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      Centers for Disease Control and Prevention’s Temporary Epidemiology Field Assignee program: Supporting state and local preparedness in the wake of Ebola

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          Abstract

          Objectives:

          The Centers for Disease Control and Prevention launched the Temporary Epidemiology Field Assignee (TEFA) Program to help state and local jurisdictions respond to the risk of Ebola virus importation during the 2014–2016 Ebola Outbreak in West Africa. We describe steps taken to launch the 2-year program, its outcomes and lessons learned.

          Methods:

          State and local health departments submitted proposals for a TEFA to strengthen local capacity in four key public health preparedness areas: 1) epidemiology and surveillance, 2) health systems preparedness, 3) health communications, and 4) incident management. TEFAs and jurisdictions were selected through a competitive process. Descriptions of TEFA activities in their quarterly reports were reviewed to select illustrative examples for each preparedness area.

          Results:

          Eleven TEFAs began in the fall of 2015, assigned to 7 states, 2 cities, 1 county and the District of Columbia. TEFAs strengthened epidemiologic capacity, investigating routine and major outbreaks in addition to implementing event-based and syndromic surveillance systems. They supported improvements in health communications, strengthened healthcare coalitions, and enhanced collaboration between local epidemiology and emergency preparedness units. Several TEFAs deployed to United States territories for the 2016 Zika Outbreak response.

          Conclusion:

          TEFAs made important contributions to their jurisdictions’ preparedness. We believe the TEFA model can be a significant component of a national strategy for surging state and local capacity in future high-consequence events.

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          Ebola Virus Disease Cluster in the United States — Dallas County, Texas, 2014

          Since March 10, 2014, Guinea, Liberia, and Sierra Leone have experienced the largest known Ebola virus disease (Ebola) epidemic with approximately 13,000 persons infected as of October 28, 2014 (1,2). Before September 25, 2014, only four patients with Ebola had been treated in the United States; all of these patients had been diagnosed in West Africa and medically evacuated to the United States for care. On September 25, a man aged 45 years (patient 1), who had arrived in the United States from Liberia 5 days earlier, went to a Dallas County, Texas, emergency department with fever, initially 100.1°F (38.4°C) but increased to 102.9°F (39.4°C), abdominal pain, and headache (Figure). He was treated for possible sinusitis and discharged. On September 28, the man returned to the hospital by ambulance with persistent fever (101.4°F [38.6°C]), abdominal pain, and new onset diarrhea; he was placed in a private room under standard, droplet and contact precautions and was tested for Ebola. On September 30, real-time polymerase chain reaction (PCR) testing at the Texas Department of State Health Services and CDC confirmed that patient 1 was positive for Ebola virus, and this represented the first imported Ebola virus infection diagnosed in the United States. A CDC team arrived in Dallas later that night by invitation from the Texas Department of State Health Services to assist with its investigation. The objectives were to 1) identify potentially exposed contacts of the Ebola patient, 2) initiate monitoring of contacts, 3) review plans for triaging and testing suspected Ebola patients, and 4) review infection control practices. Initial tracing of potentially exposed contacts (i.e., “contact tracing”) identified 48 close, unprotected contacts (i.e., had exposure to the patient, a potentially contaminated environment, or patient specimens without minimum recommended personal protective equipment [PPE]). Of the 48 contacts, 17 were persons within the community with exposure to the patient before he was admitted to the hospital and while he was symptomatic, 10 were persons who had been transported in the same ambulance that had