MERS: Is US public health ready for another infectious disease?: Imported cases put officials on alert ====================================================================================================== * Natalie McGill When a man traveling to Indiana by two planes and a bus from Saudi Arabia became the first U.S. case of Middle East respiratory syndrome coronavirus on May 2, the nation’s public health community was hardly blindsided. Thanks to the Centers for Disease Control and Prevention, state and local health departments were aware of the disease, known as MERS, two years earlier. CDC provided information on MERS to U.S. health departments, such as Indiana’s, and state public health laboratories nationwide were able to access testing kits from CDC to test for the virus — which was later diagnosed May 11 in Orlando in another traveler returning from Saudi Arabia. ![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/44/6/1.2/F1.medium.gif) [Figure1](http://www.thenationshealth.org/content/44/6/1.2/F1) A girl wears a mask while looking out a window in Taif, Saudi Arabia, in June. Two cases of Middle East respiratory syndrome were imported to the U.S. this spring by travelers returning from Saudi Arabia, where the disease was first found in 2012. Photo by Mohamed Alhwaity, courtesy Reuters While there were only two confirmed cases of MERS in the U.S. as of early July — and both were imported — public health departments and workers are preparing for a possible larger outbreak. The disease, first reported in Saudi Arabia in 2012, has no vaccine or specific treatment, and has killed 30 percent of the people it has infected worldwide as of early July, according to CDC. There were 827 laboratory-confirmed human MERS infections and 287 related deaths worldwide as of July 4, according to the World Health Organization. CDC has been preparing for MERS to reach the U.S. for a long while, Anne Schuchat, MD, director of CDC’s National Center for Immunization and Respiratory Diseases, said during a May 2 news conference. “In this interconnected world we live in, we expected MERS-CoV to make it to the United States,” Schuchat said. “We enhanced surveillance and laboratory testing capacity in states to detect cases, we developed guidance and tools for health departments, we provided recommendations for health care inspection control and other measures to prevent disease spread.” State public health labs began preparing for a possible MERS outbreak in June 2013, said Kelly Wroblewski, MPH, MT, director of infectious disease programs for the Association of Public Health Laboratories. CDC released Food and Drug Administration-approved testing kits through an FDA emergency use authorization and kits were released to 44 state public health laboratories that had the equipment needed to analyze specimens, she said. And in states that do not have kits, arrangements were made to send specimens to either CDC or labs in neighboring states, Wroblewski said. Prior experience with pandemics, such as the H1N1 influenza virus in 2009 and severe acute respiratory syndrome in 2003, improved understanding of the process needed to get the kits authorized and approved quickly, she said. The association was able to convene laboratory alert calls so all the questions about the kits could be answered in a timely manner, she said. “Everyone was familiar with the process,” Wroblewski told *The Nation’s Health.* “Labs got the kits and got them verified for use in their labs in a relatively short period of time.” In Indiana, it was past experience with tracking diseases such as H1N1 influenza and the 2012 multistate fungal meningitis outbreak that came in handy for tracking MERS, said William VanNess II, MD, the state’s health commissioner. When the first U.S. case of MERS was confirmed in the state, an Indiana health alert network notified hospitals and local health departments. Community Hospital in Munster, Indiana, where the patient stayed, had a list of all health workers who had come in contact with the patient. Additionally, there was surge capacity from other health departments within the state to help if needed, he said. “We had great collaboration, with conference calls at least once a day,” VanNess told *The Nation’s Health*. “We also coordinated with Indiana homeland security to ensure first responders in Indiana were aware, just so they would be prepared.” Risk communication — the methods of communicating with the public during a health crisis — is one of many elements that city and county health departments need to consider when an emerging infectious disease reaches their community, said Jack Herrmann, MSEd, NCC, LMHC, senior advisor and chief of public health programs at the National Association of County and City Health Officials. Other considerations include creating a dialogue with public health and other health professionals about how to be vigilant in facing an emerging infectious disease and ensuring they have a collaborative relationship with their state and local health departments. Monitoring CDC guidance on tracking, screening and treating