How the U.S. Healthcare System Would Handle Ebola
The disease is highly unlikely to spread in the U.S., in part because our hospitals are prepared.
Update September 30, 2014: The Centers for Disease Control and Prevention has said that a man currently in isolation at Texas Health Presbyterian Hospital in Dallas has the first diagnosed Ebola case in the U.S.
The man likely contracted the disease abroad, since he had recently traveled to Liberia. This story, originally published in August, shows how the U.S. healthcare system might deal with an Ebola case.
Let’s get one thing straight: You are not going to get Ebola. Donald Trump is not going to get Ebola. You are more likely to be killed by Batman, the ride. Ebola-like viruses have already breached our borders, and there were no secondary infections. There are airport workers whose job it is to identify passengers who have flu-like symptoms and quarantine them immediately. And the disease is only spread through contact with bodily fluids, so there’s little chance that even the unlucky seat-mate of the Ebola flyer would catch it.
Nevertheless, Ebola is a rare disease, and the fact that it’s both incurable and highly lethal naturally prompts morbid fascination. So let’s say there was a science-fiction scenario in which you, dear reader, were infected with this deadly hemorrhagic fever. The ways in which the American healthcare system have prepared for such a thing offer some interesting insights into infectious-disease protocols and the pharmaceutical industry.
The following is an account of what would happen if you did, in fact, come down with Ebola, according to interviews with a number of infectious disease specialists.
You wake up and feel a little weak. It’s almost like you have the flu. You stumble to the medicine cabinet and grab a thermometer. You have a fever, so you pop two Tylenols and go back to bed. The fever does not go away. You see your primary care physician, who says it looks like flu and to call her if the symptoms change.
The next day, the fever is going strong, and you feel even worse, wracked with chills and a headache. You remember that you recently butchered a West African fruit bat, for some reason. You call 911.
By the time the paramedics come, you look and feel terrible. You spew vomit as they whisk you to the ambulance. The paramedics call the local emergency room to let them know they have a suspected Ebola patient en route.
The hospital tells the ambulance to pull into a special bay. The ER personnel run out of the hospital garbed in infection-control gear—most likely consisting of fluid-impermeable gowns, gloves, masks, and face-shields. If the paramedics weren’t properly outfitted during the ambulance ride, they would be quarantined and tested for the virus. Everything you or your bodily fluids touched would be washed with bleach.
“If the symptoms look unusual, the hospital would immediately contact the infections disease personnel in the city or state they're in,” said John Auerbach, director of the Institute on Urban Health Research and Practice at Boston’s Northeastern University. (Disclosure: Auerbach is married to Atlantic magazine senior editor Corby Kummer.) “In Boston, it's Anita Barry. They'd say ‘Anita, we have a patient in here with very odd symptoms.’ Anita would tell them, ‘Okay, here's my advice to you: Immediately isolate that patient, and we want a full list of everyone who has come into contact with them.’”
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You’re wheeled on a gurney to the hospital’s special isolation unit, which has its own air-conditioning system and its own waste-disposal pipeline. The room has negative air pressure, so it doesn’t share oxygen with the rest of the hospital. This seems like overkill—Ebola isn’t transmitted by air—but it helps assuage the worries of the hospital staff. And with some medical procedures, bodily fluids can be aerosolized—blended up into tiny airborne particles—which can spread infection. Your clothes are burned.
The hospital has to take blood tests, but it doesn’t have the right tools for testing Ebola samples on-site. Four milliliters of your blood will be drawn into a plastic vial. A glass vial would be too risky, the CDC says. Specimens must be packaged in a sealable plastic bag, wrapped in an absorbent material, inserted in a secondary, leak-proof receptacle, and stuck in an outer shipping package for transport. The test comes back positive.
The isolation unit has glass walls so that hospital workers can monitor you without exposing themselves. For blood tests and IV changes, a doctor enters through an anteroom, which is equipped with a shower, where he stores his infection-prevention gear. He wears shoe covers because at this point, you are gushing diarrhea and sweat.
