Interim Guidance on Risk Assessment and Management of Persons with Potential Ebola Virus Exposure
Guidance was updated March 10, 2021, to emphasize that health departments may choose to delegate risk assessment and post-arrival management to organizations sending U.S.-based healthcare or emergency response workers to areas with Ebola outbreaks, as described in separate CDC guidance.
- CDC is recommending risk assessment and post-arrival management of travelers from countries with Ebola outbreaks to mitigate the risk of potential imported cases.
- To facilitate the recommended management, CDC will provide contact information for air passengers from Guinea and the Democratic Republic of the Congo (DRC) to U.S. health departments.
Who is this guidance for?
- State, territorial, tribal, and local health departments
What is the purpose of this guidance?
- To provide U.S. health departments minimum expectations and guidance for post-arrival management of travelers arriving in their jurisdictions from countries with Ebola outbreaks
Outbreaks of Ebola virus disease (EVD) have been identified in Guinea and DRC. While the risk of case importation via international air travel is generally thought to be low, the potential consequences of even one importation in the context of the ongoing coronavirus 2019 (COVID-19) pandemic could further stress already strained healthcare systems and erode public confidence, creating an outsized impact on public health efforts. For this reason, CDC is issuing interim guidance for U.S. state, territorial, tribal, and local health departments to help them assess exposure risk and appropriately manage travelers from Guinea and DRC who are arriving in their jurisdictions.
Ebola outbreak area means a geographic area where Ebola virus transmission has occurred in the previous 42 days, as determined by surveillance conducted by national health authorities, NGOs, and the World Health Organization (WHO). The list of outbreak areas will be maintained according to available information (Box 1). CDC will notify health departments of any changes to the list.
Close contact means being within approximately 3 feet (1 meter) of a person with symptomatic EVD while not wearing recommended personal protective equipment (PPE).
Direct contact means physical contact with a person with EVD (alive or dead) or with objects contaminated with the body fluids of a person with EVD (alive or dead) while not wearing recommended PPE.
Public health orders are legally enforceable directives issued under the authority of a relevant federal, state, or local entity that, when applied to a person or group, may place restrictions on the activities undertaken by that person or group, potentially including movement restrictions or a requirement for monitoring by a public health authority, for the purposes of protecting the public’s health. Federal public health orders may be issued to enforce isolation, quarantine or conditional release. The list of quarantinable communicable diseases for which federal public health orders are authorized is defined by Executive Order and includes EVD.
Isolation means the separation of a person or group of people reasonably believed to be infected with a communicable disease and potentially infectious from those who are not infected to prevent spread of the communicable disease. A person could be reasonably believed to be infected if he or she displays the signs or symptoms of the communicable disease of concern and there is some reason to believe that an exposure had occurred. Isolation for public health purposes may be voluntary or compelled by federal, state, or local public health order.
Quarantine in general means the separation of a person or group of people reasonably believed to have been exposed to a communicable disease but not yet symptomatic from others who have not been so exposed to prevent the possible spread of the communicable disease.
On March 2, 2021, CDC issued an Order requiring airlines and other aircraft operators to collect and transmit to CDC contact information for passengers who were in DRC or Guinea within the 21 days before their arrival in the United States. This Order is effective as of March 4, 2021. CDC will provide this information electronically to health departments through established secure mechanisms to facilitate risk assessment and post-arrival management of travelers.
CDC recommends that health departments establish contact with travelers arriving in their jurisdictions from a country with an Ebola outbreak to conduct an initial assessment of exposure risk, provide health education, conduct symptom monitoring (as indicated), and track overall success in monitoring incoming travelers, according to resources available in the jurisdiction. The initial assessment should occur as soon as feasible, ideally within 24 hours of receiving CDC’s notification of the traveler’s arrival. A summary of these recommendations is provided in the table below.
