Monitoring Programs

Interviewees highlighted the immense time and resources required to implement Ebola monitoring programs (Table 1, Topic 1). For example, 1 participant said, “The personnel available to [monitor] was stressed at times.” Active monitoring often required public health personnel to call or visit monitored individuals twice daily to record temperature/symptoms, drawing them away from daily responsibilities and negatively impacting routine operations. This difficulty limited the ability to actively monitor individuals. One participant noted, “They [public health staff] definitely weren’t visiting each person’s house…I don’t think they had the personnel to do that.” Interviewees cited the drain on public health resources from meeting necessary surge capacity as 1 of the most prominent implementation concerns.

TABLE 1

Select Interviewee Quotes About Ebola Monitoring Policy Implementation for the Domestic Response to the 2013–2016 West Africa Ebola Epidemic

Some states had to identify or develop tracking systems, another substantial time and resource investment requiring surge capacity (see Table 1, Topic 2). Participants noted that passive monitoring systems allowed monitored individuals to report their own data to health officials, which helped mitigate time requirements. Passive systems enabled monitored individuals to report their twice-daily temperature and symptom checks via phone (often a provided cell phone) or video chat (eg, Skype, FaceTime) or enter their own data into an online system. While these reporting mechanisms reduced health officials’ workload, some required additional time or resources to establish, implement, monitor, and maintain. Additionally, interviewees identified privacy as a primary concern for these systems, and dedicated effort was required to protect personally identifiable and confidential medical information.

Local health officials often conducted initial visits with monitored individuals to establish trusted relationships (see Table 1, Topic 3). These visits provided an opportunity to establish rapport, discuss monitoring procedures and movement restrictions, provide instructions about reporting temperature/symptoms, and gather additional information about the individual’s exposure risk. Many individuals arriving from West Africa lacked a local support network, and visits from public health officials helped identify the need for ancillary support services related to their personal needs (eg, dietary restrictions, religious requirements), particularly for those under movement restrictions. One interviewee commented on the importance of providing support for affected individuals, especially those with language barriers, explicitly discussing the value of a “personal touch” and having “a person from the local health department that they felt comfortable with.” Health officials often collaborated with community or faith-based organizations to address these issues and make affected individuals comfortable during the monitoring period. Products and services such as cell phones– provided by the CDC at airport screening stations starting in July 2015– and Internet access provided monitored individuals with mechanisms to contact the health department for symptom reports and facilitated contact with family and friends during the monitoring period.

Movement Restrictions

Movement restrictions ranged from limitations on non-local travel and use of public transportation to full quarantine. In addition to issuing and enforcing movement restriction orders, state and local health departments were required to manage associated logistical challenges ancillary to the implementation of movement restrictions. While some individuals were able to remain at home during their monitoring/restriction period, not everyone had a local residence. Issues arose in identifying housing for individuals under movement restrictions– including hotel rooms, rented properties, or properties owned by local health or elected officials (Table 2, Topic 1). This process was often difficult, or inordinately expensive, due to concern about Ebolavirus contamination and the owner’s ability to rent the property in the future. One interviewee described the process of renting houses for high-risk individuals, stating, “[W]e kept those two houses on contract for roughly a year. And we paid in that one year what…we could have purchased those houses for.” Additional concerns included security– both to enforce movement restriction orders and protect the safety and privacy of affected individuals– and support (eg, food, medical care, religious, and mental health services) for affected individuals.

TABLE 2

Select Interviewee Quotes About Ebola Movement Restriction Policy Implementation for the Domestic Response to the 2013–2016 West Africa Ebola Epidemic

The legal environment for, approach to, and interpretation of “quarantine” varied between states. Some participants noted that they altered CDC guidance to account for state legislation regarding the process for ordering and enforcing quarantine or other movement restrictions. Some interviewees described “voluntary quarantine” or “home restriction” as less restrictive alternatives to mandatory quarantine, because formal orders were not issued and it was viewed as a cooperative effort between health officials and affected individuals (see Table 2, Topic 2). Without the formal process of issuing a mandatory order or the involvement of law enforcement, “voluntary” quarantine was easier to implement. Mandatory orders were available in the event that individuals indicated that they would not comply voluntarily. In fact, 1 participant stated that if individuals indicated that they would not comply with voluntary quarantine, health officials would show them the mandatory order in hopes of coaxing them into complying with the “voluntary” order.

Another challenge was cross-jurisdictional coordination, in particular, determining the authority responsible for enforcing movement restriction orders and the appropriate response for non-compliant individuals (see Table 2, Topic 3). In some jurisdictions, quarantine legislation and policies existed but had rarely been implemented or challenged. In contrast, isolation laws are used more regularly for infectious disease patients, and the processes, requirements, and legal authority are well established. Although some interviewees were confident their quarantines would hold up in court, others were not. One said that while his/her health department had successfully upheld isolation orders for tuberculosis patients in court, “[O]urquarantine authority has never really been tested in our courts…so we’re not really sure if that was going to hold up.” Additionally, responsibility for authorizing and enforcing movement restrictions may be spread across public health, judicial, and law enforcement agencies.

Questions and concerns, particularly from law enforcement officials, included how to operationally enforce movement restriction orders, particularly with respect to the level of force justified or authorized to ensure compliance and avoid exposure (see Table 2, Topic 4). Participants indicated that officers expressed concern about the prospect of touching a quarantined individual for fear of being infected, which would make it difficult to restrain someone without using elevated levels of force (eg, Tasers, firearms). One interviewee recalled a law enforcement officer asking, “Do you expect me to shoot somebody if they won’t stay in their house?” Another noted that explicit coordination was required with state law enforcement to ensure that the state would provide personnel to enforce quarantine orders if local law enforcement refused to do so.