It’s a Small World: Lessons from Ebola and MERS

CDC mock Ebola Treatment Unit (photo credit: Cleopatra Adedeji)

By Emma MacAllister, BSN

The most recent Ebola outbreak all began in West Africa with one 18-month-old boy in the remote village of Meliandou, Guinea. From there the outbreak exploded into a global crisis that claimed over 11,000 lives worldwide and counting. An inability to halt the virus’ spread left health officials alarmed. Yet, in the Fall of last year, experts in the United States were confident in the nation’s health system’s ability to control an outbreak if Ebola crossed our borders.  We possessed the ability, resources and technology to effectively treat the ill and stop the virus in its tracks.  This attitude proved overoptimistic.

When Eric Thomas Duncan walked into the Emergency Department at Texas Health Presbyterian Hospital in September 2014, we were not ready.  Issues with the hospital’s electronic medical records and miscommunication between staff resulted in Mr. Duncan’s discharge, placing others at risk of contracting the virus and delaying treatment that may have provided him a better chance of survival.  When Mr. Duncan was finally admitted, inadequate protocols on personal protective equipment for this particular strain resulted in the infection of two nurses.

Guinea Ebola Training Facility (photo credit: Dr. Heidi Soeters/CDC)

The United States was quick to find problem areas and apply solutions that addressed them.  The CDC responded by revising the Ebola protocols used by health care providers while the Pentagon formed a 30-person multidisciplinary team ready to consult hospitals anywhere in the country.  In addition, Texas Health Presbyterian made changes to their electronic health records, filling in the gaps that came to light during the investigation. Subsequently, no new cases appeared connected with Mr. Duncan. But what about the next big outbreak?  Could any system shortcomings, or the solutions we created, be applied to other diseases and locations?

MERS Outbreak: Frightening Similarities to Ebola and Stunning Differences

When the story behind the MERS (Middle East respiratory syndrome) outbreak in South Korea began to emerge, it sounded frustratingly familiar.  MERS, like Ebola, has no known cure and has, until recently, remained mainly isolated to a specific region of the world.  Both Ebola and MERS originated in resource-poor settings and their appearance in the United States and South Korea, both nations with strong economies and health systems, shocked many.    There was no detection of MERS in the index case upon initial examination at a hospital in Seoul just as a diagnosis of Ebola went unnoticed in Dallas.  Healthcare providers in both Seoul and Dallas did not know how to handle the illness they faced, resulting in the infection of health workers caring for the sick.  The major difference in these two incidents has been the scope of the outbreak: with no new cases since July 4th, the numbers in South Korea seem to have leveled off at 186 cases with 36 deaths.

While the two situations seem to have much in common, a deeper look into the catalysts of the MERS outbreak reveal a picture unique to this virus and the country of South Korea for which the United States’ experience could not have prepared them.  Although MERS is a less communicable disease than Ebola, two factors led to wider transmission of MERS in South Korea than Ebola in the United States. First, as a relatively new disease to humans, we are still learning about how MERS transmits, the best ways to detect it, and how to treat it.  Second, the index case in South Korea visited many hospitals before being diagnosed.  This second factor was health care providers’ unfamiliarity with the virus and was further fueled by South Korean healthcare culture where it is common for patients to network their way through many facilities before finally settling at the largest hospitals, where they believe they can get access to the best doctors.  Other cultural factors, such as the tendency for family members to stay at the hospital and perform some nursing tasks for their ill loved ones, results in extremely crowded hospital environments.  Visits to multiple facilities and crowded hospitals create the perfect storm for a virus like MERS that presents itself unassumingly with cold-like symptoms, so patients are not isolated at first despite being extremely contagious.

We need to continue to absorb knowledge As we approach the first anniversary of Ebola entering the United States, the question remains: are we truly ready to face the next great infectious disease? In many ways, the answer is a sobering no. However, examining and analyzing our past experiences will help us prepare for the unknown. New infectious diseases, for which we cannot anticipate, will continue to appear.  Ebola in the United States and MERS in South Korea was contained fairly quickly because of solid public health structures in these nations.  Yet Sierra Leone and Saudi Arabia, where the index cases acquired Ebola and MERS respectively, are just two countries among many where an inadequate public health structure has resulted in an inability to control infectious disease.  The Ebola and MERS outbreaks taught us that there is a pressing need for updated protocols and electronic medical record software on a global scale.   We need to continue to absorb knowledge from our encounters with disease and share new knowledge across borders. Our world is more interconnected than ever before, and as such, we are only as prepared as our weakest region. Global cooperation and transparency when it comes to outbreak preparedness and prevention will be the most effective way to ensure health for all.



Emma MacAllister, BSN is a 2015 graduate of the University Of Pennsylvania School Of Nursing. In addition to her nursing studies, Ms. MacAllister has completed research related to nursing responses to disaster with a focus specifically on the 2012 Hurricane Sandy and the recent Ebola epidemic.  She is beginning a staff nurse position in the Cardiac Intensive Care Unit at Massachusetts General Hospital in the Fall.

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