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Be ready for anything: Recent infectious-disease outbreaks a reminder that state public-health systems must be strong before disaster hits

by Kate Tormey ~ November 2014 ~ PDF of Stateline Midwest article »
When emergencies strike — whether a disease outbreak or a natural disaster — it can feel like everything is out of the ordinary.
But public-health experts say that during an emergency, the response should feel as familiar and routine as possible. That’s because in order to successfully handle a disaster, the preparation and practice should happen before trouble is on the horizon.
Take the recent outbreak of the Ebola virus, a deadly disease that is ravaging western Africa. As of early November, there were more than 13,000 cases of the illness there, with a mortality rate of about 70 percent.
With nine Ebola patients having been treated here in the United States, health officials at the state and federal levels are bracing to handle additional cases.
But Ebola is just the current threat to public health in America. Recent outbreaks of infectious diseases such as measles and whooping cough, and natural disasters such as tornadoes and blizzards, have long tested preparedness measures in our region and beyond. And the threat of man-made disasters, including bioterrorism, is on the minds of many emergency experts too.
‘Preparing for a variety of risks’
How do our states prepare for public-health emergencies, and how can policymakers support systems designed to prevent and address these events?
The federal government has a role in handling large-scale emergencies that affect multiple states or that involve national security. But states are generally responsible for the health and well-being of their own citizens, because these powers are not specifically assigned to the federal government in the U.S. Constitution.
State public health departments, however, receive the bulk of their preparedness funding from the federal government, through grants offered by the U.S. Centers for Disease Control and Prevention’s Office of Public Health Preparedness and Response. Last year, the agency’s grants to 50 states, four major cities (including Chicago) and eight territories totaled $585 million. In fiscal year 2013, states in the Midwest received more than $100 million in grants.
States can spend these funds on planning, training and other activities in order to be prepared in 15 specific areas in which the CDC tracks progress. Each year, the center releases a report assessing how well states are improving their capabilities in everything from public information and warning systems to laboratory testing and epidemiological investigation.
The CDC’s goal is to provide guidance and support to states using an “all hazards” approach. In other words, states are encouraged to use the funding not just to react to the latest public health threat, but instead develop systems that could be used to address anything from a pandemic to an earthquake.
“That is the advantage to this funding stream,” says Steve Boedigheimer, deputy director of the CDC’s Division of State and Local Readiness. “If it were earmarked for the disease of the month, you’re only prepared to address that disease. When it comes to preparing for an emergency that could put people in harm’s way, preparing for a variety of risks that could emerge in our communities is a good investment.”

Being strategic about investing this funding has become even more crucial in recent years because the CDC’s public health preparedness grant program has seen a dramatic decline (a 40 percent drop) since its inception in 2001, when $1 billion in federal funds was distributed to states.
This decrease in federal support, coupled with states’ own fiscal challenges, has put a strain on public health departments. In part because of funding gaps, more than 45,000 jobs have been lost in state and local health departments since 2008, according to the Robert Wood Johnson Foundation.
When funding erodes, it can be tempting to cut back on investments in preparedness. But experts in this area warn that recent history proves this strategy can backfire.
“Public health preparedness needs to be seen as part and parcel of everyday operations in state and local government. It really is part of not only the public health foundation, but also the larger public-safety and emergency-response arms,” says Paul Kuehnert, a former county health director and deputy state health director now with the Robert Wood Johnson Foundation.
One of the ways states can improve their preparedness is to make sure everyone who could be involved in response efforts — from local health directors to senior government officials — gets to know one another by taking part in drills, training and exercises together.
“People need to have these relationships in place before a disaster or major outbreak strikes,” he says. “Those don’t get built in the middle of an emergency.”
Boedigheimer agrees: “An emergency-operations center is not the place to be exchanging business cards.”
Good communication is something that the Minnesota Department of Health’s infectious-disease team practices each day in its morning meeting, says division director Kristen Ehresmann. And she works to stay connected with her counterparts in emergency preparedness, environmental health and elsewhere.
She says that connection is possible in part because Minnesota has invested well in its public health infrastructure. She remembers reading after 9/11 about the importance of infrastructure, which she admits isn’t very “exciting.” But she tells policymakers again and again that without it, the state can’t successfully respond in an emergency; it takes too long to figure out, for example, how and where to find enough medical professionals to treat an influx of patients.
“If you have not invested in public health in your state, and then there is a crisis, there is no way you can just say, ‘We’ll put money into it now’ and be able to respond,” Ehresmann says.
Minnesota’s public health infrastructure has already been tested this year. In April, a suspected case of Ebola turned out to be Lassa Fever, which is also a viral hemorrhagic illness. Word of the infection came in on the department’s 24-hour provider hot line; state officials then worked with the hospital to prevent the illness from spreading and to get a specimen to the laboratory for testing. The system worked well, Ehresmann says, and it was a good test run for any potential Ebola cases.
Last month, Minnesota health officials tested at least five patients for Middle East Respiratory Syndrome, or MERS, a severe viral illness with a 30 percent mortality rate. The state had put out an alert to health providers around the state to be aware of the symptoms and to ask about international travel.
All infectious diseases are logged in the state’s real-time disease surveillance system, which allows state officials to track trends in illness or suspected cases. The system is tracking everything from measles to foodborne illness. And despite the widespread fear about Ebola, Ehresmann says, it doesn’t change Minnesota’s public health strategy.
“The risk to public health really comes with complacency about supporting the system,” she says. “If we have a strong system, we can feel confident we’ll be able to respond to anything.”
