Revised CSTE Comments

Appendix 2a. Consultations Outside the Federal Government - CSTE

Appendix 2a

Comments from the COUNCIL ON STATE AND TERRITORIAL EPIDEMIOLOGISTS (CSTE)

Received from Dr. Jeff Engel, Executive Director (jengel@cste.org) on Monday, November 10, 2014 9:22 PM through Walter Daley (CDC/OPHPR/DSLR).

• Dr. Engel compiled general comments with their authors, from 3 state epidemiologists and documents 1, 3, 4, and 5 with Track Changes and comments all from NYC.

Verbatim comments:

Reviewer 1

I made the mistake of looking at the algorithms first and I think they should ditch them, as they are not useful and in some parts inexplicable on their own (why are you going outside and then putting on gloves?).  The guidance for active monitoring itself is refreshingly clear, reasonable and enlightened, especially the part about “technologic solutions” and using occupational health.  Most of our direct actives are going to be returning healthcare workers. 

I think the guidance on visiting people needs more work.  One size does not fit all, but the idea of keep your distance and bring only gloves is good.  Although many of our boards of health have physicians, only 3 of our 351 local health departments have anyone who fits the description of a “PHMD”.  However, I understand most states have county health departments with PHMDs.  Maybe they could leave this a bit open, as in call the designated public health line and consult on management.  We have epis on call who can reach one of the physicians in our Bureau of Infectious Disease as the designated public health official.  Maybe other states, even with county health departments are centralizing the triage of symptomatics. 

I think they should recommend a distance of at least 3 feet.  There is still controversy about 3 versus 6 for droplets.  We are recommending 6 feet (while saying 3 feet is probably enough). 

As always, they need to keep forms for the field simple and let the “designated health official” collect clinical information over the phone; a detailed symptom checklist being done by the now gloved visitor seems burdensome. 

Looking around for blood, vomitus and body fluids on the floor and furniture seems kind of silly considering who we are visiting and where they are being visited (should we look behind the couch, just in case?).

Reviewer 2

I didn’t have time to review the CDC documents closely because I’ve been finalizing our own state-specific protocols, forms and voluntary compliance agreements. For the most part, our state’s procedures look like they will be fairly close to what Randolph and team have developed.  I appreciate that they have sought our input, but we needed these a week or more ago and there is enough variance in each state’s approach, personnel resources, organizational structure and geography that these documents won’t be “one size fits all”. Is Randolph aware that 20+ states have deviated from CDC’s interim guidance?

Reviewer 3

We have some comments on the "Possible Strategies for Evaluation and Triage" document:

We recognize that these documents were initially developed re contact management. Use of the term "traveler" and "contact" are used interchangeably throughout the document-- would probably be best to stick with one term (traveler), as not all travelers are necessarily contacts of EVD cases.

A PHMD might not be universally used in all states (in NJ for example, we won't be using just our PHMDs but also other public health/health care partners who can help make assessments. We would suggest using a broader, less specific term for those of us who don't rely on a PHMD for everything.

Re term "Ebola compatible" symptoms-- is there a pretty universal understanding of what that means? (We aren't necessarily comfortable with this looser terminology).

Reviewer 4

Selection from Appendix 2a - NYC Comments on “Possible Strategies for the Evaluation and Triage of Persons Under Active Monitoring for Ebola with Routine or Urgent Medical Concerns, Including Symptoms Compatible with Ebola Virus Disease”

Initial Report of Symptom(s) by a Person Under Active Monitoring

1. Symptom(s) reported at scheduled home visit

• Upon reaching the residence, a brief and general initial assessment should be done at the door. If there is any indication that the person under active monitoring is exhibiting symptoms consistent with Ebola, monitoring staff should:

  • not enter the residence

  • maintain a distance of 3 feet,

  • and proceed with a temperature and detailed symptom check at the door

• If monitoring staff learn that a person under active monitoring is symptomatic only after entering the person under active monitoring’s residence, they should:

  • Immediately determine whether it is safe to remain in the residence and take steps to safeguard themselves as outlined in contact tracing guidelines:

    • exit the premises if there is any sign of blood or bodily fluid contamination (doing so by asking the person under active monitoring or a family member to open the door, or if the staff doing active monitoring has medical gloves on hand, using a gloved-hand to open the door)

  • If there is no immediate hazard, monitoring staff should:

    • maintain a distance of 3 feet,

    • stand throughout the visit,

    • avoid touching objects,

    • and proceed with a temperature and detailed symptom check

• If safe to do so, monitoring staff should:

  • attempt to gather a complete and detailed symptom history including factors such as:

    • Time of onset, duration, location, intensity

    • alleviating and aggravating factors

    • comparison to baseline health status and usual symptoms

    • any treatment and the response to that treatment

  • complete the full Ebola symptom screening (insert document name or hyperlink)

  • perform an observed temperature check as outlined in contact tracing guidance (insert document name or hyperlink), taking care not to handle the thermometer

• After completing their assessment of a person under active monitoring, monitoring staff should:

  • Advise the person under active monitoring to provide a contact phone number, isolate him/herself in a room that has its own bathroom (preferably a bathroom that is not shared), and await further instruction

  • report a contact with Ebola-like symptoms, that person’s history, and his/her contact phone number to the designated local health official, such as the Public Health Medical Director (PHMD)

