Initial Costs of Ebola Treatment Centers in the United States

To the Editor: The 2014–2015 outbreak of Ebola virus disease (EVD) in West Africa was unprecedented in scale and scope. During the outbreak, 11 patients with EVD were cared for in the United States (1). Safely caring for patients with suspected EVD requires specialized protocols and training for hospital staff in the use of personal protective equipment (PPE) and isolation precautions (2,3). The care of a hospitalized patient with confirmed EVD in high-level isolation units requires large specialized teams of nurses, physicians, laboratory technologists, environmental service workers, and waste management specialists, and inpatient care may continue for weeks (3,4). The staff-to-patient ratio necessary to care for a patient with EVD in high-level isolation is much higher than that in a typical intensive care unit because of the extensive PPE used and the need for partners to assist with PPE donning and doffing. 
 
In response to preparedness challenges in the United States, the Centers for Disease Control and Prevention recommended a multitiered framework of hospitals with advanced capabilities for Ebola care: frontline facilities, Ebola assessment hospitals, and Ebola treatment centers (ETCs) (2). Within this federal framework, 55 hospitals in the United States have been designated by their states as ETCs, which have the advanced capabilities required to provide medical care to patients with confirmed EVD throughout their illness (5). Although the cost of preparing these healthcare facilities to care for EVD patients was believed to be substantial (5–7), we aimed to directly survey the ETCs to determine the costs incurred to prepare their facilities to manage and treat EVD patients. 
 
In April 2015, we sent a 19-question electronic survey to all 55 ETCs, including the 3 preexisting biocontainment patient care units (Technical Appendix). Participation was voluntary, and individual responses were confidential. The survey assessed the ETCs’ general organization and the costs incurred to establish the ETC. Of the ETCs, 45 indicated interest in participating in the establishment of the United States Highly Infectious Diseases Network to establish infection control metrics and competencies for high-level patient isolation centers. The Institutional Review Board of the University of Nebraska Medical Center declared this study exempt. 
 
Of the 55 ETCs, 47 (85.5%) responded to the survey; 45/47 reported the total costs incurred to establish their ETC, and 43/47 provided a detailed assessment of costs. The 45 ETCs reporting total costs incurred a cumulative total of $53,909,701 (mean $1,197,993/ETC) to establish the ETCs (Table). The most costly activity was facility construction and modifications. Costs incurred to provide initial training for staff averaged $267,075 (range $10,000–$1,624,639). Each ETC spent $172,581 (mean per facility; range $3,000–$560,000) on other expenses not included in the 5 specified categories (Table). Examples of additional costs included computer hardware and software, nonmedical equipment, office supplies, and employee apparel. Costs and expenses allocated to specific purchases varied by region (Technical Appendix Figures 1, 2). 
 
 
 
Table 
 
Initial costs in US$ incurred by 45 Ebola treatment centers in the United States* 
 
 
 
With the exception of 3 hospitals that had preexisting biocontainment units, 52 hospitals had to undertake novel activities to prepare to care for patients with EVD, including development of plans, recruitment of facility leadership, recruitment and training of a multidisciplinary team of volunteers, and purchase of specialized supplies and equipment. The nearly $54 million in previously unbudgeted expenses was a substantial financial burden on the ETCs. Wide variations for overall expenditures and for specific types of expenditures were noted. 
 
Because 10 ETCs did not report financial data, the overall costs reported here do not fully estimate the expenses incurred by ETCs. Furthermore, these overall costs represent only the initial start-up costs of establishing ETCs and do not include the costs of ongoing maintenance such as resupplying validation reagents for the laboratory, purchasing supplies and equipment, continual training of staff, or testing the units and programs. 
 
This study had limitations. We could not validate self-reported data from the ETCs with information from expense reports. We also acknowledge that many additional hospitals undertook similar efforts to those of the designated ETCs but were not included in this survey (8). The costs incurred by public and private public health organizations also were not included. 
 
In conclusion, we have described the initial preparation costs incurred by designated ETCs in the United States. The substantial start-up costs as well as ongoing maintenance costs of EVD programs underscore the need for specialized facilities to treat EVD (9,10). A tiered nationwide network of healthcare facilities that can rapidly identify, isolate, and treat patients with EVD has been established to improve the nation’s preparedness for EVD and can serve as a valuable resource for future outbreaks of other highly infectious diseases. Ongoing resources will be needed to sustain the readiness of such a network. 
 
Technical Appendix: 
Questionnaire sent to all Ebola virus disease treatment centers in the United States, average total costs incurred in each of the 10 US Health and Human Services regions (US$), and the interquartile ranges of the distribution of costs of 45 Ebola treatment centers. 
 
