The Check and Report Ebola (CARE+) Program to Monitor Travelers for Ebola After Arrival to the United States, 2014-2016

Abstract

The 2014-2016 Ebola epidemic in West Africa influenced how public health officials considered migration and emerging infectious diseases. Responding to the public’s concerns, the US government introduced enhanced entry screening and post-arrival monitoring by public health authorities to reduce the risk of importation and domestic transmission of Ebola while continuing to allow travel from West Africa. This case study describes a new initiative, the Check and Report Ebola (CARE+) program that engaged travelers arriving to the United States from countries with Ebola outbreaks. The Centers for Disease Control and Prevention employed CARE ambassadors, who quickly communicated with incoming travelers and gave them practical resources to boost their participation in monitoring for Ebola. The program aimed to increase travelers’ knowledge of Ebola symptoms and how to seek medical care safely, increase travelers’ awareness of monitoring requirements, reduce barriers to monitoring, and increase trust in the US public health system. This program could be adapted for use in future outbreaks that involve the potential importation of disease and require the education and active engagement of travelers to participate in post-arrival monitoring.

The 2014-2016 Ebola epidemic in West Africa affected how public health officials considered migration and traveler health protections for emerging infectious diseases. In the worst Ebola outbreak to date, there were 28 616 suspected, probable, and confirmed cases of Ebola virus disease in Guinea, Liberia, and Sierra Leone and 11 310 reported deaths.¹ The World Health Organization (WHO) also documented 36 suspected, probable, and confirmed cases of Ebola virus disease and 15 deaths in other countries, including the United States.² Travelers made approximately 350 000 trips internationally from Guinea, Liberia, and Sierra Leone from August 2014 through March 2016,³ about 58 500 of which were made to the United States (unpublished data, “Data In, Intelligence Out. Market Intelligence, Fares and Market Sizes,” Global LLC, 2016).

In response to the Ebola crisis abroad and the public health threat Ebola posed domestically, the US government introduced interventions to reduce the threat of importation and domestic transmission of Ebola while using the least restrictive means possible. One of these interventions was post-arrival monitoring of incoming travelers for signs and symptoms of Ebola virus disease using the active participation of the travelers themselves. This was the first time the Centers for Disease Control and Prevention (CDC) established such a program. This case study describes a component of that monitoring effort, Check and Report Ebola (CARE+), an attempt to increase adherence with post-arrival monitoring by intercepting incoming travelers from affected countries at designated airports, educating them about the need for monitoring, and giving them the tools they needed to comply.

In August 2014, after the WHO declaration of a Public Health Emergency of International Concern, CDC published the “Interim US Guidance for Monitoring and Movement of Persons With Potential Ebola Virus Exposure” (hereinafter, Monitoring and Movement Guidance), which provided standards for US public health measures based on clinical criteria and risk of exposure.³ The Monitoring and Movement Guidance was based on principles of the International Health Regulations, which are intended to prevent both the international spread of infectious diseases through measures at airports, ports, and ground crossings as well as unwarranted restrictions on travel and trade.⁴ For travelers arriving to the United States from countries with Ebola outbreaks, CDC’s August 2014 Monitoring and Movement Guidance recommended self-monitoring for signs and symptoms of Ebola virus disease and, depending on risk exposure or symptoms, controlled movement, such as preclusion from long-distance travel on commercial transportation.³

As the epidemic intensified in West Africa in autumn 2014, several events prompted an increased public health response in the United States. On September 25, 2014, a traveler from Liberia sought care at an emergency department in Dallas, Texas; was treated for possible sinusitis; and was discharged.⁵ Three days later, the traveler returned to the same hospital and was diagnosed with Ebola virus disease; the traveler was treated but died 12 days later. Two of the nurses who cared for him were subsequently infected with Ebola virus disease. One asymptomatic infected nurse flew on 2 domestic commercial flights during the early stage of infection, and contact investigations ensued.^5-7 In a separate event, a physician in New York City tested positive for Ebola in late October 2014.^8,9 The physician, who provided clinical Ebola care in Guinea, had in the days before his diagnosis been in close contact with friends and family, used public transportation, and spent time at a bowling alley, sparking fears of the start of a potential outbreak. During this time, media coverage intensified, and debates ensued about whether and how to safely allow travelers from countries in West Africa with Ebola outbreaks to enter and travel in the United States.^10-12

CDC has the legal authority to detain, medically examine, and conditionally release persons arriving to the United States or traveling between states who are suspected of being infected with or having been exposed to certain communicable diseases.^13,14 In October 2014, after the aforementioned events, CDC revised the Monitoring and Movement Guidance to recommend active monitoring and direct active monitoring of travelers arriving to the United States from countries with Ebola outbreaks.³ Active monitoring, in this instance, meant that travelers checked and documented their own health twice per day (ie, taking their temperature and evaluating themselves for symptoms of Ebola virus disease, such as headache, muscle pain, and fatigue) and communicated the results at least once each day to a state or local health department. Direct active monitoring was more intensive; it included direct observation by a public health official at least once daily.

