Basic Protocol for VDH Acceptance of Passengers Identified Through Airport Screening At Washington Dulles International Airport for Ebola Virus Disease (EVD) and Active Monitoring of Incoming Travelers Destined for Virginia
- Definitions of Key Terms
- Role and Responsibilities:
- Step-by-Step Process
- Summary table of risk categories and public health response
- Data collection and data management.
- Planning Considerations
This VDH plan is based on current published CDC guidance as of October 28, 2014, specifically, the following 3 documents:
- CDC Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure (October 27, 2014) available at http://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html
- CDC Ebola Virus Disease Case Definitions (October 27, 2014) available athttp://www.cdc.gov/vhf/ebola/hcp/case-definition.html
- CDC Epidemiologic Risk Factors to Consider when Evaluating a Person for Exposure to Ebola Virus (October 27, 2014) available at http://www.cdc.gov/vhf/ebola/exposure/risk-factors-when-evaluating-person-for-exposure.html
- Version 3 updates to this plan addresses changes since CDC guidance was issued on October 27, 2014.
Screening of incoming passengers began October 16, 2014 at Washington Dulles International Airport in Loudoun County and involves multiple partners, including Customs and Border Protection (CBP), CDC’s Division of Global Migration and Quarantine (DGMQ) quarantine station staff, referral hospital staff and VDH, including Loudoun Health District, Fairfax County Health Department, other health districts and Division of Surveillance and Investigation (DSI). The main steps for handling these travelers are described in detail below. In general, the same procedures would be followed if a person is screened at one of the other four US airports where enhanced screening is being performed (Chicago O’Hare, Atlanta Hartsfield-Jackson, Newark, and JFK).
Definitions of Key Terms
- Active monitoring: public health actively monitors the health of an asymptomatic person as opposed to relying on the person to self-monitor and report symptoms if they develop. The recommended frequency and mechanism (direct or indirect) will depend on exposure risk category; see Summary table of risk categories and public health response.
- Direct, active monitoring: public health authority conducts active monitoring through direct observation
- Conditional release includes active monitoring by public health to ensure immediate actions are taken if symptoms develop. Does not necessarily require separation from others or restriction of movement within the community.
- Controlled movement limits the movement of people. For those subject to controlled movement, travel by long-distance commercial conveyances (e.g., aircraft, ship, bus, train) should not be allowed; if travel is allowed, it should be by noncommercial conveyance such as private chartered flight or private vehicle, and occur with arrangements for uninterrupted active monitoring. Federal public health travel restrictions (Do Not Board) may be used to enforce controlled movement. For people subject to controlled movement, use of local public transportation (e.g., bus, subway) should be discussed with and only occur with approval of the local public health authority.
- Isolation is used to separate ill individuals who are infectious.
- Quarantine is used to separate and restrict the movement of persons exposed or presumed exposed to a communicable disease for the purpose of active monitoring and maintaining their separation from others, with or without the requirement that they be contagious at the time. In Virginia, quarantine for EVD could be voluntary or involuntary.
- Self-monitoring means that individuals monitor themselves for fever or other symptoms, and seek healthcare or notify the public health authority if fever or other symptoms develop.
- VDH Agreements
- Voluntary Agreement – Low, but not Zero Risk: outlines monitoring requirements
- Voluntary Agreement – Some Risk: outlines movement and travel restrictions and monitoring requirements
- Voluntary Agreement – High Risk: outlines movement and travel restrictions and monitoring requirements (See Appendix A and Appendix B)
Role and Responsibilities:
- CBP perform primary and secondary screening at airport.
- DGMQ quarantine station staff
- Perform tertiary screening at airport
- If referral to hospital is indicated, notify the hospital, facilitate patient transport, and notify public health
- Referral hospital will evaluate ill travelers who are referred for medical evaluation
- Division of Surveillance and Investigation:
- Coordinate with DGMQ staff, referral hospital, EMS and other state or jurisdiction health departments.
- Discuss passengers of concern based on their health status and/or exposure history and facilitate communication relative to patient transport and medical evaluation and/or transfer to public health for management.
