Development and Implementation of the Ebola Traveler Monitoring Program and Clinical Outcomes of Monitored Travelers during October – May 2015, Minnesota

BACKGROUND In October 2014, the United States began actively monitoring all persons who had traveled from Guinea, Liberia, and Sierra Leone in the previous 21 days. State public health departments were responsible for monitoring all travelers; Minnesota has the largest Liberian population in the United States. The MDH Ebola Clinical Team (ECT) was established to assess travelers with symptoms of concern for Ebola virus disease (EVD), coordinate access to healthcare at appropriate facilities including Ebola Assessment and Treatment Units (EATU), and provide guidance to clinicians. METHODS Minnesota Department of Health (MDH) began receiving traveler information collected by U.S. Customs and Border Control and Centers for Disease Control and Prevention staff on October 21, 2014 via encrypted electronic communication. All travelers returning from Liberia, Sierra Leone, and Guinea during 10/21/14-5/15/15 were monitored by MDH staff in the manner recommended by CDC based on the traveler's risk categorization as "low (but not zero)", "some" and "high" risk. When a traveler reported symptoms or a temperature ≥100.4° F at any time during their 21-day monitoring period, an ECT member would speak to the traveler and perform a clinical assessment by telephone or via video-chat. Based on the assessment the ECT member would recommend 1) continued clinical monitoring while at home with frequent telephone follow-up by the ECT member, 2) outpatient clinical evaluation at an outpatient site agreed upon by all parties, or 3) inpatient clinical evaluation at one of four Minnesota EATUs. ECT members assessed and approved testing for Ebola virus infection at MDH. Traveler data, calls to the ECT and clinical outcomes were logged on a secure server at MDH. RESULTS During 10/21/14-5/15/15, a total of 783 travelers were monitored; 729 (93%) traveled from Liberia, 30 (4%) Sierra Leone, and 24 (3%) Guinea. The median number monitored per week was 59 (range 45-143). The median age was 35 years; 136 (17%) were aged <18 years. Thirteen of 256 women of reproductive age (5%) were pregnant. The country of passport issuance was known for 720 of the travelers. The majority of monitored travelers (478 [66%]) used a non-U.S. passport including 442 (61%) Liberian nationals. A total of 772 (99%) travelers were "low (but not zero)" risk; 11 (1%) were "some" risk. Among monitored travelers, 43 (5%) experienced illness symptoms; 29 (67%) had a symptom consistent with EVD. Two were tested for Ebola virus disease and had negative results. Most frequently reported symptoms were fever (20/43, 47%) and abdominal pain (12/43, 28%). During evaluation, 16 (37%) of 43 travelers reported their symptoms began prior to travel; chronic health conditions in 24 travelers including tumors/cancer, pregnancy, and orthopedic conditions were most common. Infectious causes in 19 travelers included upper respiratory infection, malaria, and gastrointestinal infections. DISCUSSION Prior to 2014, no similar active monitoring program for travelers had been performed in Minnesota; assessment and management of symptomatic travelers was a new activity for MDH. Ensuring safe entrance into healthcare was particularly challenging for children, and pregnant women, as well as those without an established connection to healthcare. Unnecessary inpatient evaluations were successfully avoided by close clinical follow-up by phone. Before similar monitoring programs are considered in the future, careful thought must be given to necessary resources and the impact on affected populations, public health, and the healthcare system.