Introduction
During the 2014–2016 West Africa Ebola virus disease (EVD) epidemic, the US government designated certain US healthcare institutions as Special Pathogen Treatment Centers (SPTCs). 1 There were 56 SPTCs when they were established in 2016. Reference Herstein, Biddinger and Kraft2 At the same time, the Assistant Secretary for Preparedness and Response, later renamed to Administration for Strategic Preparedness and Response (ASPR), established the National Ebola Training and Education Center, now renamed the National Emerging Special Pathogens Training and Education Center (NETEC), a consortium of 3 healthcare institutions that treated patients with EVD in 2014: Emory University, the University of Nebraska Medical Center/Nebraska Medicine, and New York City Health and Hospitals/Bellevue Center. NETEC’s mission is to prepare US healthcare facilities to care for patients with special pathogens, including viral hemorrhagic fevers (VHF) such as EVD, Lassa fever, and Marburg virus disease (MVD). However, the number of SPTCs has fluctuated over time, with several facilities recently decommissioning their SPTC capabilities due to inadequate funding. Reference Herstein, Le and McNulty3,Reference Herstein, Biddinger and Gibbs4
Since NETEC was established, there have been multiple VHF outbreaks. In 2024, Rwanda experienced its largest MVD outbreak to date. In 2025, there have been outbreaks of MVD in Tanzania, Ebola Sudanvirus in Uganda, Lassa fever in Nigeria, Crimean–Congo hemorrhagic fever in Iraq, and Nipah virus in India. 5–11 The need to support institutional readiness for VHF within the United States was further reinforced after a patient returning from West Africa passed away from Lassa fever in Iowa in October 2024. 12
Given the lack of medical countermeasures for VHFs, the primary treatment for these illnesses with very high baseline mortality is supportive critical care. Reference Fowler, Fletcher and Fischer13 This was highlighted during the EVD outbreak in 2014, where most patients treated in the United States and Europe survived, likely because they had access to timely critical and supportive care that is not always available in resource-constrained settings. Reference Uyeki, Mehta and Davey14,Reference Spencer15 Given this, NETEC has developed numerous resources to support critical care delivery for patients with VHF. However, there remains a wide range of institutional comfort and experience with providing critical care interventions to these patients. Furthermore, there is a lack of national consensus on which interventions should be offered and when.
A 2020 prepandemic survey of SPTCs found that most were prepared to provide intubation, chest compression, and renal replacement therapy (RRT) to suspected or confirmed VHF cases but were not ready to provide interventions such as extracorporeal membranous oxygenation (ECMO) and cricothyrotomy. Reference DiLorenzo, Baker and Herstein16 Conducted in the early months of the COVID-19 pandemic, the survey provided a snapshot of SPTCs’ VHF critical care capabilities before the pandemic caused widespread impacts to the healthcare system, including healthcare worker burnout and attrition. Reference Martin, Kaminski-Ozturk, O’Hara and Smiley17 To determine if the strain from the pandemic affected SPTC capabilities to provide critical care interventions to VHF patients, the authors, several of whom contributed to the 2020 survey, developed a follow-up survey structured to mirror the 2020 survey. This study reassesses SPTC readiness for critical care interventions and examines the COVID-19 pandemic’s impact on the training, staffing, and VHF readiness strategies of facilities to provide care to a suspected or confirmed VHF case.
Methods
Study instrument
A 54-item survey was prepared using RedCap (Appendix A). The survey asked participants about institutional capabilities in 9 critical care areas: (1) RRT, (2) endotracheal intubation and mechanical ventilation, (3) ECMO, (4) chest compressions, (5) pharmacologic cardioversion, (6) electrical cardioversion, (7) defibrillation, (8) cricothyrotomy, and (9) code status. For each of these areas, participants were asked to respond to a “yes/no” question on whether their institution had a policy and to summarize their policy if one existed. They were also asked to indicate if (a) they had prior experience providing a given critical care intervention to a suspected or confirmed VHF case, (b) whether they were currently ready to provide that intervention to either a suspected and/or a confirmed VHF case and (c) if their institutional policy stated that a given intervention would not be offered to a suspected and/or a confirmed VHF case.