patients is also key. Talking to people who may have been exposed is an important public health function, and health workers are specifically trained to conduct interviews to figure out who may need life-saving treatment or further screening, Herrmann said. “It’s not like anybody can pick up the phone and start asking questions,” said Paul Etkind, DrPH, MPH, former senior director of infectious diseases at NACCHO. “There’s a skill to interviewing without overly unnerving or panicking the person you’re talking to.” NACCHO has been monitoring MERS during the past year and a half, Herrmann said. As a result, NACCHO has provided information about the emerging virus to city and county health departments to help them better prepare and understand what the implications would be when the virus made its way to the U.S. Local health departments have been looking at how they have responded to other emerging infectious diseases, such as SARS and the H1N1 flu virus, to make sure they have the capacity to deal with a MERS case, Herrmann said. NACCHO, the Association of State and Territorial Health Officials, the Association of Public Health Laboratories and the Council of State and Territorial Epidemiologists were designated as official liaisons to CDC’s Emergency Operations Center and regularly share information, said Jim Blumenstock, MA, ASTHO’s chief program officer of public health practice. “There were no surprises,” Blumenstock told *The Nation’s Health.* “There were no gaps in knowledge or information sharing. It was forward leaning and very effective. We got into a nice rhythm real soon.” As of June, neither the case in Indiana or Florida had spread to members of the patients’ households nor the health workers who treated them, CDC said. The Indiana man was cleared to leave the hospital on May 9, VanNess said. The Florida patient was discharged from the hospital, according to a May 19 statement from the state’s Department of Health. A third suspected U.S. case, linked to the Indiana patient and reported in May, turned out to be negative, CDC said. ![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/44/6/1.2/F2.medium.gif) [Figure2](http://www.thenationshealth.org/content/44/6/1.2/F2) Lab worker Shay Wilinksi works at Community Hospital in Munster, Indiana, where a patient with MERS was in isolation in May. Public health workers have been preparing for the disease to come to the U.S. since it was identified in 2012. Photo by Jim Young, courtesy Reuters ## Readiness hindered by cuts to budgets While the public health community was prepared to handle the first U.S. cases of MERS, concerns remain about whether the nation can handle a widespread outbreak. Those concerns are rooted in the fact that public health funding has taken multiple blows on federal, state and local funding levels in recent years. In particular, the Division of State and Local Readiness in CDC’s Office of Public Health Preparedness and Response has seen a decrease of $86 million since fiscal year 2010, and the Department of Health and Human Services’ Hospital Preparedness Program has lost $165 million over the same four-year period. The programs assist health departments and hospitals achieve the capacity and capabilities to handle public health emergencies such as natural disasters, acts of terrorism and infectious disease outbreaks. At the federal level, public health preparedness and response funding under CDC would be cut by $54 million under President Barack Obama’s proposed fiscal year 2015 budget. Blumenstock said that while he is pleased with the public health response to MERS, he is still concerned about the impact of the funding cuts, especially with the need to manage multiple threats at the same time, such as a foodborne disease outbreak. “Not to diminish the level of efforts, but you’re only talking about two cases that were imported from another country,” Blumenstock said. “What if we get more imported cases or there’s a strong indication that it’s being transported from person to person on our mainland? That changes the complexity of investigation and response.” Capacity at the community level is also a concern. From 2008 to 2013, more than 48,000 local health department jobs have been lost either through layoffs or attrition, according to an April NACCHO report. More than a quarter of all local health departments reported budget cuts in the current fiscal year, the report said. “In small communities, the person at the local health department working to make sure kids are vaccinated for school might also make sure restaurant food and water supplies are safe, and they can also be the person responsible for tracking MERS,” said Karl Moeller, MPA, executive director of the Campaign for Public Health Foundation. “If that health department had five or 10 people a few years ago and now they have four or five, how can they be as prepared as they were before?” For more information about MERS, visit [www.cdc.gov/coronavirus/mers/index.html](http://www.cdc.gov/coronavirus/mers/index.html). * Copyright The Nation’s Health, American Public Health Association