transported the patient before it was completely cleaned and disinfected, and 21 were health care workers (HCWs) with potential exposures to body fluid without the protection of complete PPE. Beginning October 1, all 48 contacts underwent direct active monitoring (one in-person and one telephone follow-up per day to check for fever or symptoms of Ebola) for 21 days (the upper limit of the Ebola incubation period) from their last exposure date; six close community contacts were quarantined. Patient 1 died on October 8. On October 11, a nurse (patient 2) previously involved in direct care of patient 1 developed fever (100.6°F [38.1°C]) and sore throat; she was confirmed to have Ebola by real-time PCR later that day. On October 14, a second nurse (patient 3) with similar exposure had a fever (100.5°F [38.1°C]) and rash and was confirmed to have Ebola by real-time PCR on October 15. Before her diagnosis, patient 3 had visited Ohio during October 10–13 (3). Contact tracing of patients 2 and 3 identified three household contacts of the two patients. Additional community contacts of patient 3 were identified from the Ohio visit and have been described (3). Because patients 2 and 3 had used PPE during their care of patient 1 without reported exposures, all HCWs with any contact with any of the three Ebola patients, their laboratory specimens, or potentially contaminated environmental surfaces were interviewed beginning on the morning of October 12. All 147 HCW contacts of any of the patients, irrespective of PPE use, were actively monitored from October 12 until 21 days from their last exposure to an Ebola patient; those HCWs who had ever been in any of the three patients’ rooms were instructed not to use any long-distance and local public conveyances, and those who had ever been in patient 1’s room were additionally instructed not to attend mass gatherings (e.g., religious services). A subset of 20 HCWs volunteered to quarantine themselves. In addition to contact tracing and monitoring, the Dallas Ebola investigation team 1) conducted technical consultations with five Dallas area hospitals to assist them in planning for providing care for confirmed Ebola patients; 2) established an emergency medical services transportation plan for known or suspected Ebola patients; 3) developed a plan for safely handling Ebola patient remains; 4) established capacity for PCR Ebola testing to be conducted at the Dallas County public health laboratory; 5) trained 160 HCWs on PPE use (e.g., proper selection and supervised donning and doffing) and infection control practices appropriate for caring for Ebola patients; and 6) helped establish a triage unit for evaluating contacts with symptoms compatible with Ebola. During this investigation, CDC developed new infection control guidance* and new guidance for assessing the risk of potential Ebola exposure.† By November 7, all 177 contacts of patients 1, 2, and 3 (some persons were contacts of more than one patient) completed 21 days of monitoring. In addition to patients 2 and 3, 12 persons who had contact with one or more of the Ebola patients were tested for Ebola after they developed fever or other symptoms potentially compatible with the disease during their monitoring period. Active monitoring aided in the prompt identification and evaluation of these contacts. None of those evaluated were found to have Ebola. The Dallas Ebola cluster highlights many important issues that might be encountered by other jurisdictions in which an Ebola diagnosis is made locally, and for which jurisdictions should plan, including the need to 1) identify patients with Ebola at presentation to minimize potential exposures, 2) rapidly identify contacts of Ebola patients and evaluate their level of exposure risk, 3) monitor potentially large numbers of community and health care contacts, 4) assess infection control practices and conduct large-scale training sessions, 5) develop protocols to safely transport suspected Ebola patients to hospitals and safely evaluate these patients within a hospital, and 6) designate facilities to care for patients with confirmed Ebola.§
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              Ebola Virus Disease in a Humanitarian Aid Worker — New York City, October 2014

