Public health and healthcare funding is a priority during a disease outbreak such as Ebola. However, when ongoing funding is unavailable, government agencies must scramble to find ways to support public health response efforts. Three funding opportunities may help address these current gaps and avoid disease-specific funding for response efforts after the threat is realized.
The largest outbreak of Ebola continues its devastation in the West African countries of Sierra Leone, Liberia, and Guinea. As of 18 February 2015, the World Health Organization reported that the total number of suspected and confirmed Zaire ebolavirus cases is 23,253. Thousands of people have died in these countries as healthcare systems continue their struggle to respond to this epidemic. In the United States, two imported cases of Ebola with one death and two locally acquired cases greatly challenged the healthcare system. While thousands of health workers are making efforts to contain this deadly outbreak at its source, the U.S. government has taken aggressive steps to provide international support as well as to ensure domestic preparedness for Ebola Virus Disease (EVD).
Raising the Preparedness Question In August 2014, some Americans were concerned when the U.S. government brought infected citizens home for treatment. All of these cases were successfully treated and Ebola-free patients were released. The United States had one fatality in the case of a Liberian national who traveled from Liberia to Texas. This one fatality in the United States, along with subsequent infections in two healthcare workers, caused much angst in the medical community, increased public scrutiny, and raised the question, “Is the United States prepared for threats such as Ebola?”
Over the years, the Association of Public Health Laboratories (APHL) has communicated the importance of sustained funding for preparedness and response. In its February 2012 position statement, “The Need for Sustained Funding of Public Health Laboratories to Ensure All-Hazard Preparedness,” APHL noted, “It is essential that public health laboratories receive sustained funding to acquire and maintain the sophisticated instrumentation, highly trained technical staff and essential infrastructure necessary to ensure their ability to respond to all-hazard emergencies quickly and reliably at any time.” Simply put, a one-time funding approach cannot produce a robust system that will be fully functional to respond to something as deadly as Ebola.
Although state and local health departments received increased federal funds after 9/11 and the subsequent anthrax attacks, these funds have declined steadily over the years. However, the expectation to deliver a rapid response with massive electronic communications still remains. It is true that federal funds have strengthened the public health and healthcare systems to respond to a wide range of threats, but these successes are in jeopardy if Congress continues to cut programs such as the U.S. Centers for Disease Control and Prevention (CDC) Public Health Emergency Preparedness (PHEP) Cooperative Agreement.
Partnerships for Stronger Laboratories CDC’s Laboratory Response Network (LRN) for Biological Threats Preparedness is comprised of three primary tiers:
Sentinel Clinical Laboratories, which will likely be the first to encounter patient samples and thus must be able to rule-out and refer potential threats to the next tier;
Reference Laboratories, 70 percent of which are state and local public health laboratories capable ofentifying potential threats; and
National Laboratories, which are select federal laboratories that provide further strain characterization of threat agents and also lead research and development efforts.
Many of the state and local public health laboratories, which comprise the Reference Level, have used CDC PHEP funding to strengthen their systems in various ways. They have: hired qualified personnel and trained them; purchased modern technologies to rapidly and accurately detect threats; upgraded their facilities to ensure workers and the public are protected from potential biological agents; and performed outreach and training to their private clinical partners. Moreover, these laboratories have cross-trained many of their staff members so they are prepared to respond to naturally occurring outbreaks and acts of terrorism.
CDC is utilizing a similar approach, which they demonstrated in August 2014 when they partnered with the Department of Defense (DOD) United States Army Medical Research Institute of Infectious Diseases (USAMRIID) to deploy their Ebola assay to select laboratories within the LRN. A major success in the U.S. response to Ebola was the CDC-DOD USAMRIID partnership to rapidly initiate testing capability across the LRN. Currently, 55 U.S. public health laboratories are able to conduct preliminary testing for the Zaire ebolavirus using DOD’s real-time reverse transcription polymerase chain reaction (rRT-PCR) test, which was deployed by the LRN.