- Receive information via Epi-X about travelers who do not have symptoms and do not have a positive exposure history whose ultimate destination is Virginia; coordinate initiating public health monitoring as needed for these individuals
- Coordinate with VDH Office of Commissioner for developing Quarantine Orders
- Loudoun Health District:
- Meet and assess at airport asymptomatic travelers with high-exposure risk
- Determine potential compliance with VDH Voluntary Agreement – High-Risk
- Issue a VDH Voluntary Agreement – High-Risk for a high-risk, asymptomatic traveler
- Serve involuntary quarantine order issued by Commissioner
- Health Commissioner
- Approves all VDH Voluntary Agreement – High-Risk
- Signs Quarantine Order if indicated for involuntary quarantine in Loudoun Health District
- Fairfax County Health Department
- Coordinate with Loudoun Health District, receiving hospital, DSI for ill travelers referred to Reston Hospital Center or other Fairfax County hospital for medical evaluation.
- All Virginia health districts
- If a traveler is issued a temporary VDH Voluntary Agreement – High-Risk by Loudoun Health District and traveler will be destined for a different health district, issue a new VDH Voluntary Agreement – High-Risk for traveler(s) arriving in their health district from Loudoun Health District
- Assume responsibility for public health active monitoring of the traveler(s) if final destination is in their district
- Coordinate documentation of relevant activities by providing data to DSI
- Provide support to northern health districts
Note: VDH is checking with CDC Division of Global Migration and Quarantine for airport screening for any changes in their procedures.
1. Primary Screening at Airport: All travelers entering the US from or through an Ebola-affected country (Guinea, Sierra Leone, or Liberia) will be screened at Washington Dulles International Airport (or 4 other US airports conducting enhanced screening) by CBP.
2. Secondary Screening at Airport: All incoming travelers from these Ebola-affected countries will undergo a secondary screening by CBP that includes a temperature check, visual observation, collecting exposure history and CBP staff completing a CDC 1-page form, US Traveler Health Declaration.
Travelers who do not exhibit or report any EVD symptoms, have no measured fever, AND have been determined to have low, but not zero risk will be released and will require public health monitoring for a 21-day period since their last possible exposure (i.e., departing the outbreak-affected area).
Public health actions:
- At the airport, these travelers will be issued a CDC “CARE” (“Check and Report Ebola”) kit which will include a fact sheet and instructions to self-monitor for signs and symptoms, a temperature and symptoms log, a thermometer, and a contact sheet with the 24/7 phone numbers of the state health departments with instructions to contact the appropriate state health department if they have any questions, concerns, or to report becoming symptomatic.
- If these travelers have additional travel that day after leaving the CBP-screening area, they will be allowed to continue on their journey, including by commercial conveyance, if approved by CBP/CDC at the airport.
- DSI will receive notification of these travelers who report Virginia as their final destination via Epi-X. Once DSI is notified, passenger information will be distributed to districts for them to initiate daily active public health monitoring.
- In brief, VDH will assess each traveler and confirm exposure risk.
- For asymptomatic persons with low, but not zero risk
- An in-person interview is recommended but not required; electronic mechanisms to capture signature (i.e., taking a picture of the signed document, faxing, scanning) are acceptable.
- Active monitoring entails once daily contact either by phone, e-mail or in-person to query the health status. Exceptions: Direct active monitoring for U.S.-based healthcare workers caring for symptomatic Ebola patients while wearing appropriate PPE and travelers on an aircraft with, and sitting within 3 feet of, a person with Ebola will require once daily, in-person monitoring by public health.
- Movement is not restricted; however, the traveler should notify VDH of any travel >50 miles from residence during the 21-day period.
- Refer to Summary table of risk categories and public health response.
3. Tertiary Screening at Airport
Travelers who report any symptoms of EVD, have a measured fever, OR report a high- or some- risk exposure during secondary screening will undergo further evaluation by DGMQ.
- Note: VDH is checking with CDC Division of Global Migration and Quarantine for airport screening for any changes in their procedures. Our current thinking is presented below.
- DGMQ staff will complete a 3-page risk assessment on these travelers and will categorize travelers into 3 main groups –those ill travelers needing further medical evaluation, those with high-risk not allowed to travel by commercial conveyance, and those with some-risk will be released with subsequent notification to the state health department via Epi-X for active monitoring.
