Analyzing Variability in Ebola-Related Controls Applied to Returned Travelers in the United States

The Cost and Public Health System Effects of Active Monitoring and Illness Response for Ebola Virus Disease: A Case Evaluation of Georgia

In August 2014, the World Health Organization declared the Ebola virus disease epidemic in West Africa a public health emergency of international concern. After 2 imported cases of the disease were identified in the United States in autumn 2014, the Centers for Disease Control and Prevention recommended that all jurisdictions begin active monitoring of travelers at risk of developing Ebola virus disease for 21 days from the last day of a potential exposure to minimize the risk of disease transmission. Here we describe the infrastructure development, monitoring processes, total planned expenditures, and effects on the public health system in Georgia associated with active monitoring and illness response of all travelers from Ebola-affected West African countries from October 2014 to March 2016. We conducted qualitative interviews with Georgia Department of Public Health (GDPH) staff. We identified state active monitoring and illness response infrastructure investments and monitoring activities and state and federal funds spent in both areas. And, we evaluated whether active monitoring and illness response enhanced Georgia's ability to respond to future infectious disease outbreaks. Developing the infrastructure to support the monitoring and response required investment in information technology, training of public health and medical personnel, increasing laboratory capacity, and securing personal protective equipment. Estimated total expenditures were $8.25 million, with 76% spent on infrastructure and 17% on daily monitoring. The GDPH leveraged internal resources and partnerships to implement active monitoring and illness response. Infrastructure investment increased surveillance capacity, strengthened relationships between the GDPH and medical providers, and led to the creation of infectious disease transport and hospital networks. Active monitoring and illness response increased outbreak preparedness, but it warrants comparison with other possible responses to determine its overall value.

How evolutionary behavioural sciences can help us understand behaviour in a pandemic

The COVID-19 pandemic has brought science into the public eye and to the attention of governments more than ever before. Much of this attention is on work in epidemiology, virology and public health, with most behavioural advice in public health focusing squarely on 'proximate' determinants of behaviour. While epidemiological models are powerful tools to predict the spread of disease when human behaviour is stable, most do not incorporate behavioural change. The evolutionary basis of our preferences and the cultural evolutionary dynamics of our beliefs drive behavioural change, so understanding these evolutionary processes can help inform individual and government decision-making in the face of a pandemic. Lay summary: The COVID-19 pandemic has brought behavioural sciences into the public eye: Without vaccinations, stopping the spread of the virus must rely on behaviour change by limiting contact between people. On the face of it, "stop seeing people" sounds simple. In practice, this is hard. Here we outline how an evolutionary perspective on behaviour change can provide additional insights. Evolutionary theory postulates that our psychology and behaviour did not evolve to maximize our health or that of others. Instead, individuals are expected to act to maximise their inclusive fitness (i.e, spreading our genes) - which can lead to a conflict between behaviours that are in the best interests for the individual, and behaviours that stop the spread of the virus. By examining the ultimate explanations of behaviour related to pandemic-management (such as behavioural compliance and social distancing), we conclude that "good of the group" arguments and "one size fits all" policies are unlikely to encourage behaviour change over the long-term. Sustained behaviour change to keep pandemics at bay is much more likely to emerge from environmental change, so governments and policy makers may need to facilitate significant social change - such as improving life experiences for disadvantaged groups.

Raising the Yellow Flag: State Variation in Quarantine Laws

Quarantine is an important but often misused tool of public health. An effective quarantine requires a process that inspires trust in government, only punishes noncompliance, and promotes a culture of social responsibility. Accomplishing successful quarantine requires incentives and enabling factors, payments, job security, and a tiered enforcement plan. In this article, we examine the variation in state-level quarantine laws and assess the effectiveness of these laws and regulations. We find that most states allow for an individual to have a hearing (63%) and to have a voice in burial and cremation procedures (71%), yet are weak on all other individual rights measures. Only 20% of states have provisions to protect employment when an individual is under quarantine, and less than half have plans for safe and humane quarantines. Decision makers at the state and local levels must make a concerted effort to revise and update quarantine laws and regulations. Ideally, these laws and regulations should be harmonized so as to avoid confusion and disruption between states, and public health officials should work with populations to identify and address the factors that will support successful quarantines if they are ever required.

Public Health Resilience Checklist for High-Consequence Infectious Diseases-Informed by the Domestic Ebola Response in the United States

CONTEXT

The experiences of communities that responded to confirmed cases of Ebola virus disease in the United States provide a rare opportunity for collective learning to improve resilience to future high-consequence infectious disease events.

DESIGN

Key informant interviews (n = 73) were conducted between February and November 2016 with individuals who participated in Ebola virus disease planning or response in Atlanta, Georgia; Dallas, Texas; New York, New York; or Omaha, Nebraska; or had direct knowledge of response activities. Participants represented health care; local, state, and federal public health; law; local and state emergency management; academia; local and national media; individuals affected by the response; and local and state governments. Two focus groups were then conducted in New York and Dallas, and study results were vetted with an expert advisory group.

