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: Joseph Nasr, M.D.[2]; Rim Halaby, M.D. [3]
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.[1]
Since the original 2014 CDC guidance, several important updates have emerged from subsequent outbreaks (DRC 2018–2020, Guinea 2021, Uganda 2022) and evolving evidence. The UK Health Security Agency (UKHSA) issued updated risk stratification recommendations in 2021 with three risk categories for returning workers who are asymptomatic contacts of EVD patients.[2] Additionally, the availability of FDA-approved monoclonal antibody therapies (ansuvimab [Ebanga] and REGN-EB3 [Inmazeb]) and the licensed rVSV-ZEBOV (Ervebo) vaccine has introduced new options for post-exposure prophylaxis (PEP) that should be integrated into monitoring and management algorithms.
Exposure Risk Categories
Overview of Risk Stratification
The CDC 2014 interim guidance stratified potential Ebola virus exposures into four categories: high risk, some risk, low (but not zero) risk, and no identifiable risk. This framework remains the foundation for U.S. public health actions. The UKHSA 2021 guidance simplified this into three categories for returning healthcare workers. A more detailed stratification by exposure type, incorporating consideration of post-exposure prophylaxis, was proposed by Jacobs and colleagues based on a case series of eight healthcare workers, classifying exposures as maximum, intermediate, low, or very low risk.[3]
Factors to Consider in Risk Assessment
A rapid risk assessment should be performed following any potential exposure to Ebola virus. Factors that should be considered include:
- The mechanism of exposure (e.g., needlestick injury, mucous membrane splash)*
- The potential inoculum size*
- Whether a PPE breach was involved*
- The vaccination status of the exposed individual*
- Underlying immunosuppression and other medical comorbidities of the exposed individual*
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, 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 as follows:
- 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*
Duration of Monitoring
The standard monitoring period is 21 days after the last known exposure, consistent with the maximum incubation period of EVD (range 2–21 days; mean 8.4 days based on pooled estimates).[4] However, modelling data suggest the incubation period of Zaire ebolavirus (ZEBOV) could be longer than 21 days in approximately 4.1% of individuals, indicating that it may be appropriate to extend monitoring to 25 days to cover the maximum predicted incubation period. A 2025 retrospective cohort study of the 2022 Sudan ebolavirus (SUDV) outbreak in Uganda found that the risk for being diagnosed with SUDV extended beyond 21 days, up to the 28th day post-exposure, further supporting consideration of extended monitoring periods.[5]
For individuals who receive post-exposure prophylaxis (PEP) with monoclonal antibody therapies, extended monitoring totalling 28 days has been recommended to account for potential delayed onset of clinical symptoms following antiviral therapy.
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 Specific Groups and Settings
Healthcare Workers
For the purposes of risk exposure to Ebola, regardless of country, direct patient contact includes doctors, nurses, physician assistants and other healthcare staff, as well as ambulance personnel, burial team members, and morticians. In addition, others who enter into the treatment areas where Ebola patients are being cared for (such as observers) would be considered to potentially have patient contact and be at risk. Healthcare workers who have no direct patient contact and no entry into active patient management areas, including epidemiologists, contact tracers, airport screeners, as well as laboratory workers who use appropriate PPE, are not considered to have an elevated risk of exposure to Ebola, i.e., are considered to be in the low (but non-zero) risk category.
The high toll of Ebola virus infections among healthcare workers providing direct care to Ebola patients in countries with widespread transmission suggests that there are multiple potential sources of exposure to Ebola virus in these countries, including unrecognized breaches in PPE, inadequate decontamination procedures, and exposure in patient triage areas. Due to this higher risk, these healthcare workers are classified in the some risk category, for which additional precautions are recommended upon their arrival in the United States (see Table).
Healthcare workers who provide care to Ebola patients in U.S. facilities while wearing appropriate PPE and with no known breaches in infection control are considered to have low (but not zero) risk of exposure because of the possibility of unrecognized breaches in infection control and should have direct active monitoring.