              In late October 2014, Ebola virus disease (Ebola) was diagnosed in a humanitarian aid worker who recently returned from West Africa to New York City (NYC). The NYC Department of Health and Mental Hygiene (DOHMH) actively monitored three close contacts of the patient and 114 health care personnel. No secondary cases of Ebola were detected. In collaboration with local and state partners, DOHMH had developed protocols to respond to such an event beginning in July 2014 (1). These protocols included safely transporting a person at the first report of symptoms to a local hospital prepared to treat a patient with Ebola, laboratory testing for Ebola, and monitoring of contacts. In response to this single case of Ebola, initial health care worker active monitoring protocols needed modification to improve clarity about what types of exposure should be monitored. The response costs were high in both human resources and money: DOHMH alone spent $4.3 million. However, preparedness activities that include planning and practice in effectively monitoring the health of workers involved in Ebola patient care can help prevent transmission of Ebola. On October 23, 2014, NYC DOHMH was notified by Médecins Sans Frontières (MSF) that one of its physicians who had returned to NYC nine days earlier from treating Ebola patients in Guinea had an oral temperature of 100.3°F (37.9º C). The physician reported fatigue for 2 days without other symptoms (e.g., vomiting, diarrhea, cough, muscle aches, or abnormal bleeding). He reported having used prescribed personal protective equipment without a known breach and following MSF’s protocol of twice daily oral temperature checks and self-monitoring for symptoms since his return to the United States. Because of his travel and work history and symptoms consistent with Ebola, DOHMH arranged for immediate transfer by the Fire Department of New York Emergency Medical Services (FDNY-EMS) to Bellevue Hospital Center, a medical facility designated by the DOHMH and the NYC Health and Hospitals Corporation (HHC) to treat Ebola patients in NYC. DOHMH’s laboratory performed nucleic acid amplification testing on blood from the patient, and within 3 hours of specimen receipt, reported a preliminary positive result for Ebola virus on October 23; this result was confirmed at CDC on October 24. DOHMH investigators used the date of reported onset of fatigue (October 21) to set the initial time of exposure for potential contacts. This was a decision based on knowledge about how the disease might present and an attempt to not miss any persons who might have been exposed. After interviewing the patient about his movements and contacts, DOHMH investigators identified three persons with close (i.e., direct physical) contact. Contact A was a member of the patient’s household, and contacts B and C had intermittent close contact during varying time periods after October 21. All three contacts were interviewed, evaluated for symptoms, and, under orders from DOHMH, required initial home confinement and direct active monitoring of oral temperature and symptoms. This included a daily face-to-face visit between the close contact and a DOHMH or vendor staff member, followed by a second daily face-to-face visit or telephone call. After additional evaluation and assessment, contacts B and C were released from home confinement after 10 and 12 days, respectively. Contact A was released from home confinement after 19 days. All three contacts completed direct active monitoring by DOHMH for 21 days (2); none developed signs or symptoms suggestive of Ebola. The patient was hospitalized at Bellevue Hospital Center from October 23–November 11 but released from the isolation unit on November 10 after clinical improvement and two nucleic acid amplification tests of blood for Ebola virus had negative results. DOHMH actively monitored 114 health care personnel based on three criteria: direct patient care responsibilities, entry into the patient’s room, and handling of non-decontaminated laboratory specimens. Monitored personnel included seven FDNY-EMS workers, one from the DOHMH laboratory, and 106 at Bellevue Hospital Center. The 106 hospital workers included clinical (38), laboratory (42), environmental management (22), transport (3), and support (1) staff members. All 114 personnel reported using appropriate personal protective equipment without any known breach and were categorized as low (but not zero) risk as directed by CDC guidance of October, 2014 (2). Symptoms and twice-daily oral temperatures were reported every day by telephone to DOHMH for 21 days; no movement or work restrictions were imposed. No secondary cases of Ebola were detected among these 114 health care worker contacts. No other cases of Ebola were reported in NYC in the 42 days (two incubation periods) after the patient was first identified. Discussion In response to the Ebola epidemic in West Africa, in July 2014 DOHMH began preparation for the potential arrival of imported Ebola cases with enhanced preparedness and interagency collaboration. This included enhancing surveillance to rapidly recognize and respond to a report of a patient meeting the CDC clinical and risk factor criteria for a person under investigation (3); working with hospitals to prepare to evaluate any returning traveler with symptoms consistent with Ebola; deploying the U.S. Department of Defense-developed Ebola virus assay at DOHMH’s laboratory as part of CDC’s Laboratory Response Network; and providing 24-hour per day testing, specimen packaging, and transport services (1). Initial interagency collaboration focused on streamlining preparedness activities. The FDNY-EMS established protocols for responding to emergency telephone (911) calls involving persons with illness and a history of recent travel to an Ebola-affected country, and worked with HHC and DOHMH to perform triage on such persons. The FDNY-EMS and DOHMH also worked with John F. Kennedy International Airport Border Health Station and the Port Authority of New York and New Jersey to prepare for potentially ill travelers. After New York City designated Bellevue as a hospital to manage a patient with Ebola, HHC worked with the hospital to prepare the isolation unit and develop staffing plans for safely treating such patients. DOHMH responded to HHC drills to test and practice safe triage of persons under investigation. The Office of the Chief Medical Examiner, a division of DOHMH, developed procedures for handling the body of a person under investigation or with Ebola. On October 3, 2014, in response to the Ebola case identified in Texas in late September 2014 (4), DOHMH activated its incident command system. The goals of incident command system activation were to 1) enhance interagency coordination and accelerate planning for health care system readiness; 2) quarantine and actively monitor close contacts of an Ebola case; 3) manage waste; and 4) conduct public outreach in NYC. DOHMH collaborated with the New York State