Participants were also asked to rate, on a 5-point Likert scale with 1 being “Does not limit care” and 5 being “Limits Care,” how much the following 5 factors influenced their ability to provide critical care to a suspected or a confirmed VHF case: (1) staff safety, (2) lack of appropriate technology, (3) lack of guidelines on how to provide care, (4) clinical futility, and (5) limitations of the physical building or ward. They were also asked about how their strategies around staffing, technology, and training for VHF preparedness had changed since the COVID-19 pandemic, and whether their institution felt more or less prepared to care for both confirmed and suspected VHF cases since December 2019.
Inclusion criteria
The survey was distributed by email to representatives from 74 different institutions that had been identified as SPTCs either through designation as a treatment center in 2014 or through their affiliation with NETEC. Reference Herstein, Biddinger and Kraft2,18 Participants could take part in the study if they were a clinician involved in an active or previously designated SPTC program and were knowledgeable about their program’s VHF treatment protocols. Each institution only submitted one response.
IRB approval and participant consent
This study was approved by the New York University Langone Health Institutional Review Board (H-38993). Consent was obtained through an introductory email that described the study goals. Participation was voluntary. If a participant chose to start the survey, they were considered to have provided consent. All responses were de-identified upon receipt.
Study period
The survey was sent on April 5, 2023, with 2 email reminders sent to identified contacts at 1-month intervals. Data collection concluded on July 18, 2023. We calculated frequencies and percentages for ordinal and categorical data pertaining to the participating centers’ characteristics and policies. For qualitative data about the participating centers’ critical care policies, perceived challenges, and innovations used to provide care, we conducted a thematic analysis to identify recurring patterns and themes. For the Likert scale analysis, responses of 4 and 5 were considered to indicate that the factor limited the facility’s ability to provide care.
Results
Respondent characteristics
Fourteen institutions (19%) completed the survey. One (7%) no longer considered itself an active SPTC, although they indicated they maintain the capability to care for a suspected or confirmed VHF case. All Health and Human Services (HHS) regions except Region 8 were represented with the most (29%, n = 4) responses coming from HHS Region 3 (Table 1). Most (57%, n = 8) individuals who completed the survey were physicians working in critical care, emergency medicine, or infectious diseases. The other respondents held roles in nursing, hospital epidemiology, and institutional administration.
Descriptive data on survey respondents (eg, clinical role, region, etc.)
Demographic information of the respondents and the institution in which they work. Note. HHS, Health and Human Services; SPTC, Special Pathogen Treatment Center; IQR, interquartile range; VHF, viral hemorrhagic fever.
Policy scope, patient experience, and institutional readiness
Most responding SPTCs were ready to provide intubation/mechanical ventilation (79%, n = 11), pharmacologic cardioversion (79%, n = 11), RRT (71%, n = 10), and defibrillation (71%, n = 10) to a confirmed VHF case (Table 2). Few were prepared to provide cricothyrotomy (36%) and ECMO (29%) to confirmed VHF patients, and fewer had specific policies around code status (14%). Institutional policy details from those that provided them (n = 10) are in Table 3.
Readiness to provide critical care interventions for confirmed adult VHF patients
Critical care capabilities that respondents were ready to provide to a confirmed adult VHF patient. Note. VHF, viral hemorrhagic fever.
Critical care policy details for suspected and confirmed VHF cases
This table displays the institutions that have hospital policies surrounding critical care interventions for VHF patients. Note. VHF, viral hemorrhagic fever; RRT, renal replacement therapy; PPE, personal protective equipment; ECMO, extracorporeal membrane oxygenation; DNR, do not resuscitate; CPR, cardiopulmonary resuscitation; RN, registered nurse; MD, doctor of medicine.
Factors influencing the provision of critical care
When determining which critical care interventions to provide to a suspected case, most (71%) institutions named staff safety, and half (50%) cited clinical futility as a factor influencing the decision (Table 4). Few institutions cited lack of appropriate technology (36%), lack of care guidelines (36%), and building/ward limitations (21%) as factors. The response rates for each factor were the same for both suspected and confirmed VHF cases, except for clinical futility, where the proportion of participants citing this as a concern increased from 50% to 64%, respectively.
Factors impacting clinical care of a VHF patient
Barriers that impact the ability of survey respondents to provide critical care to a suspected and a confirmed patient. Note. VHF, viral hemorrhagic fever.