CDC specified 3 risk categories for the purpose of guiding monitoring and movement restrictions: “low but not zero risk,” “some risk,” and “high risk.”¹⁵ Most travelers arriving to the United States from countries with Ebola outbreaks were classified as “low but not zero risk,” for which CDC recommended active monitoring. CDC recommended direct active monitoring for travelers classified as “some risk” or “high risk.” Active monitoring and direct active monitoring continued until 21 days after travelers’ last potential Ebola virus exposure.¹⁵

CDC based the October 2014 recommendation on its legal authority at the ports of entry and states’ legal authorities in their jurisdictions. As with the initial guidelines, and in line with the International Health Regulations, the revised set of strategies aimed to use the least restrictive means possible to manage travelers arriving to the United States from countries with Ebola outbreaks.

The standard for active monitoring included in the October 2014 Monitoring and Movement Guidance recommended that state and local public health authorities establish regular communication with travelers in their jurisdictions and collect daily health reports.³ Although CDC’s revised Monitoring and Movement Guidance specified the minimum standards for active monitoring and direct active monitoring, policies and procedures varied by state and local jurisdiction.^16-18 Most state and local public health authorities monitored travelers by telephone, although a few jurisdictions also used text messaging, email, or an online interface. All jurisdictions reported basic aggregate monitoring results and metrics to CDC weekly, with the goal of 100% traveler compliance with post-arrival monitoring requirements.¹⁵

In early October 2014, CDC worked with US Customs and Border Protection (CBP) to establish the enhanced risk assessment of travelers from countries with Ebola outbreaks, in part as a mechanism to collect contact information for travelers to facilitate active monitoring. To implement enhanced risk assessment with maximum efficiency and minimal disruption to travel, CBP restricted entry into the United States of travelers from countries with Ebola outbreaks to 5 major international US airports: John F. Kennedy International Airport, Washington Dulles International Airport, Newark Liberty International Airport, Hartsfield–Jackson Atlanta International Airport, and O’Hare International Airport.¹⁹ This enhanced risk assessment process included (1) identifying travelers either through scheduled flight itineraries or during customs and immigrations inspection, (2) directing those travelers to a designated assessment area, (3) obtaining contact and travel itinerary information for each traveler, (4) administering an exposure and symptom questionnaire, (5) checking temperature, and (6) observing each traveler for signs of illness.¹⁹

CDC recognized that, for post-arrival monitoring to be successful, travelers needed tailored, easily understood information and instructions about these procedures. In previous border health responses, CDC provided written health information to travelers at the point of arrival.^20,21 However, post-arrival monitoring for inbound travelers using the traveler’s own active participation and sustained adherence had never before been implemented. Accordingly, CDC communication specialists developed the Check and Report Ebola (CARE) kit, which contained instructions for checking and reporting possible symptoms of Ebola virus disease, a digital thermometer with instructions, a 21-day symptom and temperature log, information on whom to call if medical care was needed, and a wallet card that reminded travelers to monitor their health and served as an alert when presented to health care workers evaluating travelers for illness. The CARE kit, developed with visual depictions for a low-literacy audience, was pilot-tested with near-peer audiences before and during initial deployment (October 2014).²² The kit was available at all 5 airports in English and French (Figure 1).

Figure 1.

Centers for Disease Control and Prevention Check and Report Ebola (CARE) kit and prepaid mobile phone distributed to travelers arriving to the United States from countries with outbreaks of Ebola virus disease during the 2014-2016 Ebola epidemic.

From October 15 through November 16, 2014, approximately 400 inbound travelers per week participated in entry risk assessment and post-arrival monitoring.²³ In the early weeks of implementation, CDC, CBP, state and local health departments, and travelers had numerous challenges. CBP officers provided the CARE kit to travelers but, because of their security mission, had limited time to give instructions for post-arrival monitoring or CARE kit use or to explain the reasons for collecting contact and itinerary information. CDC heard that, during the early phase of enhanced entry risk assessments, travelers expressed anxiety about potential movement restrictions and Ebola stigma, and they often told CBP officers and CDC Quarantine Station staff members that they were confused about the requirements (oral communication, Harlem Gunness, CDC New York Quarantine Station, 2015).

