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.[1]
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.[1]
- Direct active monitoring means the public health authority conducts active monitoring through direct observation.[1]
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.[1]
Active Monitoring
Active monitoring should consist of, at a minimum[1]:
- 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 as follows:[1]:
- 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[1]:
- 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.[1]
- 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.[1]
- 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.[1]
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.[1]
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.[1]
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.[1]
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.[1]
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).[1]
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.[1]
- 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.[1]
- Review and approval of work, travel, use of public conveyances, and attendance at congregate events are not indicated or recommended for such healthcare workers.[1]
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.[1]
- 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.[1]
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.[1]
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.[1]
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.[1]
Recommendations for Evaluating Exposure Risk to Determine Appropriate Public Health Actions[1]
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 (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.[1]
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.[2]
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.[2]
- The PUI is afebrile off antipyretics for 24 hours, or there is an alternative explanation for fever.[2]
- All symptoms that are compatible with Ebola (e.g., diarrhea or vomiting) have either resolved or can be accounted for by an alternative diagnosis.[2]
- The PUI has no clinical laboratory results consistent with Ebola, or those that could be consistent with Ebola have been otherwise explained.[2]
- 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.[2]
- 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.[2]
- Local and state health departments have been engaged and concur.[2]
- 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.[2]
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.[2]
- 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.[2]
- Positive Ebola virus RT-PCR results are considered presumptive until confirmed by CDC.[2]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 "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) - ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 "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)