Recommendations for Organizations: Ebola Disease or Marburg Virus Disease Outbreaks

Recommendations for organizations sending U.S.-based healthcare or emergency response workers to areas with Ebola disease or Marburg virus disease (MVD) outbreaks and predeparture assessment and post-arrival management of any workers traveling from Ebola disease or MVD outbreak areas to the United States

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While this guidance applies specifically to Ebola disease and Marburg virus disease, recommendations for management of people with high-risk exposures and requirements for travel to the United States apply to other viral hemorrhagic fevers* and should be followed in any situation where the organization knows or suspects that a worker is infected with, or has experienced a high-risk exposure to, one of these viruses. Organizations should maintain awareness of endemic infectious disease risks as well as outbreaks occurring in countries where they are deploying workers; destination-specific information is available on CDC’s Travelers’ Health website.

*Lassa, Crimean Congo Hemorrhagic Fever (CCHF) and the South American Hemorrhagic Fevers (i.e., those caused by Junin, Machupo, Chapare, Guanarito and Sabia viruses). Note, for Crimean Congo Hemorrhagic Fever, management should continue until 14 days after the last known high-risk exposure.

Updates to this guidance

April 13, 2023

Generalized guidance to additionally apply to Marburg virus disease outbreaks

Aligned to updated guidance for health departments

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Key Points

  • CDC recommends that organizations sending U.S.-based workers to areas with Ebola disease or MVD outbreaks ensure the health and safety of those workers before, during, and after their deployment.
  • Pre-deployment recommendations include educating workers about Ebola disease and MVD, travel vaccines, healthy behaviors, personal protective equipment, and travel insurance.
  • During-deployment recommendations include remaining in contact with all workers, periodically asking about any symptoms of Ebola disease or MVD or exposures to ebolaviruses or marburgviruses, and contacting in advance the U.S. state or local health departments that have jurisdiction in the areas where workers will be staying after arrival in the United States.
  • Predeparture health and exposure assessment is recommended for all workers in an outbreak area who are traveling to the United States. The scope of the assessment should be determined by the degree of potential occupational risk (see definitions below).
  • Post-deployment recommendations include staying in contact with all workers for 21 days after they leave the outbreak area (while they self-monitor for symptoms of Ebola disease or MVD) and conducting symptom monitoring at certain time points during the 21-day monitoring period.

Audience

Audiences for this document include:

  • Organizations such as nongovernmental, faith-based, academic, or aid organizations that send U.S.-based workers (employees, contractors, or volunteers) to areas where Ebola disease or MVD outbreaks are occurring.
  • Organizations whose non-U.S.-based workers, such as locally employed personnel or U.S. expatriates working in the outbreak area, intend to travel to the United States during the 21 days after departure from the outbreak area.

Definitions

High-risk exposures are defined below.

For the purpose of these recommendations:

Workers with higher potential occupational health risk include those assigned to occupational roles listed below as situations with additional exposure potential.

Workers with lower potential occupational risk include those whose routine activities are unlikely to result in exposure to a person with Ebola disease or MVD or to ebolavirus- or marburgvirus-contaminated body fluids, such as epidemiologists, contact tracers, emergency operations center workers, logisticians, and airport screeners.

Organization Responsibilities Before, During, and After Worker Travel to Ebola disease or MVD Outbreak Areas

Pre-deployment: Before Workers Travel to Outbreak Areas

Workers providing clinical care or testing patient specimens in non-Ebola disease or MVD outbreak settings in an area where ebolaviruses or marburgviruses are spreading may encounter patients (or specimens from patients) with undiagnosed ebolavirus or marburgvirus infections. In such situations, workers may be at high risk of exposure if they don’t recognize the potential risk and take steps, including using appropriate personal protective equipment (PPE), to protect themselves.

Remind healthcare workers in an Ebola disease or MVD outbreak area about the importance of remaining vigilant for patients with acute febrile illnesses and following appropriate procedures for isolation, testing, and notification of public health officials. Remind laboratory workers to follow routine safety protocols to avoid exposure to clinical specimens.