3a. Immediate Referral of Ill Traveler to Hospital for Medical Evaluation
Any traveler with fever (subjective or measured temperature ≥ 100.4) or additional symptoms of EVD (regardless of exposure risk) will be sent to pre-identified hospital for medical evaluation.
- If the traveler is ill and is non-compliant with medical evaluation then a Virginia isolation order might be used with or without a federal isolation order.
- If EVD is suspected and testing is indicated based on clinical and exposure criteria, the case will be discussed with the facility, DSI, DCLS and ultimately with CDC for testing approval.
- Depending on the likelihood of EVD, identification of possible contacts might begin before presumptive results are available at DCLS; otherwise, if EVD is presumptively identified at DCLS, VDH will initiate active contact monitoring and consider the need for restriction of activities in contacts.
- If the person is medically evaluated and discharged with a diagnosis other than EVD, then
- Those with high- or some-risk exposure will now be treated as asymptomatic persons with a high- or some-risk exposure, respectively.
- For those with high-risk exposures:
- They will be asked to sign a VDH Voluntary Agreement – High-Risk issued by local health district where referral hospital is located; if needed, a quarantine order will be issued.
- Their movement will be restricted within the community and these persons will be prohibited to travel on commercial conveyances.
- Active monitoring would consist of twice daily check-in with the traveler, including 1 in-person visit per day.
- Refer to Summary table of risk categories and public health response
- For those with some-risk exposures: see 3b, below
- For those with low, but not zero risk: see 2, above
- For those with high-risk exposures:
- Those with high- or some-risk exposure will now be treated as asymptomatic persons with a high- or some-risk exposure, respectively.
3b. Any non-ill traveler with some-risk exposure
- For asymptomatic persons with some risk:
- VDH believes notification will occur via Epi-X.
- An initial in-person interview to review the conditions of the VDH Voluntary Agreement– Some-Risk should be conducted. The agreement should be signed by the traveler and the District Director.
- Active monitoring entails twice daily contact including 1 in-person visit to query the health status.
- Movement will be restricted. Refer to Summary table of risk categories and public health response.
3c. Conditional release of non-ill Traveler with High-Risk Exposure
Any traveler without EVD symptoms but who reported a high-risk exposurewill be referred by DGMQ to local public health under a conditional release and a decision about quarantine will be made.
- The conditional release will restrict travel via public conveyance (e.g., commercial planes, ship, train, long-distance bus).
- Loudoun Health District (Dr. Goodfriend) is currently the primary contact person to receive calls from DGMQ.
- In response to notification by DGMQ of a traveler (or travel unit) being issued a conditional release, Loudoun Health District staff will go to the airport to assess the traveler or travel unit. DGMQ will provide information collected to date (i.e., US Traveler Health Declaration; CDC Risk Assessment for Travelers from Ebola-Outbreak-Affected Countries).
- VDH will use a supplemental traveler assessment form to gather information about intended travel and points of contact. The passengers will have reported a possible exposure but no symptoms and thus do not pose a risk to anyone’s health at that time.
- The public health assessor, referred to as the Public Health Representative, will collect extensive contact information on the traveler(s) and US contacts for them, and determine the travel destination and what the living arrangements are at that location.
- CDC will release these individuals using a Conditional Release and subsequently VDH will issue either a VDH Voluntary Agreement – High-Risk or Quarantine Order according to the following criteria.
- If a person lives in Virginia, Washington, D.C., Maryland, or within a 6-hour (360 miles) drive in West Virginia or Pennsylvania, is clearly willing to be quarantined, understands the quarantine requirements, has an available home base (i.e., a private residence, not a hotel or motel) and appropriate arrangements there (either all in the home are quarantined or there is a separate room and bathroom for the quarantined individual(s)) and the Commissioner has agreed , then a VDH Voluntary Agreement – High-Risk issued by Loudoun County will be considered. This can be signed by Dr. Goodfriend and delivered by the Public Health Representative. The traveler(s) can travel by personal car, rental car, private vehicle pick-up by friend/family member or government vehicle to the quarantine destination. Using an escort vehicle to ensure that the traveler reaches his/her destination can be considered, but is not required. The quarantined persons will have to go directly to the location of quarantine; it is reasonable to allow a limited number of brief stops for bathroom or food needs during travel to the quarantine location. The local health department serving the location of quarantine will ensure essential needs are met, presumably through arrangements made with social services/community-based organizations.