- As long as these healthcare workers have direct active monitoring and are asymptomatic, there is no reason for them not to continue to work, including in hospitals and other patient care settings, nor is there a reason for them to have restrictions on travel or other activities.*
- Review and approval of work, travel, use of public conveyances, and attendance at congregate events are not indicated or recommended for such healthcare workers.*
Healthcare workers taking care of Ebola patients in a U.S. facility where another healthcare worker has been diagnosed with confirmed Ebola without an identified breach in infection control are considered to have a higher level of potential exposure (exposure level: high risk). A similar determination would be made if an infection control breach is identified retrospectively during investigation of a confirmed case of Ebola in a healthcare worker.
- These individuals would be subject to restrictions, including controlled movement and the potential use of public health orders, until 21 days after the last potential unprotected exposure.*
In U.S. healthcare facilities where an unidentified breach in infection control has occurred, assessment of infection control practices in the facility, remediation of any identified deficiencies, and training of healthcare workers in appropriate infection control practices should be conducted. Following remediation and training, asymptomatic potentially exposed healthcare workers may be allowed to continue to take care of Ebola patients, but care of other patients should be restricted. For these healthcare workers, the last potential unprotected exposure is considered to be the last contact with the Ebola patient prior to remediation and training; at 21 days after the last unprotected exposure, they would return to the low (but not zero) risk category under direct active monitoring. Healthcare workers whose first Ebola patient care activities occur after remediation and training are considered to be in the low (but not zero) risk category.
Pre-Exposure Vaccination for Healthcare Workers
The U.S. Advisory Committee on Immunization Practices (ACIP) recommends pre-exposure vaccination with rVSV-ZEBOV (Ervebo) for adults ≥18 years of age who are at highest risk of potential occupational exposure to Zaire ebolavirus, including:[6]
- Healthcare personnel working at federally designated Ebola Treatment Centers in the United States*
- Laboratory workers and other staff at biosafety level 4 (BSL-4) facilities in the United States who have potential for occupational exposure to Zaire ebolavirus*
Crew on Public Conveyances
Crew members on public conveyances, such as commercial aircraft or ships, who are not subject to controlled movement are also not subject to occupational restriction and may continue to work on the public conveyance while under active monitoring.
People with Confirmed Ebola Virus Disease
For people with confirmed Ebola, isolation and movement restrictions are removed upon determination by public health authorities that the person is no longer considered to be infectious.
Post-Exposure Prophylaxis (PEP)
The availability of FDA-approved monoclonal antibody therapies and the licensed rVSV-ZEBOV vaccine has introduced new options for post-exposure management of individuals with significant Ebola virus exposures.
Monoclonal Antibody PEP
Ansuvimab (mAb114, Ebanga) and REGN-EB3 (Inmazeb) are FDA-approved for treatment of Zaire ebolavirus infection and have been evaluated as PEP agents. In a prospective study in the DRC during the 10th EVD outbreak, 23 non-vaccinated high- and intermediate-risk contacts received monoclonal antibody PEP (ansuvimab or REGN-EB3) at a median delay of 1 day after contact. All contacts remained symptom-free and had negative RT-PCR at day 14.[7]
Monoclonal antibodies may be preferred over vaccination for PEP because their activity is immediate and not dependent on the host immune response. However, these agents are only effective against Zaire ebolavirus and do not have activity against non-ZEBOV species (e.g., Sudan ebolavirus).
Vaccine PEP
rVSV-ZEBOV (Ervebo) has been used as PEP in early cases of high-risk occupational exposure, with vaccination administered within 48 hours of exposure and no reported cases of EVD developing. However, rVSV-ZEBOV is only effective against Zaire ebolavirus.
