Annotated bibliography

confidential and convenient treatment—two critical com- ponents of STI care. Therefore, it is time for state and local public health departments and health care providers to advance clinical processes and practice to fully realize the potential of EPT to address the worsening STI crisis.

Cornelius D. Jamison, MD, MSPH Tammy Chang, MD, MPH, MS

Okeoma Mmeje, MD, MPH

CONTRIBUTORS The authors contributed equally to the conceptualization, writing, and revision of the editorial, and all of the authors ap- proved the final version.

REFERENCES 1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2016. Atlanta, GA: US Department of Health and Human Services; 2017.

2. Finer LB, Zolna MR. Declines in un- intended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374(9): 843–852.

3. Centers for Disease Control and Pre- vention. Pelvic inflammatory disease (PID)—CDC fact sheet. Available at: https://www.cdc.gov/std/pid/stdfact- pid.htm. Accessed August 14, 2017.

4. Hayes R, Watson-Jones D, Celum C, van de Wijgert J, Wasserheit J. Treatment of sexually transmitted infections for HIV prevention: end of the road or new beginning? AIDS. 2010;24(suppl 4): S15–S26.

5. Owusu-Edusei K Jr, Chesson HW, Gift TL, et al. The estimated direct medical

cost of selected sexually transmitted in- fections in the United States, 2008. Sex Transm Dis. 2013;40(3):197–201.

6. Centers for Disease Control and Pre- vention. STD & HIV screening recom- mendations. Available at: https://www. cdc.gov/std/prevention/screeningreccs. htm. Accessed August 14, 2017.

7. Centers for Disease Control and Pre- vention. Expedited partner therapy in the management of sexually transmitted dis- eases. Available at: https://www.cdc.gov/ std/treatment/eptfinalreport2006.pdf. Accessed August 14, 2017.

8. Ferreira A, Young T, Mathews C, Zunza M, Low N. Strategies for partner notification for sexually transmitted infections, including HIV. Cochrane Database Syst Rev. 2013;(10): CD002843.

9. Mmeje O, Wallett S, Kolenic G, Bell J. Impact of expedited partner therapy (EPT) implementation on chlamydia

incidence in the USA. Sex Transm Infect. 2017; Epub ahead of print.

10. Ford JV, Ivankovich MB, Douglas JM Jr, et al. The need to promote sexual health in America: a new vision for public health action. Sex Transm Dis. 2017;44(10): 579–585.

11. Schillinger JA, Gorwitz R, Rietmeijer C, Golden MR. The expedited partner therapy continuum: a conceptual frame- work to guide programmatic efforts to increase partner treatment. Sex Transm Dis. 2016;43(2 supp 1):S63–S75.

12. Rosenfeld EA, Marx J,Terry MA, Stall R, Pallatino C, Miller E. Healthcare providers’ perspectives on expedited partner therapy for chlamydia: a qualita- tive study. Sex Transm Infect. 2015;91(6): 407–411.

Ebola Virus Disease Preparations Do Not Protect the United States Against Other Infectious Outbreaks

The 2014–2016 West African Ebola virus disease (EVD) epidemic took the world by surprise. While 11 patients were treated in the United States, it challenged public health, health care, and emergency response infrastructures.1

The outbreak highlighted the need for robust systems of screening and care for patients with highly hazard- ous communicable diseases (HHCDs), especially because the outbreak showed how modern travel hastens in- ternational disease spread. The May 2018 EVD out- break in the Democratic Republic of Congo rein- forces this need and demon- strates the uphill battle against emerging and reemerging diseases.

In the beginning of the 2014 outbreak, most health care facilities in the United States

were unprepared to identify, isolate, and provide care for patients who presented to their facilities with suspected EVD.1

Responding to this deficiency, the United States, led by the Assistant Secretary for Preparedness and Response and the Centers for Disease Control and Prevention (CDC), developed a tiered EVD care system that outlined the mini- mum expected capabilities for frontline hospitals, assessment hospitals, and Ebola treatment centers.2 Designated assessment hospitals and Ebola treatment centers collectively made signif- icant modifications to their facilities to enhance infection control, purchased greater quantities of personal pro- tective equipment, and en- hanced staff training.3 In addition, the Assistant Secretary for Preparedness and Response designated and funded one

hospital in each of the 10 Department of Health and Human Services regions as a regional Ebola and other special pathogens treat- ment center (RESPTC), requiring these facilities to make more upgrades than the other two tiers to receive designation as first-choice locations to provide care for patients with confirmed EVD. These efforts resulted in signifi- cant progress in our domestic capability to safely care for patients with EVD.1

