CDC Memo

TO:

State Health Officers

FROM:

Thomas R. Frieden, MD, MPH
Director, Centers for Disease Control and Prevention (CDC)

DATE:

November 1, 2014

SUBJECT:

Active Monitoring including Direct Active Monitoring

Thank you for your continued partnership and hard work as we respond to Ebola. The country is
counting on us, and public health must deliver. In the United States, this means ensuring that if
people develop Ebola, they are quickly and safely isolated and diagnosed and safely and
effectively treated. The Active Monitoring (including Direct Active Monitoring) program is a
critical aspect of our response and relies on essential components of the response at state and
local levels.
Critical functions of the response in each area of the country include:
• Managing the Active Monitoring (including Direct Active Monitoring) program at the
state and—in coordination with local health officers—local levels, including responding
appropriately to people who are lost to follow-up or non-adherent with monitoring.
• Establishing, drilling, and publicizing a 24/7 phone number for people who may have
symptoms and exposure consistent with Ebola to call.
• Establishing and drilling systems to safely transport such people to a health care facility.
• Ensuring that the receiving health care facilities are prepared, including through
completion of drills, to provide at least initial isolation, evaluation, and diagnostic testing
(including specimen collection and shipment) of any patient suspected to have Ebola in
consultation and coordination with CDC.
A brief reporting template is attached to this document and is intended to capture the state’s plan
for managing these critical functions. Please return this plan to CDC no later than November 7.
Plans can be sent to CDC at [email protected]. CDC staff are available to assist in the
development of this plan. States can request assistance by emailing [email protected].
Active and Direct Active Monitoring
On October 27, CDC released Guidance for Monitoring and Movement of Persons with Potential
Ebola Virus Exposure (www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-withexposure.html). This guidance describes recommended risk stratification for people traveling
from Liberia, Sierra Leone, and Guinea and recommended public health actions for each risk

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category. Two public health actions, daily Active Monitoring and daily Direct Active Monitoring
for 21 days post potential exposure are particularly important to prevent transmission in the
United States. Daily monitoring of health status and fever is essential to rapidly identify
potentially ill people and to ensure immediate isolation and rapid referral for medical evaluation.
We expect that several people who have returned from these countries will develop fever and
other symptoms each day, but that only a very small proportion of symptomatic returning
travelers, if any, will be found to have Ebola. Because of the severe consequences of not
ensuring appropriate isolation, transfer, evaluation, diagnosis, and treatment of all such patients
in the case of a diagnosis of Ebola, meticulous planning, practice, and execution of every aspect
of the response will be essential. Each incident of a returning traveler who rules out for Ebola is
an opportunity to evaluate the process and learn lessons for future improvement. Note that we
expect that the number of travelers in the “some” and “high risk” categories—and hence
requiring Direct Active Monitoring—will be small.
Active Monitoring began Monday, October 27 with a focus on the six states (New York, New
Jersey, Pennsylvania, Maryland, Virginia, and, Georgia) that receive 70 percent of travelers from
the impacted areas of West Africa. The remaining states and Washington, DC should begin
Active Monitoring as soon as possible and no later than Wednesday, November 5. We ask
states to report their activities related to Direct Active Monitoring on a daily basis
beginning Monday, November 3, and to report their activities related to Active Monitoring
on a weekly basis. We will work with you to establish the most useful and efficient formats and
methods of reporting.
State and Local Responsibilities
State and local public health authorities are responsible for establishing regular daily
communication with potentially exposed individuals to assess the presence of symptoms and
fever. Direct Active Monitoring requires state and local public health officials to directly observe
the person being monitored. Specifically, a public health official or someone authorized by you
(e.g., visiting nurse service, hospital occupational health program) must directly observe the
individual at least once a day to review symptoms and assess temperature and report that
information.
Direct Active Monitoring should also include a discussion of plans to work, travel, take public
transportation, or go to congregate gathering places to determine whether, for some risk people
these activities are allowed. Direct Active Monitoring applies to all persons in the high risk and
some risk categories. It also applies—not including movement restrictions—to the small
proportion of those in the low (but not zero) risk who are health care workers caring for
symptomatic Ebola patients while wearing appropriate personal protective equipment (PPE) in
this country and to travelers on an aircraft sitting within 3 feet of a person with Ebola, if any.

Page 3 – State Health Officials

RISK LEVEL

HIGH risk
SOME risk
LOW risk
NO risk

PUBLIC HEALTH ACTION
Restricted Public
Monitoring
Activities
Yes- Direct Active Monitoring Yes
Case-by-case
Yes- Direct Active Monitoring
assessment
Yes- Active Monitoring for
some; Direct Active
No
Monitoring for others
No
No

Restricted Travel
Yes
Case-by-case
assessment
No
No

CDC Resources to Assist with Program Implementation
CDC will assist state and local health officials to implement Active Monitoring, including Direct
Active Monitoring. Resources include expedited approval processes to redirect CDC Public
Health Emergency Preparedness cooperative agreement funds for Ebola-related activities,
reassignment of CDC-funded field staff to Ebola activities, and deployment of Public Health
Associate Program staff to assist states with Ebola preparedness and response activities. CDC
has a dedicated call center to ensure travelers who require monitoring can connect with the
appropriate state health public departments. States can contact CDC at [email protected]
to report any issues with incorrect contact information or other details regarding travelers
residing in their states during the 21-day monitoring period.
The eyes of the nation are on public health. I am sure we will stand together, be meticulous in
our work, and demonstrate that we keep the nation safe from Ebola. Thank you for your work
and dedication.

Thomas R. Frieden, MD, MPH
Director, CDC
Attachment
cc: Paul Jarris, ASTHO
[email protected]
Jim Blumenstock, ASTHO
[email protected]

Page 4 – State Health Officials

Robert Pestronk, NACCHO
[email protected]
Jack Herrmann, NACCHO
[email protected]
Joxel Garcia, Washington, DC Department of Health
[email protected]
Patrice Harris, Fulton County Health Services
[email protected]
Jacquelyn Duval-Harvey, Baltimore City Health Department
[email protected]
Bechara Choucair, Chicago Department of Public Health
[email protected]
Mary Bassett, New York City Department of Health and Mental Hygiene
[email protected]
James Buehler, City of Philadelphia Department of Public Health
[email protected]