By Chris Aldridge, MSW, Senior Director, Infectious Disease, NACCHO; Umair A. Shah, MD, MPH, Executive Director, Harris County Public Health and Environmental Services; and Robert Kim-Farley, MD, MPH, Director, Communicable Disease Control and Prevention, Los Angeles County Department of Public Health (LACDPH), together with the LACDPH Ebola Incident Command System Team and the LAC Ebola Response Planning Taskforce

The West African Ebola epidemic is expected to continue throughout 2015 and potentially into 2016. This is the largest outbreak of Ebola ever, and it is the first time cases have been diagnosed and transmission has occurred in countries outside of Africa. The first case was diagnosed in the United States on Sept. 30, 2014, followed by transmission to two healthcare workers who had cared for the individual. The Centers for Disease Control and Prevention (CDC) responded to the situation by implementing new guidance for monitoring travelers and healthcare workers returning to the United States. The CDC provided guidance on topics such as patient care, use of personal protective equipment, environmental cleaning, and handling of laboratory specimens; implemented a new hospital strategy; and sent teams into the field to ensure hospital readiness.

Ebola is a highly virulent virus that causes Ebola Virus Disease. Ebola is not transmitted through the air; rather it requires contact with bodily fluids (blood, sweat, saliva, vomit, diarrhea, urine) of a patient symptomatic with the disease. Patients who are not symptomatic do not transmit the virus. Ebola can survive for several days on surfaces that have been contaminated with bodily fluids from an infected patient, making it possible to become infected after touching an inanimate object.

Dr. Shah presents at the Harris County Department of Education Safe and Secure Schools Workshop about Ebola readiness activities

Symptoms of Ebola can appear between two and 21 days after exposure, with eight to 10 days being the average. Symptoms often resemble those of other infectious diseases and can include fever, weakness, headache, muscle pain, and sore throat. Later symptoms include vomiting, diarrhea, rash, and impaired kidney and liver functions. Patients may also exhibit internal and external bleeding. When diagnosing Ebola, healthcare professionals should rule out other diseases including malaria, meningitis, and hepatitis.

While media attention has slowed since the intense coverage following the first U.S. case, the risk of Ebola in the United States continues. Until the West African epidemic is brought under full control, that risk will remain. Although initially slow, the international response to the situation in West Africa continued to grow throughout 2014. The response focused on controlling the rate of growth in Guinea, Sierra Leone, and Liberia, and preventing the disease from taking hold in Mali and Nigeria.

Local health departments are playing a leading role in response to potential Ebola cases in the United States. They are working with state and federal counterparts and local stakeholders including hospitals, law enforcement, and emergency medical systems. Their goal is to ensure that individuals at risk for Ebola are monitored according to CDC guidance and symptomatic individuals are quickly isolated and transported to an appropriate medical facility. Their efforts are critical to ensuring quick control of the disease if additional cases appear in the United States. This articles addresses the efforts of two local health departments as they respond to Ebola.

Harris County, TX

Harris County Public Health and Environmental Services (HCPHES)—the county health department for the Harris County jurisdiction located in Houston—routinely tracks infectious disease outbreaks such as Ebola worldwide as part of its global situation awareness. HCPHES was one of the first health departments in the nation to submit specimens for Ebola virus testing (submitting the first specimen in late July) and developed two early epidemiological investigation forms—one for phone consultations and the other for investigation of suspects. Shortly after news broke of a patient confirmed with Ebola in Dallas on Sept. 30, 2014, the work of HCPHES increased significantly. While the unfolding events in the Dallas metro area would likely affect Harris County, no one could predict exactly how much.

HCPHES monitored information coming out of Dallas through local and state partners and addressed many requests for information from the local community. The health department formed an Ebola readiness team to address public concerns and implement appropriate preparedness measures should someone be confirmed with Ebola in Harris County. The team comprised members of the executive leadership and local health authorities; public health preparedness and response; disease control and epidemiology; public information and communications; legal; and operations staff. Using Incident Command System principles, HCPHES coordinated efforts with local, state, and federal partners and local healthcare and educational systems to help the community better achieve a state of readiness.

