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The Inside Scoop on Ebola Post-Arrival Active Monitoring: A State Perspective

Posted By Laurie Forlano, DO, MPH, Friday, December 19, 2014

Dulles International Airport in Loudoun County, Virginia just outside Washington, DC saw nearly 7 million international passengers in 2013. As one of the most highly trafficked international travel hubs in the country, Dulles became one of five major airports in October adopting new screening and monitoring procedures for Ebola Virus Disease. Practically overnight, the Virginia Department of Health had to originate new procedures and practices based on Centers for Disease Control and Prevention (CDC) guidance. In Virginia, as I’m sure is true for other states, it was important that we adapted CDC guidance to our own jurisdiction. This created a surge of new work for us. In Virginia, we are fortunate to have a unified health department—that is, our local health departments (with a few exceptions) are part of the state system. This well established, collaborative model continues to be a critical part of our planning and response.

To stand up the airport screening and post-arrival monitoring program in Virginia, a central monitoring team was developed at the state level to support the implementation of the protocols at the local level. The priority tasks related to the airport program included developing a comprehensive Virginia-specific monitoring protocol on how to handle arriving travelers, delineated by risk level. The central or “State” team in Richmond, Virginia developed protocols, forms, interview scripts, educational materials, letters, and the data management tool. In parallel, the local health department teams worked to quickly establish staffing schedules and local procedures for conducting the monitoring visits and phone calls. Local teams also worked quickly to identify local hospital partners and engage community partners who would be needed to support the planning and response, such as county government officials, local Emergency Medical Services (EMS) systems, and neighboring jurisdictions, such as Maryland and Washington, DC.

Since October 27, Virginia has handled, in one way or another, over 200 travelers who have named Virginia as their final destination. The central office team receives daily line lists via Epi-X. The line lists are divided among the respective local health departments, who then initiate daily monitoring. Local health officials communicate the 21-day protocol to the travelers, and issue an agreement letter that details the expectations of the monitoring period, and what to do if the individual becomes ill. The most important part of this program is that local staff develop relationships with these people so that communicating early signs and symptoms is efficient and easy. The data exchange between local and state health department happens weekly, in addition to any consultations during the week.

Per our local health department staff, we’ve found that travelers in general really want to be responsible, which facilitates our monitoring program and makes it a lot easier. Sometimes, we’ve even had people overseas contact us before arriving in the United States. Thankfully, the vast majority of our travelers have been in the low-risk but not zero-risk category. The number of travelers in the Virginia post-arrival monitoring program changes daily, as travelers sometimes transfer to and from other states, and there is frequent cross-border travel as many travelers live or stay in the Maryland or Washington, DC metro areas. We’ve had the opportunity to continue to work closely with Maryland and Washington, DC health departments, and it has been a powerful partnership that has helped facilitate learning for all of us along the way. Along with the monitoring program, like all other health departments across the country, we field calls for physicians who suspect Ebola among patients. Though the frequency of these calls seems to be lessening, they are complex and time-intensive consultations. We work together as a team to ensure prompt answers are given to our clinical partners in Virginia.

While obvious to most, I do believe it’s important to acknowledge that state and local health departments are charged with a host of daily tasks for other communicable diseases and reportable conditions, so there is always concern when some of our local health districts are stretched more than others. Each health district in Virginia has a dedicated epidemiologist, so Virginia is fortunate to have a strong base capacity for such a complex undertaking. With that said, some of our local health districts have been impacted more than others by the airport program. If one of the more impacted districts also simultaneously experienced a significant disease outbreak investigation, for example, our capacity to respond would indeed be stretched thin. We have thought about this and are planning to explore some creative solutions for shifting of duties, in absence of additional funding supporting the Ebola response.

Data management requires constant attention, and staff have rotating schedules to respond 24 hours a day, including weekends and holidays. The management of those numbers is what epidemiologists do best, but here in Virginia we did need to establish a dedicated monitoring team to maintain operations and send weekly reports to CDC. I think what is hardest to all of us to process is we aren’t sure for how long this will go on. As public health always does, we will rise to the task, but if I’m being completely honest, I do worry about how we will all sustain this level of intensity and volume of work.

There aren’t enough words to express how proud I am of the epidemiology teams in both our state and local offices and what they have accomplished throughout the profound changes that have happened over the last few months. Equally, it has been nothing short of a privilege to plan for this response in collaboration with our clinical partners in both domestic and international settings. Their service in the patient care realm is obviously so important, and I think the public health and epidemiology role has been complimentary to that clinical care function. Virginia’s success through the present in balancing Ebola response with other routine responsibilities stems from our teamwork, open communications, and quality staff. Engaging with the public and individual travelers, we use consistent messages and take extra care to address fears. We hope the new tools we’ve created can be applied usefully in other states. Please visit our state health department website to access resources on Ebola management. Of course, there are many additional tools available in our internal system, which we are happy to share with our peers at any time.

We’d like to thank the following additional team members: Dr. Raja’a Satouri, Deputy Director for Medical Services and Incident Commander; Katie Brewer, Assistant Director and Operations Chief; Shawn Kiernan, District Epidemiologist and technical expert; Dr. Thomas Yun, Public Health Physician - Clinical Consultation; Jessica Ong, Public Health Nurse; Lauren Earyes, Public Health Nurse; Meg Marcus, Public Health Nurse; DeAnn Ryberg, Public Health Nurse; Kris Murphy, Public Health Nurse; and Josie Gutierrez, Public Health Nurse.
Laurie Forlano, DO, MPH is the State Epidemiologist in Virginia. For more information, CSTE members can visit the CSTE page on Ebola Virus Disease.
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