Response to an infectious disease outbreak is greatly influenced by the governance structure of a specific municipality or state and these differences often determine lines of authority and responsibility. Across all four communities, participants noted that the response chain of command (e.g., via the Incident Command System [ICS]), with a single designated leader at each level (e.g., facility, local, state) was critically important to ensure that responders, the public, and the media knew who was in charge.

Participants stressed that senior local government officials should be prepared to play a visible role in the response even if they are not the Incident Commander. The personal relationships, influence, and understanding of available resources that these individuals can contribute to the response are invaluable. Further highlighted as an important ingredient for success was a clear understanding of relevant federal, state, and local roles that ensures the inclusion and integration of all stakeholders, including public health, in a unified cross-sectoral response effort.

Public trust is key to a successful infectious disease response, but it can be easily lost due to poor communication. Many participants noted that fear of the unknown, particularly when coupled with changing or conflicting information, may trigger unintended responses from the public. The political, social media, traditional media, and social environment in which the domestic Ebola response occurred required robust information campaigns and public outreach by trusted and influential community leaders and experts to mitigate acute fear and stigmatization of some affected populations (e.g., patients, clinical staff and their families). Participants commented that efforts to communicate transparently and build trust were important in improving the response, even if not always completely successful.

The most effective responses involved organizations and officials who had built up stores of public trust through “good neighbor” policies in advance of the event and thus could retain public confidence and receive the benefit of the doubt by the community. For instance, two of the studied facilities with biocontainment units had engaged the local community and media prior to the Ebola response and, as a result of this prior open relationship, enjoyed better support during the response.

Due to the pathology, symptomology, and epidemiology of EVD, many individuals identified as being at risk for exposure to Ebolavirus were monitored by public health for the onset of EVD symptoms and to reduce the need for quarantining these individuals. Many study participants reflected on the fact that the monitoring programs used during the domestic Ebola response required extensive resources to implement and would likely be a tremendous burden in future HCID events in which they were utilized. Although these endeavors may reduce the need for quarantine, they are time consuming and difficult, requiring the effort of many individuals who may have other responsibilities, especially during a large-scale infectious disease event. Participants noted that although funding restrictions often limit the number of staff that can be made available for monitoring and for a larger public health response, surge capacity is vital.

Successful monitoring programs require the development of a relationship between public health and the person under monitoring. Study participants noted that initial face-to-face meetings facilitated the development of trusted relationships and provided an opportunity for public health officials to explain monitoring requirements and for monitored individuals to ask questions. Although this is an appropriate and beneficial approach for successful monitoring, participants explicitly noted the incredible burden this process placed on their limited time and resources.

Some individuals under monitoring may require assistance to participate in required check-in activities. While cell phones provided to monitored individuals during the domestic Ebola response were costly—and may have been unnecessary for some—many individuals under monitoring, particularly those without a strong local network of family and friends, needed this resource to successfully report to local public health authorities. Study participants cited online systems, phone applications, video chats (e.g., Skype and FaceTime), and other technology-enabled monitoring systems as ways to reduce the workload on public health; however, these may require additional investments (e.g., purchasing or developing a system) including staff time to learn and manage the system. In addition, these mechanisms can limit intrusion on monitored individuals’ lives and provide them with a sense of greater control. Safeguards are required to ensure data security, particularly for medical data and personally identifiable information, and prevent false reporting of data by monitored individuals.

Study participants noted that monitoring programs during the domestic Ebola response required significant coordination with federal partners and neighboring jurisdictions. Travelers crossing into and between jurisdictions required local, state, and federal authorities to coordinate closely to identify monitored individuals and transfer appropriate data and responsibility. Furthermore, monitored individuals occasionally reside outside of a typical community setting (e.g., homeless and incarcerated populations), requiring coordination with a variety of non-traditional public health partners. For instance, incarcerated individuals that required monitoring posed unique challenges due to their prolonged close contact with others, potential lack of cooperation by inmates, limited on-site clinical and isolation capabilities, and requirements for patient escort (potentially including armed escort). Additionally, corrections officers have little or no training in infection control practices, and they may be unwilling to interact with monitored or symptomatic individuals. Close coordination with local EMS and healthcare facilities was also needed to facilitate transfer to appropriate medical facilities as necessary.

