Ebola monitoring and movement of persons following exposure

Ebola Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Ebola from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Algorithm for the Evaluation of the Returned Traveler
Emergency Department Evaluation
Case Definition
History and Symptoms
Physical Examination
Laboratory Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Hospital Preparedness
Checklists
Air Medical Transport
Monitoring and Movement Following Exposure
Primary Prevention
Future or Investigational Therapies
Postmortem Care
Postmortem Care
Case Studies
Case #1
Ebola monitoring and movement of persons following exposure On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Ebola monitoring and movement of persons following exposure All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Ebola monitoring and movement of persons following exposure
CDC on Ebola monitoring and movement of persons following exposure
Ebola monitoring and movement of persons following exposure in the news
Blogs on Ebola monitoring and movement of persons following exposure
Directions to Hospitals Treating ebola
Risk calculators and risk factors for Ebola monitoring and movement of persons following exposure

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

Early recognition is critical to controlling the spread of Ebola virus. Health care providers should be alert for and evaluate any patients with symptoms consistent with Ebola virus disease (EVD) and potential exposure history. Standard, contact, and droplet precautions should be immediately implemented if EVD is suspected. Both clinical presentation and level of exposure should be taken into account when determining appropriate public health actions, including the need for medical evaluation or monitoring and the application of movement restrictions when indicated.

Active and Direct Active Monitoring

• Active monitoring means that the state or local public health authority assumes responsibility for establishing regular communication with potentially exposed individuals, including checking daily to assess for the presence of symptoms and fever, rather than relying solely on individuals to self-monitor and report symptoms if they develop.
• Direct active monitoring means the public health authority conducts active monitoring through direct observation.

The purpose of active (or direct active) monitoring is to ensure that, if individuals with epidemiologic risk factors become ill, they are identified as soon as possible after symptom onset so they can be rapidly isolated and evaluated. Active (or direct active) monitoring could be either conducted on a voluntary basis or compelled by legal order. Active (or direct active) monitoring and prompt follow-up should continue and be uninterrupted if the person travels out of the jurisdiction.

Active Monitoring

Active monitoring should consist of, at a minimum:

• Daily reporting of measured temperatures and symptoms consistent with Ebola (including severe headache, fatigue, muscle pain, fatigue or weakness, diarrhea, vomiting, abdominal pain, or unexplained hemorrhage) by the individual to the public health authority.
• Temperature should be measured using an FDA-approved thermometer (e.g. oral, tympanic or noncontact).
• People being actively monitored should measure their temperature twice daily, monitor themselves for symptoms, report as directed to the public health authority, and immediately notify the public health authority if they develop fever or other symptoms. *Initial symptoms can be as nonspecific as fatigue.
• Clinical criteria for required medical evaluation according to exposure level have been defined (see Table below), and should result in immediate isolation and evaluation. Medical evaluation may be recommended for lower temperatures or nonspecific symptoms based on exposure level and clinical presentation.

Direct Active Monitoring

For direct active monitoring, a public health authority directly observes the individual at least once daily to:

• Review symptom status and monitor temperature
• A second follow-up per day may be conducted by telephone in lieu of a second direct observation.
• Direct active monitoring should include discussion of plans to work, travel, take public conveyances, or be present in congregate locations. Depending on the nature and duration of these activities, they may be permitted if the individual has been consistent with direct active monitoring (including recording and reporting of a second temperature reading each day), has a normal temperature and no symptoms whatsoever, and can ensure uninterrupted direct active monitoring by a public health authority.

For healthcare workers under direct active monitoring:

• Public health authorities can delegate the responsibility for direct active monitoring to the healthcare facility’s occupational health program or the hospital epidemiologist.
• Facilities may conduct direct active monitoring by performing fever checks on entry or exit from the Ebola treatment unit and facilitate reporting during days when potentially exposed healthcare workers are not working.
• The occupational health program or hospital epidemiologist would report daily to the public health authority.

Controlled Movement

Controlled movement limits the movement of people.

• For individuals subject to controlled movement, travel by long-distance commercial conveyances (e.g., aircraft, ship, bus, train) should not be allowed; if travel is allowed, it should be by noncommercial conveyance such as private chartered flight or private vehicle, and occur with arrangements for uninterrupted active monitoring.
• Federal public health travel restrictions (Do Not Board) may be used to enforce controlled movement. For people subject to controlled movement, use of local public transportation (e.g., bus, subway) should be discussed with and only occur with approval of the local public health authority.

Isolation

Isolation means the separation of an individual or group who is reasonably believed to be infected with a quarantinable communicable disease from those who are not infected to prevent spread of the quarantinable communicable disease. An individual could be reasonably believed to be infected if he or she displays the signs and symptoms of the quarantinable communicable disease of concern and there is some reason to believe that an exposure had occurred.

