ILLUSTRATION BY ABIGAIL GOH

The patient in back lies in an isolation chamber. It’s just big enough for one person, and he’s completely enclosed inside it. An observer might conclude that he’s no ordinary patient, and this is no ordinary ambulance ride.

Actually, the patient is a person pretending to be sick with Ebola. And this is a full-scale training exercise that involves several hospitals, two ambulance crews and a team of responders.

The exercise was run by Barnes-Jewish Hospital in St. Louis, which is designated by the U.S. Centers for Disease Control and Prevention (CDC) as an Ebola assessment hospital—the only such facility in Missouri. Through its Emerging Infectious Diseases Program, started in 2015, Barnes-Jewish Hospital is prepared to manage and assess not only potential patients with Ebola but also people suspected of having six other emerging infectious diseases: Middle East respiratory syndrome (MERS), severe acute respiratory syndrome (SARS), Nipah virus, pneumonic plague, highly pathogenic avian influenza and smallpox—the latter of which has been eradicated but still exists in labs, making it a potential bioterrorism threat.

In fact, Barnes-Jewish Hospital is part of a nationwide network of hospitals that are ready to put carefully planned and practiced protocols into action as soon as a person is identified as potentially having one of these diseases. This type of large-scale, coordinated, community-based response is a relatively new development. Emerging infectious diseases, on the other hand, are not.

A brief history of infectious disease

The Black Death in the Middle Ages. Smallpox in the 1500s. Spanish flu in 1918. These are just a few examples of emerging infectious diseases over the centuries.

The impact of these diseases was widespread and devastating. In the earlier two outbreaks in particular, the medical and public health communities were a long way from understanding what caused infections—and how to control them. In the Middle Ages, treatments for the Black Death, which actually is a type of plague, included bloodletting, self-flagellation and vinegar. The lack of effective methods for prevention and treatment meant that disease outbreaks frequently escalated to epidemic proportions.

By the time the Spanish flu pandemic was underway in 1918, understanding of infection control and prevention had greatly improved, with health officials instituting quarantines. St. Louis had a notable response, with the city health commissioner ordering schools, businesses, sporting events and other public gathering places to close. Thanks to this response, which wasn’t exactly popular among business owners, the death rate in St. Louis was the lowest among major U.S. cities.

And today, thanks to huge scientific advances beginning in the late 19th and early 20th centuries, many infectious diseases either have been eradicated or can be effectively prevented, treated and controlled. But that doesn’t mean that new diseases no longer emerge — or that they aren’t a threat to human health.

The CDC defines emerging infectious diseases as “those whose incidence in humans has increased in the past two decades or threatens to increase in the near future.” According to the World Health Organization, an emerging infectious disease is one that “has appeared and affected a population for the first time, or has existed previously but is rapidly spreading, either in terms of the number of people becoming infected, or to new geographical areas.”

IF A PERSON SUSPECTED TO HAVE AN EMERGING INFECTIOUS DISEASE PRESENTS TO A HOSPITAL ANYWHERE IN THE U.S., THAT HOSPITAL WILL CONTACT THEIR LOCAL ASSESSMENT HOSPITAL.

Either way, humans often have little, if any natural immunity to emerging infectious diseases, making them a serious public health threat. In recent years, diseases such as SARS and MERS have caused panic when they appeared in humans. SARS is believed to have spread to humans from small mammals in China called civets, while researchers believe MERS crossed over from camels to humans. SARS affects the lungs and is a severe form of pneumonia. MERS symptoms, ranging from mild to severe, include shortness of breath, fever, cough and diarrhea. Both viruses can be deadly.

But with the implementation of infection control measures, pandemic preparedness plans and travel alerts, the SARS outbreak was contained a few months after it started in 2003. No known cases of SARS have been reported since 2004. MERS, which was first reported in humans in 2012 in Saudi Arabia, has only ever been diagnosed in two people in the United States, both of whom were health care workers who had lived and worked in Saudi Arabia. The CDC continues to monitor MERS globally.

Although serious diseases will continue to emerge—and re-emerge—the national and international medical and public health communities are better prepared and equipped to deal with them than ever before. The Emerging Infectious Diseases Program at Barnes-Jewish Hospital, started in response to the 2014-2016 Ebola outbreak in West Africa, demonstrates this well.

