The Ebola Response: 10 Years Later

Steve Schmitt: [00:00:10] Welcome to Let's Talk ID, the podcast that's all ID, all the time. I am Steve Schmitt. I'm president of IDSA. This year, we are marking the 10th anniversary of the West African Ebola epidemic. This disease took the lives of a lot of people in West Africa, but also crossed over into the United States, which caused a pretty big response. And I think it's fitting that we reflect on that event and what we learned from it. For that, we've enlisted the help of two people who were significantly involved in the response to the 2014 outbreak. And first, I'd like to welcome Dr. Arjun Srinivasan, who's the deputy director for program improvement in the Division of Healthcare Quality Promotion at the US CDC and a captain in the US Public Health Service. Arjun, thank you so much for being with us today.

Arjun Srinivasan: [00:01:06] Thanks so much, Steve. Pleasure to be here.

Steve Schmitt: [00:01:08] We also have with us Dr. Angela Hewlett, who is a professor in the Division of Infectious Diseases at the University of Nebraska and the George W. Orr and Linda Orr Chair in Health Security. In addition, Dr. Hewlett is the medical director of the Orthopedic Infectious Diseases Service and the Nebraska Biocontainment unit. And as an aside, she's been president of the Musculoskeletal Infectious Disease Society, which is something she and I share. Angela, thank you so much for sharing your experience with us today.

Angela Hewlett: [00:01:42] Thanks for having me.

Steve Schmitt: [00:01:44] So let's get to it. Arjun, I wonder if you could briefly recall how the outbreak evolved in West Africa in 2014 and CDC's response?

Arjun Srinivasan: [00:01:56] You know, it was really an interesting and obviously a frankly terrifying time for all of us because, you know, historically, these Ebola outbreaks, this obviously this was not the first outbreak of Ebola. These outbreaks go back decades. And historically, you know, every time they happen, it's a handful of cases, usually in a fairly remote area and relatively quickly, it either is brought under control, but most of the time it kind of seemed to burn out. They seem to burn out on their own, right? There usually wasn't a massive response effort. I mean, CDC sent people frequently to help support control of these outbreaks, but there usually wasn't like a big mass mobilization. And so this one began unfolding in just a really extraordinarily peculiar way with urban center involvement, really large numbers of cases, you know, unprecedented numbers of cases. And it was really kind of that very unusual constellation. You know, this outbreak just didn't look like the other outbreaks. And as we know from our experience in infectious diseases, anything that looks different from what you would expect it to has the potential to be bad and something that you really need to pay attention to. What really began the massive mobilization that we saw is, you know, there were some of these modeling projections done early in the course of the pandemic that suggested, you know, look, if we don't do something and do something relatively quickly, you know, we are very in a in a short order, we are going to be looking at tens or hundreds of thousands of cases, huge numbers of deaths.

Arjun Srinivasan: [00:03:41] And so that was kind of what began the very large mobilization, in coordination with World Health Organization, to try to get resources into the field. What was massively transformative in this country was when we began seeing this issue and this risk of an actual imported cases. So now this became an Ebola outbreak that was not the usual limited to West Africa. There's really no risk anywhere else. Very clearly, with the patient who got admitted to the hospital in Dallas, it was very clear that this was something that was going to have domestic impact and the potential for significant domestic impact very early on. And I think a lot of that is what really began this incredibly large mobilization to try to get on top of it.

Steve Schmitt: [00:04:28] Yeah, it's amazing. At what point did you think that you had some difference in the virus itself or in the way the transmission was going or what? What did you think was going on over there?

Arjun Srinivasan: [00:04:41] There were lots of different theories. That's a different. Something's changed about the virus. But I think fairly early on, you know, the experts said, look, you know, this is probably not anything different with the virus. This is probably the same virus in a different circumstance. Right? It's in an urban area. There's just more risk for there to be transmission than in previous. This isn't, you know, just a zoonotic event with a little bit of spillover. This is a contagious disease in a big urban area where there's a lot more risks for transmission.

Steve Schmitt: [00:05:16] Well, thanks a lot, Arjun. That's a tremendous description of how that went. And then of course, we started to see some folks in the US. And one of the centers that got involved in this was the University of Nebraska. And Angie, you were involved in that response. And I wonder if you could recall for us how that went, how you got involved in Nebraska and how you got involved personally in this?

