United States: Ebola Matters Of First Impression; Law Lags Behind Policy

While we turn to science and laws to guide our response to matters in the healthcare industry, the entrance of the Ebola virus into our lives here in the U.S. has challenged our abilities, both from a medical and legal perspective. We know what to do, but our abilities to respond adequately, timely and responsibly have been delayed. In some cases, the coordination of care, resources and response requires a new way of thinking and breaking down silos existing in our public health and government agencies. The U.S. houses the most skilled experts in infectious disease and prevention, as well as the capacity to respond appropriately to this new infectious threat.

The Ebola Virus

It is our responsibility, first and foremost, to ensure that accurate information is transmitted relating to the Ebola virus itself. It is most essential that we understand the epidemiology of the disease to help our clients appropriately prepare and respond.

All infectious disease experts indicate that while the Ebola virus is a serious infectious disease, it is not that hearty. According to the Centers for Disease Control and Prevention (CDC), it can be killed with bleach and hospital grade disinfectants. The virus is not airborne and can only be spread by an individual who has an active illness. Individuals are only contagious when they start showing symptoms, which include fever, muscle weakness, severe headache and (6-8 days after fever) diarrhea, vomiting, bleeding and bruising. It is only contact with bodily fluids, like blood, vomit, urine, sweat, saliva, tears, etc., that will spread the disease.

Therefore, healthcare workers are at heightened risk of transmission and the average public is not. It is our obligation to ensure this is widely understood to help contain unnecessary panic, but more importantly, focus our resources to help our healthcare workers and institutions appropriately prepare and manage the anticipated response to this virus.


Since the first patient was diagnosed and treated in Texas, several important steps have been taken to heighten the response in Texas and around the nation. The CDC has been actively updating its recommended protocols on its website since the first patient presented here in the U.S. Early identification and transfer of a patient to a higher level of care also is critical to prevent transmission of the disease. The CDC has produced an algorithm for the evaluation of a returned traveler and a checklist for patients evaluated for Ebola in the U.S., as well as information relating to caring for a suspected Ebola patient. In addition, The Joint Commission has produced several Ebola and emergency management protocols.

There are four hospitals in the U.S. that have established biocontainment units:

  • Emory Healthcare, Atlanta, Georgia
  • National Institutes of Health, Bethesda, Maryland
  • St. Patrick Hospital, Missoula, Montana
  • University of Nebraska Medical Center, Omaha, Nebraska

In addition, both Emory Healthcare and the University of Nebraska Medical Center have shared their Ebola preparedness protocols with the public and the CDC.

While all four facilities have been accessed to care for individuals diagnosed with the Ebola virus and have successfully treated these patients, it is clear that every hospital is expected to have the capacity to recognize, detect and isolate a patient. Special isolation procedures and units need to be identified and significant training of personnel must ensue. To that end, the CDC has sent what it refers to as "FAST" teams to Texas, New York, Illinois and Virginia to work with hospitals that have indicated a willingness to care for Ebola patients.

Additionally, the CDC is considering a plan aimed at creating a regional and tiered hospital approach to Ebola patient care, and several state governors and local officials have begun this undertaking. For example, the Texas governor recently identified two facilities that will serve as referral centers for the treatment of Ebola patients and has appointed a Task Force on Infectious Disease Preparedness and Response that produced specific recommendations on October 17, 2014.

Critically, the special capacity for pediatrics has been identified as a specific need. In Illinois, the mayor of Chicago, Rahm Emanuel, and the Chicago Department of Public Health announced the formation of a network of resource centers that is preparing to provide care for Ebola patients in Chicago, which includes one pediatric facility and three other adult acute care providers working together to coordinate their response and establish best practices, protocols and appropriately trained personnel.