  • Educate all workers about exposure risks for ebolaviruses and marburgviruses, symptoms of Ebola disease or MVD, and the importance of monitoring themselves for fever and other symptoms during travel while in the outbreak area and for 21 days after leaving the outbreak area. Provide information about whom a worker should contact in the event of an exposure or if symptoms develop.
  • Encourage all workers to get routine and destination-specific vaccines, including cholera and yellow fever vaccines, before travel, to follow precautions (including food and water precautions) to stay healthy and safe during travel, and to take steps to avoid malaria (including preventing mosquito bites and taking preventive medication, when indicated) and other infectious diseases.
  • The Advisory Committee on Immunization Practices (ACIP) recommends pre-exposure prophylaxis vaccination with rVSVΔG-ZEBOV-GP (Ervebo™) for adults ≥ 18 years of age in the U.S. population who are at highest risk for potential occupational exposure to Ebola virus (species Zaire ebolavirus). These include personnel responding to (or planning to respond to) Ebola virus (species Zaire ebolavirus)
    • rVSVΔG-ZEBOV-GP is safe and protects against Ebola virus (species Zaire ebolavirus), which has caused the largest and most deadly Ebola disease outbreaks to date. The vaccine does not protect against other ebolaviruses or marburgviruses. For prescribing information and detailed instructions on how to order rVSVΔG-ZEBOV-GP vaccine from the CDC, see Ebola Vaccine: Information for U.S. Healthcare Providers.
  • Arrange for or help all workers obtain travel health and medical evacuation insurance. Everyone traveling to the outbreak area should have full health insurance coverage, including coverage for emergency medical evacuation.
  • Ensure workers with higher potential occupational risk of exposure to ebolaviruses or marburgviruses have access to appropriate personal protective equipment (PPE). Provide training on the correct use of PPE and other infection control measures to prevent the spread of Ebola disease or MVD.

During Deployment: While Workers’ Are Present in Outbreak Areas

  • Remain in contact with all workers throughout their stay. Periodically ask about symptoms and potential exposures.
  • Ensure all workers are aware that CDC will not allow anyone to travel to the United States unless the travel is part of a coordinated medical evacuation, if they:
    • have confirmed ebolavirus or marburgvirus infection, until they are determined by health authorities to be no longer infectious;
    • had a high-risk ebolavirus or marburgvirus exposure (i.e., without use of appropriate and effective PPE) in the previous 21 days, even if they are asymptomatic; or
    • Have symptoms compatible with Ebola disease or MVD and history of any nonhigh-risk ebolavirus or marburgvirus exposure in the previous 21 days, unless they are medically assessed and determined not to have Ebola disease or MVD.
  • Coordinate with the nearest U.S. embassy and local health officials (country’s ministry of health) to facilitate timely medical evaluation and care of any symptomatic workers.
  • Contact CDC to discuss management of workers with high-risk exposures to ebolaviruses or marburgviruses and, if necessary, to coordinate safe return travel, of symptomatic or exposed U.S.-based workers.
High-risk Exposure Definition
  • Percutaneous (i.e., piercing the skin), mucous membrane (e.g., eye, nose or mouth), or skin contact with blood or other body fluids1 of a person with known or suspected Ebola disease or Marburg virus disease (MVD)
  • Direct contact with person who has known or suspected Ebola disease or MVD
  • Providing health care to a patient with known or suspected Ebola disease or MVD 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 other body fluids of a patient with Ebola disease or MVD while working in an Ebola disease or MVD treatment unit or associated facility (e.g., laboratory) or while taking care of a patient with Ebola disease or MVD
  • Direct contact with, or the occurrence of a breach in infection control precautions while handling, a dead body in an Ebola disease or MVD outbreak area, the body of a person who died of Ebola disease or MVD or had an illness compatible with Ebola disease or MVD, or who died of unknown cause after any potential exposure to an ebolavirus or marburgvirus
  • Living in the same household as a person with symptomatic known or suspected Ebola disease or MVD

1Body fluids include but are not limited to feces, saliva, sweat, urine, vomit, sputum, breast milk, tears, and semen.
2Recommended PPE should be sufficient to prevent skin or mucous membrane exposure to blood or body fluids. 