Preparing for outbreaks

In March 2014, the World Health Organization reported several cases of Ebola—an often fatal disease that causes symptoms including fever, fatigue and muscle pain followed by vomiting, diarrhea and bleeding—in a rural region of Guinea. By the time the outbreak was declared over in 2016, more than 28,600 people had been infected; 11,000 died. Eleven people in the United States were treated for the disease.

In response to the outbreak, the U.S. Department of Health & Human Services created a grant through the Hospital Preparedness Program with the intent of helping U.S. hospitals become better prepared to manage and treat people with Ebola. Missouri received $950,000, of which $927,000 was allocated to Barnes-Jewish Hospital for an Ebola-management program that would expand to cover other emerging infectious diseases.

“Since I was hired in 2017, we’ve been building up the program so that we are prepared to accept and assess patients with not just Ebola but also several other high-consequence pathogens,” says Kimberly Wall Lederman, MD, MPH, program manager of Barnes-Jewish Hospital’s Emerging Infectious Diseases Program.

“High-consequence” is the key term. Of the nearly 200 emerging infectious diseases in the world, just 10 to 15 are considered high-consequence, Lederman notes. These diseases are highly lethal, they spread relatively easily from person to person, and they aren’t associated with approved preventive measures, such as vaccines or known effective treatments. That makes the Barnes-Jewish Emerging Infectious Diseases Program—able to treat one or two patients at a time given the complex demands such care makes on staff and facilities—far different from a pandemic preparedness plan, which would go into effect in the event of a large epidemic of an infectious disease, whether that disease were emerging or not.

“Our goal in developing this program was to create protocols and procedures that effectively contain and treat a patient while preventing any of our staff from being infected with the pathogen and preventing the pathogen from getting out into the hospital proper and infecting other patients and staff,” Lederman says.

The program is part of a nationwide three-tier system for managing emerging infectious diseases. At the top level are 73 U.S. hospitals with biocontainment units, where infected patients receive the majority of their treatment. The bottom level includes front-line facilities: just about any hospital that receives a sick patient and identifies that patient as potentially having an emerging infectious disease. In the middle are assessment hospitals, including Barnes-Jewish Hospital. There are 217 assessment facilities nationwide, and they are the link between the initial suspicion that a patient has an emerging infectious disease and that patient’s treatment and—hopefully—recovery.

“If a person suspected to have an emerging infectious disease presents to a hospital anywhere in the U.S., that hospital will contact their local assessment hospital,” Lederman says. “At that point, there is an established process that loops in all kinds of people, including staff within the state public health department, the CDC and the assessment hospital, to make the complex call to admit the patient.”

Barnes-Jewish Hospital is the only assessment hospital in Missouri, so it would admit patients with an emerging infectious disease from across the state, though Missouri does have an agreement with the University of Kansas to accept patients from the west side of Missouri. And, as illustrated in the two-day training exercise, Barnes-Jewish Hospital can transport such patients to the biocontainment unit at the University of Iowa.

Once Barnes-Jewish Hospital agrees to receive a patient with an emerging infectious disease, a chain of long-planned protocols is set in motion. There is a protocol for getting the patient from the ambulance to an area within the ICU, or intensive care unit, which has been isolated from the rest of the hospital; a protocol for staff to put on and take off their personal protective equipment; protocols for staff to follow while caring for the patient; a protocol for cleaning and disinfecting the room. And the list goes on.

Since she came on board in 2017, Lederman has worked to develop these very plans and protocols — to think and rethink them and to make sure no key component is missing. To do this, she gets input from a number of hospital departments, including infection prevention, environmental services, public safety, laboratory services and occupational health, as well as from leadership teams from the emergency department and the ICU. So far, there’s been no need to put the plans and protocols into practice, meaning no people suspected of having Ebola or any other emerging infectious disease have been identified in Missouri.

If that does happen, Barnes-Jewish Hospital, working as an assessment facility, will be responsible for obtaining blood samples from the patient and sending them to a lab in Jefferson City—via the state Highway Patrol—and to the CDC in Atlanta for testing.

“Our state lab turns that test around in six hours,” Lederman says. “They call us with the result, and if it’s positive we prepare the patient for transfer to a biocontainment unit.”

Ensuring that the entire process is safe and efficient—without jeopardizing the health of staff or other patients—takes a lot of practice.

Strength through practice

Since the Emerging Infectious Diseases Program at Barnes-Jewish Hospital was formed, its staff has taken part in a series of training programs and exercises. These fall under the purview of Jason Campbell, the hospital’s emergency preparedness manager.

