In late October 2014, Ebola virus disease (Ebola) was diagnosed in a humanitarian
aid worker who recently returned from West Africa to New York City (NYC). The NYC
Department of Health and Mental Hygiene (DOHMH) actively monitored three close contacts
of the patient and 114 health care personnel. No secondary cases of Ebola were detected.
In collaboration with local and state partners, DOHMH had developed protocols to respond
to such an event beginning in July 2014 (1). These protocols included safely transporting
a person at the first report of symptoms to a local hospital prepared to treat a patient
with Ebola, laboratory testing for Ebola, and monitoring of contacts. In response
to this single case of Ebola, initial health care worker active monitoring protocols
needed modification to improve clarity about what types of exposure should be monitored.
The response costs were high in both human resources and money: DOHMH alone spent
$4.3 million. However, preparedness activities that include planning and practice
in effectively monitoring the health of workers involved in Ebola patient care can
help prevent transmission of Ebola.
On October 23, 2014, NYC DOHMH was notified by Médecins Sans Frontières (MSF) that
one of its physicians who had returned to NYC nine days earlier from treating Ebola
patients in Guinea had an oral temperature of 100.3°F (37.9º C). The physician reported
fatigue for 2 days without other symptoms (e.g., vomiting, diarrhea, cough, muscle
aches, or abnormal bleeding). He reported having used prescribed personal protective
equipment without a known breach and following MSF’s protocol of twice daily oral
temperature checks and self-monitoring for symptoms since his return to the United
States. Because of his travel and work history and symptoms consistent with Ebola,
DOHMH arranged for immediate transfer by the Fire Department of New York Emergency
Medical Services (FDNY-EMS) to Bellevue Hospital Center, a medical facility designated
by the DOHMH and the NYC Health and Hospitals Corporation (HHC) to treat Ebola patients
in NYC. DOHMH’s laboratory performed nucleic acid amplification testing on blood from
the patient, and within 3 hours of specimen receipt, reported a preliminary positive
result for Ebola virus on October 23; this result was confirmed at CDC on October
24.
DOHMH investigators used the date of reported onset of fatigue (October 21) to set
the initial time of exposure for potential contacts. This was a decision based on
knowledge about how the disease might present and an attempt to not miss any persons
who might have been exposed. After interviewing the patient about his movements and
contacts, DOHMH investigators identified three persons with close (i.e., direct physical)
contact. Contact A was a member of the patient’s household, and contacts B and C had
intermittent close contact during varying time periods after October 21. All three
contacts were interviewed, evaluated for symptoms, and, under orders from DOHMH, required
initial home confinement and direct active monitoring of oral temperature and symptoms.
This included a daily face-to-face visit between the close contact and a DOHMH or
vendor staff member, followed by a second daily face-to-face visit or telephone call.
After additional evaluation and assessment, contacts B and C were released from home
confinement after 10 and 12 days, respectively. Contact A was released from home confinement
after 19 days. All three contacts completed direct active monitoring by DOHMH for
21 days (2); none developed signs or symptoms suggestive of Ebola. The patient was
hospitalized at Bellevue Hospital Center from October 23–November 11 but released
from the isolation unit on November 10 after clinical improvement and two nucleic
acid amplification tests of blood for Ebola virus had negative results.
DOHMH actively monitored 114 health care personnel based on three criteria: direct
patient care responsibilities, entry into the patient’s room, and handling of non-decontaminated
laboratory specimens. Monitored personnel included seven FDNY-EMS workers, one from
the DOHMH laboratory, and 106 at Bellevue Hospital Center. The 106 hospital workers
included clinical (38), laboratory (42), environmental management (22), transport
(3), and support (1) staff members. All 114 personnel reported using appropriate personal
protective equipment without any known breach and were categorized as low (but not
zero) risk as directed by CDC guidance of October, 2014 (2). Symptoms and twice-daily
oral temperatures were reported every day by telephone to DOHMH for 21 days; no movement
or work restrictions were imposed. No secondary cases of Ebola were detected among
these 114 health care worker contacts. No other cases of Ebola were reported in NYC
in the 42 days (two incubation periods) after the patient was first identified.
Discussion
In response to the Ebola epidemic in West Africa, in July 2014 DOHMH began preparation
for the potential arrival of imported Ebola cases with enhanced preparedness and interagency
collaboration. This included enhancing surveillance to rapidly recognize and respond
to a report of a patient meeting the CDC clinical and risk factor criteria for a person
under investigation (3); working with hospitals to prepare to evaluate any returning
traveler with symptoms consistent with Ebola; deploying the U.S. Department of Defense-developed
Ebola virus assay at DOHMH’s laboratory as part of CDC’s Laboratory Response Network;
and providing 24-hour per day testing, specimen packaging, and transport services
(1).
Initial interagency collaboration focused on streamlining preparedness activities.
The FDNY-EMS established protocols for responding to emergency telephone (911) calls
involving persons with illness and a history of recent travel to an Ebola-affected
country, and worked with HHC and DOHMH to perform triage on such persons. The FDNY-EMS
and DOHMH also worked with John F. Kennedy International Airport Border Health Station
and the Port Authority of New York and New Jersey to prepare for potentially ill travelers.
