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Notes on the Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure

During the 2014 Ebola epidemic, CDC issued Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure to assist CDC staff and public health partners engaged in the response. The guidance provided public health authorities and partners with recommendations for monitoring people potentially exposed to Ebola and for evaluating their intended travel, including the application of movement restrictions when indicated.

The initial version (August 2014) recommended self-monitoring for most exposures, and controlled movement for higher risk exposures, with the goal of applying the least-restrictive measures necessary to protect communities and travelers. In October 2014, CDC issued revised guidance in response to increased concerns related to imported Ebola cases, infections in healthcare workers, and travel by an infected healthcare worker on commercial flights during October 2014.

Updating the guidance provided a way for CDC to balance external appeals for strict measures, such as travel bans and movement restrictions for healthcare workers, with the need for continued support to the affected region. The revised guidance shifted responsibility for monitoring travelers and other potentially exposed people to public health authorities, rather than relying on these people to monitor themselves. And while the guidance established a baseline standard, states had the authority to apply restrictions that exceeded CDC’s recommendations. Post-arrival monitoring of travelers by health departments (active monitoring) and a higher standard of monitoring for healthcare workers (direct active monitoring that included daily direct observation by public health officials) served as alternatives to more stringent measures.

From August 2014 –December 2015, the guidance was accessed online approximately 334,000 times, with more than 88,000 views during the first 4 days after the October 2014 update. Updates to the guidance continued through 2015 to accommodate new information and changes in the outbreak situation.

The guidance formed a critical cornerstone of CDC’s Ebola response by providing a framework for managing risk in a defined population, and establishing uniform standards on which federal partners, state public health authorities, and other stakeholders could base their own policies. It addressed stakeholder concerns and mitigated risk to communities and travelers without unnecessarily restricting individual liberties. The concepts of the guidance were foundational to many subsequent guidance documents developed for the 2014 Ebola response (such as those for schools, colleges, and universities; humanitarian aid workers and organizations; and clinicians), and its principles were adopted by other national health authorities and international organizations. In addition, CDC has used these principles to develop similar guidance for other communicable diseases that threaten public health, such as Middle East respiratory syndrome and novel influenza.

The Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure was specific to the 2014 Ebola epidemic. The widespread transmission that occurred in the three most affected countries (Guinea, Liberia, and Sierra Leone) in West Africa and the epidemic’s designation as a public health emergency of international concern necessitated the development of guidance to address public health concerns uniquely related to the situation. The guidance was retired on February 19, 2016, when more than 45 days had passed since Guinea was declared free of Ebola virus transmission, because widespread human-to-human transmission was at an end. Although most Ebola outbreaks will not require such extensive measures, CDC will consider the need for similar guidance during future outbreaks based on the situation, taking into account the extent of the outbreak and the risk of importation and spread of disease into the United States.