36473 The Care+ (Check and Report Ebola) Program: The Power of Interpersonal Communication in Reaching Mobile Populations

Heather Joseph, MPH1, Abbey Wojno, Ph.D.2, Onalee Grady-Erickson, CEM3, Kelly Winter, MPH, Ph.D. candidate2, Gabrielle Benenson, MPH4, Erika Willacy, MPH5, Stefanie Erskine, MPH6, Amanda MacGurn, MPH2 and Kathryn Spruit-McGoff, RN, MSN2, 1Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC), Atlanta, GA, 2Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, 3Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Maple Grove, MN, 4Office of Public Health Scientific Services, Centers for Disease Control and Prevention (CDC), Atlanta, GA, 5Division of Global Migration and Quarantine, Immigrant, Refugee, and Migrant Health Branch, Centers for Disease Control and Prevention, Atlanta, GA, 6Division of Global Migration and Quarantine, Travelers Health Branch, Centers for Disease Control and Prevention, Atlanta, GA

Background:  In October 2014, CDC partnered with U.S. Customs and Border Protection to conduct enhanced entry screening to identify travelers returning from countries with Ebola outbreaks. CDC  issued guidelines to state/local health departments to monitor those travelers until 21 days after their last possible Ebola exposure, including daily communication between health departments and travelers.  Upon initiation of enhanced entry screening, CDC developed the Check and Report Ebola (CARE) program to support screening and monitoring by providing CARE Kits to all screened travelers.  The CARE Kits included instructions and a thermometer to help travelers fulfill monitoring requirements. In November 2014, CDC began CARE+ to augment the CARE Kits and overcome  key challenges identified early on. Examples of challenges included: states reported difficulty in initiating and sustaining contact with  travelers, many travelers who were foreign nationals had unknown or temporary U.S. addresses and no U.S. cellular service, and some travelers expressed uncertainty and anxiety about potential movement restrictions. CARE+ was developed to: increase travelers’ knowledge of Ebola symptoms and how to seek medical care safely; increase travelers’ awareness of monitoring requirements and intentions  to participate in monitoring; remove barriers from participation in monitoring; and increase trust in the U.S. public health system.

Program background:  CARE+ is based on the notion that interpersonal interaction tailored to an individual traveler’s needs and responsive to specific concerns may be more effective than passive communication strategies, especially in a context of uncertainty and anxiety.  The program features CARE Ambassadors, trained health educators and social workers, who engage with travelers after they have been screened at the airport. Ambassadors review the CARE Kit with each traveler, explaining the desired behaviors specified in the Kit including performing daily health checks, connecting with the health department each day, and getting care safely if symptoms develop. All adults and unaccompanied minors also receive a  pre-paid cell phone with at least 21 days of voice and text service, which they are encouraged to use to connect with their health department.  Throughout the encounters, Ambassadors emphasize that by taking the steps outlined in the CARE Kit, travelers can keep themselves and others safe, while reinforcing that early care ensures the best health outcomes, if they should develop symptoms. 

Evaluation Methods and Results: CARE+ is currently being evaluated with preliminary results expected by August. A baseline assessment supports the rationale for CARE+, as travelers were often uncertain about the reason for the screening and monitoring process.

Conclusions:  CARE+ aimed to support  travelers through interpersonal connection and education at a time when much of the public discourse on Ebola was about isolation and fear. CARE+ creates an opportunity for travelers to connect with a credible and personable public health authority who offers reassurance, instructions, and tools for keeping themselves  and others safe.

Implications for research and/or practice:  The successes and challenges experienced during the development and implementation of CARE+ can inform similar programs aimed to prevent introduction and spread of communicable disease through mobile populations.