Although leveraging the LRN to respond to Ebola was a success, many gaps were observed in laboratory preparedness and response. These include but are not limited to:
Ability of some clinical laboratories to safely and correctly package and ship specimens to public health laboratories – There were several inconsistencies and multiple interpretations of the U.S. Department of Transportation regulations, including whether to ify EVD as a Category A or Category B infectious substance.
Lack of biosafety programs in most clinical laboratories – The CDC’s “Domestic Ebola Supplement to Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) – Building and Strengthening Epidemiology, Laboratory and Health Information Systems Capacity in State and Local Health Departments” stated, “The events surrounding laboratory testing of patient specimens suspected of Ebola virus infection point to a lack of biosafety programs in most U.S. clinical laboratories. For example, biosafety plans may be absent or outdated and staff charged with implementing and training additional staff on biosafety procedures may require additional education and practice to do so effectively and confidently. Some deficiencies illustrated during this event may span across many U.S. laboratories while others may only apply to some laboratories.”
Lack of timely guidance for clinical laboratories to perform routine diagnostic tests on patients under investigation.
Connectivity between healthcare and public health systems.
Federal Funding of Future Efforts In response to the Ebola outbreak and observed gaps in hospital preparedness, healthcare infection control, biosafety, surveillance systems for international travelers, as well as laboratory testing, epidemiological investigations, and responder safety, the U.S. government provided supplemental funding to support Ebola preparedness and response. Via the CDC, two Ebola supplemental funding opportunities have been made available to state and local public health departments: (a) the Hospital Preparedness Program and PHEP Cooperative Agreements/PHEP Supplemental for Ebola Preparedness and Response Activities; and (b) the Domestic Ebola Supplement to Epidemiology and Laboratory Capacity for Infectious Diseases (ELC).
As listed in the CDC PHEP announcement, this funding is intended to:
Support accelerated public health preparedness planning for EVD within state, local territorial, and tribal public health systems;
Improve and assure operational readiness for EVD;
Support state, local, territorial, and tribal Ebola public health response efforts; and
Assure collaboration, coordination, and partnership with the jurisdiction’s healthcare system to assist in the development of a tiered system for EVD patient care.
The ELC funding is intended to strengthen healthcare infection control practices, enhance laboratory biosafety and biosecurity practices, and enhance surveillance of migrant populations and international travelers. The U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response just released the Hospital Preparedness Program Ebola Preparedness and Response Activities funding announcement, which states that it is intended to:
"Ensure the nation’s health care system is ready to safely and successfullyentify, isolate, assess, transport, and treat patients with Ebola or patients under investigation for Ebola, and that it is well prepared for a future Ebola outbreak. While the focus will be on preparedness for Ebola, it is likely that preparedness for other novel, highly pathogenic diseases will also be enhanced through these activities."
These funding opportunities are a significant step to help state and local agencies address gaps in their public health and healthcare systems. However, an important learning lesson is to avoid the narrow approach to resourcing public health and healthcare preparedness – disease-specific funding is not the best approach to ensure a prepared nation. The challenges observed in the domestic response to Ebola point to the need for sustained resources to respond to all threats. Such resources encompass funds to ensure a trained laboratory workforce at the private clinical – for example, hospitals – and public health levels, strong biosafety programs, safe and secure facilities and modern technologies for rapid detection of threats, and electronic data messaging so results can be shared in a timely manner. There is a clear need to revisit the long-term preparedness and response strategy to ensure that the United States is ready for the next threat.
Chris N. Mangal, MPH, is the director of public health preparedness and response at the Association of Public Health Laboratories (APHL). The recipient of a bachelor’s degree in microbiology from the University of Florida, and of a master of public health degree from the University of South Florida, she is responsible for providing programmatic and scientific leadership for preparedness activities for APHL members, staff, and partner organizations, such as the U.S. Centers for Disease Control and Prevention (CDC). She has more than 12 years of experience working to improve laboratory practice in the detection of public health threats, and to expand and enhance the relationships between APHL member laboratories and CDC, other federal agencies, and private organizations involved in emergency preparedness and response, public health testing, policy, and training.