“We conduct increasingly complex full-scale exercises to demonstrate, validate and strengthen the capabilities of the Emerging Infectious Disease program,” Campbell says. “These exercises involve not just our staff but also external partners, including the state health department, our emergency medical services partners in the region and state partners through FEMA Region 7.” FEMA is the federal emergency-response program administered by the Department of Homeland Security; Region 7 includes Iowa, Kansas, Missouri and Nebraska.

The exercise in May that involved transporting a patient by ambulance from Barnes-Jewish Hospital to the biocontainment unit at the University of Iowa spanned two days. It started with six hospitals across Missouri working to diagnose a person suspected to have Ebola. One of the hospitals transferred the patient to Barnes-Jewish Hospital, whose role on day two of training was to then arrange and execute transfer to the University of Iowa. The ambulance crew, from Abbott EMS, had a scheduled stop along the way so a new crew could take over, thus avoiding the need for one crew to stay in personal protective equipment for the full drive. Once the ambulance arrived at the hospital in Iowa, staff there practiced the steps required to admit the patient to the ICU.

In the event that the Barnes-Jewish Emerging Infectious Diseases Program needed to transfer an actual patient, that patient would be taken to one of two biocontainment units: the one at University of Iowa, as in the exercise, or one at University of Nebraska. In the latter case, the patient would be taken by ambulance to St. Louis Lambert International Airport, flown to Omaha by Phoenix Air and then transferred by ambulance to the biocontainment unit.

“The core purpose of our exercise and training programs,” Campbell says, “is to identify opportunities to improve, strengthen and advance the capabilities of the hospital so that, inevitably, when we do have a patient with an infectious disease, we are able to perform at the highest caliber.”

Staff members who would be mobilized as part of the Emerging Infectious Diseases Program team come from a variety of departments: the ICU, the emergency department, environmental services, public safety, infection prevention and the microbiology lab. If the patient is a child, St. Louis Children’s Hospital would provide pediatric equipment and pediatric nurses.

Charlotte Gibson, MSN, RN, a medical ICU nurse at Barnes-Jewish Hospital, is trained to provide direct patient care. “I’ve been in this program from the very beginning,” Gibson says. “I’m part of a dedicated group of nurses who are committed to helping take care of these patients.”

The plan calls for two nurses working in a patient’s room at all times, with a third in what’s known as the “doffing zone” to help those entering and exiting the patient’s room don, or put on, and doff, or take off, their equipment. As an assessment facility, Barnes-Jewish Hospital is required to be prepared to care for a patient with an emerging infectious disease for as many as five days. Given this mandate, and the fact that nurses must rotate in and out on shifts, Lederman says 18 nurses would help support one patient.

As Gibson puts it, “It takes a village.”

Preparing through partnerships

If an emerging infectious disease is identified in the St. Louis region, the responsibility of containing it and keeping the public safe would rest not just on the health care system. A network of partners across the region would play important and distinct roles in ensuring health and safety.

State and local departments of health, and city and county emergency management agencies would join with Barnes-Jewish Hospital and other health care facilities to form the St. Louis Medical Operations Center. Through resource allocation, intelligence management, staffing and coordination with other partners, the center would support any hospital caring for a person suspected of having an emerging infectious disease.

“Our external partners fill important support roles that help ensure our community and our region are successful in keeping citizens safe,” Campbell says.

Sometimes those partners may play unexpected roles. During the training exercise in May, floodwaters impeded the planned route for the ambulance crew returning to St. Louis from Iowa. The highway patrol, the Missouri Department of Transportation and the state Department of Public Safety helped coordinate a new route.

“The floodwaters had knocked down a level, and the bridge was gone, so the ambulance ended up driving through some remote back roads on the return,” Campbell says.

This type of coordination and collaboration isn’t possible everywhere in the world. In the Democratic Republic of the Congo, more than 2,500 people have been infected with Ebola since August 2018. Armed militia groups and political instability have made it difficult for health officials to control the outbreak. But more than 170,000 doses of an experimental vaccine have been distributed, an intervention Lederman believes is the one thing preventing the outbreak from escalating further.

Back in St. Louis, though, there are ongoing plans to execute, and there are more training programs and exercises to complete. Lederman says she feels good about the program she’s developed and about the region’s ability to manage Ebola and other emerging infectious diseases.

“Our program is almost completely built,” she says. “I feel like we have a good grasp on everything we need so that we’re prepared for what might happen. We’ll continue to train our staff to ensure they are comfortable with every protocol. If the day comes when we need to put our plan into action, we’ll be ready.”