RESULTS

Participants focused on a number of important areas to improve public health resilience to high-consequence infectious disease events, including governance and leadership, communication and public trust, quarantine and the law, monitoring programs, environmental decontamination, and waste management.

CONCLUSIONS

Findings provided the basis for an evidence-informed checklist outlining specific actions for public health authorities to take to strengthen public health resilience to future high-consequence infectious disease events.

The Check and Report Ebola (CARE+) Program to Monitor Travelers for Ebola After Arrival to the United States, 2014-2016

The 2014-2016 Ebola epidemic in West Africa influenced how public health officials considered migration and emerging infectious diseases. Responding to the public's concerns, the US government introduced enhanced entry screening and post-arrival monitoring by public health authorities to reduce the risk of importation and domestic transmission of Ebola while continuing to allow travel from West Africa. This case study describes a new initiative, the Check and Report Ebola (CARE+) program that engaged travelers arriving to the United States from countries with Ebola outbreaks. The Centers for Disease Control and Prevention employed CARE ambassadors, who quickly communicated with incoming travelers and gave them practical resources to boost their participation in monitoring for Ebola. The program aimed to increase travelers' knowledge of Ebola symptoms and how to seek medical care safely, increase travelers' awareness of monitoring requirements, reduce barriers to monitoring, and increase trust in the US public health system. This program could be adapted for use in future outbreaks that involve the potential importation of disease and require the education and active engagement of travelers to participate in post-arrival monitoring.

Influencing Factors in the Development of State-Level Movement Restriction and Monitoring Policies in Response to Ebola, United States, 2014-15

During the 2014-15 domestic Ebola response, US states developed monitoring and movement restriction policies for potentially exposed individuals. We describe decision-making processes and factors in the development of these policies. Results may help health officials anticipate potential concerns and policy influencers in future infectious disease responses. Thirty individuals with knowledge of state-level Ebola policy development participated in semi-structured interviews conducted from January to May 2017. Interviewees represented 18 jurisdictions from diverse census regions, state political affiliations, and public health governance structures as well as the US Centers for Disease Control and Prevention (CDC). Limited and/or changing guidance and unique state-level public health, legal, and operational environments resulted in variation in policy responses. Federal guidance developed by the CDC was an important information source influencing state-level policy responses, as was available scientific evidence; however, other external factors, such as local events, contributing experts, political environment, public concern, news media, and the influence of neighboring states, contributed to additional variation. Improvements in timing, consistency, and communication of federal guidance for monitoring and movement restrictions at the state level-along with balanced approaches to addressing ethical concerns, scientific evidence, and public concern at the state level-are considerations for policy development for future disease responses.

Local Decision Making for Implementing Social Distancing in Response to Outbreaks

OBJECTIVES

Social distancing is the practice of restricting contact among persons to prevent the spread of infection. This study sought to (1) identify key features of preparedness and the primary concerns of local public health officials in deciding to implement social distancing measures and (2) determine whether any particular factor could explain the widespread variation among health departments in responses to past outbreaks.

METHODS

We conducted an online survey of health departments in the United States in 2015 to understand factors influencing health departments' decision making when choosing whether to implement social distancing measures. We paired survey results with data on area population demographic characteristics and analyzed them with a focus on broad trends.

RESULTS

Of 600 health departments contacted, 150 (25%) responded. Of these 150 health departments, 63 (42%) indicated that they had implemented social distancing in the past 10 years. Only 10 (7%) health departments had a line-item budget for isolation or quarantine. The most common concern about social distancing was public health impact (n = 62, 41%). Concerns about law, politics, finances, vulnerable populations, and sociocultural issues were each identified by 7% to 10% of health departments. We were unable to clearly predict which factors would influence these decisions.

CONCLUSIONS

Variations in the decision to implement social distancing are likely the result of differences in organizational authority and resources and in the primary concerns about implementing social distancing. Research and current social distancing guidelines for health departments should address these factors.

Development and Implementation of the Ebola Traveler Monitoring Program and Clinical Outcomes of Monitored Travelers during October - May 2015, Minnesota

Background

In October 2014, the United States began actively monitoring all persons who had traveled from Guinea, Liberia, and Sierra Leone in the previous 21 days. State public health departments were responsible for monitoring all travelers; Minnesota has the largest Liberian population in the United States. The MDH Ebola Clinical Team (ECT) was established to assess travelers with symptoms of concern for Ebola virus disease (EVD), coordinate access to healthcare at appropriate facilities including Ebola Assessment and Treatment Units (EATU), and provide guidance to clinicians.