CURRENT STATUS After more than three years

of efforts, and in light of the new EVD outbreak, policy- makers and the public likely expect that the United States will sustain the new capabilities that it has paid for and developed to care for patients with EVD. It is also likely they believe this infrastructure can safely be used to accommodate patients during future out- breaks of other HHCDs, such as Middle East Respiratory Syndrome and other viral hemorrhagic fevers, such as Lassa. It is true that the upgraded facilities, personal protective equipment, enhanced trainings, and disease surveillance, in tandem with updated federal guidance, bolstered funding,

ABOUT THE AUTHORS Shawn Gibbs and Aurora Le are with the Department of Environmental and Occupational Health, Indiana University School of Public Health, Bloomington. John Lowe and Jocelyn Herstein are with the Department of Environmental, Agricultural, and Occupational Health, University of Nebraska Medical Center College of Public Health, and the Nebraska Bio- containment Unit, Nebraska Medicine, Omaha. Paul Biddinger is with Massachusetts General Hospital Boston, and Harvard Medical School, Boston.

Correspondence should be sent to Shawn G. Gibbs, Indiana University School of Public Health, 1025 E Seventh St, PH 111C, Bloomington, IN 47405 (e-mail: gibbss@indiana. edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This editorial was accepted July 15, 2018. doi: 10.2105/AJPH.2018.304667

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October 2018, Vol 108, No. 10 AJPH Gibbs et al. Editorial 1327

and multisectoral collaboration, have improved our national abilities. However, there remain gaps in our nation’s ability to care for other non-EVD HHCDs such as ongoing costs and challenges associated with commonly occurring nosocomial infections that still lack robust prevention measures. Moreover, our newly developed system appears to be time-limited with sup- plemental funding mechanisms supporting these capabilities ending in 2020.

The national EVD infra- structure was created in Parts A and B of the Hospital Preparedness Program Ebola Preparedness and Response Activities, jointly funded by the Assistant Secretary for Pre- paredness and Response and the CDC.4 Part A of the funding mechanism supported “state- or jurisdiction-designated Ebola treatment centers, assessment hospitals,” as well as coalition activities, while Part B funded the development of a “regional net- work for Ebola patient care.”4(p4)

Awardees who received funds through the Part B mechanism were obligated to receive and treat up to two patients with confirmed EVD and maintain 10 beds for enhanced airborne iso- lation for care of other diseases. While grant requirements obligate the 10 RESPTCs to accept and treat confirmed patients with EVD, it is unclear if there are similar stipulations for other funded facilities. Under Part A, funds were distributed through states to the assessment hospitals and Ebola treatment centers to prepare in the event of a patient with EVD, without a clear con- tractual obligation. Ambiguity remains about whether the acceptance of these Hospital Preparedness Program funds

requires these facilities to activate for a patient with EVD or other disease and, if so, how long this obligation exists.

Programmatic activities, in- cluding development of state and regional concept of operations, were focused around the pro- vision of care for patients with confirmed EVD. Although Hospital Preparedness Program supplemental Ebola funding mechanisms Parts A and B were preparedness funds, the program language stated that,

none of the funds made available in Part A of this [funding oppor- tunity announcement] may be used to reimburse hospitals or entities for the costs associated with caring for persons under investigation for Ebola.4(p11)

This opens the question of who absorbs the cost burdens associated with treating persons under investigation or confirmed patients with another HHCD. Media estimated that the direct and indirect care costs of a sin- gle confirmed patient with EVD was in excess of $1 million5; however, there has been no public accounting of the costs of the 11 confirmed US patients with EVD, including the payee6; there is also no public record of the additional costs associated with treating US persons under investigation and expenditures associated with monitoring high-risk patients. As persons under investigation demand greater administrative controls and personal protective equip- ment usage than common infectious diseases until the HHCD is ruled out, it is likely that the costs associated with these patients are significantly greater and ab- sorbed by those health care systems.