CDC has issued separate guidance for organizations sending US-based healthcare or emergency response workers to areas with Ebola outbreaks, including recommendations for pre-departure assessment and post-arrival management. Health departments that maintain contact with these organizations may elect to accept risk assessment and/or monitoring of these workers by the sponsoring organization; they may also request updates from the sponsoring organization or assume direct responsibility for risk assessment and/or monitoring of these workers.
- North Kivu Province
- N’Zérékoré Prefecture
For questions about potential exposures in individual travelers, including those outside of the defined outbreak areas, please contact CDC’s Emergency Operations Center (770-488-7100) and ask to speak to the officer on call for Viral Special Pathogens.
- Percutaneous (i.e., piercing the skin), mucous membrane (e.g., eye, nose or mouth), or skin contact with blood or body fluids1 of a person with known or suspected EVD
- Direct contact with person who has known or suspected EVD
- Providing health care to a patient with known or suspected EVD without use of recommended personal protective equipment (PPE)2, or experiencing a breach in infection control precautions that results in the potential for percutaneous, mucous membrane, or skin contact with the blood or body fluids of a patient with EVD while working in an Ebola treatment hospital or associated facility (e.g., laboratory) or while taking care of a patient with EVD
- Direct contact with or the occurrence of a breach in infection control precautions while handling a dead body in an Ebola outbreak area, the body of a person who died of EVD or had an illness compatible with EVD, or who died of unknown cause after any potential exposure to Ebola virus
- Living in the same household as a person with symptomatic known or suspected EVD
State and local authorities have primary jurisdiction for isolation and other public health orders within their borders. Federal public health authority primarily extends to international arrivals at ports of entry and to preventing interstate communicable disease threats.
CDC recognizes that decisions and criteria to use such public health measures may differ by jurisdiction. Consistent with principles of federalism, state and local jurisdictions may choose to make decisions about isolation, other public health orders, and monitoring that provide a greater level of public health protection than recommended in federal guidance.
An initial risk assessment for Ebola virus exposure should include whether the traveler:
- was present (other than just transiting en route to airport) in an Ebola outbreak area (see Box 1)
- had any epidemiologic risk factors for exposure to Ebola virus or a person with EVD, e.g., as a caregiver, healthcare provider, laboratory worker, or burial worker
- used personal protective equipment and other recommended infection control measures during any potential exposure
- had any potential high-risk exposures (see Box 2)
Travelers should also be assessed for signs and symptoms of EVD during the initial encounter.
Health departments should ensure all travelers from a country with an Ebola outbreak know:
- how to monitor themselves for signs and symptoms of EVD
- to self-isolate immediately if symptoms develop
- how to notify public health officials should symptoms develop
Monitoring and Other Public Health Interventions
At this time, CDC is recommending that health departments conduct symptom monitoring for people with potential Ebola virus exposure by phone, video conferencing, other electronic means (e.g., text message, email, app, web form), or in person, according to resources available in that jurisdiction. The frequency of monitoring should be guided by the results of the risk assessment.
People with high-risk exposures (see Box 2) should be:
- Monitored daily
- Restricted from traveling by commercial transport
CDC requests notification regarding any individuals identified with high-risk exposures. To make these notifications, health departments should call CDC’s Emergency Operations Center (770-488-7100) and ask to speak to the officer on call for Viral Special Pathogens. See additional information in the section below.
Presence in an Ebola Outbreak Area but no High-risk Exposures
At a minimum, people who have been within the previous 21 days in an Ebola outbreak area (see Box 1) should be monitored for symptoms at the following time points:
- midway through the 21-day period, and
- at the conclusion of the 21-day period.
Health departments with access to electronic methods such as web forms, mobile applications, or automated text messaging may wish to consider more frequent monitoring, according to available resources.
