Arriving at the isolation ward of a biocontainment hospital is an anxious and frightening experience. In 2014, I spent 19 days in this room while being treated for Ebola, watching the news flash around me as the world faded to a small window, a phone, and a few health care providers in protective gear who entered the room each day.
More than a dozen Americans are currently living that way in a quarantine facility in Nebraska. Passengers aboard the MV Hondius, a cruise ship at the center of a small but fruitful outbreak of hantavirus in the Andes.
Although the plight of passengers has captured our attention, I am not worried that this outbreak will become the next pandemic. The virus does not spread well and, like Ebola, kills too many hosts to move efficiently.
But this episode has already shown us where our ability to respond to new threats excels and where we fall short.
Let’s start with what worked. Because it’s a part of the story that most Americans don’t know. The Nebraska biocontainment unit currently housing returning passengers is a Level 1 Regional Emerging Special Pathogen Treatment Center (RESPTC), the top of a national network purpose-built for moments like this.
The facility itself is over 20 years old. After the 2014 Ebola outbreak, the United States expanded it to be more comprehensive. The National Special Pathogen Treatment System (NSPS) is a tiered network of hospitals across the country, from highly specialized RESPTCs that can care for patients with the most dangerous pathogens throughout their illness, to Level 3 assessment centers that can identify, isolate, and arrange transportation. Coordinating all of this is the National Emerging and Special Pathogens Training and Education Center (NETEC), which sets clinical standards, conducts training, and keeps the network ready.
Key takeaways from WHO briefing on hantavirus cruise ship outbreak
The network has survived three administrations and changing political winds. This is a rare American success story in public health. It’s what we built when we were scared, sustained when we weren’t, and it’s still working as designed.
NETEC is not the only long-term investment in the United States that has achieved results during the current outbreak. The South African National Institute of Infectious Diseases used next-generation metagenomic sequencing to identify Andean hantavirus within 24 hours of receiving the sample. The virus is not endemic to South Africa and was not the first suspect in the outbreak of respiratory infections on board the ship.
This speed is made possible by specialized capabilities built over decades of U.S. investment. Much of that investment was made through PEPFAR and the CDC’s Global Disease Detection Program, which helped strengthen the country’s genomic surveillance infrastructure.
The World Health Organization has also proven itself to be an outlier. Last weekend, the cruise ship docked on land in the Canary Islands to evacuate the remaining passengers on board, coordinating across six countries, communicating directly with the international community and carrying out a low-key logistics operation that turned chaos into containment. If ever we needed another timely reminder of why the WHO is valuable to national biosecurity, this is it.
Despite these bright spots, the outbreak clearly reveals the impact of the complete dismantling of much of the nation’s preparedness infrastructure over the past year. Normally, the United States would be two steps ahead of an outbreak like this. In fact, it feels like we’re two weeks behind.
Let’s start with surveillance: All of the U.S. Agency for International Development programs and their staff that supported much of the infrastructure that underwrites U.S. investments to detect disease threats before they reach our country have been dismantled or defunded.
Most Americans don’t know that in 2023, CDC-trained community health workers in Tanzania identified an outbreak of Marburg disease (a filovirus in the same family as Ebola) early enough to prevent it from spreading widely. That’s what these foreign investments have given us. Outbreaks can be contained from the beginning, before they even board a ship or plane.
Research has suffered a similar blow. The United States has cut hundreds of millions of dollars from mRNA vaccine research, hampering the best platform to quickly create countermeasures against new pathogens and cancers.
And last year, the NIH cut funding supporting one of the few U.S. labs studying Andean hantaviruses. While this cut probably wouldn’t have changed the trajectory of this trend, its symbolism is hard to miss.
The CDC, America’s premier agency created to respond to threats like hantavirus, has been hollowed out, along with its research and global footprint. Up to a quarter of CDC staff disappeared. Epidemic intelligence agents (the “disease detectives” typically dispatched to events like this one) have spent the past year unsure whether they will be fired or rehired. Most CDC center director positions are vacant or filled by new people filling the role. The directorship of the National Center for Emerging and Zoonotic Diseases, the specific center that leads the CDC’s hantavirus response, is among those with a new acting director.
CDC has been without a permanent director for 15 of the past 17 months. And for Jay Bhattacharyya, acting director of the CDC, who is also director of the NIH, this workload would be too much for humans to handle, and certainly not while a new hantavirus population is moving across continents.
This tension is evident in how it is communicated, or in some cases not at all, to an anxious American public.
