Since 2015 the Los Angeles County Department of Public Health (LACDPH) has partnered with Kaiser Permanente Los Angeles Medical Center (KPLAMC) to fill a gap to clinically assess travelers from Ebola-affected areas without activating and Ebola treatment or assessment center.
Los Angeles County (LAC) is the most populous county in the United States with over 10 million residents and includes 88 cities. LAC is one of the most ethnically diverse counties in the U.S. Beginning the week of October 10, 2022, CDC and Department of Homeland Security implemented funneling of air passengers traveling to the U.S. who had been to Uganda.
Since low-risk travelers most likely have illnesses (e.g. malaria) unrelated to Ebola, in the absence of exposures to persons with Ebola virus disease (EVD), potential delays in care could occur when concerns exist in evaluating patients without ruling out EVD. Activating an Ebola treatment or assessment center for a clinically stable patient that does not need hospitalization is a heavy burden on the healthcare system. The KPLAMC mobile field assessment team has been operational since 2015 with protocols (including testing for malaria) developed in conjunction with LACDPH and Emergency Medical Services (EMS) and has been activated in an actual situation and continues to conduct drills to assess any operational gaps.
Partnerships among EMS, healthcare, and public health that led to the success of this practice which has implications to decrease burden on our healthcare system when Ebola in returning travelers is of concern. KPLAMC team responds to any resident in LAC when requiring activation regardless of Kaiser membership or health insurance status.
To reduce spread of EVD in the U.S. CDC has conducted public health entry screening for travelers arriving in the United States from Ebola affected areas to detect ill travelers and any travelers with high-risk exposures to Ebola. This occurred with the 2014-2016 Ebola outbreak in West Africa, 2021 outbreak in Democratic Republic of the Congo (DRC), and recently in 2022 with the outbreak in Uganda.
Previously published case reports illustrate inappropriate practices in evaluation and management of febrile travelers and inadequate diagnosis and treatment for malaria because of concerns about possible exposure to Ebola. Because delays in malaria or other disease diagnosis and treatment related to concerns about Ebola can occur, the LACDPH along with KPLAMC developed a field response team to clinically assess stable low-risk travelers at home so as not to delay care and evaluation when activation of an Ebola Treatment Center (ETC) for hospitalization was not clinically indicated. Previously travelers who needed evaluation would need to be evaluated at an ETC because of healthcare providers concerns regarding potential for Ebola exposures, infection control, staff training in personal protective equipment, and laboratory capability and contamination concerns.
Travelers can be evaluated by a clinical team in their home to reduce risk of exposures to other healthcare providers or the public regardless of being a Kaiser member or presence of healthcare insurance.
To our knowledge, this is the first mobile field team developed to date to evaluate returning travelers from Ebola-affected areas. Although public health field response is not new, this specific type of response is new to public health because coordination with a clinical team, ETCs, and EMS can be complex. However, we have heard of other jurisdictions interested in implementing similar local field responses especially in areas where activation of an ETC or RESPTC would create undue burden for a patient that is low-risk, clinically stable, where hospitalization is not needed. Both LACDPH and KPLAMC have shared our experience and protocols with these other jurisdictions.
Evidence exists the delays in healthcare for returning travelers from Ebola affected areas can occur and our mobile field response fills a needed gap in providing responding to ill travelers.
The mobile field response would require involvement and participation of community partners including local city Fire, EMS, and healthcare. Although initially developed in 2015, recently in 2022 during the current Uganda outbreak the same concerns regarding healthcare system burden, decreased availability of local Ebola Assessment/Treatment centers since 2016, and concerns regarding delays in patient care have resurfaced and jurisdictions have expressed interest in also implementing these mobile clinical field teams.
The goals of our model practice are to a) minimize patient discomfort and disruption while ensuring appropriate level of care, b) minimize impact on day-to-day operations at designated Ebola Treatment Center (ETC) medical facilities or Ebola Assessment Center (EAC) and c) minimize time required to obtain laboratory results.
The LACDPH activities that were implemented include partner planning meetings with CA state, emergency preparedness, communicable disease control, public health laboratory, environmental health, EMS, healthcare partners, local ETCs (UCLA, KPLAMC), Regional Emerging Special Pathogen Treatment Center (RESPTC) (Cedars Sinai), field protocol development and updating, notification protocol development, drills, field exercises and responses to actual events. LACDPH and KPLAMC field response capabilities have been shared with the California Department of Public Health, CA EMS, and Administration for Strategic Preparedness and Response (ASPR). No specific grant funds have been dedicated to this response.
Through several exercises and an actual event response, goals were achieved in each instance:
a) patient discomfort and disruption was minimized while ensuring appropriate level of care as response could be done within the patient's own home b) minimizing impact on day-to-day operations at designated Ebola Treatment Center (ETC) were achieved as patients were clinically stable and did not require inpatient intensive care unit (ICU) hospital activation which is the standard ETC activation plan, and c) time required to obtain laboratory results were optimized as specimens could be transported efficiently to our public health laboratory for expedited testing alleviating other healthcare facilities concerns regarding exposures and staff training or PPE capabilities.
After each response, a hotwash is conducted to review any gaps or opportunities for improvement and are incorporated into existing protocols. Examples of lessons learned included adding a video streaming call with the patient to assess the home environment and physical area where the clinical evaluation can take place, updating specimen packaging requirements, refining contingency plans if patient develops additional symptoms requiring transport to an ETC (e.g. vomiting or diarrhea), and updating notification contacts.
KPLAMC has used their own internal resources to partner with the LACDPH to maintain this mobile field response for returning travelers as it decreases the burden on the entire LAC healthcare system should a returning traveler become ill and need clinical assessment. They continue to be invested in its maintenance and to ensure it is sustainable after since the initial development in 2015. Currently the LACDPH and KPLAMC are committed to sustain the practice with the most recent field exercise conducted in December 2022 in response to the Uganda Ebola outbreak with our monitoring of over 160 returning travelers in LAC since October of 2022.