Local Challenges Implementing State Policy: Evaluating the Interim Guidance for Monitoring and Movement of Persons with Potential Ebola Exposure in Southeast Texas—October-December, 2014 Joseph (Greg) Rosen Public Health Associate Office for State, Tribal, Local and Territorial Support Centers for Disease Control and Prevention PHAP/PHPS Summer Seminar June 1 – 5, 2015 Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

BACKGROUND

First Travel-Associated Ebola Case in the U.S. Confirmed on September 30, 2014 (Dallas, Texas)

 Identified risk exposure categories for arriving West African travelers  Recommended public health actions based on traveler’s risk assessment and disposition  Specified active monitoring and disposition reporting duties for all jurisdictions Texas Department of State Health Services (DSHS) Interim Guidance for Post-Arrival Active Monitoring “Guidance: Monitoring and Movement of People with Potential Exposure to Ebola Virus Disease.” Texas Department of State Health Services, November “How to Take Your Temperature.” Centers for Disease Control and Prevention, October 2014.

Key Differences: CDC and Texas Interim Guidance “Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure.” Centers for Disease Control and Prevention, October 2014.

Persons under Monitoring (PUMs) in Health Service Region 6/5 South, by County, Oct – Dec 2014 (N=76) Montgomery Harris Liberty Jefferson Galveston Brazoria Fort Bend Chambers Hardin Orange Walker Waller Austin Colorado Wharton Matagorda

PUMs in Health Service Region 6/5 South, by Date of Arrival in Texas, Oct – Dec 2014 (N=76) CDC announces enhanced entry screening for travelers from Mali Christmas Day

METHODS Courtesy of the Texas Department of State Health Services, Center for Health Statistics (Austin, TX)

Clarity & Comprehensiveness DesignInputsOutputsOutcomes Context Resources  Semi-structured key informant interviews with local health department (LHD) staff  Testimony gathered on guideline implementation at the local level  Identification of a process- evaluation model Evaluation Criteria Evaluation Measures Program Performance Indicators

RESULTS Courtesy of the Centers for Disease Control and Prevention, 2014 (Atlanta, GA)

 Confusion over appropriate media for communicating with travelers and reporting results  Ambiguity of agency responsibility in reconciling errors in traveler manifests  Conflicting recommendations from public health and local emergency management Clarity and Comprehensiveness “Twice daily temperature checks at least 6 hours apart for 21 days after departure from country. Report daily monitoring outcomes to DSHS Emerging and Acute Infectious disease branch each day.”

 DSHS regional presence to engage/support LHD monitoring activities  Rotating LHD active monitoring staff inhibited institutional memory  Home visits posed geographical and capacity- related challenges Context Recommended public health action for low-risk travelers, asymptomatic upon arrival in Texas: “Notification of LHD followed by in-home visit and risk interview within 12 hours of LHD notification” Recommended public health action for low-risk travelers, asymptomatic upon arrival in Texas: “Notification of LHD followed by in-home visit and risk interview within 12 hours of LHD notification”

Courtesy of Texas Department of State Health Services, Center for Health Statistics Context

 CDC post-arrival resources for travelers utilized inconsistently  Conducting risk assessments at airports for some/high- risk PUMs required interagency cooperation  High volume of travelers = inaccuracies in distributed traveler information Resources Recommended public health action for some/high- risk travelers, asymptomatic upon arrival in Texas: “Public health meets passenger at the airport, and retakes temperature, and interviews for risk factors.” Recommended public health action for some/high- risk travelers, asymptomatic upon arrival in Texas: “Public health meets passenger at the airport, and retakes temperature, and interviews for risk factors.”

Resources

CONCLUSIONS AND RECOMMENDATIONS Courtesy of the Texas Department of State Health Services, 2015 (Austin,TX)

 Achieved maximum (100%) participation among LHDs  Guidelines unaligned with quantity of travelers and duration of active monitoring  Resources required to implement guidelines outweighed LHD capacity  Quantitative assessment of allocated resources and program outcomes  Consultations with LHDs necessary for maximizing adherence to response guidelines  Highlights importance of routine evaluation of responses involving local implementation Summary of Findings and Implications for Practice

For more information, please contact CDC’s Office for State, Tribal, Local and Territorial Support 4770 Buford Highway NE, Mailstop E-70, Atlanta, GA Telephone: CDC-INFO ( )/TTY: The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Questions or Comments? Joseph (Greg) Rosen Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support