CDC employees Chastity Walker, right, and Alyse Finkel analyze Ebola details in the Emergency Operations Center in Atlanta.(Photo: David Tulis for USA TODAY)
ATLANTA — As Thomas Eric Duncan's family mourns the USA's first Ebola death in Dallas, one question reverberates over a series of apparent missteps in the case: Who is in charge of the response to Ebola?
The answer seems to be — there really isn't one person or agency. There is not a single national response.
The Atlanta-based Centers for Disease Control and Prevention has emerged as the standard-bearer — and sometimes the scapegoat — on Ebola.
Public health is the purview of the states, and as the nation anticipates more Ebola cases, some experts say the way the United States handles public health is not up to the challenge.
"One of the things we have to understand is the federal, state and local public health relationships," says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. "Public health is inherently a state issue. The state really is in charge of public health at the state and local level. It's a constitutional issue. The CDC can't just walk in on these cases. They have to be invited in."
The CDC deployed a team of 10 — three senior epidemiologists, a communication officer, a public health adviser and five epidemic intelligence officers, or "disease detectives" — to Dallas on the night of Sept. 30, hours after the agency announced that Duncan, a Liberian national who traveled to Dallas, had the Ebola virus. The next afternoon, Dallas County Judge Clay Jenkins, head of the Dallas County Office of Homeland Security and Emergency Management; CDC director Tom Frieden; and David Lakey, commissioner of the Texas Department of State Health Services, agreed during a conference call to set up an Emergency Operations Center in Dallas County with Jenkins in charge.
The EOC was staffed by officials from Dallas County, the city of Dallas, the CDC, the county and state health departments and the Dallas County Sheriff's Department, among others.
This was the team that made decisions on matters such as isolating people who had been in direct contact with Duncan, including his fiancée, Louise Troh, her teenage son and two other male relatives. Because they were not sick, they couldn't technically be quarantined, Jenkins said Friday. Instead, Lakey issued a "control order" to keep them at home, where they could be monitored for signs of Ebola. Jenkins and Texas Gov. Rick Perry agreed to the order.
Texas officials were criticized for keeping the family inside the apartment where Duncan first showed signs of the disease, potentially exposing them to the virus. The family worried about Duncan's soiled sheets and other waste in the apartment. The response team located a private home where the family could move and got permits to clean the apartment and truck 140 55-gallon barrels of waste to an incinerator 400 miles away.
Jenkins says he has a working model for how to respond to Ebola cases. Others aren't so confident.
"In Texas, they really were slow to the plate," said Robert Murphy, director of the Center for Global Health at Northwestern University Feinberg School of Medicine. "Texas is going to be the example of what not to do."
Duncan, who arrived in Dallas on Sept. 20, somehow slipped through a Liberian airport screening process that allowed him into the country. He became ill several days later and went to the emergency room at Texas Health Presbyterian hospital Sept. 26.
According to medical records provided to the Associated Press by Duncan's family, his temperature spiked at 103 degrees during that visit. Duncan told a nurse that he had recently been in Africa, and he showed symptoms that can indicate Ebola: fever, sharp headache and abdominal pain. He was given a battery of tests and sent to his sister's apartment with antibiotics. He returned by ambulance Sept. 28, was admitted to the hospital and placed in isolation. On Sept. 30, the CDC confirmed that he had Ebola.
CDC workers analyze Ebola details in the CDC's Emergency Operations Center in Atlanta.(Photo: David Tulis for USA TODAY)
In a statement Friday, the hospital said it had made procedural changes and continues to "review and evaluate" decisions surrounding Duncan's case.
Murphy says some of the issues in Texas stem from a "system problem" in the way public health care is managed in the USA. The Centers for Disease Control provides only guidance for infection prevention and management. "What they do in Texas, what they do in Illinois, it's up to the state," he says.
"The question is, who's in charge?" Murphy says. "The states can follow all the guidelines and take the advice, which they usually do, but they don't have to. It's not a legal requirement. So there really is no one entity that's controlling things."
Though the CDC is tasked with readying the nation for an Ebola outbreak, then leading the national response, the Department of Homeland Security is responsible for protecting the borders, according to Thomas Skinner, a spokesman for the CDC, which is under the auspices of the Department of Health and Human Services.
The CDC collaborates with health departments and laboratories around the USA to make sure they are able to test for Ebola and respond rapidly if there is a case in their state, CDC spokeswoman Kirsten Nordlund said.
The agency is working to educate U.S. health care workers on how to isolate patients and protect themselves from infection; it developed a Web-based document that identifies rapidly emerging CDC guidelines for Ebola applicable to public health preparedness national standards for state and local planning.
The agency developed an introductory training course for licensed clinicians who intend to work in Ebola treatment units in Africa, and at any given time, it has 300-500 people working at CDC headquarters to support its Ebola response, Nordlund said.
Homeland Security "is focused on protecting the air traveling public and is taking steps to ensure that passengers with communicable diseases like Ebola are screened, isolated and quickly and safely referred to medical personnel," deputy secretary Alejandro Mayorkas said Thursday.
That includes issuing "do not board" orders to airlines if the CDC and State Department determine a passenger is a risk to the traveling public; providing information and guidance about Ebola to the airlines; posting notices at airports to raise awareness about Ebola; and providing a health notice called a care sheet to travelers entering the USA that have traveled from or through affected countries.
In addition, Health and Human Services has the authority to suspend the entry of persons into the USA based on outbreaks of disease in other countries and when necessary to protect public health.
Screening started Saturday at New York's John F. Kennedy airport. Medical workers will take the temperature of airline passengers originating from Guinea, Liberia and Sierra Leone, and Customs and Border Protection staffers will ask questions about their health and possible exposure to Ebola. Those suspected of possible Ebola exposure will be referred to a CDC public health officer for additional screening.
The testing will expand in the next few days to four more airports: Washington Dulles, Newark, Chicago's O'Hare and Atlanta's Hartsfield-Jackson airports.
Osterholm and Murphy say the nation's public health system leaves room for a broad array of Ebola responses from state to state.
"We have to have more clarity," Osterholm says. "We have to have a level of excellence. If that means putting the CDC in charge of these departments of public health, that means we have to find a way to do that. We can have agreements (between the states and the CDC). ... We can't leave it up to the whims of the state to do it right or not do it right."
He acknowledges that no one has called for such a change.
"Not yet," he says. "But we need it, though. Texas was an example of how not to do it."
Contributing: Rick Jervis in Dallas, Gregory Korte
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