Angela Hewlett: [00:05:46] So the Nebraska Biocontainment unit was actually founded in 2005, and I can attribute all of that to Dr. Phil Smith, who was our founding father of the unit. And was the ID division chief at the time here at University of Nebraska Medical Center. And so what Phil determined was based on some recent historical events, and that was SARS, both in China as well as some imported cases around the world, as well as an Mpox outbreak that actually occurred here in the Midwest at the time. We did not have any cases here in Nebraska, but there were definitely some hospitals and patients that were admitted to the hospital, and there were concerns surrounding those patients as far as transmissibility, training of healthcare workers, PPE, things like that. And so Phil decided that he wanted to establish a place here on our campus that would be a safe patient care space that would have some sort of unusual attributes compared to the regular patient care wards, and would also have a highly trained team. And so that really was the impetus for the development of the Nebraska Biocontainment unit. And again, that happened in 2005. And so we opened officially in 2005. As far as how I personally became involved, I at that point was still in my residency and fellowship at University of Texas Medical Branch. But at UTMB, there's the Galveston National Lab, level four laboratory down there, World Health Organization Collaborating Centre.

Angela Hewlett: [00:07:05] So a lot of interest in global health and things. And so I became interested in those fields while I was in training at UTMB and also was training in infection control at the time, which actually there's a lot of crossover between what I'm doing now and some of the principles of infection control. So I actually was presenting a poster at IDWeek and met Phil Smith that way. And so he came up to me and talked to me while I was presenting my poster. I was a third-year research fellow at the time getting a master's degree, and he asked me if I wanted to come look at Nebraska. And Phil is notably very humble and didn't say a whole lot about any of this. He said, we have a biocontainment patient care space here. And so when I came for my interview, though, I was absolutely floored by the facility here and just meeting the team. And it was definitely the reason, you know, one of the reasons for sure that I decided to move from Texas to Nebraska. So I joined the unit in 2009 as the associate medical director of the unit, because Phil said he needed a partner. So that's how it kind of got started here. But as far as how we went on after that, you know, from 2005 up until 2014 when we accepted our first patient with Ebola virus, I mean, we affectionately refer to those as as BE, or before Ebola, because things really changed really dramatically for us in 2014.

Angela Hewlett: [00:08:22] But during that time we were doing team building, trainings and we were still, you know, doing routine PPE training, doing a lot of outreach with some local hospitals, regional hospitals, things like that. I'm talking about the care of patients with highly hazardous communicable diseases. But I absolutely remember the day that we got the phone call. It was August 1st of 2014, and at that point we had been following, when you're in this field, you definitely follow what's going on throughout the world, because there's always a chance that that we could be called on to care, you know, care for patients, whether that's someone who presents to our emergency department or somewhere in the region or U.S., or somewhere elsewhere in the world. And so we were following the Ebola virus disease outbreak very closely at that time. And we got a call from the State Department actually basically saying, we'd like to come visit your facility to assess your readiness to care for patients with Ebola, should we need to care for a patient that is medically evacuated from Africa. And so at that point, I remember we said, well, when do you want to come? And it was like, we'll come tomorrow or something like that.

Angela Hewlett: [00:09:22] It was very, very quick. Within a couple of days, they were on our campus and surveyed our facility, and our team asked a lot of questions and things like that. And so we knew at that point that things were heating up and that we probably would be called on to care for patients. And then shortly thereafter, the first two patients were medically evacuated to Emory from West Africa. And so at that point, we knew we were probably next. And we were. And that our first patient I remember this vividly, too. Phil and I were walking in the hallway and we got a call saying that, also from the State Department, saying we have a patient and we'd like for you to accept this patient that's going to be medically evacuated from Africa. And I remember at that time we had some very quick conversations with our hospital leadership and our leadership team here in the Biocontainment unit, as well as our state and local health authorities. But I think it was very clear that we knew that this was our purpose and what we had been training for for all those years. And we accepted our first patient on September the 5th of 2014.

Steve Schmitt: [00:10:19] And so you never, you know, all the preparation that you had put in really puts you in position to, to do this, but you never really know what it's like until that first patient hits your door. And so what was that like when the patient arrived for you and for your team and for the caregivers and for leadership?

Angela Hewlett: [00:10:41] So our first patient arrived in early September, and we did have a short notice because this individual had to be medevac'd from Africa. So we had a couple of days to kind of get things geared up. Um, although we were we were mostly geared starting with that State Department visit in early August, we pretty much knew we were next, and so we were already, for the most part, geared up and ready to go. I remember that morning our patient was going to arrive at the airport early in the morning, very early in the morning. And so I remember, I think I picked up Phil at his house at like 4:00 in the morning and we carpooled to work together and we, you know, went to the directly to the unit to make sure everything was ready and talked with the team and the people who were going to be the initial team inside of the unit. I remember there's a large conference room actually across the hallway from the Biocontainment unit, and at that point we had lots of university leaders over there, hospital leaders, our public information officer, people like that, that were all kind of gathered very early in the morning just to await, you know, the arrival of our patient. There's a large TV on the wall. So we were able to watch some of the news coverage, which was pretty intense. You know, we were able to watch the plane land and things like that just with the news coverage.