After New York City designated Bellevue as a hospital to manage a patient with Ebola,
HHC worked with the hospital to prepare the isolation unit and develop staffing plans
for safely treating such patients. DOHMH responded to HHC drills to test and practice
safe triage of persons under investigation. The Office of the Chief Medical Examiner,
a division of DOHMH, developed procedures for handling the body of a person under
investigation or with Ebola.
On October 3, 2014, in response to the Ebola case identified in Texas in late September
2014 (4), DOHMH activated its incident command system. The goals of incident command
system activation were to 1) enhance interagency coordination and accelerate planning
for health care system readiness; 2) quarantine and actively monitor close contacts
of an Ebola case; 3) manage waste; and 4) conduct public outreach in NYC. DOHMH collaborated
with the New York State Department of Health to assess and support the readiness of
three Ebola treatment centers in NYC in addition to Bellevue. DOHMH also provided
outreach to support rapid identification and isolation of persons under investigation
at emergency departments and other ambulatory facilities. After the Ebola case was
diagnosed in NYC on October 23, DOHMH identified contractors for disposal of medical
and non-medical waste and worked with the New York State Department of Health and
CDC to refine policies for identifying and monitoring people at risk for Ebola.
What is already known on this topic?
Because Ebola virus disease (Ebola) has potential to spread and has a high case-fatality
rate, early identification and isolation of cases is essential. To prepare for a potential
Ebola case, New York City (NYC) worked to enhance public health preparedness and interagency
coordination.
What is added by this report?
The first U.S. case of Ebola diagnosed in a returning humanitarian aid worker was
detected in NYC in October, 2014. Three persons who had direct contact with the patient
and 114 health care workers required active monitoring. This monitoring was difficult
because protocols had not been finalized prior to the identification of the case.
No other persons having contact with the patient developed signs or symptoms of Ebola
during the monitoring periods. No other cases of Ebola were reported in NYC in the
42 days after the patient was identified.
What are the implications for public health practice?
Interagency preparedness can help to safely and efficiently isolate and diagnose Ebola
cases. Public health response to Ebola is likely to be resource intensive. Even as
the West Africa Ebola epidemic subsides, it is important for public health agencies
to maintain preparedness for other potential imported disease threats.
The public health response to the first case of Ebola in NYC highlighted the importance
of collaboration. First, DOHMH and MSF had an established protocol for MSF to contact
DOHMH when an MSF worker in NYC met the criteria for a person under investigation,
and MSF required its employees to self-monitor and report an elevated body temperature
or symptoms immediately. Second, beginning in August 2014, FDNY-EMS and HHC (including
Bellevue) developed protocols and conducted drills on their own and with DOHMH, which
permitted a person under investigation to be safely and quickly transported from home
to the hospital. FDNY-EMS committed to transport of these patients only by personnel
who had extensive training and experience in hazardous (chemical, biological, nuclear)
materials response and had received additional training to safely and efficiently
provide pre-hospital care for an Ebola patient. Third, protocols for packing, transporting,
and testing specimens for Ebola virus were established among the receiving hospital,
DOHMH’s laboratory, and CDC, permitting timely and efficient diagnosis. Finally, DOHMH
increased public outreach efforts and, by October 31, had participated in 34 community
events, contacted more than 160 West African organizations, sent community outreach
teams to neighborhoods to disseminate accurate information on Ebola transmission and
symptoms, and distributed 51,000 informational cards.
Despite planning and collaboration, a number of challenges remained. Creating clear
and implementable criteria for health care worker monitoring based on a worker’s tasks
or entry into specific zones was difficult. Persons entering the patient care room
clearly required monitoring according to CDC Movement and Monitoring guidance (2).
However, it was difficult to decide whether others, such as laboratory staff or waste
handlers, also required monitoring. For example, “performing laboratory work” as a
criterion for monitoring evolved as DOHMH and HHC discussed the exact laboratory work
performed. Subsequently, workers performing laboratory work on decontaminated specimens
did not require monitoring. Instituting an effective monitoring system that included
timely and clear transmission of data between DOHMH and the hospital also proved difficult.
Establishing protocols for workers to report oral temperatures and any symptoms to
the call center took several days, and some workers had to be reminded to call DOHMH.
As monitoring procedures became clearer and more efficient, worker compliance with
reporting improved. Data management for worker monitoring initially required more
than 12 full-time staff members of DOHMH and HHC, and managing data flow between the
two agencies required close communication. Finally, there was insufficient planning
on what instructions to give workers who required active monitoring if they planned
to travel outside of NYC while being monitored, especially in the context of evolving
local, state, federal, and international policies on movement restrictions for persons
in contact with Ebola patients.
In NYC, the public health response to one Ebola case was resource intensive for a
local health department, with participation of more than 500 DOHMH staff members and
expenditures of more than $4,300,000 in DOHMH funds. These figures include not only
the direct costs of the local public health response (e.g., contact tracing, environmental
issues, and health care worker monitoring) but also the indirect costs of increasing
citywide preparedness after identifying the one case (e.g., enhancing hospital preparedness,
active monitoring of returning travelers, and community outreach). Ebola preparedness
might include advanced planning with all designated Ebola hospitals to establish efficient
monitoring programs for workers involved in caring for Ebola patients, as well as
a plan for local resource allocation needed once an Ebola case has been confirmed.