Situations with Additional Exposure Potential

The following situations have potential for unrecognized ebolavirus or marburgvirus exposures and should be taken into account in the assessment of people who have been in an area affected by an Ebola disease or Marburg virus disease (MVD) outbreak in the previous 21 days but have no reported high-risk exposures.

Nonoccupational

  • Visiting a health care facility or traditional healer in an outbreak area
  • Attending a funeral or burial in an outbreak area

Occupational1

  • Providing health care or environmental cleaning in an Ebola disease or MVD treatment unit (E/MTU)
  • Entry into a patient care area of an E/MTU for any other reason
  • Providing health care in an outbreak area to acutely ill patients not known to have Ebola disease or MVD
  • Environmental cleaning in a non-E/MTU healthcare facility in an outbreak area
  • Clinical laboratory work associated with an E/MTU or other health care setting in an outbreak area
  • Burial work in an outbreak area

1These occupational exposure situations assume correct and consistent use of personal protective equipment (PPE). Correct and consistent use of PPE during situations with occupational exposure risk is highly protective and prevents transmission to healthcare or other personnel.  However, unrecognized errors during the use of PPE (e.g., self-contaminating when removing contaminated PPE) may create opportunities for transmission to personnel.

Predeparture: Before Workers Depart from Outbreak Areas and Travel to the United States

  • For workers with lower potential occupational risk based on assigned duties, conduct a limited pre-departure assessment that confirms the following:
    • Occupational activities did not change in a way that could increase the risk of ebolavirus or marburgvirus exposure
    • Worker had no known high-risk ebolavirus or marburgvirus exposures or to a person with signs and symptoms of Ebola disease or MVD in the previous 21 days
    • Worker does not report any situations with additional exposure potential (see nonoccupational situations)
    • Worker has no signs or symptoms of Ebola disease or MVD
  • For workers with higher potential occupational risk:
    • Ensure workers undergo a comprehensive exposure and health assessment before travel to the United States. Incorporate this activity into existing occupational health and safety protocols. See additional information and template tools below.
  • See additional guidance below for any workers identified with high-risk exposures or signs and symptoms of Ebola disease or MVD.
  • For all workers, contact the U.S. state, local and territorial health departments that have jurisdiction in the areas where workers will stay during their 21-day monitoring period after leaving the outbreak area. CDC can help establish the initial contact between your organization and the health departments.
    • Establish points of contact between your organization, health departments of jurisdiction, and returned workers.
    • Work with the health departments to develop processes for medical evaluation of workers exhibiting signs and symptoms of Ebola disease or MVD. Processes should include information about whom the worker should call first and expected next steps in evaluating the worker.

CDC recommends that workers self-monitor for 21 days after leaving an Ebola disease or MVD outbreak area with additional monitoring by their employer or sponsoring organization. However, U.S. state and local health departments have the authority to determine how they want monitoring conducted within their jurisdiction. Health departments may elect to accept risk assessment and/or monitoring 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. CDC has provided separate interim guidance for health departments.

Post-deployment: After Workers Depart from the Outbreak Area

  • Ensure workers self-monitor for signs and symptoms of Ebola disease or MVD for 21 days after leaving the outbreak area and know how to reach the organization and their health department if they become symptomatic.
  • Intermittently monitor workers with higher potential occupational risk, and those who report nonoccupational situations with additional exposure potential, for symptoms at a minimum at the following time points:
    • After arrival in the United States,
    • Midway through their 21-day monitoring period, and
    • At the conclusion of their 21-day monitoring period.
  • For workers with lower potential occupational health risk and no reports of nonoccupational situations with additional exposure potential, conduct a single follow-up at the end of the 21-day period to confirm the outcome of self-monitoring.
  • Monitoring may be conducted by phone, video conferencing, other electronic means (e.g., text message, email, app, web form), or in person, according to resources available.
  • Ensure that returned healthcare personnel who intend to provide care to patients in U.S. healthcare facilities during their 21-day monitoring period first notify the facility’s infection control or occupational health professional of their recent travel and self-monitoring activities.
  • Notify the state or local health department immediately if any worker located in the United States develops symptoms during the 21-day monitoring period. Health departments are responsible for coordinating a rapid and safe medical evaluation.
  • Notify state and local health departments of a worker’s travel plans during the 21-day monitoring period, including if a worker intends to relocate to another state or leave the United States.
    • For interstate travel, the state or local health department of jurisdiction will decide if health departments at the new destination need notification, based on the timing within the 21-day monitoring period and duration of travel.
  • If workers intend to deploy to another country within 21 days after leaving the outbreak area for the purpose of providing humanitarian aid, notify the ministry of health of the destination country in advance of their arrival.