Angela Hewlett: [00:11:46] Phil and I were in the unit for the most part for the rest of the morning, just kind of doing kind of some last-minute checks and making sure that everything all the, you know, supplies and everything, everything we needed would be there. There's also a lot of unknowns when it comes to. I mean, this is you know, the transports are very long and these individuals have been on planes for a very long time. Ebola virus disease can progress very rapidly in cases. And so we didn't really, we had gotten some checkout information and things along the way, but not a huge amount. And so we had to really be prepared for anything. For the most part, we didn't know if this individual would arrive critically ill or severely ill or, you know, what the status would be. And so we really had to be ready, you know, for the most part, for any degree of, of, of clinical illness.

Angela Hewlett: [00:12:28] I remember right before the patient arrived in the unit, Phil kind of gave a few sort of inspirational remarks to our team who were standing there. And then we all kind of took our spots, and then our transport team arrived and wheeled the patient back into the room and to the room that we had chosen to provide care. And we initially I know Phil and I were, we have a telemedicine setup, actually, where we were initially able to observe the arrival and things via the telemedicine setup.

Angela Hewlett: [00:12:54] While the nursing team was kind of getting the patient settled, which we all know is important, actually. And so we go in there when we need to go in there for sure. But we wanted to allow our stellar nursing team to kind of get the patient settled and get everything, everything set up. And then Phil actually volunteered. He said, I will go back and see the patient. We had an agreement that we would send essentially one, one physician, or the physician that needed to see the patient that day, was the one that saw the patient. This would never be a situation like our usual rounds, where we have a bunch of students and residents and all kinds of people with us. You know, from an infection control perspective, we're very careful about who we bring into the unit, let alone the direct patient care room, just from a safety perspective. And so we had agreed that one of us would go back. And I remember that day, Phil said he wanted to go, and he told me he was being chivalrous, which was pretty funny. But what he what he actually meant, and he told me later, was that he thought it'd be a lot easier to put on PPE and go back and see the patient than to have to do all the medical documentation and arrange for the labs and do all that kind of stuff, which he left to me.

Angela Hewlett: [00:14:00] But I was able to observe the first exam on the telemedicine equipment while he was in the room. And then from then on out, we kind of, you know, tag teamed during the days that the patient was there. But there was some anxiety that day. I mean, I remember that pretty vividly. Understandably, I think that's a normal human reaction to this type of scenario. But there was also sort of a weird excitement amongst our team. I mean, these are our team or volunteers, so we don't compel anyone to do this work here. They're all volunteer team members who sign up to do this. And so because of that, there was a bit of excitement. And I remember Phil, during his kind of initial remarks, just said, this is exactly what we've been trained to do. And that was the truth. And so we once we once we met the patient, it was very easy for us to, to really want to do everything, absolutely everything in our power to take care of him and to get him through the horrible disease he was experiencing. It was it was definitely a, I remember a whole lot of things about that day, literally like it was yesterday.

Steve Schmitt: [00:15:02] And what was the public response like initially?

Angela Hewlett: [00:15:05] I think people were nervous and anxious here locally, and I totally understand that. I will say that we had done a lot of work before our patient arrived. You know, it wasn't a surprise that the Biocontainment unit is here at our hospital and is here in Omaha. Our local community, over the years, we had done a lot of work with a variety of different, um, different outbreaks or education or things like that. And the media would come in and they would do a story on the unit or they'd show people in PPE. So it definitely was not a big surprise. And I think that helped us actually, because it wasn't like all of a sudden, look at this crazy facility in our hometown. It really wasn't like that. I think most people in the community were pretty aware of our situation. Um, you know, there again, was obviously some anxiety, understandably, because these individuals were being medically evacuated into our city. But I do think that as time went on, our public information officer and our media team just did an excellent job of really keeping the public informed. Our state and local health authorities also set up phone lines where people could call in and ask questions and things like that. We had a lot of communications throughout our facility, as well to our patients, clinic patients. You know, all of the inpatients received a visit from the nurse managers to talk to them about what was going on, as well as letters. It just was there was a lot of communication. And I think that's really the key to being able to provide this type of care and to get to gain the trust of your, you know, of your community, which can really be an asset. So, yeah, I can't emphasize that enough. Just making sure that we're, you know, providing we're being very, you know, very open and communicative with our community as well as our local employees and patients here at the hospital.