- For other travelers who are bound for locations in West Virginia or Pennsylvania that are > 6-hour (360 miles) or bound for other states, a VDH Voluntary Agreement – High-Risk issued by Loudoun County that requires staying at a Loudoun County identified facility for the full 21-day period will be considered if travelers indicate compliance (see above); otherwise, a Quarantine Order issued by the Commissioner will be pursued.
- If at any point, any person whom the Public Health Representative suspects will not comply voluntarily with movement restrictions, an (involuntary) Quarantine Order, which has to be signed by the Commissioner, would be considered.
- The Public Health Representative would call the Epi Phone with the information necessary for the order. The person carrying the Epi Phone needs to locate a DSI Quarantine Team member so that the customized information can be entered into the existing draft order. Then DSI will send the order up quickly for the Commissioner’s signature.
- We are asking the Office of the Attorney General if a faxed order is acceptable. If so, we will fax the order to the Quarantine Station at Dulles. Otherwise, our plan is to pdf and scan the order and send it by email. A computer and printer and access to email set up at the airport are needed for that to work. Public health can deliver the order themselves or enlist the assistance of law enforcement to serve the order with them. Loudoun County is identifying locations where persons who are initially not allowed to travel to their final destination can be housed during all or part of the period of quarantine.
- Active monitoring entails twice daily contact including 1 in-person visit to query the health status. For the in-person visit, note that direct contact with the person is not necessary for these checks. Speaking to the person from the doorway or having them come out of the household so you can see them while you are on the phone with them (gathering information about temperature, symptoms, status of others in the home, and essential needs) is sufficient. The purpose of these visits is two-fold: to check for any symptoms of illness and to ensure they are where they are supposed to be. If anyone under a VDH Voluntary Agreement – High-Risk is not at home, an (involuntary) Quarantine Order will be considered. Local law enforcement might have an additional role in ensuring the safety of those under quarantine.
- If the person lives in Virginia and does not live in Loudoun County, either the Public Health Representative or DSI will work with the city or county of residence to alert the local health department to the arrival of a person under quarantine. Once they arrive in their destination city/county, the District Director would issue a new VDH Voluntary Agreement – High-Risk, if the person is under an initial voluntary agreement issued by Dr. Goodfriend. The Commissioner’s Order would apply anywhere they are in Virginia. The health department of the quarantine location would need to pick up the twice daily symptom and compliance checks.
- If anyone under quarantine develops fever or other symptoms of EVD, they are to communicate immediately with their public health contact person. Subsequent assessment, approvals for testing (with DCLS and CDC) and alerting of EMS and the receiving hospital would follow as for any person with suspected EVD.
Summary table of risk categories and public health response
Table 1. Summary of movement, travel restrictions and public health monitoring of asymptomatic persons by exposure risk*
|Exposure Risk Category|
|High Risk||Some Risk||Low-but not Zero Risk|
|LHD Documentation Needed||Voluntary Agreement – High Risk (or quarantine order)||Voluntary Agreement – Some Risk||Voluntary Agreement – Low but not Zero Risk|
|Movement and Activities Restriction?||Yes||Yes
– Live in usual home and engage in usual family/friend interactions
– Run errands to meet essential needs, e.g., grocery shopping, visiting pharmacies. Note: Errands for essential needs should be run during off-peak shopping hours and person should maintain 3 ft distance from others
– Small group gatherings are allowed where all attendees are known and can be identified later
– Interactions where ≥3 feet can be maintained from strangers
– Activities in the community where ≥3 feet from strangers cannot be maintained (e.g., the gym, restaurants, places of worship)
– Attendance at large gatherings where ≥3 feet from strangers cannot be maintained (e.g., concerts, ball games, movies)
|Travel Restrictions?||Yes via state agreement and Federal Do Not Board list||Yes
– Travel on commercial conveyance (e.g., bus, subway, train, plane) is not allowed; travel within community on foot or private vehicle is allowed.