On October 20, 2014, the CDC updated its guidelines for healthcare workers, involving recommendations for Personal Protective Equipment (PPE). The "donning and doffing" (putting the gear on and taking it off) of PPE is a critical safety component in the management of Ebola patients. One of the most confounding issues to date has been the practical concern that PPE is not widely or readily available due to a significant backlog of requests and orders. This raises the question of how can the production and purchase of PPE be expedited—especially for facilities identified as designated referral centers for suspected Ebola cases? At the time of publication, we are unaware of any official recognition of the need to expedite the purchase and processing of requests for PPE and other special supplies for facilities in cities identified as likely entry points and resource centers for Ebola patients. This situation also has worked to impede the ability of many facilities to train and drill clinical staff in the safe and effective donning and doffing of PPE.

Hospitals also have seemingly been left on their own in addressing many of the practical issues associated with managing the treatment team. For example, how to address the limitations inherent in the PPE's ability to accommodate every body type, as well as physical limitations and medical conditions that may necessitate a clinical worker's withdrawal from the treatment team. Our advice has been to ensure the health and safety of the healthcare workers, and if such safety may be compromised due to their physical or other limitations, such individuals should not be included in the first line care of Ebola patients.

Issues involving the use of medical trainees, such as residents and interns, have arisen, since they are usually present in the emergency room and around the hospital on various rotations and, in fact, may be among the first individuals to have contact with a patient. While the Accreditation Council for Graduate Medical Education (ACGME) has put out guidance expecting that such students will be properly trained and supervised, many medical schools have determined that its students and residents should not be allowed to treat Ebola patients. Thus, training for residents and interns will be important to ensure identification of the disease, even if further care in other areas of the hospital may be restricted.

Medical waste disposal is another primary concern due to the sheer volume and virulence of the waste caused by the Ebola virus. In Texas, the U.S. Department of Transportation (DOT) worked with state and local officials in granting special waivers for the packaging, transport and disposal of medical waste (including sheets, towels, curtains, PPE and other things that do not typically fall within a Category A type waste stream). The U.S. Department of Health and Human Services (HHS) has acknowledged this issue and on a recent hospital preparedness call held by the Assistant Secretary for Preparedness and Response at HHS, the DOT indicated that it has since worked with several waste carriers across the country, Stericycle, Veolia as well as the CDC, to develop a waste packaging system and non-site-specific waiver to transport accumulated waste from anywhere in the country. The DOT's Pipeline and Hazardous Materials Safety Administration has posted a safety advisory notice and guidance to its website that prescribes best practices on packaging suspected Ebola contaminated waste.

Quarantine Laws

Most prominently, the legal issues of quarantine have arisen for the first time in many years. The ability of the state and federal government to protect the general health and welfare of its citizens comes into conflict with our notion of personal liberties. This will be an issue we will hear and see more of as various state legislatures convene and the medical community works to contain the virus.

Each state has its own set of quarantine laws, the rights and powers of which also differ by state. While a majority of states authorize quarantine by the department of health, others empower the public health officer to order quarantine or require a judicial order from the courts. Although many states have worked to update their public health laws, they have lagged behind with quarantine laws, some of which may date back more than 100 years. Inconsistencies between state public health and quarantine laws will become more obvious as a greater number of states confront the issue of healthcare workers returning from West Africa. One approach, and a vehicle that already exists, is the Model State Emergency Health Powers Act, which was proposed as a state standard for comprehensive public health quarantine and emergency powers laws.

The federal government has the authority to issue quarantine under certain circumstances identified in the Public Health Services Act. Such authority exists under the Commerce Clause of the U.S. Constitution and focuses on the prevention of the introduction of communicable diseases from foreign countries and transmission between states, if the state response is found to be insufficient. The role of the CDC is a direct relation to this power and the interplay between federal and state quarantine authority has been the subject of daily reports in the press.

In Texas, the state health department had the authority to issue quarantine, known as a "control order," applicable to individuals and property since the first patient presented to the emergency room in Dallas. The state's Health and Human Services commissioner chose not to issue the control order initially, electing first to allow individuals to self-monitor. Many have criticized this action. In fact, to date, governors in New York, New Jersey and Illinois have more readily used their state's quarantine authority after the experience in Dallas. The quarantine of healthcare workers and individuals suspected of carrying the disease will be governed by the quarantine laws of each state.