Steve Schmitt: [00:16:47] That's really a tremendous observation. I remember the anecdote from Northeast Ohio is that a health care worker had come here and then gone back to point of origin and gotten sick after getting back, and that caused no small amount of consternation and concern in both our hospital and in the, because we figured at the Cleveland Clinic we would be possibly called upon and so or at least identifying people up front. So there was a lot of preparation here. And then lots of conversation in the media. What you sort of touched on there, Angela, is what what can we learn from this experience and how can we apply it to future epidemics, pandemics, outbreaks, etc.? And so, Arjun, I wonder if you could comment about what Ebola taught us in the US and globally to help us prepare.

Arjun Srinivasan: [00:17:43] One of the most important things that it taught us is that no place is immune from any infectious disease. And I think if you had asked people before Ebola, is there going to be an outbreak of one of these kind of really severe viral hemorrhagic? They said, nah, that's not, that'll be somewhere else. But that's not something that we have to worry about here in the US. Ebola completely reversed everybody's way of thinking about infectious diseases, and I think it truly raised that awareness and made it really clear that it doesn't matter what the disease is. Any infectious disease anywhere can be everywhere in this day and age. We have seen that come true over and over again with things like, you know, Zika and dengue and Oropouche, you know, all these things where people are like, oh, well, that, you know, yes, that happens, but it won't happen here. I to me, I think that's like kind of the most important lesson that we learned from this is that we're not safe or immune from any of these diseases, no matter how rare they are or how remote they might be. And to me, that is one of the most important lessons learned. The second lesson learned. I hesitate when I say learned because I'm not sure how effectively we learned. This one is that you know this. It's important to be prepared, even if that preparedness has to sit dormant for a long, long time.

Arjun Srinivasan: [00:19:13] I mean, you just heard from Angela like, that center opened in 2005, and for nine years, it "didn't do anything" right. Sat vacant. There's a center here at Emory that for years and years and years sat vacant. No patients being cared for. However, when we needed that capacity, we needed that capacity. And if we had, you know, if in 2013, uh, folks in Nebraska had said, hey, you know, it's been eight years now, we should just shut this thing down, right? We're never going to need it. Where would we have been in 2014? I'm not sure that's a lesson learned because we do still as a nation have a fairly short memory. And I think the Covid pandemic is an exemplar of that. So many of the things, the capacity that we needed, bonus, you know, the surplus PPE, extra expanded PPE, production capacity, test capacity, vaccine production capacity, we have a lot of that, uh, quote surplus or surge capacity. Go. And that is not going to stand us. Well when not if but when there's another pandemic. But the Ebola pandemic demonstrated to us is like, you have to build that capacity, and then you have to be willing to say, look, we don't need it today. We might not need it this year or next year, but we're going to maintain it.

Steve Schmitt: [00:20:47] Yeah, agreed 100%. You had also started to talk about that. Angela, I wondered if you had any further thoughts about sort of that preparation and communication piece and what that taught us.

Angela Hewlett: [00:20:58] Communication. I mentioned the outward communication, but in 2014, I will tell you, it became very obvious very quickly that we need to all work together in these response efforts. I mean, we can look back and think about Covid now, but in 2014, you know, this was something Ebola was not a disease that had ever been seen in the United States. And so there were a lot of unknowns. The environment in the Biocontainment unit is very different from where Ebola patients had been cared for in places in Africa, in country before, just in the fact that we were able to provide aggressive, supportive care, but also critical care interventions like mechanical ventilation, dialysis, things like that. I mean, these were entirely new in the care of Ebola patients, for the most part, and nobody really knew what labs would look like. There were all kind of there are a lot of unknowns clinically. And I think, you know, it became really important that we network and communicate with those who were also caring for patients. And we did that, I think, very well during, you know, during the early days when we were taking care of the Ebola patients. I became really good friends with the ID and critical care docs, um, both at Emory and also in New York City at Bellevue, who they were also caring for a patient. And we kind of leaned on each other and, you know, provided support and advice on clinical management and other things as well.

