The missteps in Dallas's handling of the first Ebola case diagnosed in the United States have revealed an uncomfortable reality: state and city plans for handling the deadly virus are based on generic recommendations for everything from measles to floods, to hurricanes and dirty bombs.
Officials acknowledge they need to do more.
Reuters checks with health departments in six states and cities that have large West African communities, Philadelphia, Boston, New York City, Minnesota, New Jersey, Maryland and Rhode Island, show that they are scrambling to adapt those generic plans to Ebola.
If they are not able to stay one step ahead of any cases, then lapses that characterized Ebola patient Thomas Eric Duncan’s treatment in Dallas could recur. In the Texas case that led to unnecessary exposure to the victim.
“To think the first patients would go flawlessly are an overestimation of our systems,” said Dr. Craig Smith, medical director for infectious disease at University Hospital in Augusta, Georgia. “I would expect there would be a few stumbles.”
There is a lot to do: hospital drills, 911 emergency operator guidelines, quarantine rules, even details such as checking that plastic body bags meet the minimal thickness - 150 micrometers - recommended by the U.S. Centers for Disease Control and Prevention.
“It takes a certain amount of reverse engineering to get the plan to where it can respond to new, emerging threats,” said political scientist Chris Nelson, an expert on public health systems at Rand Corp.
While departments contacted by Reuters said they were confident they would be able to identify, treat and contain Ebola, "nobody is charged with reviewing all 2,800 departments' plans," said Jack Herrmann, chief of public health programs at the National Association of County & City Health Officials.
Among the lapses in Dallas were the hospital's failure to admit Duncan when he first went to the emergency room and told staff there of his recent arrival from Liberia, delaying his treatment by at least two crucial days. It took almost a week to clean the apartment where he stayed. And health officials briefly lost track of a homeless man who they were monitoring for Ebola symptoms.
“We're learning from what's going on in Dallas, too," said Dr. Jay Varma, a deputy commissioner at the New York City Department of Health. "We have a plan that we think is strong but we don't have the final answers to a lot of questions."
While the CDC advises states on 15 “preparedness capabilities” they need to respond to public health emergencies, the list was last evaluated in 2011 and is fairly general— “emergency operations coordination” and “information sharing”.
Local health departments have varying capabilities, preventing the CDC from crafting a single national plan, so it provides guidelines. Thus local authorities decide what is an “adequate” stockpile of protective gear, and which community and other “partners” need to be involved.
That reflects the common view that states and localities should lead health emergencies as a matter of right and responsibility, said Dr. Michael Osterholm of the University of Minnesota, an expert on infectious disease.
There is no detailed national plan or protocol for Ebola, he said, and "some states are much, much better prepared from a public health perspective to handle (an outbreak) than others."
The closest things to nationwide plans are those developed for pandemic flu and for so-called "all-hazards emergencies," said Herrmann.
Still, it would be difficult if not impossible for those preparing for a health emergency to learn separate protocols for every individual contingency.
The generic plans cover obvious needs such as calling in additional staff to handle a flood of patients. There are also less obvious needs: if schools are closed, hospitals will need to provide daycare for their workers’ children, said Jeff Levi, executive director of the private non-profit Trust for America's Health, a research and advocacy group.
Even top hospitals are learning that a plan for dealing with infectious disease outbreaks may still leave them exposed to Ebola.
Vanderbilt University Medical Center recently ran an Ebola drill with a pretend patient arriving at the emergency room, being admitted and placed in an isolation unit.
During the drill, when doctors and nurses removed gowns, masks and other protective equipment "they wanted to get out of that stuff and do it quickly," Dr. William Schaffner, chairman of the Department of Preventive Medicine, told an audience at the Woodrow Wilson International Center for Scholars on Tuesday.
Moving quickly raised the risk of accidentally touching fluids on clothes, a likely reason for infection of healthcare workers in West Africa and possibly Spain, Schaffner said. All staffers have since been instructed to remove protective gear with a partner, "to count to 10" during each step "and do it slowly."
According to National Nurses United, 76 percent of nurses surveyed say their hospital has not communicated to them any policy regarding potential admission of Ebola patients, 85 percent say their hospital has not provided education sessions where nurses can ask questions, and just over one-third say their hospital has insufficient supplies of face shields and impermeable gowns.
Dr. Leon Yeh, director of emergency medicine at Saint Francis Medical Center in Peoria, Illinois, said, "It's happened so fast we haven't drilled specifically on Ebola."
That patchiness characterizes other elements of Ebola preparedness: New York City 911 dispatchers have been asking callers with Ebola symptoms about their travel history for about a week, but in Ohio's Cuyahoga County, which includes Cleveland, they have not.
Some blame lack of funds.
The CDC’s budget for Public Health Emergency Preparedness fell from $1.1 billion in 2006 to $698 million in 2010 to $585 million last year. From 2008 to 2013, local health departments lost 48,300 jobs to layoffs and attrition, or about 15 percent. "Those job losses absolutely eroded the capabilities that would be needed if we had to deal with Ebola," said Herrmann.
In New York City, several hospitals have run drills with actors portraying Ebola patients. Nurses, doctors and lobby security guards - who might be the first people a patient encounters – are put to the test.
"It's the nitty-gritty details that we're now trying to work out," Varma said, including how to dispose of waste generated by an Ebola patient and who would provide food for people under quarantine.