Department of Health to assess and support the readiness of three Ebola treatment centers in NYC in addition to Bellevue. DOHMH also provided outreach to support rapid identification and isolation of persons under investigation at emergency departments and other ambulatory facilities. After the Ebola case was diagnosed in NYC on October 23, DOHMH identified contractors for disposal of medical and non-medical waste and worked with the New York State Department of Health and CDC to refine policies for identifying and monitoring people at risk for Ebola. What is already known on this topic? Because Ebola virus disease (Ebola) has potential to spread and has a high case-fatality rate, early identification and isolation of cases is essential. To prepare for a potential Ebola case, New York City (NYC) worked to enhance public health preparedness and interagency coordination. What is added by this report? The first U.S. case of Ebola diagnosed in a returning humanitarian aid worker was detected in NYC in October, 2014. Three persons who had direct contact with the patient and 114 health care workers required active monitoring. This monitoring was difficult because protocols had not been finalized prior to the identification of the case. No other persons having contact with the patient developed signs or symptoms of Ebola during the monitoring periods. No other cases of Ebola were reported in NYC in the 42 days after the patient was identified. What are the implications for public health practice? Interagency preparedness can help to safely and efficiently isolate and diagnose Ebola cases. Public health response to Ebola is likely to be resource intensive. Even as the West Africa Ebola epidemic subsides, it is important for public health agencies to maintain preparedness for other potential imported disease threats. The public health response to the first case of Ebola in NYC highlighted the importance of collaboration. First, DOHMH and MSF had an established protocol for MSF to contact DOHMH when an MSF worker in NYC met the criteria for a person under investigation, and MSF required its employees to self-monitor and report an elevated body temperature or symptoms immediately. Second, beginning in August 2014, FDNY-EMS and HHC (including Bellevue) developed protocols and conducted drills on their own and with DOHMH, which permitted a person under investigation to be safely and quickly transported from home to the hospital. FDNY-EMS committed to transport of these patients only by personnel who had extensive training and experience in hazardous (chemical, biological, nuclear) materials response and had received additional training to safely and efficiently provide pre-hospital care for an Ebola patient. Third, protocols for packing, transporting, and testing specimens for Ebola virus were established among the receiving hospital, DOHMH’s laboratory, and CDC, permitting timely and efficient diagnosis. Finally, DOHMH increased public outreach efforts and, by October 31, had participated in 34 community events, contacted more than 160 West African organizations, sent community outreach teams to neighborhoods to disseminate accurate information on Ebola transmission and symptoms, and distributed 51,000 informational cards. Despite planning and collaboration, a number of challenges remained. Creating clear and implementable criteria for health care worker monitoring based on a worker’s tasks or entry into specific zones was difficult. Persons entering the patient care room clearly required monitoring according to CDC Movement and Monitoring guidance (2). However, it was difficult to decide whether others, such as laboratory staff or waste handlers, also required monitoring. For example, “performing laboratory work” as a criterion for monitoring evolved as DOHMH and HHC discussed the exact laboratory work performed. Subsequently, workers performing laboratory work on decontaminated specimens did not require monitoring. Instituting an effective monitoring system that included timely and clear transmission of data between DOHMH and the hospital also proved difficult. Establishing protocols for workers to report oral temperatures and any symptoms to the call center took several days, and some workers had to be reminded to call DOHMH. As monitoring procedures became clearer and more efficient, worker compliance with reporting improved. Data management for worker monitoring initially required more than 12 full-time staff members of DOHMH and HHC, and managing data flow between the two agencies required close communication. Finally, there was insufficient planning on what instructions to give workers who required active monitoring if they planned to travel outside of NYC while being monitored, especially in the context of evolving local, state, federal, and international policies on movement restrictions for persons in contact with Ebola patients. In NYC, the public health response to one Ebola case was resource intensive for a local health department, with participation of more than 500 DOHMH staff members and expenditures of more than $4,300,000 in DOHMH funds. These figures include not only the direct costs of the local public health response (e.g., contact tracing, environmental issues, and health care worker monitoring) but also the indirect costs of increasing citywide preparedness after identifying the one case (e.g., enhancing hospital preparedness, active monitoring of returning travelers, and community outreach). Ebola preparedness might include advanced planning with all designated Ebola hospitals to establish efficient monitoring programs for workers involved in caring for Ebola patients, as well as a plan for local resource allocation needed once an Ebola case has been confirmed.
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                Author and article information

                Journal
                SAGE Open Med
                SAGE Open Med
                SMO
                spsmo
                SAGE Open Medicine
                SAGE Publications (Sage UK: London, England )
                2050-3121
                16 May 2019
                2019
                : 7
                Affiliations
                Division of State and Local Readiness, Center for Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
                Author notes
                Victor M Cáceres, Division of State and Local Readiness, Center for Preparedness and Response, Centers for Disease Control and Prevention, Mailstop H21-5, 1600 Clifton Road, Atlanta, GA 30329-4027, USA. Email: vac5@ 123456cdc.gov
                Article
                10.1177_2050312119850726
                10.1177/2050312119850726
                6537056
                7993b980-cdb7-45b7-a084-37265d07f8ad
                © The Author(s) 2019

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

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                January-December 2019

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