Important Considerations
- Concurrent administration of rVSV-ZEBOV vaccine and monoclonal antibodies directed against the Ebola virus glycoprotein is not recommended, as the monoclonal antibodies would be expected to interfere with vaccine replication and attenuate its immunogenicity.[8]*
- If both monoclonal antibody PEP and vaccination are indicated, they should be administered with temporal separation, though the optimal interval has not been established.*
- For individuals who receive PEP, extended monitoring totalling 28 days is recommended to account for potential delayed symptom onset following antiviral therapy.*
- A strategic integration of monoclonal antibodies (for immediate protection) and vaccines (for long-term protection) as PEP could provide both immediate and sustained protection against EVD.[9]*
Recommendations for Evaluating Exposure Risk to Determine Appropriate Public Health Actions
The following table summarizes the CDC recommendations for public health actions based on exposure risk category and clinical status.
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Exposure Category |
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Clinical Criteria |
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Public Health Actions |
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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 (no fever or other symptoms consistent with Ebola) |
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Some 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 (no fever or other symptoms consistent with Ebola) |
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Low (but not zero) 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 (no fever, vomiting, diarrhea, or unexplained bruising or bleeding) |
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No Identifiable Risk
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Symptomatic (any) |
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Asymptomatic |
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Table adapted from the "Centers for Disease Control and Prevention - Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure".[1]
+The temperature and symptoms thresholds provided are for the purpose of requiring medical evaluation. Isolation or medical evaluation may be recommended for lower temperatures or nonspecific symptoms (e.g., fatigue) based on exposure level and clinical presentation.
Additional restrictions, such as use of public health orders, may be warranted if an individual in the some or low (but not zero) risk categories fails to adhere to the terms of active (or direct active) monitoring. Such noncompliance could include refusal by an individual with documented travel from a country with widespread transmission, or other potential contact with a symptomatic Ebola patient, to participate in a public health assessment. Without such information, public health authorities may be unable to complete a risk assessment to determine if an individual has been exposed to, or has signs or symptoms consistent with, Ebola. For travelers from a country with widespread transmission who refuse to cooperate with a public health assessment and appear ill, medical evaluation will be required and isolation orders issued.
Post-Exposure Prophylaxis Algorithm
The following table summarizes the recommended approach to post-exposure prophylaxis based on exposure risk level and vaccination status, incorporating updated evidence from the DRC 2018–2020 outbreak experience and the 2024 Lancet Infectious Diseases review.
| Exposure Risk Level | Vaccination Status | Recommended PEP | Monitoring Duration |
|---|---|---|---|
| High risk (e.g., needlestick injury, unprotected mucous membrane splash) | Unvaccinated | Monoclonal antibody therapy (ansuvimab or REGN-EB3) administered as soon as possible; consider rVSV-ZEBOV vaccination with temporal separation | 28 days |
| High risk | Previously vaccinated with rVSV-ZEBOV | Monoclonal antibody therapy (ansuvimab or REGN-EB3); revaccination generally not indicated | 28 days |
| Some risk (e.g., PPE breach without direct body fluid contact) | Unvaccinated | rVSV-ZEBOV vaccination within 48 hours of exposure; consider monoclonal antibody PEP based on individual risk assessment | 21–28 days |
| Some risk | Previously vaccinated | Active monitoring; monoclonal antibody PEP based on individual risk assessment | 21 days |
| Low (but not zero) risk | Any | Active monitoring only; PEP generally not indicated | 21 days |
| No identifiable risk | Any | No action needed | None |
Note: All monoclonal antibody PEP recommendations apply only to confirmed or suspected Zaire ebolavirus exposures. Ansuvimab and REGN-EB3 do not have activity against Sudan ebolavirus or other non-ZEBOV species.
