Ebola monitoring and movement of persons following exposure

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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.

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 Category	Clinical Criteria	Public Health Actions
High Risk Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of a person with Ebola while the person was symptomatic Exposure to the blood or body fluids (including but not limited to feces, saliva, sweat, urine, vomit, and semen) of a person with Ebola while the person was symptomatic 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 with widespread Ebola virus transmission Having lived in the immediate household and provided direct care to a person with Ebola while the person was symptomatic	Fever (subjective fever or measured temperature ≥ 100.4 °F or 38 °C) OR any of the following: Severe headache Muscle pain Vomiting Diarrhea Stomach pain Unexplained bruising or bleeding	Implement rapid isolation with immediate contact of public health authorities to arrange for safe transport to an appropriate healthcare facility for Ebola evaluation Medical evaluation is required Isolation orders may be used to ensure compliance Air travel is permitted only by air medical transport If medically evaluated and discharged with a diagnosis other than Ebola, conditions as outlined for asymptomatic individuals in this exposure category will apply
	Asymptomatic (no fever or other symptoms consistent with Ebola)	Direct active monitoring Public health authority will ensure, through orders as necessary, the following minimum restrictions: Controlled movement: exclusion from all long-distance and local public conveyances (aircraft, ship, train, bus and subway) Exclusion from public places (e.g., shopping centers, movie theaters), and congregate gatherings Exclusion from workplaces for the duration of the public health order, unless approved by the state or local health department (telework is permitted) Non-congregate public activities while maintaining a 3-foot distance from others may be permitted (e.g., jogging in a park) Federal public health travel restrictions (Do Not Board) will be implemented to enforce controlled movement If travel is allowed, individuals are subject to controlled movement Travel by noncommercial conveyances only Coordinated with public health authorities at both origin and destination Uninterrupted direct active monitoring
Some Risk of Exposure In countries with widespread Ebola virus transmission: direct contact while using appropriate PPE with a person with Ebola while the person was symptomatic Close contact in households, healthcare facilities, or community settings with a person with Ebola while the person was symptomatic Close contact is defined as being for a prolonged period of time while not wearing appropriate PPE within approximately 3 feet (1 meter) of a person with Ebola while the person was symptomatic	Fever (subjective fever or measured temperature ≥ 100.4 °F or 38 °C) OR any of the following: Severe headache Muscle pain Vomiting Diarrhea Stomach pain Unexplained bruising or bleeding	Implement rapid isolation with immediate contact of public health authorities to arrange for safe transport to an appropriate healthcare facility for Ebola evaluation Medical evaluation is required Isolation orders may be used to ensure compliance Air travel is permitted only by air medical transport If medically evaluated and discharged with a diagnosis other than Ebola, conditions as outlined for asymptomatic individuals in this exposure category will apply
	Asymptomatic (no fever or other symptoms consistent with Ebola)	Direct active monitoring The public health authority, based on a specific assessment of the individual’s situation, will determine whether additional restrictions are appropriate, including: Controlled movement: exclusion from all long-distance and local public conveyances (bus, subway) Exclusion from public places (e.g., shopping centers, movie theaters), and congregate gatherings Exclusion from workplaces for the duration of the public health order, unless approved by the state or local health department (telework is permitted) Non-congregate public activities while maintaining a 3-foot distance from others may be permitted (e.g., jogging in a park) Other activities should be assessed as needs and circumstances change to determine whether these activities may be undertaken Any travel will be coordinated with public health authorities to ensure uninterrupted direct active monitoring Federal public health travel restrictions (Do Not Board) may be implemented based on an assessment of the particular circumstance For travelers arriving in the United States, implementation of federal public health travel restrictions would occur after the traveler reaches the final destination of the itinerary
Low (but not zero) Risk Having been in a country in which an EVD outbreak occurred within the past 21 days and having had no exposures Having brief direct contact (e.g., shaking hands), while not wearing appropriate PPE, with a person with Ebola while the person was in the early stage of disease Brief proximity, such as being in the same room for a brief period of time, with a person with Ebola while the person was symptomatic In countries without widespread Ebola virus transmission: direct contact while using appropriate PPE with a person with Ebola while the person was symptomatic Traveled on an aircraft with a person with Ebola while the person was symptomatic	Fever (subjective fever or measured temperature ≥ 100.4 °F or 38 °C) OR any of the following: Vomiting Diarrhea Unexplained bruising or bleeding	Implement rapid isolation with immediate contact of public health authorities to arrange for safe transport to an appropriate healthcare facility for Ebola evaluation Medical evaluation is required Isolation orders may be used to ensure compliance Air travel is permitted only by air medical transport If medically evaluated and discharged with a diagnosis other than Ebola, conditions as outlined for asymptomatic individuals in this exposure category will apply
	Asymptomatic (no fever, vomiting, diarrhea, or unexplained bruising or bleeding)	No restrictions on travel, work, public conveyances, or congregate gatherings Direct active monitoring for: U.S.-based healthcare workers caring for symptomatic Ebola patients while wearing appropriate PPE Travelers on an aircraft with, and sitting within 3 feet of, a person with Ebola Active monitoring for all others in this category
No Identifiable Risk Contact with an asymptomatic person who had contact with person with Ebola Contact with a person with Ebola before the person developed symptoms Having been more than 21 days previously in a country with widespread Ebola virus transmission Having been in a country without widespread Ebola virus transmission and not having any other exposures as defined above Traveled on an aircraft with a person with Ebola while the person was symptomatic	Symptomatic (any)	Routine medical evaluation and management of ill persons, as needed
	Asymptomatic	No actions needed