– Any travel outside of the community (≥50 miles) is not allowed; public health may grant exceptions on a case-by-case basis depending on multiple factors (e.g., monitoring compliance, trip duration, continued ability to monitor, timing with respect to incubation period, and access to care if symptoms develop).
– Federal restrictions may be imposed to restrict commercial conveyance (Federal Do Not Board list)
|No restriction, but traveler should notifyLHD of travel ≥50 miles from the residence and monitoring should be ensured|
|Public Health Monitoring||2x/day including 1 in-person visit||2x/day including 1 in-person visit||Usually 1x/day check-in (remotely via phone, Facetime, email, text, survey, etc)‡|
– If a healthcare worker, direct patient care is not allowed
– Generally restricted but exceptions can be granted on a case-by-case basis depending upon multiple factors (e.g., employer’s approval, ability to maintain 3 feet distance, minimize contacts with strangers)
– Teleworking from home (with employer’s approval) is encouraged if feasible
– Children are not allowed to attend school or daycare
– College/university students are not allowed to attend classes in person
*All travelers are advised to conduct twice daily symptom check, including taking their temperature. If a traveler is non-compliant with VDH recommendations or monitoring, an involuntary quarantine order will be considered.
‡If the individual is either 1) a healthcare worker (HCW) based in the US caring for a symptomatic Ebola patient while wearing appropriate PPE, or 2) a traveler on an aircraft with, and sitting within 3 feet of, a person with Ebola, then direct active monitoring (i.e., in-person visit) 1x/day is required.
Data collection and data management
Several forms are being used throughout this process. CDC and VDH forms that will be collected include the following:
- CDC US Traveler Health Declaration Form (all travelers)
- CDC Risk Assessment Form (if evaluated by CDC DGMQ staff)
- CDC Conditional Release Form (if conditionally released)
- VDH Traveler Assessment Form (if conditionally released by CDC)
- VDH VDH Voluntary Agreement – High-Risk or (involuntary) Quarantine Order
- VDH Voluntary Agreement – Some-Risk
- VDH Voluntary Agreement – Low, but not Zero Risk
- VDH Daily Monitoring Form
The LHD should maintain copies of forms for each traveler destined for their jurisdiction. Copies of forms should also be faxed to DSI to the Attention of DSI Quarantine Team for data entry into a centralized database for analysis and reporting.
- Enhanced screening at 5 US airports is currently underway. At the start of the project, an estimated 150 people would be screened daily across these 5 airports, accounting for 94% of all travelers entering the US and originating from these 3 Ebola-affected countries. On October 21, 2014 Department of Homeland Security announced that all travelers from Ebola outbreak countries would be funneled through these five US airports.
- After JFK, Washington Dulles handles the second highest number of travelers from these impacted areas. Affected flights routinely arrive from 8am to midnight.
- The duration of this enhanced screening is not known at this point.
- Loudoun Health District and the Northern Virginia districts will be disproportionately impacted by this screening.
- Loudoun Health District is developing guidance for logistical considerations for involuntary quarantine in the district.
- Regional support for during business hours and after-hours coverage must be considered for long-term sustainability.
- All districts, especially the Northern districts, need to consider staffing for conducting public health monitoring.
- Prepare to conduct public health monitoring as described in this document.
- Those with high- or some-risk exposures require twice daily public health contact (including an in-person visit) and having a consistent Public Health Representative is recommended.
- All districts should
- Be prepared to accept a traveler in their jurisdiction and perform active monitoring.
- Be prepared to issue VDH Voluntary Agreements for high-risk, some-risk and low-but not zero risk.
- Have a low threshold for issuing a Quarantine Order for non-compliant persons who are under a VDH Voluntary Agreement – High-Risk.
- Ensure a community agency/organization is prepared to assist with meeting the essential needs of quarantined individuals.
- Ensure local law enforcement is aware of their potential roles in delivering and enforcing orders of quarantine and protecting the safety of those under order.