Glaring loophole

The glaring loophole in U.S. virus response: Human error

Mistakes already abound as health officials prepare for outbreaks across the United States.

By BRIANNA EHLEY

Even as the Trump administration and Congress prepare to direct billions of dollars to coronavirus prevention, human error remains a formidable threat to preventing the spread of the virus.

Mistakes already abound as federal, state and local public health departments scramble to prepare for outbreaks in the United States — or detect those that may already have begun.

Flaws in a test developed by the Centers for Disease Control and Prevention, coupled with initial federal rules limiting who should be tested, delayed the ability to diagnose patients. A hospitalized patient in California wasn’t initially tested for the virus for days, potentially leaving health care workers exposed. A whistleblower has alleged health workers weren’t properly protected when they met flights carrying American evacuees back from China.

A recent cluster of cases at a long-term care facility in Washington state — where six people have tested positive so far and one person has died — shows that those types of mistakes could already have allowed the virus to outpace the attempts to stop it.

Past epidemics show just how quickly human error can lead to disaster. During the Ebola outbreak in 2014, a Dallas emergency room failed to recognize an Ebola case — nearly creating a national emergency.

“Diseases surprise us,” Nancy Messonnier, director of the CDC's National Center for Immunization and Respiratory Diseases, told reporters on a recent call. “We need to be reacting to the current situation even if it differs from what we planned for.”

The United States built up public health preparedness and stockpiles for either a natural outbreak or bioterrorism after the anthrax attacks in 2001. Since then, public health experts have been tested — and gained experience — through a flu pandemic, Ebola, Zika, SARS, MERS and a few false alarms.

But the best-laid plans go awry. Every single person has to perform their given tasks flawlessly. Every system has to work. Foreign countries have to do their part and do it well. When encountering a dangerous new disease that jumped from animal to human, luck also plays a role.

The crisis response lodestar is to plan for every possible scenario — and still expect the unexpected. “These are your classic low-likelihood, high-magnitude events.” said Nirav Shah, director of Maine’s CDC. “They’re unpredictable by nature.”

But the red flags are mounting — even as the White House and administration officials are sending mixed messages about the possible severity of an eventual widespread outbreak in the United States.

Washington state over the weekend reported the country’s first two coronavirus-related deaths. Seattle and King County have reported 10 cases so far, including six people who contracted the virus in the long-term care facility. Those cases — along with possible coronavirus symptoms by dozens of patients and staff — elevated concerns that there may be an outbreak in that health center, which houses older and sicker people particularly vulnerable to the disease.

A whistleblower has accused HHS of sending workers without training or protective gear to greet people being evacuated from China and quarantined in the U.S. after possible exposure to the virus. Administration officials say they followed protocol.

The California patient who presented coronavirus symptoms wasn’t tested for an entire week because the person had no known exposure or travel history — criteria the CDC relied upon when deciding whom to test. That patient was later confirmed to be the first case of potential community spread in the U.S., possibly unknowingly exposing countless others to the virus.

CDC Director Robert Redfield told a congressional panel last week that as soon as the agency discovered the California case, it broadened the criteria for testing, allowing anyone who doctors or public health officials suspect may have the coronavirus to get the test.

A handful of cases have been diagnosed in the last few days in Washington, California, Rhode Island and Illinois. As broader testing gears up, there could be an influx of new cases — and a clearer picture of how much the disease has spread and how much public health ground was lost to the faltering start to testing.

There have been other errors. In San Diego, a woman who had been evacuated from China and hospitalized was declared free of the virus and allowed to return to the evacuees’ quarantine quarters because of a mix-up that meant her samples weren’t even tested. By the time doctors diagnosed her, she could have exposed others.

And troubles with the diagnostic tests sent to public health labs around the country have both slowed down testing of potential patients and delayed the start of broader surveillance efforts to see if the disease is already stealthily spreading.

Until state labs are up and running, the CDC has to do the testing itself, and it has limited capacity. Vice President Mike Pence on Sunday said CDC was sending out 15,000 tests to state and local health officials and that the government is working with a private contractor to distribute an additional 50,000 tests. The Association of Public Health Laboratories told POLITICO it understands there will be enough kits to test 75,000 patients by the end of the week.

Tom Frieden, who was CDC director under former President Barack Obama during the 2014 Ebola crisis, said the unpredictable nature of emergencies, mixed with the possibility for mistakes, means officials must be adaptable and be transparent when things go wrong.

“It’s very important to tell people what you know and when you know it,” Frieden told POLITICO, noting that officials must often make decisions quickly and with incomplete information.

In 2014, a Dallas hospital didn’t recognize that a man from Liberia — the epicenter of the worst Ebola outbreak on record — had symptoms of the disease. Not only did hospital staff return him to the community, exposing others and triggering panic, but their error also delayed care that might have saved his life.

In addition, two nurses in that hospital were not properly instructed on how to protect themselves and also became infected with the deadly virus, though both survived. The CDC modified its protocols and also decided to send any Ebola patients to a handful of specially equipped hospitals, rather than assume community hospitals could safely treat them.

Frieden credited the CDC — an agency that’s mostly career staff, not political appointees — with being upfront about the coronaviru challenges, including its problems with testing capacity and protocols.

“To produce hundreds of thousands of tests in a matter of days, it is not surprising this happened. I’m sure in other systems there would be a lot less openness. To admit something like that has happened, is why the CDC is widely trusted,” he said.

“In emergencies like this, one of the things that’s really important is that you base decisions on science ... with the most up-to-date information analyzed by people who understand it best,” Frieden said.

CDC’s Redfield on Thursday told a congressional panel his agency is working to address shortfalls in coronavirus testing, and was shipping new tests out to states.

Asked if he thinks states, already working overtime and stretching their resources, will be prepared to handle an influx of cases as a result of broader testing capabilities, he replied, "I think the public health community is going to be able to meet that need."

State and local health departments, meanwhile, are having to divert staff and resources to prepare for coronavirus spread in their communities.

Philip Huang, director of the Dallas County Health Department, says his staff is working overtime to prepare for all the different possibilities.

"Nothing goes perfect and we have to deal with whatever realities and different scenarios there are," he said.