Quarantine

Quarantine in general means the separation of an individual or group reasonably believed to have been exposed to a quarantinable communicable disease, but who is not yet ill (not presenting signs or symptoms), from others who have not been so exposed, to prevent the possible spread of the quarantinable communicable disease.

Use of Public Health Orders

Equitable and ethical use of public health orders includes supporting and compensating persons who make sacrifices in their individual liberties and freedoms for public good. Specifically, considerations must be in place to provide shelter, food and lost wage compensation, and to protect the dignity and privacy of the individual. Persons under public health orders should be treated with respect and dignity. Considerable thoughtful planning is needed to implement public health orders properly.

Postexporure Management

Postexposure management among patients with close contact to Ebola may include:

• Conditional release
• Controlled movement
• Self-monitoring

Close contact is defined as:

• Being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or care area for a prolonged period of time (e.g., health care personnel, household members) while not wearing recommended personal protective equipment (i.e., standard, droplet, and contact precautions); or
• Having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended personal protective equipment.

• Brief interactions, such as walking by a person or moving through a hospital, do not constitute close contact.

Conditional Release

Conditional release means that people are monitored by a public health authority for 21 days after the last known potential Ebola virus exposure to ensure that immediate actions are taken if they develop symptoms consistent with EVD during this period. People conditionally released should self-monitor for fever twice daily and notify the public health authority if they develop fever or other symptoms.

Controlled Movement

Controlled movement requires people to notify the public health authority about their intended travel for 21 days after their last known potential Ebola virus exposure. These individuals should not travel by commercial conveyances (e.g. airplane, ship, long-distance bus, or train). Local use of public transportation (e.g. taxi, bus) by asymptomatic individuals should be discussed with the public health authority. If travel is approved, the exposed person must have timely access to appropriate medical care if symptoms develop during travel. Approved long-distance travel should be by chartered flight or private vehicle; if local public transportation is used, the individual must be able to exit quickly.

Quarantine

Quarantine is used to separate and restrict the movement of persons exposed to a communicable disease who don’t have symptoms of the disease for the purpose of monitoring.

Self-Monitoring

Self-monitoring means that people check their own temperature twice daily and monitor themselves for other symptoms.

Early Recognition and Reporting of Suspected Ebola Virus Exposures

Early recognition is critical to controlling the spread of Ebola virus. Health care providers should be alert for and evaluate any patients with symptoms consistent with EVD and potential exposure history. Standard, contact, and droplet precautions should be immediately implemented if EVD is suspected. Both clinical presentation and level of exposure should be taken into account when determining appropriate public health actions, including the need for medical evaluation or monitoring and the application of movement restrictions when indicated.

Recommendations for Evaluating Exposure Risk to Determine Appropriate Public Health Actions

Exposure Level	Clinical Criteria	Public Health Actions
High Risk Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of EVD patient Direct skin contact with, or exposure to blood or body fluids of, an EVD patient without appropriate personal protective equipment (PPE) Processing blood or body fluids of a confirmed EVD patient without appropriate PPE or standard biosafety precautions Direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is occurring	Fever OR other symptoms consistent with EVD without fever	Consideration as a probable case Medical evaluation using infection control precautions for suspected Ebola, consultation with public health authorities, and testing if indicated If air transport is clinically appropriate and indicated, only air medical transport (no travel on commercial conveyances permitted) If infection control precautions are determined not to be indicated: conditional release and controlled movement until 21 days after last known potential exposure
	Asymptomatic	* Conditional release and controlled movement until 21 days after last known potential exposure
Some Risk of Exposure Household contact with an EVD patient Other close contact with an EVD patient in health care facilities or community settings	Fever WITH OR WITHOUT other symptoms consistent with EVD	Consideration as a probable case Medical evaluation using initial infection control precautions for suspected Ebola, consultation with public health authorities, and testing if indicated If air transport is clinically appropriate and indicated, air medical transport only (no travel on commercial conveyances permitted) If infection control precautions are determined not to be indicated: Conditional release and controlled movement until 21 days after last known potential exposure
	Asymptomatic or clinical criteria not met	Conditional release and controlled movement until 21 days after last known potential exposure
No Known Exposure Having been in a country in which an EVD outbreak occurred within the past 21 days and having had no exposures	Fever WITH other symptoms consistent with EVD	Consideration as a person under investigation (PUI) Medical evaluation and optional consultation with public health authorities to determine if movement restrictions and infection control precautions are indicated If movement restrictions and infection control precautions are determined not to be indicated: travel by commercial conveyance is allowed; self-monitor until 21 days after leaving country
	Asymptomatic or clinical criteria not met	No movement restrictions Travel by commercial conveyance allowed Self-monitor until 21 days after leaving country