Methods

Minnesota Department of Health (MDH) began receiving traveler information collected by U.S. Customs and Border Control and Centers for Disease Control and Prevention staff on October 21, 2014 via encrypted electronic communication. All travelers returning from Liberia, Sierra Leone, and Guinea during 10/21/14–5/15/15 were monitored by MDH staff in the manner recommended by CDC based on the traveler’s risk categorization as “low (but not zero)”, “some” and “high” risk. When a traveler reported symptoms or a temperature ≥100.4° F at any time during their 21-day monitoring period, an ECT member would speak to the traveler and perform a clinical assessment by telephone or via video-chat. Based on the assessment the ECT member would recommend 1) continued clinical monitoring while at home with frequent telephone follow-up by the ECT member, 2) outpatient clinical evaluation at an outpatient site agreed upon by all parties, or 3) inpatient clinical evaluation at one of four Minnesota EATUs. ECT members assessed and approved testing for Ebola virus infection at MDH. Traveler data, calls to the ECT and clinical outcomes were logged on a secure server at MDH.

Results

During 10/21/14–5/15/15, a total of 783 travelers were monitored; 729 (93%) traveled from Liberia, 30 (4%) Sierra Leone, and 24 (3%) Guinea. The median number monitored per week was 59 (range 45–143). The median age was 35 years; 136 (17%) were aged <18 years. Thirteen of 256 women of reproductive age (5%) were pregnant. The country of passport issuance was known for 720 of the travelers. The majority of monitored travelers (478 [66%]) used a non-U.S. passport including 442 (61%) Liberian nationals. A total of 772 (99%) travelers were “low (but not zero)” risk; 11 (1%) were “some” risk. Among monitored travelers, 43 (5%) experienced illness symptoms; 29 (67%) had a symptom consistent with EVD. Two were tested for Ebola virus disease and had negative results. Most frequently reported symptoms were fever (20/43, 47%) and abdominal pain (12/43, 28%). During evaluation, 16 (37%) of 43 travelers reported their symptoms began prior to travel; chronic health conditions in 24 travelers including tumors/cancer, pregnancy, and orthopedic conditions were most common. Infectious causes in 19 travelers included upper respiratory infection, malaria, and gastrointestinal infections.

Discussion

Prior to 2014, no similar active monitoring program for travelers had been performed in Minnesota; assessment and management of symptomatic travelers was a new activity for MDH. Ensuring safe entrance into healthcare was particularly challenging for children, and pregnant women, as well as those without an established connection to healthcare. Unnecessary inpatient evaluations were successfully avoided by close clinical follow-up by phone. Before similar monitoring programs are considered in the future, careful thought must be given to necessary resources and the impact on affected populations, public health, and the healthcare system.

News media coverage of U.S. Ebola policies: Implications for communication during future infectious disease threats

The Ebola outbreak of 2014-2015 raised concerns about the disease's potential spread in the U.S. and received significant news media coverage. Prior research has shown that news media coverage of policy options can influence public opinion regarding those policies, as well as public attitudes toward the broader social issues and target populations addressed by such policies. To assess news media coverage of Ebola policies, the content of U.S.-focused news stories (n=1262) published between July 1 and November 30, 2014 from 12 news sources was analyzed for 13 policy-related messages. Eight-two percent of news stories mentioned one or more policy-related messages. The most frequently appearing policy-related messages overall were those about isolation (47%) and quarantine (40%). The least frequently mentioned policy-related message described dividing potentially exposed persons into distinct groups based on their level of Ebola risk in order to set different levels of restrictions (5%). Message frequency differed depending on whether news sources were located in an area that experienced an Ebola case or controversy, by news sources' political ideological perspective, and by type of news source (print and television). All policy-related messages showed significant increases in frequency after the first case of Ebola was diagnosed in the U.S. on September 30, 2014, with the exception of messages related to isolation, which showed a significant decrease. Results offer insight into how the news media covers policies to manage emerging disease threats.

Controlling Tuberculosis in the United States: Use of Isolation and Other Measures Throughout the Country

OBJECTIVES

We sought to better understand the tools used by public health officials in the control of tuberculosis (TB).

METHODS

We conducted a series of in-depth interviews with public health officials at the local, state, and federal levels to better understand how health departments around the country use isolation measures to control TB.

RESULTS

State and local public health officials' use of social distancing tools in infection control varies widely, particularly in response to handling noncompliant patients. Judicial and community support, in addition to financial resources, impacted the incentives and enablers used to maintain isolation of infectious TB patients.

CONCLUSIONS

Instituting social distancing requires authorities and resources and can be impacted by evidentiary standards, risk assessments, political will, and community support. Awareness of these factors, as well as knowledge of state and local uses of social distancing measures, is essential to understanding what actions are most likely to be instituted during a public health emergency and to target interventions to better prepare health departments to utilize the best available tools necessary to control the spread of disease. (Disaster Med Public Health Preparedness. 2017;11:337-342).