State and local health authorities reported varying success in initiating and maintaining communication with travelers. Often, travelers who lived overseas lacked detailed contact information and a functional mobile phone. About 10% of travelers crossed state borders during the monitoring period, requiring the states to transfer travelers’ monitoring records to other states for continued monitoring (CDC internal report, “Weekly Report on Persons Under Direct Active Monitoring or Active Monitoring Due to Ebola Virus Exposure Risk,” 2014). In addition, travelers sometimes reported temperatures that appeared to be invalid.^24,25 Some state and local health authorities suspected that travelers did not understand how to use a digital oral thermometer (oral communication, Laura Tabony, MPH, Texas Department of State Health Services, 2015). Given these challenges, state and local health authorities struggled to monitor 100% of their travelers.²⁶

Methods

In November 2014, CDC established a new program, CARE+, to help alleviate some of the challenges in monitoring travelers. CARE+ engaged and educated travelers and provided resources at the time they entered the United States. CARE+ had the following objectives:

1. Increase travelers’ knowledge of symptoms of Ebola virus disease and how to seek medical care safely.

2. Increase travelers’ awareness of monitoring requirements.

3. Remove barriers to participation in monitoring.

4. Increase trust in the US public health system.²⁷

CARE+ was the first federally sponsored border health education program implemented at US ports of entry that delivered standardized messages in person to affected inbound travelers. The program was designed according to principles of behavioral science. Beliefs about susceptibility to a disease, seriousness of the disease, and benefits of action are known to influence adherence to recommendations.²⁸ The credibility and trustworthiness of message sources, social norms, and the availability of resources or tools needed to perform recommended behaviors are also important.^29-31 CARE+ also drew from interdependence theory, which suggests that relationships that bring persons closer through feelings of attachment or equality can be effective in changing behavior in a sustained way.³² CARE+ used the relationship between the traveler and a public health worker, called a CARE ambassador, to motivate compliance with monitoring. The program positioned CARE ambassadors as credible paraprofessionals who were more similar to travelers than were CBP officers.^33-35

Central to CARE+ was a 5- to 8-minute in-person educational session (called a CARE encounter) in which travelers, as either individuals or families, met with CARE ambassadors immediately after being released by CBP (Figure 2). The CARE ambassador reviewed the CARE kit with the traveler, demonstrated use of the digital thermometer, and explained the expected post-arrival monitoring behaviors: performing twice-daily health checks, connecting with the health department once per day, and seeking care safely if symptoms developed. In the discussion, CARE ambassadors emphasized the seriousness of Ebola virus disease and the value of monitoring behaviors for travelers and their family and friends.

Figure 2.

A Centers for Disease Control and Prevention Check and Report Ebola (CARE) ambassador meets with a traveler at a US airport where enhanced entry risk assessment for Ebola virus disease was conducted during the 2014-2016 Ebola epidemic.

The CARE encounter occurred at semi-private individual tables in the CBP Federal Inspection Services area at each of the 5 airports and was integrated into the operational flow. To help generate feelings of communality and trust, CARE ambassadors wore street clothes rather than uniforms (in contrast to CBP and CDC quarantine officers), were friendly and conversational, and sat across a small table from travelers without physical barriers. The encounter was conducted in the traveler’s preferred language, either by a bilingual CARE ambassador or with the help of a telephone interpretation service, bilingual airport or airline staff member, or another traveler (when only a West African dialect was spoken).

Because some travelers did not have mobile phones with US service, all adult travelers and unaccompanied minors received a prepaid mobile phone with at least 21 days of voice and text messaging service from a major US telecommunications company (Figure 1). CARE ambassadors encouraged travelers to use the mobile phone to connect with the public health authority charged with monitoring them. CARE ambassadors reviewed the mobile phone instructions included in the CARE kit and showed each traveler how to use the mobile phone. CBP documented the CARE phone number, which was sent along with other contact information to the receiving public health authority (state or local health department). Giving mobile phones to all affected travelers helped ensure a contact mechanism. Although providing phones was intended to reinforce a sense of collaboration, goodwill, trust, and importance of monitoring, it also proved useful to some travelers for meeting basic needs.