‘All disasters are local’
While Minnesota has had success in turning attention to public health by investing in surveillance and response, other states are now working to strengthen their systems.
In Indiana, public-health officials have been working closely with local officials to prepare them for emergencies.
“In a sense, all disasters are local,” says Lee Christenson, director of public health preparedness and response for the Indiana Department of Public Health. “We think the best approach to defense is to get those folks prepared as best we can.”
The department has built 10 health care coalitions throughout the state — teams made up of hospitals, rural health clinics, local health departments, emergency managers and even philanthropic organizations such as the Red Cross.
“It is very important for them to get used to working together,” Christenson says, “because in an emergency they’ll have to do that quickly.”
Indiana’s approach to emergency management focuses largely on using existing resources and private partners, in part because the state has not traditionally received a high level of federal support for public health preparedness. In FY 2013, Indiana ranked last in the nation in terms of per-capita support from the CDC’s programs in this area, according to the Trust for America’s Health.
“If you have not been awarded those federal grants, you have not had the opportunity to build your infrastructure,” says Dr. Joan Duwve, chief medical consultant for the Indiana Department of Health. “But now that funding is contingent on that infrastructure being in place. … We’ve missed out on a lot of funding.”
Of the funds the state receives for health care preparedness, about 85 percent goes to hospitals. But recent cuts in federal funding — a 40 percent drop in Indiana — hit hard, causing health care providers to scale back their own training and drills.
So health officials at the state level are working to fill in the gaps and to make resources stretch a little further. For example, the state is looking to identify a single emergency communications system for all hospitals in the state, which would cost 75 percent less than the current practice of each hospital choosing its own platform.
Meanwhile, they are also working to help elected officials understand the importance of investing in preparedness.
“A little bit of money on the front end to prepare yourself can go a long way in a disaster,” Christenson says.
States set Ebola monitoring policies
Many state public-health systems are being put to the test as they prepare for one of the biggest public health threats in recent history: Ebola. As of early November, there had been four cases confirmed in the United States and five patients treated here after being diagnosed with the virus while working in Africa. Two patients were treated at the Nebraska Medical Center.
With travelers coming into the United States each day from the center of the outbreak, officials in this region are setting policies to monitor those who arrive in their states. Flights from western Africa arrive at one of five U.S. airports (including Chicago’s O’Hare), at which point they are screened for symptoms. If they’re free of any sign of the virus, they are asked to provide information about where they’re going next.
States then receive information about travelers entering their jurisdictions, and public health officials set policies to closely monitor people with potential risk of developing Ebola.
The CDC recommends that people potentially exposed to Ebola be sorted into one of four categories. The highest-risk individuals would include anyone who had direct contact with an Ebola patient’s bodily fluids or who cared for a patient without wearing proper personal protective equipment.
“Some risk” includes being within 3 feet of someone sick with Ebola for an extended period of time. “Low risk” includes situations such as shaking hands with a patient or being on an airplane with someone who is ill with the virus. Some travelers will be deemed to have no risk: for example, if they had contact with a healthy person who later showed symptoms of Ebola.
The CDC says its guidelines are based on evidence showing that unless a patient has physical symptoms of Ebola, he or she cannot transmit it to other people and is not a danger to the public. Most states have chosen to closely follow those guidelines.
Minnesota, for example, uses risk categories similar to those laid out by the CDC. The state’s active monitoring system is based on risk and exposure, and as of early November, Ehresmann was not aware of any high-risk residents or visitors. If any were identified, the state would ask the person to voluntarily restrict movement, avoiding mass transit and public places.
But going for a walk or doing other activities that don’t involve contact with other people would still be OK. Meanwhile, public health officials would be checking in with the high-risk individual, either in person or by video, to monitor possible symptoms.
But for now, lower-risk individuals are being asked to monitor their own temperatures and symptoms and to check in with state health officials.
The policy in Minnesota was crafted with the goal of balancing individual rights with the public good, Ehresmann says. And under Minnesota statute, the state has to make a compelling case that an individual represents a health threat to the public in order to invoke mandatory quarantine or isolation.
“If you’re not following the science, then when push comes to shove, you don’t have a leg to stand on,” Ehresmann says. “You have to have data to show someone is a health risk as you exercise your quarantine and isolation authority.”
In Indiana, field staff from the state Department of Health are visiting local health departments and hospitals to provide information and answer questions about Ebola. They’re making sure, too, that providers and local health departments are ready for anything, from monitoring at-risk individuals for 21 days to isolating a patient until infectious-disease experts can arrive.
Right now, the state is monitoring only low-risk individuals, and local officials are using a variety of methods — in-person visits, Skype and telephone calls — to keep an eye on individuals who may have been exposed to Ebola.
Providers have access to a 24/7 hot line for questions or concerns. There is also a hot line for the public to call with questions, which is important, Duwve says, in quelling fears and providing fact-based information to citizens.
Quarantine policies in the Midwest differ from the high-profile announcements in states such as New Jersey, where health workers returning from west Africa will face a mandatory 21-day home quarantine.
Illinois has put in place a mandatory home quarantine for individuals in the “high risk” category. As of early November, no one returning to Illinois had been deemed “high risk.”
While states sort out how to prepare for the possibility of more Ebola cases in the United States, many public health experts view the Ebola outbreak as a good reminder of the importance of being ready for anything.
“It could be Ebola this week and influenza next week,” Boedigheimer says. “Epidemiology and laboratory expertise, emergency response planning and practicing the basic tools: that gives us the resiliency we need to be ready.”