Interim Guidance on Risk Assessment and Management of Persons with Potential Ebola Virus Exposure

Updates to this guidance

October 7, 2022: Updated to incorporate guidance issued in response to the outbreak of Sudan ebolavirus in Uganda for which health departments are recommended to follow-up with travelers.

Specific updates include:

  • Guidance for monitoring persons with no known high-risk exposures
  • Travel guidance for persons being monitored who have no known high-risk exposures

Key Points

  • If certain triggers are met, CDC may recommend public health risk assessment and post-arrival management of travelers from countries with Ebola virus disease (EVD) outbreaks to mitigate the risk of potential imported cases.
    • Recommendations below reflect guidance issued in response to the 2022 outbreak of Sudan ebolavirus in the Republic of Uganda.
  • For U.S.-based healthcare or emergency response workers returning from EVD outbreak countries, health departments may elect to delegate post-arrival management to the response worker’s sponsoring organizations. CDC has issued separate guidance for this purpose.
    • If monitoring is conducted by a sponsoring organization, it should be in accordance with guidance below.

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 EVD outbreaks

Introduction

If certain triggers are met, CDC may recommend public health risk assessment and post-arrival management of travelers from countries with Ebola virus disease (EVD) outbreaks to mitigate the risk of spread by facilitating early identification and management of potential imported cases. Triggers will be based on various factors including but not limited to the size of the outbreak, the volume of air travel between the outbreak country and the United States, and border health measures implemented in the outbreak country. To facilitate the recommended risk assessment and management, CDC will provide contact information for air passengers from countries with Ebola outbreaks to U.S. health departments.

On September 20, 2022, the Ugandan Ministry of Health confirmed an outbreak of EVD (Sudan virus) in Mubende District, in central Uganda. This guidance provides specific recommendations for post-arrival risk assessment and management of travelers from Uganda as part of the domestic U.S. response to this outbreak.

Definitions

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 designated outbreak areas for which CDC recommends post-arrival risk assessment and management of travelers 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.

Person Under Investigation (PUI) for EVD is defined as on this webpage. 

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.

International Air Passenger Contact Information

CDC will obtain contact information for travelers from countries with Ebola outbreaks and provide it electronically to health departments through established secure mechanisms.

Risk Assessment and Post-arrival Management

Health departments should 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 specified below), 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 a structured 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. If monitoring is conducted by the sponsoring organization, it should be in accordance with guidance below.

Box 1. Designated Ebola Outbreak Areas as of October 7, 2022

See map for designated outbreak area in Uganda.

For questions about potential exposures in individual travelers, including those outside of designated outbreak areas, health departments may contact CDC’s Viral Special Pathogens Branch (VSPB) by calling the Emergency Operations Center (770-488-7100) and asking to speak to VSPB’s on-call epidemiologist, or by emailing spather@cdc.gov.

Box 2. High-risk Exposure Definition
  • 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

1 Body fluids include but are not limited to feces, saliva, sweat, urine, vomit, sputum, breast milk, tears and semen.

2 Recommended PPE should be sufficient to prevent skin or mucous membrane exposure to blood or body fluids.

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 spread of communicable diseases.

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.

Risk Assessment

An initial risk assessment for Ebola virus exposure should include whether the traveler:

  • was present (other than just transiting en route to airport) in a designated 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)

A sample exposure screening and assessment tool is available here. [PDF – 2 pages]

Travelers should also be assessed for signs and symptoms of EVD during the initial evaluation.

Health departments can consult CDC’s Viral Special Pathogens Branch (VSPB, call CDC’s Emergency Operations Center [770-488-7100] and ask to speak to VSPB’s on-call epidemiologist or email spather@cdc.gov) if they identify symptomatic or potentially exposed travelers. CDC requests notification regarding any travelers identified with potential high-risk exposures.

Health Education

Health departments should ensure all travelers from a country with a designated Ebola outbreak know:

  • know the signs and symptoms of EVD
  • to self-isolate immediately if symptoms develop
  • how to notify public health officials should symptoms develop

CDC has posted After Travel recommendations for travelers from countries with Ebola outbreaks (available in English and French). Health departments may choose to use this resource as part of their health education activities.

Monitoring and Other Public Health Interventions

Health departments should 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, as specified below.

High-risk Exposures

People with high-risk exposures (see Box 2) should be:

  • Quarantined
  • 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 on-call epidemiologist for the Viral Special Pathogens Branch, or email spather@cdc.gov. See additional information in the section below.

Presence in a Designated Ebola Outbreak Area but no High-risk Exposures

People who have been  in a designated Ebola  outbreak area (see Box 1) within the previous 21 days should be monitored for symptoms at least twice weekly until 21 days after they departed Uganda.

Presence in Country with Ebola Outbreak but not in Designated Outbreak Area

People who were present in Uganda but not in a designated outbreak area and who have no other epidemiologic risk factors should be monitored at least weekly until 21 days after they departed Uganda.

Travel by People with No Known High-risk Exposures

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 monitoring period, they should notify the monitoring health department. The health department should notify the destination health department (for travel within the United States). 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.

Table. Summary of Post-arrival Management Recommendations for Asymptomatic Travelers by Exposure Category

Table. Summary of Post-arrival Management Recommendations for Asymptomatic Travelers by Exposure Category
Intervention Reported High-risk Exposure Present in Designated Outbreak Area Present in Outbreak Country but not Designated Outbreak Area
Initial Risk Assessment Yes Yes Yes
Health education Yes Yes Yes
Symptom monitoring Daily At least twice weekly until 21 days after departure from Uganda At least weekly until 21 days after departure from Uganda
Movement restrictions Quarantine None None
Travel Not permitted Advance notification to health department and coordination with destination health department Advance notification to health department and coordination with destination health department

Symptomatic people with suspected or confirmed EVD, and asymptomatic travelers with reported high-risk exposures

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.

If a diagnosis of EVD is considered, state/local public health officials should coordinate with CDC to ensure appropriate precautions are taken to help prevent potential spread of EVD and to arrange for testing. As a resource for public health departments, CDC’s Viral Special Pathogens Branch (VSPB) is available 24/7 for consultations regarding suspected viral hemorrhagic fever  or EVD cases by calling the CDC Emergency Operations Center at 770-488-7100 and requesting VSPB’s on-call epidemiologist, or by emailing spather@cdc.gov.

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 asymptomatic persons 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).

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 Quarantine), 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 eocreport@cdc.gov). The aircraft operator should also coordinate with the U.S. embassy or consulate 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.