Health officials would interview your family and anyone else you’ve interacted with since you began to show symptoms. Your family would be isolated, likely in a similar hospital room, until their lab tests cleared them. Because you’re infected, your family might only be able to wave at you through the glass partition and talk with you through an intercom system.
Past strains of Ebola have killed 90 percent of those infected, but this one seems slightly less lethal, at just 55 percent. Still, you don’t like those odds. So far the doctors are giving you supportive care—water and antibiotics—but there’s no cure.
There are a few potential therapeutics for Ebola, but none that have cleared human trials yet. In fact, it would take weeks, if not months, for drug companies to develop any sort of reliable treatment.
“If we got some kind of an outbreak in the U.S., we're technically screwed,” said Michael Pollastri, an associate professor of chemistry, also at Northeastern University. “It doesn't work like the movies where you get a cure in three days. The thing is with these antibodies, you have to grow them up in living cells. People don’t just run out of the lab and say, ‘I have it right here! Give it to that guy!’”
You start to think maybe there’s hope for you in an experimental serum like ZMapp, the drug used to treat the missionaries Kent Brantly and Nancy Writebol, who contracted Ebola while treating patients in Liberia.
The first step would be for the hospital to appeal to the FDA for permission to be allowed to use an experimental therapy under the agency’s “compassionate use” provision. The FDA says “yes” 98 percent of the time, so this isn’t your biggest hurdle, according to Arthur Caplan, director of the division of medical ethics at NYU’s Langone Medical Center.
Unfortunately for you, though, neither the hospital nor the government decides who gets experimental treatments; the drug companies do. ZMapp, the antibody given to Brantly and Writebol, is made by a tiny California company called Mapp Biopharmaceutical Inc. It has nine employees and only a tiny amount of ZMapp. Yesterday, Bloomberg reported that Mapp is apparently sending ZMapp to West Africa, and it has now depleted its meager supply of the drug.
But let’s say there was some ZMapp left. The decision to give it to you would be the manufacturer’s.
“There's no authority to compel the company to give you anything,” Caplan said. “A company can set the terms, it can say, ‘Yep, you can have it, you just have to pay us enough money.’”
A tiny company like Mapp, Caplan said, might want to recoup its investment. Antibodies like ZMapp typically run in the tens of thousands of dollars per dose, he added. Insurance likely won’t cover it, since it’s an experimental therapy. If they ask you to pay, it’s up to you to either rake together the cash, make some beseeching media appearances, or run one hell of a Kickstarter.
“It's a measure of whether you're connected or vocal,” Caplan said. “It's not like we have a system. We don’t.”
Fortunately, Mapp Biopharmaceutical, or some other tiny pharmaceutical company, opts to give you an experimental drug for free. It arrives with a set of instructions describing how it worked when the scientists gave it to monkeys, which is the only kind of primate it’s been tested on so far. Until now, that is.
There’s no clear-cut dosage, so your doctors embark upon a strange sort of trial-and-error mission, jabbing you with syringes full of the stuff until it starts to look like you’re turning a corner. (Brantly, for example, ended up needing two doses of ZMapp.)
After a few days of hiccups—another Ebola symptom—you finally start to feel better. Several weeks after you first fell ill, you stop showing symptoms, are no longer contagious, and can be discharged.
Your doctors will want to observe you for side effects, possibly for months after the ordeal. “If the treatment destroys your liver, that’s not a cure,” Caplan said.
The effects of Ebola can linger: You might have memory problems and other health issues for up to a year after the fact.
Donald Allegra, chair of infection control at Newton Medical Center in New Jersey, said he strongly doubts there would ever be an Ebola outbreak in the U.S. But local public health officials might still be on the lookout for potential Ebola cases among Americans who have recently traveled to West Africa.
Several aid groups, including the Peace Corps, are currently repatriating Americans who were stationed in the Ebola-affected nations. According to Allegra, that means that some hospitals might soon be getting calls to the effect of, “I just got back from Liberia and I have a little fever. What should I do?"