The Texas Task Force on Infectious Disease Preparedness and Response in its recommendations, indicated that these quarantine laws be improved and strengthened to allow authorized enforcement of the control orders. Currently, Texas control order authority does not allow the commissioner the authority to enforce the order via law enforcement if the individual leaves the designated premises and moves into the public domain. Thus, the issues of personal freedom vs. public health once again are thrust into the limelight and likely will be debated in legislatures across the U.S.

For now, we are limited by our laws and the judgment of public health authorities in state and local government to ensure that we practically produce and disseminate capital, intellectual, medical and hard asset resources to allow our hospitals, physicians, nurses and facilities experts to help quell this disease in the U.S. and export our knowledge in a more robust way to those countries more seriously impacted.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

In association with
Related Video
Up-coming Events Search
Font Size:
Mondaq on Twitter
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
Email Address
Company Name
Confirm Password
Mondaq Topics -- Select your Interests
 Law Performance
 Law Practice
 Media & IT
 Real Estate
 Wealth Mgt
Asia Pacific
European Union
Latin America
Middle East
United States
Worldwide Updates
Mondaq Ltd requires you to register and provide information that personally identifies you, including what sort of information you are interested in, for three primary purposes:
  • To allow you to personalize the Mondaq websites you are visiting.
  • To enable features such as password reminder, newsletter alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our information providers who provide information free for your use.
  • Mondaq (and its affiliate sites) do not sell or provide your details to third parties other than information providers. The reason we provide our information providers with this information is so that they can measure the response their articles are receiving and provide you with information about their products and services.
    If you do not want us to provide your name and email address you may opt out by clicking here
    If you do not wish to receive any future announcements of products and services offered by Mondaq you may opt out by clicking here

    Terms & Conditions and Privacy Statement

    Mondaq.com (the Website) is owned and managed by Mondaq Ltd and as a user you are granted a non-exclusive, revocable license to access the Website under its terms and conditions of use. Your use of the Website constitutes your agreement to the following terms and conditions of use. Mondaq Ltd may terminate your use of the Website if you are in breach of these terms and conditions or if Mondaq Ltd decides to terminate your license of use for whatever reason.

    Use of www.mondaq.com

    You may use the Website but are required to register as a user if you wish to read the full text of the content and articles available (the Content). You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these terms & conditions or with the prior written consent of Mondaq Ltd. You may not use electronic or other means to extract details or information about Mondaq.com’s content, users or contributors in order to offer them any services or products which compete directly or indirectly with Mondaq Ltd’s services and products.


    Mondaq Ltd and/or its respective suppliers make no representations about the suitability of the information contained in the documents and related graphics published on this server for any purpose. All such documents and related graphics are provided "as is" without warranty of any kind. Mondaq Ltd and/or its respective suppliers hereby disclaim all warranties and conditions with regard to this information, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. In no event shall Mondaq Ltd and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of information available from this server.

    The documents and related graphics published on this server could include technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Mondaq Ltd and/or its respective suppliers may make improvements and/or changes in the product(s) and/or the program(s) described herein at any time.


    Mondaq Ltd requires you to register and provide information that personally identifies you, including what sort of information you are interested in, for three primary purposes:

    • To allow you to personalize the Mondaq websites you are visiting.
    • To enable features such as password reminder, newsletter alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
    • To produce demographic feedback for our information providers who provide information free for your use.

    Mondaq (and its affiliate sites) do not sell or provide your details to third parties other than information providers. The reason we provide our information providers with this information is so that they can measure the response their articles are receiving and provide you with information about their products and services.

    Information Collection and Use

    We require site users to register with Mondaq (and its affiliate sites) to view the free information on the site. We also collect information from our users at several different points on the websites: this is so that we can customise the sites according to individual usage, provide 'session-aware' functionality, and ensure that content is acquired and developed appropriately. This gives us an overall picture of our user profiles, which in turn shows to our Editorial Contributors the type of person they are reaching by posting articles on Mondaq (and its affiliate sites) – meaning more free content for registered users.

