EVD, the collaborative also opened a conversation about other needs and concerns such as mental health services, discrimination, and job loss. Local health departments met with these communities and distributed materials. The outreach helped NYSDOH establish a relationship with the state’s West African communities. In addition, the department created websites that provided updated Ebola information for the general public. Since August 13, 2014, and as of July 14, 2015, the department website has received 147,285 views from 61,615 users (Stefan Kidalowski, BA, e-mail communication, July 15, 2015). NYSDOH also created a 1-800 hotline to address questions and concerns. HANYS and GNYHA created and continue to maintain websites for the hospital and provider communities.
TRAVELER MONITORING
Preparations across New York involved public health monitoring of travelers from Liberia, Guinea, and Sierra Leone. Since early recognition is critical to controlling the spread of EVD, monitoring helped to identify compatible illness among travelers before they sought care on their own, allowing designated hospitals and their staff to be safely prepared before traveler arrival.
The type of monitoring that was performed depended on the individual’s epidemiologic risk. Those whose risk was categorized by the CDC as “low but not zero,” such as being in a country with a large outbreak or being in brief proximity to an infected person, underwent active monitoring in which local health departments established twice daily communication (primarily by telephone) with the traveler to assess for the presence of symptoms and fever, rather than relying solely on individuals to self-monitor and report symptoms. Individuals characterized by the CDC as having “some” or “high” risk, those who had direct or close contact with a person with EVD or body fluids from a person with EVD, underwent direct active monitoring in which NYSDOH staff directly observed the individual twice a day (in person or by video) to assess their health and record their temperature. Local hospitals and EMS providers were alerted of the presence of a high-risk individual (without patient identifiers) in the area, and a defined action plan was created, spelling out details such as how the traveler would be transported to a hospital, which hospital would receive the traveler, and how they would enter the facility.
Between October 11, 2014, and June 8, 2015, a total of 2960 travelers underwent active monitoring and 21 underwent direct active monitoring. 8 Two travelers outside New York City who were monitored by NYSDOH became ill during their monitoring period and required medical evaluation at a hospital, although none required EVD testing. At press time, data on the number of travelers being monitored in New York City was not available.
HEALTH CARE COMMUNICATIONS
As part of its preparedness efforts, the state remained in regular contact with health care providers across New York, using the online Health Commerce System, the electronic communication system between NYSDOH and all health care providers. 9 Between October 6, 2014, and December 31, 2014, the state issued more than 436,000 distinct e-mail messages, made more than 4300 phone calls, and notified more than 627,000 users about 313 health alerts (Kevin Buettner, BS, e-mail communication, August 5, 2015). Additionally, NYSDOH conducted regional calls with the designated hospitals, EMS agencies, and local health departments to discuss patient triage, health care worker monitoring, traveler monitoring, and other issues around the care of patients suspected of having or diagnosed with EVD.
The department continued working with NYCDOHMH, health care associations, and unions to provide education and technical assistance. To educate health care workers and address their concerns, which were significant, the GNYHA and the 1199 Service Employees International Union, the state’s largest health care workers union, held a regional informational event in New York City days before New York’s first and only case of EVD. The event, which attracted 5000 workers and coverage in 70 newspapers in addition to radio and TV stations (Jenna Mandel-Ricci, MPH, MPA, e-mail communication, October 8, 2015), was simulcast in Los Angeles and other areas across the country and featured a demonstration of appropriate donning and doffing of PPE that attracted widespread media attention and became a critical training tool. 10 The video of the event has been accessed more than 85,000 times (Jenna Mandel-Ricci, MPH, MPA, e-mail communication, October 8, 2015).
PREPARING FOR AND RESPONDING TO NEW YORK’S CONFIRMED EBOLA PATIENT
In April 2014, NYC Health+Hospitals, an entity that operates the public hospitals and clinics in New York City, began a comprehensive, emergency-management-centric approach to preparing for Ebola and the myriad persons under investigation it would safely and effectively treat. Executive clinical and operational leadership determined that NYC Health+Hospitals/Bellevue, given its long-standing history as a leading health care institution, would serve as the hub with all such care centralized there. Across the other 10 acute care hospitals in the NYC Health+Hospitals system, fever and travel history screening was implemented. By August, twice daily centralized reporting of all such patients began. Ongoing collaboration with external partners such as NYSDOH, NYCDOHMH, and the Fire Department of the City of New York continued with tabletop exercises at all 11 acute care hospitals. By September, no-notice, mystery patient drills were underway to ensure each facility’s readiness.
Additional powered air purifying respirators were procured for Bellevue, and PPE policies and procedures ensured zero skin exposure of covered personnel. Drills were conducted with the NYC Office of the Chief Medical Examiner to ensure safe handling of decedents, and executive leadership commenced twice daily meetings from the Central Office Emergency Operations Center.
On October 23, New York’s first and only confirmed Ebola patient was admitted to Bellevue. The intensive preparations around managing an Ebola patient helped to ensure that the paramedics who came to retrieve him were appropriately dressed in PPE, and the patient was quickly ushered through a rear door to the isolation unit. The patient was discharged on November 11. No subsequent infections arose from his care. In all, NYC Health+Hospitals, in collaboration with local, state, regional, and federal partners, cared for 19 persons under investigation, 4 of whom were pediatric patients. Together with Emory University Hospital in Atlanta and the University of Nebraska Medical Center in Omaha, the NYC Health+Hospitals is now part of the National Ebola Training and Education Center (Nicholas Cagliuso Sr, PhD, MPH, Laura Evans, MD, e-mail communication, May 20, 2016).