Strategies that have changed during the COVID-19 pandemic
Six (43%) institutions cited no changes to their strategy for providing critical care to VHF patients due to the COVID-19 pandemic. Among the remaining 8 institutions, all cited changes to their training strategy, 4 cited changes to their staffing strategies, 2 changed their philosophy on resuscitating a suspected or confirmed VHF patient, and 1 changed its technology strategy.
Less than half (36%) of institutions stated that the COVID-19 pandemic positively affected their ability to care for a suspected or confirmed VHF patient. Factors contributing to this included increased awareness by hospital leadership on the importance of maintaining a diverse, well-trained special pathogens team, better understanding of staffing challenges and the impact of long-term unit activation, better awareness of personal protective equipment (PPE) utilization and donning/doffing skills, and the ability to perform surge maneuvers. Another 36% stated that the COVID-19 pandemic negatively affected their ability to provide critical care to VHF patients, citing staff attrition, PPE training burnout, and inability to maintain regular training sessions as contributing factors. The other 28% of institutions did not feel the COVID-19 pandemic impacted their institutions’ ability to care for VHF patients.
As far as preparedness to care for a suspected or confirmed VHF case, 21% of institutions felt more prepared due to increased real-world experience and a stronger culture around the importance of PPE use. In contrast, 43% of institutions felt less prepared to care for VHF patients, citing less trained staff, difficulty providing specialized VHF PPE training to staff, staff turnover, and infrequent equipment testing as factors. The remaining 36% of institutions felt there was little to no change in their preparedness since prepandemic.
Discussion
The US network of SPTCs is crucial to maintaining the nation’s special pathogen preparedness capabilities. This survey included fewer institutions than the one conducted in 2020, but several SPTCs have been decommissioned since the original survey was conducted. Reference Herstein, Biddinger and Gibbs4 As in 2020, most institutions felt comfortable providing RRT, intubation/mechanical ventilation, chest compressions, pharmacologic conversion, and electrical cardioversion to patients with VHF. Reference DiLorenzo, Baker and Herstein16 Providers continue to have less comfort and experience providing ECMO and cricothyrotomy to VHF patients. The data we found in this and our prior survey are similar to that found in a recent NETEC survey of 10 federally funded Regional Emerging Special Pathogen Treatment Centers (RESPTCs). 1 These RESPTCs were surveyed on only 3 of the policy areas queried in this survey: RRT, intubation/mechanical ventilation, and ECMO. All were able to provide RRT and intubation/mechanical ventilation to patients, while only 40% were ready to provide ECMO.
A review of the literature highlighted the benefits of a special pathogens program during the COVID-19 response. In a 2020 survey of 20 hospitals that had an onsite consultation with NETEC, 95% of institutions reported PPE shortages, but 80% were able to use their special pathogens program’s PPE to support their COVID-19 response, and 63% used their biocontainment unit to provide education to frontline staff. Reference Vasa, Pacino, Vasistha, ElRayes and Lowe19 A similar 2021 survey of SPTCs found that trained special pathogen response staff, shared developed protocols, and donated supplies improved their COVID-19 response. Reference Herstein, Biddinger and Gibbs4
However, despite these prior studies’ findings, only 36% of participants felt that COVID-19 positively impacted their ability to care for VHF patients, and only 21% felt more prepared. Several factors may explain this discrepancy in reported preparedness after the COVID-19 pandemic. First, the expertise and training required to care for a COVID-19 patient compared to a VHF patient are different, with the latter requiring more complex PPE and donning and doffing procedures. Second, the COVID-19 pandemic has led to significant burnout among healthcare workers. Although it is challenging to precisely quantify, higher rates of physicians, nurses, nurse practitioners, and physician assistants have left healthcare in the years since the pandemic started than in the years before it and are being replaced by younger staff with less experience and expertise. Reference Rotenstein, Brown, Sinsky and Linzer20,Reference Shen, Eddelbuettel and Eisenberg21 This burnout has been linked to concerns about staff safety, which in this study was cited as the most important factor when determining whether to provide care to patients with suspected or confirmed VHF. Reference Shenoy and Weber22 Furthermore, although our survey focused on the United States, global high-level isolation units are also experiencing significant staffing shortages, which will affect the management of high-consequence pathogens globally. Reference Herstein, Stern, Flinn, Garland, Lowe and Sauer23