Angela Hewlett: [00:22:18] Team management and things like that. And there were a lot of calls with the CDC and individuals like Dr. Srinivasan, but also Dr. Tim Uyeki. I mean, these guys were also very supportive to us and really helped us navigate some of the issues we were dealing with, particularly with infection control. Um, you know, investigational therapeutics, you know, we were on the phone with the FDA a whole lot, and we had lots of calls with the WHO, which were actually clinical care calls. It was like giving a clinical care case conference. Um, and amongst a bunch of centers that were all caring for patients with Ebola around the world, including places in Europe and things like that. So that was all extremely helpful. I think, to our team, just being able to reach out and to communicate and kind of share ideas during that time because there were so many unknowns. The 2014 experience with investigational therapeutic agents also did inform some of our preparedness for Covid 19, just in the fact that how to actually get in, do good research, but also be able to provide individuals with these, with these agents and be able to conduct research in the midst of a crisis was really important. And that was a big lesson learned that I think did help us.

Angela Hewlett: [00:23:27] My other big lesson learned was just the importance of assimilating a strong team and maintaining preparedness. And it is not easy all the time. I mean, it is something that is an ongoing issue, you know, making sure that, like was just said, memories can be short term and making sure that we have adequate funding to support these efforts and these hospitals, I mean, we did drill for, you know, an exercise for almost ten years before we received our first patient. And so, um, but we know that maintaining our preparedness is the right thing to do. Um, and when we need it, we need it just like Dr. Srinivasan said. And so we also, I will say, are very fortunate here in Nebraska that we have a very supportive leadership team within our hospital. Our both our hospital and university leaders recognize the importance of this work and have been supportive of us through the years. It's the only way we were really able to survive from 2005 up until, um, until 2014. Um, now we have some grant funding to support some of this work, but there were a lot of very lean years where we really did depend on our hospital as well as our our state and local health departments to help us, help us through. So I think that's also very important to making sure that you're networking with your local leaders to influence their thoughts on this work and the importance of it.

Arjun Srinivasan: [00:24:42] One of the other things that was novel and we learned from the fear was staggering. The media attention that for like what, 15 total domestic cases or something in that neighborhood. But it, I mean this dominated the news. I mean this was on CNN. It was on the crawl on major news networks. It was the lead story in the news every night. I mean, as Angela's described, I mean, there was a tent city of press set up outside the of both. I know I saw I drove by it every day at Emory, and I'm sure it was the same in Nebraska. And the managing that fear, I think it became its own job because, you know, you're trying to help people fear, you know, it's natural to to be afraid. But the fear, obviously, in this case was like, you know, massively out of proportion to anyone's risk. And it really, it required though, we couldn't just say, hey, you have nothing to be worried about. Go on with your lives. You know, it really required thoughtful attention to how we were messaging and how we were going to allay those fears. And that became, I think, a very, very important function that we desperately needed.

Angela Hewlett: [00:26:01] Yeah, I think the way you counteract that, that we learned at least and I just shout out again to our media team and our public information officer here who were just doing amazing work, really just trying to combat some of the, you know, some of the fears that were out there. And I guess the way that we decided we would combat it is with transparency. And we essentially did something every day. You know, we would have a news conference. We involved a lot of our team members, you know, both our nursing team and our physician team. You know, we would do joint things with our state and local health authorities. I mean, it was just, it was we were out there all the time and they would yeah, I mean, people were just hungry for information. I mean, like, I know it was the same at Emory where the news media wanted to know all sorts of things, and we had to obviously bridge making sure that we were only relating things that our patient and family would allow. But we would ask the patient and family what would you like us to tell the media today? Is there anything you know we can talk to them about? Because they're going to ask us questions.

Angela Hewlett: [00:26:56] And there were, I mean, literally they reported on everything. I think the one of our patients choice of ice cream made CNN. And it was extraordinary the way that that was attacked. Yeah. I mean, you know, saying he had a Gatorade today and it was like this huge thing, you know, he drank some fluids, you know, I mean, it just was it was extraordinary. But I, I yeah, I mean, at the time people were just hungry for information. But I think our media folks just said you really have to give them, you know, you have to give information in order for people not to make up things on their own, whether that's the public not being aware and then creating things in fear and all of that. And so we did our best to really try to combat that. And I do think that we were reasonably successful in that here in here in Nebraska. But it definitely was. We had camp Ebola too, and media trucks and people set up all around campus. But yeah, it was an interesting time for sure.

Steve Schmitt: [00:27:47] Thank you so much Arjun and Angela, for what you've taught us today. It's an amazing experience and certainly lots of lessons for us, not the least of which are creating and maintaining resilient systems for when that outbreak comes and then communicating actively. I think that's, these are things that, as Arjun says, we're still learning. Thanks so much to both of you for your perspectives, and I will encourage our audience to come join us at IDWeek, the 16th to the 19th of October in Los Angeles. It's going to be a fantastic event. Stay tuned to this space for more episodes of Let's Talk ID.