During the domestic Ebola response, quarantine was occasionally used in an attempt to reduce potential risks to the public. Public health laws are the foundation for quarantine and isolation orders, but these laws are complex and differ between jurisdictions.¹⁰ Participants highlighted the importance of understanding the scope and limitations as well as the processes and mechanisms for implementing and enforcing these laws prior to the onset of an event. Furthermore, careful consultation with legal experts may be required to identify potential areas for legal challenge and ensure that existing legislation will withstand legal scrutiny.

Several participants commented on the importance of due process with respect to quarantine activities and explicitly noted that caution should be taken to avoid unnecessarily infringing on individuals’ civil rights. Although public health provided a range of support services, several participants indicated that it was difficult for quarantined individuals to challenge quarantine orders expeditiously. Participants noted the need for legal expertise, both to support public officials in the implementation and enforcement of quarantine laws and policies and to ensure appropriate legal counsel is available to quarantined individuals. This counsel can protect the rights of affected individuals throughout the quarantine process and ensure they are afforded due process, including their right to challenge issued orders.

Participants also noted that scalability is a major challenge for quarantine operations. The provision of services may be manageable when overseeing the quarantine of a few individuals, but they may quickly exceed local capacity as a greater number of individuals are placed under quarantine. Study participants noted that public health officials often assumed responsibility for the care of affected individuals while in quarantine. Individuals subject to quarantine require food and drink, clothing (appropriate for varying religions and personal needs), shelter, privacy and security, the ability to communicate with family and friends, and mental health support, and they may additionally require clinical care for unrelated medical conditions, recuperation of lost wages, assistance with child/elder/pet care, and/or legal counsel.

Interviewees also indicated that the use of quarantine requires coordinated planning and response across multiple entities outside the traditional scope of public health. For instance, local law enforcement was often required to provide security, both to ensure compliance with quarantine orders and protect individuals under quarantine. Additionally, coordination with EMS and the healthcare system was also necessary in the event that a quarantined individual became symptomatic and required transport to a treatment or assessment facility.

Several study participants described the use of “voluntary” quarantine as a means of avoiding the use of mandatory quarantine orders. While this may expedite and simplify quarantine processes for public health officials and model a cooperative approach to epidemic control, some drawbacks were noted. For instance, some degree of coercion or duress may be implicit in offering individuals a choice between “voluntary” quarantine or a mandatory quarantine order. In addition, one quarantined participant noted that for an individual who consents to voluntary quarantine but later believes the quarantine to be unjust, the process by which to challenge the “voluntary” quarantine without significant stigma and public backlash is unclear.

Environmental decontamination of buildings and objects that had potentially been contaminated with Ebolavirus also proved difficult for public health during the domestic Ebola response. Participants noted that in situations where scientific evidence surrounding transmission and safety may not be clear, expenditures on decontamination can become extraordinary and the number of willing and decontamination-qualified contractors scarce. They highlighted the importance of pre-event planning, recognizing that authorities and contractors must continually seek out the authoritative guidance for different pathogens and be alert for potentially changing guidance during an event.

Many participants commented that the decision to engage in decontamination activities should be based on scientific evidence and that overly aggressive actions taken “out of an abundance of caution” can undermine science-based policies in the rest of the response. For example, private citizens and business owners may engage in additional decontamination efforts on their own, but public health and government should not take responsibility for activities that go beyond decontamination efforts supported by science.

During the domestic Ebola response, participants highlighted waste management as one of the most vexing and difficult problems to overcome. Care for patients with a HCID may potentially generate enormous amounts of hazardous sewage and solid waste. Participants noted that although hospital facilities have a primary role in determining how to manage this waste, public health may play an important role in planning for waste handling, transportation, and storage. When interstate transportation of waste was required, multiple states, the Environmental Protection Agency, and other organizations needed to be involved to coordinate response operations. In the case of the Ebola response, communicating about these plans, including hospital wastewater sanitation, with the media and the public was necessary to address public fears.