Comprehensive Predeparture Exposure and Health Assessment for Workers with Higher Potential Occupational Risk Traveling from Ebola disease or MVD Outbreak Areas to the United States

Before workers with higher potential occupational risk (as described above) travel from Ebola disease or MVD outbreak areas to the United States, assess them for signs and symptoms compatible with Ebola disease or MVD and for possible high-risk ebolavirus or marburgvirus exposures.

CDC recommends a predeparture exposure and health assessment for the following reasons:

  • To prevent the public health consequences of importing a case of Ebola disease or MVD to the United States
  • To prevent workers who are infectious with Ebola disease or MVD from traveling by commercial airline

At a minimum, the predeparture assessment should include the following:

  • Careful assessment for potential ebolavirus or marburgvirus exposures
  • Review of signs and symptoms compatible with Ebola disease or MVD
  • Determination that the worker appears well
  • Oral temperature measurement

Conduct the exposure assessment after the last possible occupational exposure, and the health assessment within 24-36 hours of departure. For workers in an Ebola disease or MVD treatment unit (E/MTU), CDC recommends the E/MTU’s safety officer complete the exposure assessment and the organization’s medical supervisor complete the health assessment. Workers outside health care settings can complete their own exposure assessments for review by the organization’s medical supervisor; the medical supervisor should perform the health assessment.

CDC has developed template tools (Workers in E/MTUs (print only) [PDF – 3 pages]) and Workers in non-E/MTU settings (print only) [PDF – 3 pages] that organizations can choose to use or modify to help structure the comprehensive predeparture assessment. Organizations may also opt to develop their own forms.

While CDC does not request copies of predeparture assessment forms, it does recommend that both the sponsoring organization and the returning worker retain the documentation, in case it is requested by the state or local health department where the worker resides or is located.

Symptomatic or Exposed U.S. Workers Located Overseas

CDC is available to provide consultation to organizations that identify

Illness compatible with Ebola disease or MVD includes elevated body temperature (≥100.4°F or 38°C), subjective fever, or signs or symptoms of Ebola disease or MVD, including severe headache, fatigue, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained bruising or bleeding.

CDC prohibits travel to, within, or from the United States by commercial airline of any person with confirmed ebolavirus or marburgvirus infection until they are determined by health authorities to be no longer infectious; any person with known high-risk ebolavirus or marburgvirus exposure in the previous 21 days, even if the person is asymptomatic; or any person with symptoms compatible with Ebola disease or MVD and history of nonhigh-risk ebolavirus or marburgvirus exposure in the previous 21 days, unless they are medically assessed and determined not to have Ebola disease or MVD. CDC will assess such situations case by case and, if necessary, may use federal public health travel restrictions to safeguard the public’s health.

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 ebolavirus or marburgvirus infection 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 viral hemorrhagic fevers.

Options for transport of asymptomatic people with a high-risk exposure to an ebolavirus or marburgvirus 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 ebolavirus or marburgvirus infection 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 Port Health 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 and health authorities 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, tribal, local, and territorial governments to ensure compliance with all applicable laws and regulations.

CDC will support organizations or workers in requesting assistance from the U.S. Department of Health and Human Services and the U.S. Department of State for noncommercial transport to the United States. CDC can also facilitate communications with U.S. jurisdictions as needed.

Contacting CDC

For urgent consultations regarding symptomatic or potentially exposed workers, please call the CDC Emergency Operations Center (available 24/7) at 770-488-7100 and ask to speak to the on-call epidemiologist for the Viral Special Pathogens Branch (VSPB). Consultations to VSPB can also be made by emailing spather@cdc.gov.

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