  • If monitoring staff are unsure whether a person’s symptoms are consistent with Ebola, they should consult with the PHMD

• The designated local health official will telephone the person under active monitoring to review his/her history and gather additional information as needed

2. Symptom(s) reported over the phone

• If the contact reports Ebola-like symptoms by telephone, monitoring staff should attempt to gather a complete and detailed symptom history including factors such as:

  • Time of onset, duration, location, intensity

  • alleviating and aggravating factors

  • comparison to baseline health status and usual symptoms

  • any treatment and the response to that treatment

• monitoring staff should also:

  • complete the full Ebola symptom screening

  • have the contact perform a temperature check

• After completing their assessment of a contact, monitoring staff should:

  • Advise the person under active monitoring to provide a contact phone number, isolate him/herself in a room that has its own bathroom (preferably a bathroom that is not shared), and await further instruction

  • report a person under active monitoring with Ebola-like symptoms, that person’s history, and his/her contact phone number to the designated local health official, such as the Public Health Medical Director (PHMD)

Triage of Persons under Active Monitoring with Routine or Urgent Medical Concerns

The following outline provides a categorization of the types of medical concerns that state and local health officials conducting active monitoring may need to address and approaches for managing them.

Non-Emergent (Routine) Medical Concerns

1. Non-Emergency complaint, NOT Ebola compatible

• PHMD calls PCP to discuss symptoms, review the exposure risk tier of the person under active monitoring

• PCP calls person under active monitoring and determines if management can occur at home or if transport to a health care facility is necessary

  • Home management

    • PHMD, PCP, and monitoring staff should coordinate follow-up of the person under active monitoring

  • Health care facility management

    • PCP notifies PHMD that transport to health care facility is needed

    • PCP and PHMD determine the appropriate means of transport

      • Privately-owned conveyance

      • EMT transport

        • PHMD notifies EMT services of need to transport person under active monitoring and the risk tier of person under active monitoring

    • PHMD notifies receiving hospital (Emergency Department) as determined by PCP

2. Non-Emergency complaint, Ebola compatible

• PHMD determines hospital of acceptance based on PCP affiliation

• PHMD determines appropriate means of transport to health care facility based on symptom acuity

  • Privately-owned conveyance

  • EMT transport

    • PHMD notifies EMT services of need to transport contact and the risk tier of person under active monitoring

• PHMD calls designated hospital official AND receiving Emergency Department

Selection with comments from Appendix 2b - NYC Comments on “Guidance for Travelers from an Ebola-Affected Country, United States”

Why are you being asked to monitor your temperature and symptoms for this time period?

You are being asked to closely monitor your health for 21 days after your arrival to the United States from an Ebola-affected country in order to rapidly to detect illness and provide careTwenty-one days is the longest possible time between when you may have been exposed to Ebola and when symptoms may begin.

It is critical for you to monitor your health during this time period so that you can be taken care of and treated if you become sick.

How should you monitor your health during this time period?

When you first arrived in the United States, you received a Check and Report Ebola (CARE) Kit from a CDC team at the airport. This kit included a monitoring form for you to use to record your temperature and possible symptoms. You will report daily to your health department and they may also schedule regular visits with you during your monitoring period. The health department will tell you which day you should stop monitoring yourself for fever and symptoms.

The symptoms of Ebola may be similar to other more common infections that begin with “flu-like” symptoms such as fever, muscle aches, or chills. If you develop a fever or any symptoms, it doesn’t mean that you have Ebola. However, if you develop a fever and other symptoms of Ebola, you may need medical care and testing.

Selection from Appendix 2c - NYC Comments on “Interview Form for Travelers From Ebola Outbreak-Affected Countries”

Section I. Traveler Information: Would checkboxes include a test check of their telephone number, if cell then can confirm correct, if for a land line confirm that it reaches stated residence and that the person is hosting the visitor

Selection from Appendix 2d – NYC Comments on “Guidance for Active Monitoring of Persons with recent travel to Ebola-affected countries, United States”

As part of entry screening, a returning traveler’s exposure risks are assessed. If the person has been found to have had High risk exposures, travel by commercial conveyance is not permitted. If the person has been found to have had Some risk exposures (including healthcare workers who cared for Ebola patients using appropriate Personal Protective Equipment), travel by commercial conveyance to the final destination is permitted, although no further travel by public or commercial conveyance is allowed and follow-up will be under direct active monitoring (see Monitoring and Movement guidance). If the returning traveler was found to have neither high nor some risk exposures while in an Ebola-affected country, Low (but not zero) risk is considered and active monitoring would apply.

Persons under direct active monitoring or active monitoring will be followed each day for 21 days following the date of their last exit from an Ebola-affected country. Similar to contact tracing, an effort is made to ensure the health of the returned traveler and to take actions if the traveler develops symptoms or is lost from follow-up. However, in the returned traveler with low (but not zero), the person has not reported any specific activities that are a known Ebola exposure. Therefore, the risk of developing Ebola is very low. Active monitoring ensures that if the returned traveler develops Ebola due to some unrecognized or unreported exposure, the person will still be quickly identified and appropriate care sought.

Safety: Efforts should be made to anticipate safety concerns for health monitors and travelers themselves. Health monitors are encouraged to maintain situational awareness, work in teams of at least two people, and conduct in-person visits during daylight hours.