The following two months afforded many occasions for “real-time” activities, which were quite instructive to preparedness efforts for the rapidly evolving situation. The team met twice daily (including weekends), frequently through video conferencing. The team was extremely busy with various tasks including monitoring and disease control activities. The “disease detectives” were on the phone day and night handling healthcare system calls to help support the front-line of the Ebola response.

HCPHES also handled “spill-over” and “popcorn” effects. The spill-over effect meant that whatever happened in the Dallas metro area would also affect a community like Harris County. The popcorn effect described the way that healthcare providers and the general public often thought any situation they were involved in was Ebola until proven otherwise.

The HCPHES Public Information Officer Team developed outreach messages for the public, healthcare partners, educational settings, and travelers to ensure access to factual Ebola-related information, including infographics that would help them better understand if they were at risk of being exposed to Ebola.

In addition, HCPHES used media partners to provide credible, reliable messages about Ebola through interviews, town hall meetings, and educational sessions. Coordinated efforts with community partners to build and leverage relationships were critical. HCPHES continues to reach out to local communities from Liberia, Guinea, Sierra Leone, and Mali to address their concerns about this devastating disease.

While the community will not be at “theoretical risk zero” until Ebola is contained overseas, HCPHES continues to monitor the ongoing situation and remains “ready” for what lies ahead.

Los Angeles County, CA

The Los Angeles County Department of Public Health (LACDPH) activated an Incident Command Structure to elevate Ebola preparedness activities and to ensure that activities were coordinated and adequately resourced. Ongoing activities focus on improving readiness throughout the healthcare system and among first responders; improving readiness within the health department and other county departments; and conducting outreach to organizations and the public.

A Los Angeles County Interdepartmental Task Force on Ebola Preparedness and Response was jointly convened by LACDPH and the Los Angeles County Chief Executive Office (CEO) Office of Emergency Management (OEM). The task force initially met weekly to discuss, identify, and evaluate the county’s planning and anticipated response. The task force included representatives from CEO, OEM, LACDPH, Department of Health Services (DHS), DHS Emergency Medical Services, Fire, Sheriff, Coroner, Internal Services, Public Social Services, Mental Health, Children and Family Services, Community and Senior Services, Animal Care and Control, Public Works, Parks and Recreation, Probation, Los Angeles County Office of Education, Los Angeles County Metropolitan Transportation Authority, and the Los Angeles City Emergency Management Division.

Key activities and experiences in Ebola response included the following:

• Activating a Joint Information Center to coordinate and streamline public information;
• Developing and disseminating a standardized non-medical screening form on Ebola risk for the non-healthcare community (jails, schools, etc.);
• Finalizing a protocol for handling Ebola cases by the Department of Medical Examiner-Coroner;
• Holding audience-specific conference calls with school districts, city managers, hospital public information officers, and local media managers;
• Conducting a tabletop exercise on Ebola;
• Constructing a multilingual Ebola website;
• Developing a multilingual Ebola fact sheet;
• Partnering with 2-1-1 (a countywide hotline) operators to handle calls from the general public;
• Preparing animal care and control guidance for pets of patients suspected or confirmed with Ebola;
• Holding conference calls with chief executive officers and other senior executives of several hospitals to affirm their readiness to receive patients who may be infected with Ebola and to assess their current and future needs;
• Working with hospital preparedness staff and infection prevention counterparts to improve planning, healthcare worker training, and other preparedness activities at county hospitals through drills and consultation;
• Disseminating Health Alert Network alerts on Ebola;
• Presenting on Ebola at hospitals and professional and community venues;
• Collaborating with the Los Angeles International Airport for Ebola readiness and response activities, including a preparedness drill;
• Training LACDPH staff on use of personal protective equipment and offering intensive information sessions on Ebola;
• Holding media events to reach local audiences through television, print, and web.

The magnitude of preparedness activities and the successful interdepartmental collaboration among county departments for Ebola greatly enhanced the level of preparedness in Los Angeles County. This singular readiness effort helped the health department to prepare for any future emerging infectious diseases that could potentially threaten public health and safety.

This article was originally published in NACCHO Exchange. To read the entire issue, download the newsletter from NACCHO’s online bookstore. (Login required).