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

Updates

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 persons screened at a U.S. port of entry
• 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, once the 21-day period after last presence in a Rwandan healthcare facility is complete, if there is any time remaining in the 21 days since the person left Rwanda, they should continue self-monitoring during this period
• Added an exception to the interim recommendations for certain U.S.-based healthcare personnel who deployed to Rwanda on or after October 8, 2024

Overview

On September 27, 2024, the Ministry of Health of the Republic of Rwanda reported an outbreak of MVD, including illnesses in healthcare workers. These are the first known cases of MVD in Rwanda. For more information see First Marburg Virus Disease Outbreak in the Republic of Rwanda.

Currently, the risk of Marburg virus exposure in returning healthcare personnel is unknown. However, given concerns with infection prevention and control practices in health care facilities in Rwanda, and identification of MVD cases in healthcare personnel, CDC is taking a modified approach to managing these healthcare personnel from what is currently published, until the risks are better defined. A key change is the recommendation that personnel who have been present in a healthcare facility (including outpatient settings or traditional healers) in Rwanda, should be excluded from work duties in a U.S. healthcare facility until 21 days after their last presence in a healthcare facility in Rwanda.

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

At this time CDC is currently making the following recommendations for healthcare personnel who have been present in any healthcare facility (including outpatient settings, nonpatient care areas, or traditional healers) in Rwanda in the previous 21 days. Although MVD cases have been reported only in certain districts in Rwanda, CDC is applying these recommendations to the entire country.

These recommendations may be updated based on information available from the evolving outbreak situation in Rwanda. They may also be updated if any U.S.-based healthcare personnel are identified as having MVD while in or after departing Rwanda.

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 personnel depart from Rwanda, assess them for exposure risks and signs 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 signs or symptoms compatible with MVD, CDC must 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 persons identified to have high-risk exposures or suspected or confirmed MVD must 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

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

1. Conduct an exposure risk assessment.
   1. Health departments may request a copy of the person's predeparture assessment. For persons screened at a U.S. port of entry, health departments may choose to defer to the risk assessment conducted by CDC staff.
   2. 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.
2. Educate persons regarding self-monitoring and what to do if they become symptomatic during their monitoring period, including how to reach the health department 24/7 for guidance about seeking health care.
3. Exclude these persons from working in either clinical or non-clinical roles in a U.S. healthcare facility until 21 days after their last presence in a Rwanda healthcare facility.
4. Advise these persons to avoid nonessential visits (e.g., for elective surgeries) to U.S. healthcare facilities until 21 days after their presence in a Rwandan healthcare facility
5. Monitor these persons daily until 21 days after their last presence in a Rwandan healthcare facility.
   1. 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.
   2. Health departments at their discretion may choose to delegate monitoring to the occupational health program of the employing or sponsoring organization.
   3. CDC requests health departments provide aggregate, deidentified data for persons being monitored during this outbreak. Information for how to submit these data has been provided to health departments.
   4. Quarantine or movement restrictions are not recommended as long as the person remains asymptomatic. Asymptomatic individuals may remain at home but should have a plan to isolate from others in the household in the event that they develop signs or symptoms compatible with MVD.
6. Coordinate continued monitoring with the health department at the person's destination if travel to another jurisdiction occurs.
7. 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:
   1. Name
   2. Passport number
   3. Date of birth
   4. Travel itinerary
   5. Contact information at destination (address, phone number, email address)
   6. Date of last presence in a healthcare facility in Rwanda
8. Once the 21-day period after last presence in a Rwandan healthcare facility is complete, advise travelers to continue self-monitoring if there is any time remaining in the 21 days since they left Rwanda.

If any person develops signs and symptoms compatible with MVD, they should immediately self-isolate and contact the 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. Persons 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.

Exception for certain U.S.-based healthcare personnel

CDC is issuing an exception to the above interim recommendations for a subset of U.S.-based healthcare personnel who meet all of the following criteria:

• Are trained in hospital infection prevention and control precautions recommended for clinical management of patients with suspected or confirmed VHF
• Deployed to Rwanda on or after October 8, 2024, with a sponsoring organization (e.g., World Health Organization, Médecins Sans Frontièrs) that has experience with infection prevention and control of VHF in treatment units designated for clinical management of patients with VHF (such as an Ebola or Marburg Treatment Unit)
• Worked only in a designated Marburg Treatment Unit in Rwanda and did not enter any other areas of Rwandan healthcare facilities
• Have no identified high-risk exposures to Marburg virus

For these persons, the following are recommended after U.S. arrival:

1. No exclusion from working, including in clinical roles, or other presence in any U.S. healthcare facility, as long as they remain asymptomatic.
2. Intermittent monitoring (e.g., weekly or every few days) or as otherwise directed by the health department. Health departments, at their discretion, may choose to delegate monitoring to the occupational health program of the employing or sponsoring organization.