Guidance for HD for Travelers (Non-HCW) Arriving in the US from Countries with Widespread Ebola Transmission

11/18/2014 (Form 3a)

Guidance for Health Departments for Travelers (Not Health Care Workers^*) Arriving in the U.S. from Countries with Widespread Ebola Transmission

Purpose

This document provides guidance for temperature and symptom monitoring by a public health official of persons who have recently arrived in the United States from an Ebola-affected country, until 21 days after the last potential exposure.

Introduction

Ebola virus disease (Ebola) is a rare and severe viral illness characterized by fever, vomiting, diarrhea, muscle pain, headache, rash, and hemorrhagic symptoms. Ebola is spread through direct contact with the blood or body fluids (e.g., vomit, sweat, urine, or diarrhea) of a person with Ebola through a break in the skin or inoculation of the mucous membranes (typically by touching the eyes, nose or mouth). Asymptomatic persons do not transmit disease. An infected person may remain asymptomatic for up to 21 days before developing symptoms, although the time between infection and symptom onset is usually 8-10 days.

The purpose of active and direct active monitoring is to ensure that an individual with epidemiologic risk factors who becomes ill is identified as soon as possible after symptom onset so he or she can be rapidly isolated and evaluated. Monitoring could be conducted on a voluntary basis or compelled by legal order.

Exposure risk assessment

Each traveler’s exposure risks should be assessed, and classified into one of 3 exposure categories: High risk, some risk, low (but not zero) risk. Detailed information about what types of exposure define each risk category, as well as the work, travel, monitoring and movement restrictions (if any) applicable to each are available on the CDC website at http://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html.

Type of monitoring by exposure risk category

Exposure category	Type of monitoring
High risk	Direct active monitoring
Some risk	Direct active monitoring
Low (but not zero) risk	Direct active monitoring for US-based healthcare workers caring for symptomatic Ebola patients while wearing appropriate personal protective equipment (PPE) AND travelers on an aircraft seated within 3 feet of a person with Ebola Active monitoring for all other travelers in this category

Active monitoring means that the state or local public health authority assumes responsibility for establishing regular communication with potentially exposed people, 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. Check-ins can be done through daily phone calls, interactive voice response, internet reporting, or via Skype or other video conferencing, with possible follow-up home visits as needed.

Direct active monitoring

Direct active monitoring means that the state or local public health authorities directly observe the individual at least once to review symptom status and monitor temperature; a second daily follow-up may be conducted by telephone insetead 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.

Direct active monitoring is recommended for persons in the high risk and some risk categories, and for some individuals in the low (but not zero) risk category. For other persons in the low (but not zero) risk category, active monitoring is recommended.

Procedures for direct active monitoring:

Persons under active or direct active monitoring should be followed each day until 21 days after their last potential exposure to a person with Ebola. The goal is to monitor the health of the person and to take actions if the person develops symptoms or is lost to follow-up.

Supplies for the direct active monitoring visits should include:

• 21-day fever and symptom log

• Ebola education materials (e.g. description of the disease, symptoms, etc.)

• Enough digital thermometers to distribute one to each person being monitored in case the thermometer provided at the airport has been lost or is not working

• Medical examination gloves

Needs assessment

It is important for health monitors to assess the needs of each traveler. A needs assessment can include determining that the traveler’s basic requirements are met (e.g., for a traveler who is not permitted to travel by public conveyance and does not have a private vehicle, access to food, facilitating bill payment if unable to work, prescription refills for chronic conditions, etc.) Ensuring that the traveler’s needs are addressed during the follow-up period will help facilitate compliance, particularly if movement restrictions are imposed. Attention to mental health needs can also help to reduce the many stresses travelers feel, which can stem from being made aware of their potential exposure, concern for similarly affected family members, or feeling stigmatized by their communities. Travelers should be informed of their follow-up requirements and associated movement restrictions, if applicable, and each traveler should be asked if he or she has any questions, concerns, or needs.

Procedures for direct active monitoring:

1. The public health official should call ahead to ask if the person has symptoms. If they do, the public health official should immediately notify the public health department at XXX-XXX-XXXX. If the person has an urgent health situation, the first call should be to 911 and the second call should be to the public health department.

2. When in the presence of the person being monitored, monitors should maintain a distance of three feet and defer any direct contact, such as handshakes. Monitors are also advised to remain standing, avoid leaning on walls or furniture, and to keep themselves between the person being monitored and the door.

3. If at any point during the visit, the person appears ill or affirms that they have symptoms consistent with Ebola, the monitor should ask the person to go to a room (preferably with access to a non-shared bathroom), close the door, and await further instruction. The team should then exit the residence, taking care to let themselves out only after putting on the latex exam gloves in their pocket. The team should also exit if they see any blood or body fluid contamination of surfaces, again asking the person being monitored to seclude him/herself in a room and to await further instruction.

4. The public health official will interview the person about the presence or absence of fever and any Ebola symptoms using the 21-day fever and symptom log to ensure thoroughness and consistency.

5. The temperature and symptoms should be recorded on the 21-day fever and symptom log.

   • Record if a the person is taking any medication with aspirin, Tylenol^® (acetaminophen), paracetomol, Aleve^® (naproxen), Motrin^® or Advil^® (ibuprofen). Temperature readings should be taken before the person’s next dose of any such medication.