Considerations for Discharging Persons Under Investigation (PUI) for Ebola Virus Disease
The decision to discharge a patient being evaluated as a Person Under Investigation (PUI) for Ebola who has not had a negative RT-PCR test for Ebola (RT-PCR testing for Ebola virus infection has not yet been performed or RT-PCR test result on a blood specimen collected less than 72 hours after onset of symptoms is negative) should be based on clinical and laboratory criteria and on the ability to monitor the PUI after discharge, and made by the medical providers caring for the PUI, along with the local and state health departments.[10]*
Health Care Providers Evaluating a PUI Should Consider These Criteria When Deciding to Discharge a PUI
- In the clinical judgment of the medical team, the PUI's illness no longer appears consistent with Ebola.*_
- The PUI is afebrile off antipyretics for 24 hours, or there is an alternative explanation for fever.*_
- All symptoms that are compatible with Ebola (e.g., diarrhea or vomiting) have either resolved or can be accounted for by an alternative diagnosis.*_
- The PUI has no clinical laboratory results consistent with Ebola, or those that could be consistent with Ebola have been otherwise explained.*_
- The PUI is able to self-monitor (or to monitor a child, if the PUI is a child) and comply fully with active monitoring and controlled movement.*_
- There is a plan in place for the PUI to return for medical care if symptoms recur, which has been explained to the PUI, and the PUI understands what to do if symptoms recur.*_
- Local and state health departments have been engaged and concur.*_
- Active monitoring and controlled movement still apply for persons who have had Ebola virus exposures and are under follow-up as contacts for the full 21-day period following their last exposure.*_
Important Information About RT-PCR Testing for Ebola Virus
- A negative RT-PCR test result for Ebola virus from a blood specimen collected less than 72 hours after onset of symptoms does not necessarily rule out Ebola virus infection.*_
- If the patient is still symptomatic after 72 hours, the test should be repeated.***
- If the patient has recovered from the illness that brought them to medical attention, a repeat test is not required.***
- A negative RT-PCR test result for Ebola virus from a blood specimen collected more than 72 hours after symptom onset rules out Ebola virus infection.*_
- Positive Ebola virus RT-PCR results are considered presumptive until confirmed by CDC.***
Updated Diagnostic Considerations
Since 2020, several rapid diagnostic tests have been developed and deployed in outbreak settings. The WHO has prequalified the OraQuick Ebola Rapid Antigen Test for use in field settings, which provides results within 30 minutes from a fingerstick blood sample. However, RT-PCR remains the gold standard for confirmatory testing, and the timing considerations described above remain applicable.
Contact Tracing
Lessons from Recent Outbreaks
Contact tracing remains the cornerstone of Ebola outbreak control. During the 2022 Sudan ebolavirus outbreak in Uganda, a retrospective cohort study of 2,495 contacts found that the overall incidence of SUDV among contacts was 2.6%. Predictors of transmission included being a household contact (adjusted hazard ratio [aHR] 3.21), being a healthcare worker contact (aHR 2.87), and having had direct physical contact with the index case (aHR 4.15). The risk for being diagnosed with SUDV extended beyond 21 days, up to the 28th day post-exposure.[5]
During the 10th DRC Ebola outbreak (2018–2020), targeted post-exposure prophylaxis with monoclonal antibodies was integrated into the contact tracing framework. Among 23 high- and intermediate-risk contacts who received monoclonal antibody PEP, none developed EVD, compared with a background attack rate of approximately 4% among unvaccinated contacts.[7]
Digital Contact Tracing
The use of digital tools for contact tracing has expanded since the 2014–2016 West Africa outbreak. Mobile phone-based applications and electronic databases have improved the speed and completeness of contact identification and follow-up. These tools facilitate real-time data sharing between field teams and coordination centers, enabling more rapid identification of contacts who develop symptoms.
References
- ↑ 1.0 1.1 "Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure". www.cdc.gov. Centers for Disease Control and Prevention (CDC). October 27 2014. Retrieved October 28 2014. Check date values in:
|accessdate=, |date=(help) - ↑ Moso MA, Lim CK, Williams E, Patel S, Bull RA, Williamson DA (2024). "Prevention and Post-Exposure Management of Occupational Exposure to Ebola Virus". Lancet Infect Dis. 24 (2): e93–e105. doi:10.1016/S1473-3099(23)00376-6. PMID 37722397 Check
|pmid=value (help). - ↑ Jacobs M, Aarons E, Bhagani S, Buchanan R, Cropley I, Hopkins S, Lester R, Martin D, Marshall N, Mepham S, Rodger A, Zambon M, Jacobs M (2015). "Post-Exposure Prophylaxis Against Ebola Virus Disease With Experimental Antiviral Agents: A Case-Series of Health-Care Workers". Lancet Infect Dis. 15 (11): 1300–4. doi:10.1016/S1473-3099(15)00228-5. PMID 26321189.