    We are only able to provide the material on the Mondaq (and its affiliate sites) site free to site visitors because we can pass on information about the pages that users are viewing and the personal information users provide to us (e.g. email addresses) to reputable contributing firms such as law firms who author those pages. We do not sell or rent information to anyone else other than the authors of those pages, who may change from time to time. Should you wish us not to disclose your details to any of these parties, please tick the box above or tick the box marked "Opt out of Registration Information Disclosure" on the Your Profile page. We and our author organisations may only contact you via email or other means if you allow us to do so. Users can opt out of contact when they register on the site, or send an email to unsubscribe@mondaq.com with “no disclosure” in the subject heading

    Mondaq News Alerts

    In order to receive Mondaq News Alerts, users have to complete a separate registration form. This is a personalised service where users choose regions and topics of interest and we send it only to those users who have requested it. Users can stop receiving these Alerts by going to the Mondaq News Alerts page and deselecting all interest areas. In the same way users can amend their personal preferences to add or remove subject areas.


    A cookie is a small text file written to a user’s hard drive that contains an identifying user number. The cookies do not contain any personal information about users. We use the cookie so users do not have to log in every time they use the service and the cookie will automatically expire if you do not visit the Mondaq website (or its affiliate sites) for 12 months. We also use the cookie to personalise a user's experience of the site (for example to show information specific to a user's region). As the Mondaq sites are fully personalised and cookies are essential to its core technology the site will function unpredictably with browsers that do not support cookies - or where cookies are disabled (in these circumstances we advise you to attempt to locate the information you require elsewhere on the web). However if you are concerned about the presence of a Mondaq cookie on your machine you can also choose to expire the cookie immediately (remove it) by selecting the 'Log Off' menu option as the last thing you do when you use the site.

    Some of our business partners may use cookies on our site (for example, advertisers). However, we have no access to or control over these cookies and we are not aware of any at present that do so.

    Log Files

    We use IP addresses to analyse trends, administer the site, track movement, and gather broad demographic information for aggregate use. IP addresses are not linked to personally identifiable information.


    This web site contains links to other sites. Please be aware that Mondaq (or its affiliate sites) are not responsible for the privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of these third party sites. This privacy statement applies solely to information collected by this Web site.

    Surveys & Contests

    From time-to-time our site requests information from users via surveys or contests. Participation in these surveys or contests is completely voluntary and the user therefore has a choice whether or not to disclose any information requested. Information requested may include contact information (such as name and delivery address), and demographic information (such as postcode, age level). Contact information will be used to notify the winners and award prizes. Survey information will be used for purposes of monitoring or improving the functionality of the site.


    If a user elects to use our referral service for informing a friend about our site, we ask them for the friend’s name and email address. Mondaq stores this information and may contact the friend to invite them to register with Mondaq, but they will not be contacted more than once. The friend may contact Mondaq to request the removal of this information from our database.


    From time to time Mondaq may send you emails promoting Mondaq services including new services. You may opt out of receiving such emails by clicking below.

    *** If you do not wish to receive any future announcements of services offered by Mondaq you may opt out by clicking here .


    This website takes every reasonable precaution to protect our users’ information. When users submit sensitive information via the website, your information is protected using firewalls and other security technology. If you have any questions about the security at our website, you can send an email to webmaster@mondaq.com.

    Correcting/Updating Personal Information

    If a user’s personally identifiable information changes (such as postcode), or if a user no longer desires our service, we will endeavour to provide a way to correct, update or remove that user’s personal data provided to us. This can usually be done at the “Your Profile” page or by sending an email to EditorialAdvisor@mondaq.com.

    Notification of Changes

    If we decide to change our Terms & Conditions or Privacy Policy, we will post those changes on our site so our users are always aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. If at any point we decide to use personally identifiable information in a manner different from that stated at the time it was collected, we will notify users by way of an email. Users will have a choice as to whether or not we use their information in this different manner. We will use information in accordance with the privacy policy under which the information was collected.

    How to contact Mondaq

    You can contact us with comments or queries at enquiries@mondaq.com.

    If for some reason you believe Mondaq Ltd. has not adhered to these principles, please notify us by e-mail at problems@mondaq.com and we will use commercially reasonable efforts to determine and correct the problem promptly.

    By clicking Register you state you have read and agree to our Terms and Conditions