Interim Recommendations for Public Health Management of U.S.-based Healthcare Personnel Returning from Rwanda

Updates

On November 4, 2024:

• Removed all healthcare facilities listed as having known transmission risk to reflect the evolving situation
• Added items related to Marburg treatment units in the definition of "other situations with exposure potential"

Overview

In response to the evolving outbreak of Marburg virus disease (MVD) in the Republic of Rwanda, CDC has issued updated interim recommendations for management of U.S.-based healthcare personnel returning from Rwanda. These interim recommendations may be updated based on information available from the evolving outbreak situation in Rwanda, including identification of unlinked cases or cases associated with nosocomial transmission. They may also be updated if any U.S.-based healthcare personnel are identified as having MVD while in or after departing Rwanda.

Definitions

Healthcare facilities with known transmission risk

No healthcare facilities are currently included in this category.

Outbreak Area

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Other situations with exposure potential

The following situations have potential for unrecognized Marburg virus exposures:

Nonoccupational

• Visiting a health care facility or traditional healer in the outbreak area
• Attending a funeral or burial in the outbreak area
• Having exposure to a person with acute febrile illness (not known or suspected to have MVD) in the outbreak area

OccupationalA

• Providing health care or environmental cleaning in a Marburg treatment unit
• Entering a patient care area of a MTU for any reason
• Providing healthcare in an outbreak area to acutely ill patients not known to have MVD
• Cleaning in a non-MTU healthcare facility in the outbreak area
• Performing clinical laboratory work associated with an MTU or other healthcare setting in the outbreak area
• Participating in burial work in the outbreak area

U.S.-based healthcare personnel

For the purpose of these interim recommendations, U.S.-based healthcare personnel include anyone who works or volunteers in a U.S. healthcare facility (inpatient or outpatient) in any capacity.

Sponsoring organizations

Sponsoring organizations should take the following actions for all returning U.S.-based healthcare personnel who may have been present in a Rwanda healthcare facility (including outpatient settings, nonpatient care areas, or traditional healers) in the previous 21 days:

1. Before healthcare personnel depart from Rwanda, assess them for exposure risks and symptoms compatible with MVD.
   1. This assessment should be conducted by an occupational health, infection prevention and control, or other comparable professional, and should not be a self-assessment by the individual. A modified template tool has been developed for this outbreak that can be used for this purpose. A copy of the completed assessment may be requested by the U.S. health department of jurisdiction.
   2. If any person is identified as having potential high-risk exposures or symptoms compatible with MVD, CDC should be consulted prior to authorizing travel. An emergency CDC consultation can be obtained 24/7 by calling CDC’s Emergency Operations Center (EOC) at 770-488-7100 and asking for the on-call epidemiologist for the Viral Special Pathogens Branch (VSPB).
   3. Any person identified to have high-risk exposures or suspected or confirmed MVD should be managed in accordance with CDC guidance for Public health management of people with suspected or confirmed viral hemorrhagic fever (VHF) or high-risk exposures.
2. Notify the health department with jurisdiction for each person's final U.S. destination before the person travels to the United States.
   1. Contact information for U.S. state, local and territorial health departments is available at: 24-hour Epi-on-Call Contact List
   2. Information provided should include the person’s name, address at U.S. destination, contact information (phone, email address), and flight itinerary. 

U.S. health departments

Healthcare personnel information

For healthcare personnel who are recommended to be monitored by a health department, CDC will provide contact information, as well as a copy of the risk assessment conducted during public health screening at U.S. ports of entry, to health departments through established secure mechanisms.

Data request

CDC requests that health departments submit data for the number of healthcare personnel being monitored during this outbreak. Information for how to submit these data has been provided to health departments.

Recommendations

U.S. health departments are recommended to take the following actions for all returning U.S.-based healthcare personnel during the 21 days after the person was last present in the MVD outbreak area in Rwanda:

• Conduct an exposure risk assessment.
  • Health departments may request a copy of the person's predeparture assessment from the individual or sponsoring organization. For healthcare personnel screened at a U.S. port of entry, health departments may choose to defer to the risk assessment conducted by CDC staff. CDC has provided a template tool health departments can use if they choose to do their own assessments.
  • If any high-risk exposures are identified, the person should be managed in accordance with CDC guidance for Public health management of people with suspected or confirmed VHF or high-risk exposures.
• Educate these healthcare personnel about self-monitoring (including temperature checks) and what to do if they develop symptoms compatible with MVD, including how to reach the health department 24/7 for guidance about seeking health care.
• Follow additional interim recommendations according to circumstances as detailed below. Please note, healthcare personnel who complete daily monitoring following presence in a facility with known transmission risk might be recommended to have intermittent monitoring if they were subsequently in another situation with exposure potential (for example, a healthcare facility in the outbreak area not known to have transmission risk).
• At the end of their monitoring period, advise healthcare personnel to continue watching their health for symptoms compatible with MVD until 21 days after they left Rwanda.