Finally, CARE ambassadors reviewed travelers’ itineraries and the contact information related to their final destination. If they discovered that important information shared with CBP during the enhanced entry risk assessment was missing or incorrect, CARE ambassadors documented the change and sent the updated information to CDC headquarters, which then disseminated the information to the receiving public health authority. CARE ambassadors also showed a 5-minute CARE+ video (in English or French) to the traveler when deemed useful.

Early in the program, staff members from CDC and elsewhere in the US Department of Health and Human Services, including civil servants, Public Health Associate Program fellows, and US Public Health Service officers, as well as Federal Emergency Management Agency responders, served as CARE ambassadors because they could be granted port authority security badges within a week. By March 2015, a service contract was in place to hire temporary contract staff members at all 5 ports of entry. A lengthy security clearance process was required before contractors could work without an escort in the secure areas of the airports where risk assessment activities occurred. Because of the length of this process, surge staff members supplemented contractors as CARE ambassadors from November 2014 through June 2015. By July 2015, contractors fully staffed the program. The approximately 100 CARE ambassadors hired through the service contract were required to have degrees in social work or health education. All CARE ambassadors received training about CARE+ and supervised practice in conducting encounters.

CARE ambassadors met flights at all times of the day and night. Two to 6 CARE ambassadors were present when most travelers from affected countries arrived, which meant 24-hour coverage at John F. Kennedy International Airport. The program, including the cost of the mobile phones, was initially funded by the CDC Foundation and later through Ebola supplemental funds.³⁶

Outcomes

The CARE+ program began implementation at John F. Kennedy International Airport on November 16, 2014, and was implemented at all 5 airports by December 22, 2014. The CARE+ program ended for travelers from Liberia on September 21, 2015, and was fully decommissioned on December 29, 2015, when post-arrival monitoring ended for travelers from Guinea.³ From November 16, 2014, to December 29, 2015, approximately 35 000 travelers were assessed at US ports of entry. CARE ambassadors greeted approximately 7100 flights and provided 23 800 mobile phones and 34 400 CARE kits.²³

CDC evaluated the CARE+ program but has not yet published the results of the evaluation. It is difficult to establish the extent to which the CARE+ program improved the rate of adherence to post-arrival monitoring requirements (ie, taking one’s temperature daily and reporting it to a local public health authority). One published report of data from all airports in the United States indicated that the number of monitored persons who could not be contacted decreased from a median of 23 persons per week (1.4% of all monitored persons) in November 2014 (the start of CARE+) to <1 person per week (0.03%) in February 2015.¹⁵ The median number of persons who had monitoring gaps that were ≥48 hours decreased from 20 persons per week (1.0%) to 3 persons per week (0.2%) during this same period. Another report from New York City described a generally high level of compliance with monitoring (95%) from October 25, 2014 to December 29, 2015. However, contact was never made with 86 “zero to low risk” travelers. Of these 86 travelers, 75 (87.0%) arrived before December 2014.³⁷ In another report from the same jurisdiction, authors reported that their data quality improved, especially the accuracy of contact numbers, after CARE+ began providing mobile phones.³⁸ Some state health department staff members reported anecdotally that CARE mobile phones made initial contact and retention easier to achieve, reduced reliance on emergency contacts and home visits, and made tracking jurisdiction transfers easier (oral communication, Laura Tabony, MPH, Texas Department of State Health Services, 2015). Additional evaluation of the program may shed light on its effectiveness, but it seems probable that CARE+ helped address the needs of some of the most difficult-to-reach travelers and contributed to more effective post-arrival monitoring over time.

Lessons Learned

CARE+ was an important component of targeted risk assessment at entry and post-arrival monitoring to prevent importation and transmission of Ebola virus disease into the United States. These efforts were attempts to respond to pressing demands from the public and policy makers in late 2014 to reduce the risk of domestic Ebola virus disease transmission to an acceptably low level so that travel between the United States and West Africa could continue. CARE+ was an attempt to maximize the number of travelers who initiated and stayed in post-arrival monitoring for Ebola virus disease. A program with similar elements could be used in a future Public Health Emergency of International Concern, such as a large outbreak of Middle East Respiratory Syndrome or Severe Acute Respiratory Syndrome. It could also be used for a population of travelers targeted for public health interventions after arrival, such as refugees for whom CDC provides specific recommendations for medical examination and care.

CDC’s CARE ambassadors aimed to use their short engagement with travelers to share information, build trust, and promote adherence to post-arrival monitoring. CARE+ also responded to travelers’ practical needs by providing the tools needed to participate in post-arrival monitoring. Similar models may be applicable in future outbreaks that involve the potential importation of disease and in other contexts that require active engagement with travelers.