People who are being monitored, have no high-risk exposures, and are asymptomatic do not need movement restrictions and may travel. If they plan to travel to another jurisdiction during the 21-day period, they should notify the monitoring health department. Health departments should determine if notification of another health department is needed (for travel within the United States). If notification is made, the two health departments should agree as to whether responsibility for monitoring will be transferred, depending on the timing within the 21-day period and the duration of travel.
Presence in Country with Ebola Outbreak but not in Outbreak Area
People who were not in outbreak area and who have no other epidemiologic risk factors may be allowed to self-monitor. Health departments may consider a single follow-up at the end of the 21-day period, at the discretion of the health department according to available resources. These people may travel; prior notification to the health department is at health department’s discretion.
|Intervention||High-risk||Present in Outbreak Area||Present in Outbreak Country but not Outbreak Area|
|Initial Risk Assessment||Yes||Yes||Yes|
||End of 21-day period, optional at health department’s discretion|
|Travel||Not permitted||Permitted with advance notification to health department||No restrictions|
Health departments should conduct an assessment of any potentially exposed person with signs or symptoms compatible with EVD to determine if the definition for person under investigation (PUI) for EVD is met and coordinate additional medical evaluation as needed. The purpose of the public health assessment is to ensure appropriate infection control precautions are in place during transport and at the healthcare facility for a patient who meets the definition of PUI for EVD. The assessment is also intended to minimize potential unintended consequences in managing a symptomatic traveler as a PUI if the exposure risk is very low, including unnecessary implementation of infection control precautions suitable for EVD or delayed recognition and management of other potentially life-threatening conditions while ruling out EVD. CDC has published clinical guidance for assessing viral hemorrhagic fever risk in an international traveler.
Symptomatic people with suspected or confirmed EVD should remain in isolation until they have been determined not to have EVD (if suspected) or to be no longer infectious (if confirmed). Asymptomatic people with high-risk exposures to Ebola virus (see Box 2) should remain in quarantine until 21 days after their last high-risk exposure. Quarantine or isolation may be voluntary or under public health orders, at the discretion of the health department of jurisdiction. Health departments may request use of federal public health travel restrictions for individuals with suspected or confirmed EVD or with high-risk exposure, if they intend to travel before being cleared to do so by public health authorities, by contacting the CDC quarantine station with jurisdiction for the area where the person is located.
People with suspected (i.e., meets PUI definition) or confirmed EVD, and those with high-risk exposures, are not permitted to travel by commercial transport until cleared by public health officials. If travel is necessary (e.g., to obtain medical care that is not available locally), transportation should be conducted in a manner that does not expose operators (e.g., air crews, bus drivers) or other travelers. The mode of transportation (e.g., ground vs. air transportation) should be determined by distance to final destination as well as the clinical condition of the traveler (i.e., whether medical care may be needed en route).
- People with suspected or confirmed EVD should be transported only by medical transport (i.e., ground or air ambulance) with infection control precautions in place to protect medical personnel.
- CDC has issued separate guidance for air medical transport for patients with suspected or confirmed EVD.
- For more information on developing interfacility transport plans see: Guidance for Developing a Plan for Interfacility Transport of Persons Under Investigation or Confirmed Patients with Ebola Virus Disease in the United States
- Options for transport of asymptomatic people with a high-risk exposure to Ebola virus are private vehicle or chartered or private aircraft with precautions in place to protect air crews.
For international air transport of a person with suspected or confirmed EVD or high-risk exposure to a destination within the United States, per CDC regulations (42 Code of Federal Regulations, Part 71: Foreign Quarantineexternal icon), the aircraft operator must notify CDC in advance through the CDC quarantine station with jurisdiction for the port of entry or the CDC Emergency Operations Center (770-488-7100 or email@example.com). The aircraft operator should also coordinate with the U.S. embassy or consulateexternal icon for the country where the individual is located, CDC, the Federal Aviation Administration, and U.S. Customs and Border Protection, as well as appropriate foreign, state, local, territorial, and tribal governments to ensure compliance with all applicable laws and regulations.