In the event of emerging (and reemerging) infections, outbreaks, and pandemics, there is an expectation that state public health officials and the agencies they lead are “first, right, and credible” with the actions they take and the information they share publicly and with response partners.1 There is also an expectation that these public health emergencies will be addressed in a way that will minimize risk to the community.
Middle East Respiratory Syndrome (MERS) is a new infection offering just 1 example of the challenges to state health officials in dealing with public health emergencies. Increased post September 11 investments of federal public health preparedness funding to states—resources that have significantly eroded in recent years—have allowed state, territorial, and local public health agencies to prepare to respond to an array of threats, including emerging infections such as MERS. These additional resources bolstered the public health infrastructure, helping state health agencies to be nimble, responsive, and proactive—yes, prepared when a new pathogen is found in the United States.
The first case of MERS in the United States was a matter of “when,” not “if.” Federal, state, and local public health agencies, and a group of national public health associations representing state public health, had anticipated the first case in the United States for at least a year and were ready for it.
Role of Public Health
State public health agencies have a long history of responding to emerging infections. From cholera to tuberculosis to severe acute respiratory syndrome (SARS), state health agencies, in tandem with CDC, work to detect cases of infectious diseases, respond to cases of infection or a larger-scale outbreak, and prevent further transmission. Achieving these multiple objectives requires a significant amount of coordination across federal, state, and local public health agencies and among multiple departments within the agencies. From preparedness planning, to epidemiology and surveillance, to the state laboratory, to the office of public affairs, each of these departments helps to inform and facilitate the critical public affairs and communications aspects of an infectious disease investigation or outbreak.
These departments have independent functions as a part of the day-to-day operations of a state health agency. The roles of each department are well defined, exercised, and assessed.
The day-to-day operations and the periodic preparedness exercises help establish confidence among the departments, so that when an outbreak occurs, the many facets of the agency can respond together. Disease surveillance, communication with healthcare providers and the public, and the initiation of other interventions such as isolation and quarantine are some of the roles that state health agencies play in emergency situations.
State health agencies also depend on a coordinated public-private partnership to effectively respond to emerging infectious disease outbreaks, epidemics, or pandemics. An important role for public health is to establish connections and build partnerships, particularly those within the healthcare sector. An example of the importance of this partnership was demonstrated in the recent MERS response in Indiana.
The identification of suspected cases of MERS depends on astute clinicians who see patients in clinics and emergency departments and make the connections between patients’ symptoms and guidance provided by CDC and state and local health agencies to allow proper and prompt diagnosis. The next step—notifying the state health agency—is a critical link between healthcare and public health. Without that link, a confirmed diagnosis cannot be made, and the appropriate mitigation strategies to minimize or eliminate the possibility of transmission cannot be implemented.
Indiana was the first state to identify and confirm a MERS-infected patient. The quick identification was due in part to the pre-deployment of approved MERS test kits by CDC under an Emergency Use Authorization to 45 public health labs across the United States. CDC and the Indiana State Department of Health established clear communications channels with the facilities collecting test specimens, said Pamela Pontones and Shawn Richard, the state and respiratory epidemiologists for Indiana, Lixia Liu of the Indiana state public health laboratory, Amy Reel with the office of public affairs, and Joan Duwve with the Indiana University School of Public Health, who spoke with ASTHO. Recently, additional states, including Maryland,2 have formalized these procedures through administrative directives and orders, requiring providers to notify the state health agency of suspected MERS cases.
When dealing with a new pathogen about which little is known, an abundance of caution is the only appropriate response. Speaking with ASTHO, Pontones, Richard, Liu, Reel, and Duwve, said that the state health agency and the healthcare facility operated as if the index patients were infected with MERS even before the positive identification. To ensure that no further transmission occurred, Indiana, state agencies in other states, and CDC began tracing contacts who had known exposures, and those who may have been exposed while on a flight, in an airport, on a bus, or in meetings with the patient.
Further caution was taken when CDC and Illinois’ state public health agency reported a professional contact to the index patient who had a positive initial test for MERS, but later announced the contact was not infected after the results of the more conclusive, more time-intensive assay came available from the CDC. In the midst of a response, sharing the best and most up-to-date information is essential even if that information changes as the situation develops.
Prevention efforts related to MERS are difficult, given that there is relatively little known about the natural course of infection. The limited understanding of the epidemiology of MERS in some ways makes decision making regarding prevention easier—take all available precautions to protect the population and take all available opportunities to add to the scientific and epidemiological base of knowledge about the virus. As such, the Indiana state public health laboratory began testing a voluminous number of specimens from the patient, the patient’s household contacts, and healthcare workers who were exposed to the patient.
On the part of the healthcare facility, out of an abundance of caution and concern for their patients and employees, they decided to furlough those employees who were exposed until they could confirm that they were not infected. This degree of caution, while appropriate, comes with costs: tracing of contacts, expense of the laboratory tests, around-the-clock staffing of the lab to conduct the tests, and the added cost of paying replacement staff at the healthcare facility while their employees were furloughed.
The Indiana MERS case, followed closely by a second case in Florida, clearly demonstrates that infectious diseases know no borders. Domestic cases of diseases like MERS are a reminder that the United States public health agencies play a critical role in protecting our homeland as part of the global health security agenda.
A threat to the health of a nation is literally only a plane ride away. Given the complex nature of travel in the Indiana case—involving multiple planes and a bus—a large number of potentially exposed individuals across more than 30 states needed to be contacted.
The response to the first case of MERS in the United States was successful due to advances in science and policy, investments in public health infrastructure, strong intergovernmental relationships and communications pathways, and timing. The science of developing and testing assays moves much more quickly than even a decade ago. The ability to use an Emergency Use Authorization under improved legal frameworks is easier now and facilitates moving the new, expeditiously approved assays to the field of practice.
Unfortunately, state public health agency preparedness efforts have experienced a large decrease in federal funding and human capital over the past several years.3 The resources for these programs help public health agencies and healthcare coalitions achieve the capacity and capabilities to handle a breadth of public health emergencies, including natural disasters, acts of terrorism, and infectious disease outbreaks. Due to this erosion of the public health infrastructure, it is increasingly difficult for health agencies to respond to more than one emergency at a time.
The timing of the index case identification was fortunate in that there were no other evolving public health emergencies. If the MERS case had occurred coincident with a major environmental disaster or natural disaster, terrorist attack, or other infectious disease incident such as a large scale foodborne illness outbreak, health agencies and their partners could have been taxed beyond their limits and would not have had the resources necessary to conduct the MERS case investigation and the multiple layers of public education needed to prevent further transmission and assure the public health of citizens.
The public health response to MERS in Indiana and other affected states showcased the best of public health preparedness and response. The “system” worked as planned and practiced. Federal, state, and local health agencies remain vigilant toward disease detection, response, and prevention, and hopeful that a similarly successful response will be mounted with the next public health emergency, be it additional cases of MERS, chikungunya fever, H7N9 influenza, or another emerging infection. The framework for preparedness relies on the strength of federal, state, and local partnerships. The foundation depends on the availability of sufficient and sustained resources.