   • The health monitor should not touch the person or the thermometer but should visually observe the reading on the thermometer. In addition to the daily visit by a public health official, the person being monitored should also take his/her temperature one additional time per day.

7. If the person has a fever or feels feverish, reports at least one of the other symptoms, or the public health official observes signs of illness, the public health official will immediately notify the public health department at XXX-XXX-XXXX. If the person has an urgent health situation, the first call should be to 911 and the second call should be to the public health department.

8. If the second follow-up per day is being conducted by telephone, arrangements shuld be made for the public health authorities to receive the results by phone, email, or other means to confirm symptoms have been monitored and the individual remains asymptomatic.

9. If the person under direct active monitoring has not been observed for two or more consecutive days, additional efforts should be made to find and observe the person.

Active Monitoring

Persons under active monitoring should measure their temperature twice daily and monitor themselves for symptoms. They should report the results of their monitoring to the health authority at least once a day for their 21-day monitoring period.

Procedures for active monitoring:

1. The public health official should confirm that the traveler received a 21-day fever and symptom log as part of their CARE package at the airport, still has this long, and understands how to complete the form. The public health official can also provide instruction on how to properly take a temperature with a digital oral thermometer.

   • Initial in-person, training is helpful to explain the monitoring process, ensure that the person being monitored understands the required follow-up and to establish rapport. If that cannot be done, training by telephone is an option.

   • If an initial in-person visit is to be made, the public health official should call ahead to ask if the person has symptoms. If they do, the public health official should immediately notify the public health department at XXX-XXX-XXXX. If the person being monitored has an urgent health situation, the first call should be to 911 and the second call should be to the public health department.

2. Each day, the individual will take their temperature twice (morning and night) and record their temperature and the presence or absence of all symptoms on the 21-day fever and symptom log.

• The contact should record if they are taking any medication with aspirin, Tylenol® (acetaminophen), paracetomol, Aleve® (naproxen), Motrin® or Advil® (ibuprofen). Temperature readings should be taken before the contact’s next dose of any such medication.

3. The person being monitored should report daily to public health officials by phone, email, or other means to confirm symptoms have been monitored and the individual remains asymptomatic.

4. If the person has a fever or feels feverish or reports at least one of the other symptoms on the checklist, s/he should immediately notify the public health department at XXX-XXX-XXXX. If the person has an urgent health situation, the first call should be to 911 and the second call should be to the public health department.

5. If a person has not monitored or recorded the presence or absence of symptoms for two consecutive days, additional efforts should be made to increase adherence to the follow-up protocol, such as in-person visits. The public health department should be notified at XXX-XXX-XXXX.

If at any point during the monitoring period, a person under active or direct active monitoring develops any of the symptoms listed on the fever and symptom log, the health department should be immediately contacted at XXX-XXX-XXXX.

If the public health authorities decide that the person should undergo medical evaluation for Ebola, the person should be isolated and arrangements should be made for safe transport to an appropriate healthcare facility for evaluation.

The Centers for Disease Control and Prevention can be contacted at (770-488-7100) if additional advice is needed on whether a person should undergo medical evaluation for Ebola.

21-day fever and symptom log for persons being monitored for Ebola, days 1-10

Name: _______________________________________ Age (yrs): _______ Sex: M F

Street address: ________________________City, State: ____________________________Telephone number: ______________________

Last date in a country with widespread Ebola transmission(mm/dd/yyyy): _________________

Instructions: Temperatures should be taken in the morning and in the evening, preferably around the same time. Indicate if any of the symptoms listed on this form are present. Circle ‘Y’ for yes and ‘N’ for no for each symptom. The public health department (XXX-XXX-XXXX) should be contacted if there are any symptoms are present. Don’t leave any spaces blank.

Day number (after last contact)

1

2

3

4

5

6

7

8

9

10

Date

On fever-reducing medicine?

AM or PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

Temperature

Feeling weak or tired

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Muscle pain

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Headache

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Sore throat

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Vomiting

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Diarrhea

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Rash

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Unexplained bleeding*

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

*Unexplained bleeding means bleeding from your mouth or nose, bloody diarrhea, or coughing up blood, or bruising under the skin

21-day fever and symptom log for persons being monitored for Ebola, days 11-21

Name: _______________________________________ Age (yrs): _______ Sex: M F

Street address: ________________________City, State: ____________________________Telephone number: ______________________

Last date in a country with widespread Ebola transmission(mm/dd/yyyy): _________________

Instructions: Temperatures should be taken in the morning and in the evening, preferably around the same time. Indicate if any of the symptoms listed on this form are present. Circle ‘Y’ for yes and ‘N’ for no for each symptom. The public health department (XXX-XXX-XXXX) should be contacted if there are any symptoms are present. Don’t leave any spaces blank.

Day number (after last contact)

11

12

13

14

15

16

17

18

19

20

21

Date

AM or PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

AM

PM

Temperature

Feeling weak or tired

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Muscle pain

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Headache

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Sore throat

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Vomiting

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Diarrhea

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Rash

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Unexplained bleeding**

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

*Unexplained bleeding means bleeding from your mouth or nose, bloody diarrhea, or coughing up blood, or bruising under the skin

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