The CDC did not issue Health Alert Network notices to American clinicians until late last week, an unprecedented and significant delay for health care providers who need to know what to look for. The Department of Health and Human Services tweeted that one of the passengers brought back to the United States for observation had a “mild positive” PCR test, a phrase that reflects either an incomplete understanding of the science or a struggle to communicate clearly when clarity is most important.
I fight against misinformation online. False claims about hantavirus follow a now-familiar strategy
This work is difficult. On a good day, I feel humbled. Doing so without the necessary dedicated resources and leadership will be even more difficult.
And the most important detail is that CDC staff will now need approval to work with the WHO, a lengthy bureaucratic process. Bhattacharyya said in an interview with CBS News that no approval was needed, but workers at the site disagree. They told me that in this outbreak, this has limited the agency’s ability to quickly share epidemiological data, coordinate with WHO technical leaders, and deploy personnel through standard multinational response channels.
It would be mind-boggling that American experts would have to find workarounds just to do the basic task of interacting with a world organization that the United States itself helped establish. No matter what anyone thinks about the broader politics surrounding the WHO, its operational consequences are that we are on the back burner in events that we were supposed to help direct.
There is a way back, and there is no need for a complete change in the government’s stance. That requires some clear commitment.
Even if the Trump administration declines to rejoin the WHO (a position it has reiterated in recent days), it should ensure that the CDC can work with the WHO without permission. Operational engagement should not be a political favor but a fundamental function of an adequate disease response.
The White House also needs to strengthen the Office of Pandemic Preparedness and Response Policy (OPPR). Established in 2022 by order of Congress as a central hub for the pandemic response, it supports interdepartmental coordination and led the U.S. response to multiple infectious disease outbreaks. But the office is now virtually empty and without a leader. The administration should appoint a director who demonstrates that it is serious about responding to similar threats and provide the necessary resources to carry out the agency’s mission.
The same goes for institutions that can assist with coordination. Rebuilding the CDC is about more than just restoring personnel. That means stable leadership at all levels, a clear mandate for EIS personnel to investigate and deploy as threats emerge, both domestically and internationally, and the operational independence of experts to do what someone emailed me this week:
Similar consideration is urgently needed for the research pipeline for medical countermeasures. HHS’s decision last August to terminate 22 mRNA vaccine development contracts, which terminated nearly $500 million in research funding in a single announcement, should be reconsidered. For hantaviruses, a pathogen for which there is no approved treatment or vaccine, the mRNA platform offers the quickest response. Abandoning that infrastructure will greatly slow down the next new threat when it arrives.
Similarly, our partnerships abroad need to be restructured on terms acceptable to other countries. Bilateral health care agreements that the United States has promoted are being rejected by countries that were once American partners, citing legitimate concerns about lopsided demands. Zambia, Zimbabwe and Ghana rejected the deal with the US, citing unacceptable demands over access to sensitive medical data. If we cannot work with countries where these viruses are occurring, we will continue to be in the dark.
It’s hard not to view all of this through the lens of the coronavirus, the pandemic that brought many Americans home on cruise ships six years ago. Some of the nation’s first coronavirus patients were taken to the same Nebraska facility where passengers from the MV Hondius are currently being held. The anger and fatigue brought on by the pandemic are part of the reason we allowed so much infrastructure to be destroyed.
Spread of hantavirus infections on cruise ships is a warning sign for the US
But the lesson of the coronavirus was never that public health doesn’t work. That meant public health was difficult.
I often think about my own 19 days and the people of Nebraska today. They did not expect to become the epicenter of the outbreak. They were looking forward to a vacation with cameras tracking birds on a remote island in the Atlantic Ocean. But now the cameras are on them again. Pathogens don’t respect the walls we pretend to exist between ourselves and the rest of the world. They take every plane, every cruise ship, every border.
The Americans in the Nebraska unit are isolated and frightened. They are also the beneficiaries, consciously or not, of decisions made a decade ago to build and maintain things that weren’t particularly urgent in that day. That choice is part of what keeps this epidemic alive. If this virus gets worse, continued efforts like this will be the only thing that can avert another catastrophe.
Hantavirus is likely to disappear from the media and public eye in the coming weeks. However, the extent to which this outbreak has revealed our ability to respond and our immense susceptibility to a more powerful and devastating virus will remain. We learned that lesson once. We don’t have to learn it again.
Craig Spencer is a public health professor and emergency medicine physician at Brown University.
