Table 2 Ebola virus in Dallas and New York City

Although global public health systems had been slow to respond to the first cases in West Africa earlier in the year, by September Ebola stories were prominent in the U.S. media and professional publications. In addition, the Centers for Disease Control and Prevention (CDC), state, and local health departments throughout the country alerted hospitals, which in turn distributed this information to first line providers.

On Thursday, September 25, a Liberian resident (Mr. D) visiting relatives in Dallas, Texas developed symptoms consistent with Ebola and sought care at the Texas Health Presbyterian Hospital emergency department (ED). Despite telling one of the nurses that he was from Liberia, he was sent home. On Sunday, September 28, Mr. D returned to the same hospital by ambulance, with more severe symptoms. This time he was consider a potential Ebola case and was “isolated in the ED.” Samples were not sent for testing to CDC and the Texas Department of State Health Services until Monday, and positive results were received on Tuesday, September 30, at which point a public health response was initiated. During this 4-day period, two nurses were infected with Ebola. Mr. D died on September X, and the nurses survived.

On Wednesday, October 15, Dr. S, a physician who had been treating Ebola patients in Guinea with Médecins Sans Frontières (MSF) returned home to New York City and in the following days travelled throughout the city using public transportation. On Thursday, October 23, following MSF protocols, took his own temperature and reported a low-grade fever. A few hours later he was taken by a special ambulance to an isolation ward that had been prepared Bellevue Hospital Center. Two of Dr. S’s friends were quarantined, and by that evening the Mayor, the New York City health commissioner, and others held a press conference outlining the public health response. Dr. S was treated and survived, and there were no additional cases.

It is clearly inappropriate to directly compare the two cases – an uninsured traveler from Liberia and a physician trained by MSF – and the first case is always more difficult. One can, however, examine each system’s response. Although problems with the EHR may have contributed to the failure to diagnose Mr. D’s case the first time he came to the hospital in Dallas [42], there were additional delays in taking precautions to prevent transmission to others in the hospital and in sending samples to be tested, due in part to a lack of protocols. The Texas Health Presbyterian Hospital did not act like it was part of a public health system, with responsibilities to the community as well as its patients. In New York, on the other hand, not only did MSF have protocols in place, but the Department of Health and Mental Hygiene worked with city’s hospitals to prepare as a system, including conducting “mystery patient” drills [43].