local challenges implementing state policy: evaluating the interim guidance for monitoring and...

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) RosenPublic Health Associate

Office for State, Tribal, Local and Territorial SupportCenters for Disease Control and Prevention

PHAP/PHPS Summer SeminarJune 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 2014 <http://texasebola.org/pdfs/1505-Monitoring-Movement.pdf>.

“How to Take Your Temperature.” Centers for Disease Control and Prevention, October 2014 <http://www.cdc.gov/vhf/ebola/pdf/care-kit.pdf>.

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 <http://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html>.

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

WallerAustin

Colorado

Wharton

Matagorda

PUMs in Health Service Region 6/5 South, by Date of Arrival in Texas, Oct – Dec 2014 (N=76)

0

5

10

15

20

25

30

Monitoring Date

Num

ber o

f Tra

vele

rs

|---------------------------November-----------------------------||-----------------------------December-----------------------------|

CDC announces e

nhanced entry

screening f

or trav

elers fro

m Mali Christmas Day

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

Clarity & Comprehensiveness

Design

Inputs

Outputs

Outcomes

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

Prog

ram

Per

form

ance

Indi

cato

rs

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”

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.”

Resources

CONCLUSIONS AND RECOMMENDATIONSCourtesy of the Texas Department of State Health Services, 2015 (Austin,TX) <http://texasebola.org/>

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 30341Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: OSTLTSfeedback@cdc.gov Web: http://www.cdc.gov/stltpublichealth

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

ypp2@cdc.gov Greg.Rosen@dshs.state.tx.us

Centers for Disease Control and Prevention

Office for State, Tribal, Local and Territorial Support