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
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Fever (subjective fever or measured temperature >= 100.4 F or 38 C) OR any of the following:
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| Asymptomatic | * Conditional release and controlled movement until 21 days after last known potential exposure | |
Some Risk of Exposure
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Fever WITH OR WITHOUT other symptoms consistent with EVD |
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| Asymptomatic or clinical criteria not met |
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No Known Exposure
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Fever WITH other symptoms consistent with EVD |
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| Asymptomatic or clinical criteria not met |
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