Healthcare personnel who in the past 21 days have been present in patient care or nonpatient care areas of a healthcare facility with known transmission risk (none currently listed)

• Advise these healthcare personnel to refrain from working in either clinical or non-clinical roles in a U.S. healthcare facility, consistent with the respective jurisdiction's legal authorities.
• Advise these healthcare personnel to avoid nonessential visits (e.g., for elective surgeries) to U.S. healthcare facilities.
• Conduct daily monitoring.
  • Monitoring may be conducted by phone, video conferencing, other electronic means (e.g., text message, email, app, web form), or in person, according to resources available in the jurisdiction.
  • Health departments at their discretion may choose to delegate monitoring to the occupational health program of the employing or sponsoring organization.
  • Quarantine or movement restrictions are not recommended as long as the person remains asymptomatic. Asymptomatic individuals should have a plan to isolate from others in the household in the event that they develop symptoms compatible with MVD.
• Coordinate continued monitoring with the health department at the person's destination if travel to another jurisdiction occurs.
• Notify CDC by emailing DGMHTRAMPROPTeam@cdc.gov if an individual intends to leave the United States during the monitoring period. Please include the following information to the extent available, and encrypt or password-protect all personally identifiable information:
  • Name
  • Passport number
  • Date of birth
  • Travel itinerary
  • Contact information at destination (address, phone number, email address)
  • Date of last presence in a healthcare facility in Rwanda

Healthcare personnel who in the past 21 days have a history of being in other occupational or nonoccupational situations with exposure potential (see definition section) in the outbreak area

• Conduct weekly intermittent monitoring.
  • Monitoring may be conducted by phone, video conferencing, other electronic means (e.g., text message, email, app, web form), or in person, according to resources available in the jurisdiction.
  • Health departments at their discretion may choose to delegate monitoring to the occupational health program of the employing or sponsoring organization.
  • No refraining from working, including in clinical roles, or other presence in any U.S. healthcare facility, is recommended for these healthcare personnel as long as they remain asymptomatic.

Healthcare personnel who were in Rwanda but have no history of being in occupational or nonoccupational situations with exposure potential (see definition section) in the outbreak area

These healthcare personnel are recommended to watch their health for symptoms of MVD until 21 days after they left Rwanda following information available in Traveling to the United States from Rwanda.

• CDC will send automated text messaging to all travelers from Rwanda whose contact information is available to CDCB reminding them to watch their health and of actions to take if they develop symptoms compatible with MVD.

Symptomatic healthcare personnel

If any person develops symptoms compatible with MVD, they should immediately self-isolate and contact their health department for guidance.

1. Health departments should conduct a public health assessment to determine the likelihood that the traveler's symptoms are caused by Marburg virus infection. If MVD is suspected, refer the person for medical evaluation at a pre-determined healthcare facility with consideration of testing for Marburg virus.
2. If a diagnosis of MVD is considered, state, tribal, local, or territorial public health officials should coordinate with CDC to ensure appropriate precautions are taken to help prevent potential spread of Marburg virus and to arrange for testing. CDC's VSPB is available 24/7 for consultations regarding suspected MVD cases by calling the CDC Emergency Operations Center (EOC) at 770-488-7100 and requesting VSPB's on-call epidemiologist, or by emailing spather@cdc.gov.
3. Healthcare personnel with suspected or confirmed MVD should be managed in accordance with CDC guidance for Public health management of people with suspected or confirmed VHF or high-risk exposures.

Previous Updates

On October 25, 2024:

• Aligned timing of intermittent monitoring as "weekly" for both U.S.-based healthcare personnel and other travelers

• Removed recommendation for single check-in at 21 days for healthcare personnel who were in the outbreak area but have no history of being in other occupational or nonoccupational situations with exposure potential, to align with other travelers

On October 23, 2024:

• Limited the interim recommendations for daily monitoring and refraining from working in a U.S. healthcare facility for U.S.-based healthcare personnel who have been present in the past 21 days in specified Rwandan healthcare facilities with known Marburg virus transmission risk (previously applied to all Rwandan healthcare facilities)
• Reverted to routine guidance for intermittent monitoring of other U.S.-based healthcare personnel who have a history of being in other situations with exposure potential within a defined outbreak area

On October 11, 2024:

• Defined which staff are considered "U.S.-based healthcare personnel" for the purpose of these interim recommendations
• Added that health departments may choose to defer to the initial risk assessment conducted by CDC staff for healthcare personnel screened at a U.S. port of entry; CDC will provide contact information for these individuals to health departments
• Added recommendation that these personnel avoid nonessential visits (e.g., elective surgeries) to U.S. healthcare facilities until 21 days after they were last present in a Rwandan healthcare facility
• Added recommendation that, at the end of their monitoring period, they should continue to watch their health until 21 days after they left Rwanda
• Added an exception to the interim recommendations for certain U.S.-based healthcare personnel who deployed to Rwanda on or after October 8, 2024

On October 30, 2024

• Clarified definitions to reflect that Rwanda currently has only one Marburg treatment unit (MTU) which is now listed as a "healthcare facility with known transmission risk." Therefore, the elements of the "other situations with exposure potential" definition that specifically relate to presence in a MTU have been temporarily removed.