Although the COVID-19 pandemic may have left some institutions feeling less prepared to care for VHF patients than previously reported, there are opportunities to support healthcare workers to safely provide life-saving critical care to VHF patients. Consistent training on enhanced infection prevention and control practices—particularly in practical exercises such as simulated patient drills—would help staff develop and retain the confidence to care for VHF patients. Reference Sulmonte, Flinn and Yusuf24,Reference LoPiccolo, Tennill, Guttsman, Rajagopalan and Mukherjee25 Improved communication between SPTCs and regional RESPTC(s), NETEC, ASPR, and the Centers for Disease Control and Prevention could help ensure that providers are up to date on care guidelines and are able to share lessons learned. RESPTCs in particular are tasked with supporting and maintaining VHF preparedness efforts for their region through resource sharing during both peacetime and outbreaks. For example, project ECHO, a collaborative learning platform, was used during the COVID-19 pandemic to promote real-time peer-to-peer learning. Reference Hunt, Struminger and Redd26 Similarly, RESPTCs and NETEC regularly host webinars to share information on special pathogen threats and best practices. 27–29 By improving communication between SPTCs, providers in different locations will be able to quickly learn from other institutions and tailor innovative strategies to their own setting.
As in our 2020 survey, clinical futility was still seen as a major barrier to providing clinical care to VHF patients, particularly for confirmed cases. Although there are certainly cases of VHF where providing critical care interventions would be futile and would put staff at risk, the US experience during the EVD outbreak in 2014 highlights that when patients were able to get to well-resourced institutions that could safely provide medical care—including critical care interventions such as intubation and dialysis—their survival rate was much higher than that of patients in resource-limited settings. Reference Farmer30,31 This highlights the importance of dispelling the notion that the provision of critical care to patients with VHF is futile. Enhancing the critical care capabilities of SPTCs by providing ongoing support for dedicated staff, training, and equipment will ensure that the necessary care these patients require can be safely provided and positively impact survival after VHF infection.
This study had several limitations. First, only 19% of those who received a recruitment email responded to the survey, making it difficult to draw reliable conclusions. Second, most respondents were physicians and may have a biased perception of the impact that the COVID-19 pandemic had on their program compared to someone in an administrative or leadership role. At the same time, physicians and nurses in critical care are often the most knowledgeable on their institutions’ capabilities to provide care to a VHF patient, so this may mitigate potential bias.
Conclusion
Our study found that institutions are prepared to offer many critical care interventions to patients with VHF. However, they could benefit from additional support to train and retain staff and to develop the expertise to provide other life-saving critical care interventions to VHF patients, namely ECMO. NETEC and RESPTCs strive to provide this support by creating a community to strengthen SPTCs, and this effort was further cemented when Congress directed NETEC to be the coordinating body of the National Special Pathogens System of Care (NSPS) in 2024. 32 NSPS’s goal is to institutionalize special pathogen capabilities and practices across all levels of the US healthcare system. Given that we continue to see outbreaks of VHFs and other high-consequence pathogens (mpox) globally, institutional and governmental support for SPTCs, such as the development of the NSPS network, will be crucial going forward.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ash.2025.10167
Acknowledgments
AL, RP, and VM are members of HHS Region 2 RESPTC at Bellevue Hospital, and WE, JH, and AV are members of HHS Region 7 RESPTC at the University of Nebraska Medical Center, which both receive funding from the ASPR. This collaboration was made possible thanks to the NETEC’s Special Pathogen Research Network.
Competing interests
All authors are employed at a hospital that receives the RESPTC and the NETEC grants.
MD previously held stocks in AbbVie, Amgen Inc., Becton Dickinson, Biogen Inc., Bristol Myers and Squibb, CVS Health, DaVita Inc., Elevance Health, Gilead, Henry Schein, Hologic Inc., Humana Inc., Jazz Pharmaceuticals, Laboratory Corp, Merck and Co., Quest Diagnostics, ResMed Inc., Teladoc Health, Vertex Pharmaceuticals, and West Pharmaceuticals. All this stock was sold during or prior to January 2023.
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