LESSONS LEARNED
The state’s designated hospitals committed vast resources to the Ebola effort and should be commended for their dedication. Creating Ebola centers in New York was extremely expensive and included the cost of creating the needed infrastructure, acquiring PPE, and training staff to stand ready to care for patients under very trying circumstances. Going forward, these units should be preserved in anticipation of the next highly communicable disease such as MERS. Achieving that will require stable, ongoing federal support for health care and public health preparedness.
The most important lesson to emerge from the New York experience is the need to maintain the funding necessary to sustain preparedness in all designated hospitals as well as nondesignated hospitals and the public health system. According to a survey by the GNYHA and the HANYS, New York’s designated ETCs have already spent more than $42 million to stand ready, today and in the future, to receive patients with Ebola and other emerging infectious diseases. The federal government must allocate sufficient resources for designated treatment centers to be fairly reimbursed for both their past expenditures and the cost of maintaining their readiness. These hospitals believe in an implicit social contract that when the federal government urges them to do whatever it takes to meet a health care crisis, that same government will appropriately reimburse them. They simply want fair treatment and the assurance that they have a true partner when the next crisis occurs.
Both the national and the New York experiences underscore the fact that caring for even one Ebola patient is exceptionally resource-intensive. Bellevue Hospital Center, which expertly cared for the Ebola patient, needed 114 health care workers to care for only 1 patient for 21 days. As a result, Bellevue and the other NYS designated centers determined they could safely care for only 1, perhaps 2, Ebola patients at one time before potentially compromising their ability to provide care to the rest of their patients. So even though New York City may have 4 designated centers, the city can reasonably care for, at most, 6 patients at any one time.
The response of NYS to Ebola also demonstrated the vital intersection of public health officials and direct clinical caregivers. On the one hand, clinicians in some of the most sophisticated academic medical centers in the world required the knowledge and expertise of public health authorities to guide them as they prepared to safely care for potential Ebola patients. On the other hand, public health authorities depended on the expertise and precision of frontline clinicians, working under demanding circumstances, to ensure the containment of a highly infectious disease.
Although Bellevue was well equipped to provide clinical care for the 1 patient in New York, the experience taught us that some aspects of patient care still needed attention, including the disposal of hospital waste from Ebola patients, the cleaning of patient homes and apartments, and the monitoring of health care workers taking care of infected patients. The state’s systems of screening returning health care workers at JFK International Airport (based on CDC screening, which had already begun) and other airports, and in-home quarantine for some, was put into place as a result of the 1 case.
Another critical lesson in New York was the effectiveness of a regional approach for evaluation and treatment of patients with a novel or emerging infectious disease. Such an approach allows the system to concentrate its limited resources on select facilities that provide full treatment of patients, while the remaining hospitals prepare to isolate, stabilize, and transfer a suspect case. Routine regional planning, practice drills, and dedicated preparedness funding and personnel are essential to maintain this level of preparedness, even when no threat is imminent.
Managing health care worker fear was an ongoing issue, which was best addressed by drills and training. Some hospitals found that using smaller teams of dedicated volunteers helped ease anxiety while also preparing select staff to develop more specialized skills. Drills and training ensured that staff felt equipped to care for patients. Many hospitals also set up dedicated intranet pages and held town hall style meetings with hospital leadership to increase communication with staff and allay fears and concerns.
New York also learned that monitoring health care workers who treat a patient presents a significant challenge for state and local health departments. The 114 health care workers who took care of New York City’s sole patient all had to be monitored for 21 days after discharge. Computer-assisted telephone banks or web-based monitoring systems are being designed for this purpose in the future. Future discussions need to explore ways to minimize the number of health care workers involved in treating an EVD patient in order to reduce the possible exposures and maximize capacity.
The debate about what constituted appropriate PPE posed another challenge that spurred unnecessary fear. Many health care workers at New York’s designated hospitals viewed powered air purifying respirators as more effective, even though N95 respirators were considered to be of equivalent protection in treating a patient with EVD. A concerted effort to present the facts by government agencies and New York’s hospital associations helped alleviate the situation but consumed a great deal of time. Plans for and training with respect to PPE should be made in advance of future emergencies and should be based on both science and availability of supplies.
In addition, the importance of providing the media with clear, effective messaging was apparent throughout New York’s Ebola preparations and response to its single confirmed Ebola case and required collaboration among agencies and organizations at all levels. From the start—and with any crisis—the media needed a simple message from a reliable source who has earned the public trust. NYSDOH did just that by developing a comprehensive website and communicating regularly with media and major health care partners.
Many of the practices implemented during the Ebola crisis should be continued, including taking a patient’s universal travel history, maintaining isolation units with trained staff, and updating triage staff on global disease threats. Continued outreach to immigrant communities is also essential to gain their trust on health matters before an outbreak occurs.
Ebola strengthened New York’s level of preparedness for known and emerging infectious diseases and showcased the importance of collaboration, communication, and consistency. These concepts are the pillars of any public health emergency, be it a hurricane like Superstorm Sandy, a flu pandemic such as H1N1, or an outbreak of infectious disease like EVD. Concerns about Ebola may have diminished, but the next public health emergency is certainly not far behind. The state cannot lose the hard-won momentum gained from the lessons of EVD. New York plans to maintain key aspects of this high level of preparedness. Perhaps the most important lesson of all is this: In a world where an infectious disease is just a plane ride away, public health and health care systems must maintain basic levels of preparedness and have access to adequate resources at all times to contain a highly contagious communicable disease.
ACKNOWLEDGMENTS
The authors acknowledge the assistance of Winnie Yu of the NYS Department of Health, Sarah DuVall and Karen Roach of the Healthcare Association of New York State, and Jenna Mandel-Ricci and Susan Waltman of the Greater New York Hospital Association in the preparation of this article.