It is uncertain to what degree this infrastructure could or would be used for patients confirmed with other HHCDs. There is no commonly accepted definition of what constitutes either a special pathogen or HHCD, contrary to the specifications regarding microorganisms existing for laboratory biosafety levels. There is also limited surge capability in the current network. With- out a clear definition of which diseases should or must be cared for within this network, in tandem with the lack of clear reimbursement mechanisms in the tiered health care facility network to evaluate persons under in- vestigation or treat patients with a HHCD other than EVD, there is a potential financial disincentive to participate in response and care for any disease other than confirmed EVD.

During the EVD outbreak, several US states issued orders they believed to be in their state’s best interest—such as blocking transportation of Category A waste through their state even though it was the most direct route from the treatment facility to the disposal facility.7 It is possible that a current network facility or state government may bar the transfer of a non-EVD patient to a RESPTC during a new HHCD outbreak or a confirmed patient with EVD once the supplemental funding mechanism expires. The justifi- cation for such a move by a state could be based upon perceived safety concerns for their com- munity or to avoid being caught absorbing the exorbitant cost of care. It remains unknown if a RESPTC or others in the tiered hospital network would be willing to receive a regional out-of-state patient, with

no guarantee of cost reimbursement.

CONCLUSIONS The tiered EVD response

network has the potential to serve as the basis for the United States to address new cases of EVD and other HHCDs. The RESPTCs, in particular, could serve as the backbone of a new regional network of centers of excel- lence that could strengthen the nation’s overall pre- paredness. The systemic issues presented herein and other critical questions must be addressed, so when this network is needed for the next HHCD outbreak, these uncertainties are not bar- riers to participation and response.

Shawn G. Gibbs, PhD, MBA, CIH

John J. Lowe, PhD Aurora B. Le, MPH, CPH Jocelyn J. Herstein, MPH Paul D. Biddinger, MD

CONTRIBUTORS All authors contributed equally to this article.

ACKNOWLEDGMENTS We acknowledge the National Institute of Environmental Health Sciences Worker Training Program Ebola Bio- safety and Infectious Disease Response Training UH4 grant UH4ES027055; although the grant funding did not contribute to this work, the program did highlight the need. We acknowledge that both Nebraska Medicine–Nebraska Medical Center and Massachusetts General Hospital were funded through US Department of Health and Human Services Hospital Preparedness Program Ebola Preparedness and Response Activities (EP-U3R-15-002); although the grant funding did not contribute to this work, the program did highlight the need.

We also thank our consortium mem- bers in the Biosafety and Infectious Disease Training Initiative at the University of

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Texas Health Science Center at Houston School of Public Health—Janelle Rios, PhD, MPH, Robert Emery, DrPH, and Scott Patlovich, PhD—and Leighton Jones, MLA at Harvard T. H. Chan School of Public Health for their partnership.

REFERENCES 1. Herstein JJ, Biddinger PD, Kraft C, et al. Current capabilities and capacity of Ebola treatment centers in the United States. Infect Control Hosp Epidemiol. 2016;37(3): 313–318.

2. Centers for Disease Control and Pre- vention. Interim guidance for US hos- pital preparedness for patients under investigation (PUIs) or with confirmed Ebola virus disease (EVD): a framework for a tiered approach. Available at: https:// www.cdc.gov/vhf/ebola/healthcare-us/ preparing/hospitals.html. Accessed February 27, 2018.

3. Herstein JJ, Biddinger PD, Kraft C, et al. Initial costs of Ebola treatment centers in the United States. Emerg Infect Dis. 2016; 22(2):350–352.

4. US Department of Health and Human Services. Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities. EP-U3R-15–002. Office of Emergency Management, Division of National Healthcare Preparedness Programs. 2015. Available at: https:// www.grants.gov/view-opportunity. html?oppId=274709. Accessed March 1, 2018.

5. Sun LH. Cost to treat Ebola in the US: $1.16 million for 2 patients. Washington Post. November 28, 2014. Available at: https://www.washingtonpost.com/ news/post-nation/wp/2014/11/18/ cost-to-treat-ebola-in-the-u-s-1-16- million-for-2-patients/?utm_term=. 2dac3c02bc37. Accessed March 1, 2018.

6. Bartsch SM, Gorham K, Lee BY. The cost of an Ebola case. Pathog Glob Health. 2015;109(1):4–9.

7. Louisiana Department of Justice. AG Caldwell seeks to block Ebola waste dis- posal in Louisiana. Available at: https:// www.ag.state.la.us/Article.aspx?articleID= 914&catID=2. Accessed March 1, 2018.

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