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Academy (Table). Of these specimens, 12 (41%) were P1 type 1, 15 (52%) were P1 type 2a, and only 2 (7%) were P1 type 2c. A polyclonal distribution with 8 distinct MLVA types was observed, with the MLVA type M representing 11 (38%) of the identified MLVA types. Without the MPN1 marker, 3 MLVA types were observed. No macrolide resistance-associated mutation was detected, similar to what was observed in the 32 specimens collected in 2013. This finding is consistent with the low prevalence of macrolide resistance reported in northern Europe (6,7).
We report 2 outbreaks of M. pneumoniae infections that occurred in the first and last quarter of 2013 in western Russia (Smolensk region). Despite the high predominance of P1 type 1 strains reported in the recent literature (1,2,7), these 2 outbreaks, reported in semiclosed settings involved only the newly described P1 type 2c variant; 1 outbreak represented a monoclonal phenomenon. In the Smolensk region, the circulation of both type 1 and 2 strains was observed a few years before the outbreak; most of these strains were P1 type 2a variants, and only a minority were type 2c variants, suggesting that the new type 2c variant had spread throughout this region of Russia since at least 2006. In other parts of the world, a switch between type 1 and type 2 strains might be occurring. Indeed, in the United States, P1 type 1 isolates predominated before 2010 but dropped to 50% of isolates in 2013, and type 2 and type 2 variant strains increased (9). This cyclic pattern of type 1 or type 2 predominance in the population has previously been reported (10).
In conclusion, we detected no macrolide resistance in western Russia. The P1 type 2c variant spread throughout this region and can be responsible for monoclonal outbreaks. The epidemiologic monitoring of M. pneumoniae P1 types will assess the potential switch to P1 type 2 in the United States and other parts of the world and detect the possible emergence of the P1 type 2c variant. This study was supported by internal funding.  (1). Safely caring for patients with suspected EVD requires specialized protocols and training for hospital staff in the use of personal protective equipment (PPE) and isolation precautions (2,3). The care of a hospitalized patient with confirmed EVD in high-level isolation units requires large specialized teams of nurses, physicians, laboratory technologists, environmental service workers, and waste management specialists, and inpatient care may continue for weeks (3,4). The staff-to-patient ratio necessary to care for a patient with EVD in high-level isolation is much higher than that in a typical intensive care unit because of the extensive PPE used and the need for partners to assist with PPE donning and doffing.

Initial Costs of Ebola Treatment Centers in the United States
In response to preparedness challenges in the United States, the Centers for Disease Control and Prevention recommended a multitiered framework of hospitals with advanced capabilities for Ebola care: frontline facilities, Ebola assessment hospitals, and Ebola treatment centers (ETCs) (2). Within this federal framework, 55 hospitals in the United States have been designated by their states as ETCs, which have the advanced capabilities required to provide medical care to patients with confirmed EVD throughout their illness (5). Although the cost of preparing these healthcare facilities to care for EVD patients was believed to be substantial (5-7), we aimed to directly survey the ETCs to determine the costs incurred to prepare their facilities to manage and treat EVD patients.
In April 2015, we sent a 19-question electronic survey to all 55 ETCs, including the 3 preexisting biocontainment patient care units (online Technical Appendix, http:// wwwnc.cdc.gov/EID/article/22/2/15-1431-Techapp1.pdf). Participation was voluntary, and individual responses were confidential. The survey assessed the ETCs' general organization and the costs incurred to establish the ETC. Of the ETCs, 45 indicated interest in participating in the establishment of the United States Highly Infectious Diseases Network to establish infection control metrics and competencies for high-level patient isolation centers. The Institutional Review Board of the University of Nebraska Medical Center declared this study exempt.
Of the 55 ETCs, 47 (85.5%) responded to the survey; 45/47 reported the total costs incurred to establish their ETC, and 43/47 provided a detailed assessment of costs. The 45 ETCs reporting total costs incurred a cumulative total of $53,909,701 (mean $1,197,993/ETC) to establish the ETCs (Table). The most costly activity was facility construction and modifications. Costs incurred to provide initial training for staff averaged $267,075 (range $10,000-$1,624,639). Each ETC spent $172,581 (mean per facility; range $3,000-$560,000) on other expenses not included in the 5 specified categories (Table). Examples of additional costs included computer hardware and software, nonmedical equipment, office supplies, and employee apparel. Costs and expenses allocated to specific purchases varied by region (online Technical Appendix  Figures 1, 2).
With the exception of 3 hospitals that had preexisting biocontainment units, 52 hospitals had to undertake novel activities to prepare to care for patients with EVD, including development of plans, recruitment of facility leadership, recruitment and training of a multidisciplinary team of volunteers, and purchase of specialized supplies and equipment. The nearly $54 million in previously unbudgeted expenses was a substantial financial burden on the ETCs. Wide variations for overall expenditures and for specific types of expenditures were noted.
Because 10 ETCs did not report financial data, the overall costs reported here do not fully estimate the expenses incurred by ETCs. Furthermore, these overall costs represent only the initial start-up costs of establishing ETCs and do not include the costs of ongoing maintenance such as resupplying validation reagents for the laboratory, purchasing supplies and equipment, continual training of staff, or testing the units and programs.
This study had limitations. We could not validate selfreported data from the ETCs with information from expense reports. We also acknowledge that many additional hospitals undertook similar efforts to those of the designated ETCs but were not included in this survey (8). The costs incurred by public and private public health organizations also were not included.
In conclusion, we have described the initial preparation costs incurred by designated ETCs in the United States. The substantial start-up costs as well as ongoing maintenance costs of EVD programs underscore the need for specialized facilities to treat EVD (9,10). A tiered nationwide network of healthcare facilities that can rapidly identify, isolate, and treat patients with EVD has been established to improve the nation's preparedness for EVD and can serve as a valuable resource for future outbreaks of other highly infectious diseases. Ongoing resources will be needed to sustain the readiness of such a network.