Middle East respiratory syndrome (MERS), simmering in the Arabian Peninsula since early in 2012, arrived in Indiana in April when an infected health care worker returned to the United States from Riyadh, Saudi Arabia (see last January's Emerging Infections). Within weeks, two other U.S. MERS infections were confirmed, and health departments across the country prepared for an outbreak of MERS. It never came.
Enterovirus D68 (EV-D68), a little-known respiratory virus, was identified in Kansas City, Missouri, in August and has since caused more than 1,100 infections in 47 states. Through November 12, 11 children had died, according to the Centers for Disease Control and Prevention. As enterovirus season waned in November, the number of new cases fell.
The first cases of MERS and EV-D68 appeared in countries with stable health care infrastructures, which may be one reason these outbreaks have remained relatively contained. The Ebola virus outbreak of 2014, though, had a very different start.
The outbreak began in March, and the fact that it wasn't contained as quickly as past Ebola outbreaks ignited fears of virus mutations and airborne spread. But as Paul Farmer, an infectious disease physician with extensive experience in outbreak control around the world, pointed out in the October 23 London Review of Books, "weak health systems, not unprecedented virulence or a previously unknown mode of transmission, are to blame for Ebola's rapid spread."
The current Ebola outbreak originated in three of the world's poorest countries. Sierra Leone and Liberia recently emerged from years of civil war; Guinea, home to thousands of refugees from those wars, has also been devastated by deforestation from clear-cut logging. Farmer described these countries as having "some of the lowest public investment in health care and public health in Africa."
U.S. news outlets reported on the almost unimaginable conditions of the hospitals at the epicenter of the outbreak: the absence of gloves and other protective gear; no running water, electricity, or even flooring; a shortage of beds that forced infectious patients to return to their homes. Wrote Farmer, "Without staff, stuff, space, and systems, nothing can be done."
As of this writing, U.S. hospitals have had to manage only five cases of Ebola infection during this outbreak. Worldwide, according to the World Health Organization, more than 13,000 people have become infected, and more than 4,800 have died.
The Ebola outbreak has forced U.S. hospitals to confront their own deficits in "staff, stuff, space, and systems." Years of cutbacks in supplies, support services, and staff training have left many U.S. hospitals unprepared for Ebola and other crises. We've discovered that the ability to isolate infectious diseases, provide first-rate intensive care, and maintain sophisticated laboratory capabilities aren't enough. Preparation needs to involve more than checklists and standard operating procedures; policies and logistics need to be repeatedly reinforced through hands-on training-before the actual need arises.
Long experience has shown that ultimately, the control of any large-scale epidemic depends upon controlling it at its source. The World Bank estimates that the global cost of this Ebola epidemic could be as high as $32 billion.-Betsy Todd, MPH, RN, CIC, clinical editor