- ↑ Nash RK, Bhatia S, Morgenstern C, Doohan P, Jorgensen D, Sherrat K, Cuomo-Dannenburg G, Hicks JT, Cori A, Riley S, Kucharski AJ (2024). "Ebola Virus Disease Mathematical Models and Epidemiological Parameters: A Systematic Review". Lancet Infect Dis. 24 (12): e762–e773. doi:10.1016/S1473-3099(24)00374-8. PMID 39127058 Check
|pmid=value (help). - ↑ 5.0 5.1 Mulongo M, Matovu J, Lubaale Y, Olupot-Olupot P (2025). "Incidence and Predictors of Sudan Ebolavirus Transmission Among Contacts in Uganda in 2022: A Retrospective Cohort Study". BMC Public Health. 25 (1): 3793. doi:10.1186/s12889-025-24739-0. PMID 41194066 Check
|pmid=value (help). Vancouver style error: initials (help) - ↑ Choi MJ, Cossaboom CM, Whitesell AN, Dyal JW, Joyce A, Morgan RL, Campos-Outcalt D, Person M, Ervin E, Yu YC, Rollin PE, Harcourt BH, Atmar RL, Bell BP, Helfand R, Damon IK, Frey SE (2021). "Use of Ebola Vaccine: Recommendations of the Advisory Committee on Immunization Practices, United States, 2020". MMWR Recomm Rep. 70 (1): 1–12. doi:10.15585/mmwr.rr7001a1. PMID 33417593 Check
|pmid=value (help). - ↑ 7.0 7.1 Jaspard M, Juchet S, Serra B, Peyrouset O, Reynaud C, Henry C, Muzellec Y, Mbala P, Mulangu S, Muyembe JJ, Lacabaratz C, Levy Y, Nguyen D, Hoffmann Dahl E (2021). "Post-Exposure Prophylaxis Following High-Risk Contact With Ebola Virus, Using Immunotherapies With Monoclonal Antibodies, in the Eastern Democratic Republic of the Congo: An Emergency Use Program". Int J Infect Dis. 113: 166–167. doi:10.1016/j.ijid.2021.09.053. PMID 34587535 Check
|pmid=value (help). - ↑ Fischer WA, Vetter P, Bausch DG, Burgess T, Davey RT, Fowler R, Hayden FG, Jahrling PB, Kalil AC, Mayers DL, Mehta AK, Uyeki TM, Jacobs M (2018). "Ebola Virus Disease: An Update on Post-Exposure Prophylaxis". Lancet Infect Dis. 18 (6): e183–e192. doi:10.1016/S1473-3099(17)30677-1. PMID 29153266.
- ↑ Hoffmann Dahl E, Mbala P, Juchet S, Peyrouset O, Reynaud C, Lacabaratz C, Levy Y, Nguyen D, Muyembe JJ, Mulangu S (2024). "Improving Ebola Virus Disease Outbreak Control Through Targeted Post-Exposure Prophylaxis". Lancet Glob Health. 12 (10): e1730–e1736. doi:10.1016/S2214-109X(24)00255-9. PMID 39270687 Check
|pmid=value (help). - ↑ "Considerations for Discharging Persons Under Investigation (PUI) for Ebola Virus Disease (Ebola)". www.cdc.gov. Centers for Disease Control and Prevention (CDC). October 30 2014. Retrieved October 31 2014. Check date values in:
|accessdate=, |date=(help)