Local challenges to state policy: Evaluating the interim guidance for monitoring and movement of persons with potential Ebola Virus exposure in Southeast Texas--October-December, 2014

In October 2014, the United States Centers for Disease Control and Prevention released guidelines for monitoring travelers originating from the West African nations with active Ebolavirus disease (Ebola) transmission. Within Texas’ Houston-Galveston health region, which consists of 11 local health departments (LHDs) serving roughly 7 million inhabitants across 16 counties, at-risk travelers were identified and required active monitoring. The aim of this study is to evaluate the local implementation of the traveler monitoring program, highlighting adherence-related successes and shortcomings observed in the Houston-Galveston region.

A process-evaluation plan was developed to assess implementation of the traveler monitoring program. Program objectives and data sources, primarily health department testimony gathered from key informant interviews, informed the four evaluation measures for program delivery: (1) participation; (2) clarity and comprehensiveness; (3) context; and (4) resources. These evaluation measures were applied systematically across the program cycle elements: program design, inputs, outputs, and outcomes.

The key findings were summarized based on the four evaluation measures. (1) From October through December 2014, 76 travelers were assigned for monitoring in eight LHD jurisdictions; all LHDs participated in monitoring, yielding a 100% participation rate and meeting the desired outcome embedded in the program’s design. (2) While the guidelines specified particular LHD responsibilities involving coordination with external partners, the guidelines did not specify existing communication channels that LHDs could use to coordinate with non-public health partners, specifically commercial airlines and airport personnel, nor could it mandate compliance from these entities. (3) Due to the large influx of travelers at US airports, inaccurate traveler information was sometimes distributed, subsequently inhibiting contact between LHDs and travelers. (4) Mandated twice-daily temperature/symptom checks diverted LHD resources away from routine disease surveillance activities, particularly for LHDs with limited staff. Additionally, cell phones provided to these travelers during the initial risk assessment at US airports lacked voicemail capabilities, posing additional barriers to contacting travelers for temperature and symptom checks.

A preliminary evaluation of the traveler monitoring program demonstrated how barriers related to clarity and comprehensiveness, context, and limited resources undermined local adherence to traveler monitoring guidelines. Further examination of program delivery through systematic surveying of local health officials, as well as comparative studies with other regions and states, could provide a foundational model for coordinating high-priority public health responses at the federal, state, and local levels.