Interim Recommendations for Post-Arrival Public Health Management of Travelers from Rwanda

At a glance

This page contains tiered interim recommendations for public health management of travelers (other than U.S.-based healthcare personnel) arriving in the United States who have been in the Republic of Rwanda during the previous 21 days.

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

U.S.-based Healthcare Personnel Returning from Rwanda‎

CDC has issued separate interim recommendations for public health management of U.S.-based healthcare workers returning from Rwanda.

In response to the evolving outbreak of Marburg virus disease (MVD) in the Republic of Rwanda, CDC has updated its interim recommendations for public health management of travelers arriving in the United States if they have been in Rwanda in the previous 21 days. 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.

These interim recommendations assume no high-risk exposures were identified during a public health risk assessment of the individual. Travelers with high-risk exposures to Marburg virus should be managed in accordance with CDC guidance for Public health management of people with suspected or confirmed VHF or high-risk exposures.

Information about travelers

For travelers who are recommended to be monitored by a health department, CDC will provide contact information, as well as a copy of the public health risk assessment conducted during public health entry 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 people being monitored during this outbreak. Information for how to submit these data has been provided to health departments.

Definitions

Healthcare facilities with known transmission risk

No healthcare facilities are currently included in this category.

Outbreak area

Districts involved in the Marburg outbreak, by province. Est (Eastern): 1. Gatsibo 2. Nyagatare. Kigali City: 3. Gasabo 4. Kicukiro 5. Nyarugenge Oueste (Western): 6. Rubavu Sud (Southern): 7. Huye 8. Kamonyi
Districts involved in the Marburg outbreak, by province

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 health care 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 a MTU or other healthcare setting in the outbreak area
  • Participating in burial work in the outbreak area

Recommendations

U.S. health departments are recommended to take the following actions for travelers arriving from Rwanda for whom CDC recommends post-arrival monitoring:

  • Perform an initial risk assessment.
    • For travelers 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.
  • Educate travelers 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 recommendations according to circumstances as detailed below. Please note, travelers who complete daily monitoring following presence in the patient care area of a facility with known transmission risk might be recommended to have intermittent monitoring if they were subsequently present 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 travelers to continue watching their health for symptoms compatible with MVD until 21 days after they left Rwanda.

Travelers who in the past 21 days have been in patient care areas of a Rwandan healthcare facility with known transmission risk (none currently listed)

This group includes those who did any of the following:

  • Provided clinical care
  • Sought care
  • Visited a patient care area for any reason

For these travelers, health departments are recommended to take the following actions:

  • Advise travelers to avoid non-essential 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.
  • 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. 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 patient care area in a Rwandan healthcare facility

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

For these travelers, health departments are recommended to take the following actions:

  • 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.

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

These travelers 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 travelers 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 travelers

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

  • Health departments should conduct a public health assessment to determine the likelihood that the traveler's symptoms are caused by Marburg virus infection and, if MVD is suspected, refer the person for medical evaluation at a pre-determined healthcare facility with consideration of testing for Marburg virus.
  • 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 Viral Special Pathogens Branch (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.
  • People 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.

The purpose of conducting an initial public health risk assessment of symptomatic travelers is to ensure public health officials at the state, territorial and local levels:

  • Have situational awareness of ill people within their jurisdictions who have been in Rwanda within the previous 21 days before they seek care at a healthcare facility
  • Can identify the appropriate type of treatment center for the person if medical care is recommended, based on whether or not MVD is suspected
  • Can communicate their assessment to emergency medical services, healthcare facilities, and others as needed, in coordinating the management of symptomatic people for whom medical evaluation and care is recommended (including for diseases other than MVD)

By conducting such assessments and assuming a coordinating role in the management of symptomatic travelers, health departments will have the opportunity to:

  • Address concerns of healthcare or medical transport personnel in situations where there are no known risk factors for Marburg virus infection and testing is not recommended
  • Minimize potential unintended consequences of managing a symptomatic traveler as having suspected MVD if they have no known risk factors for infection, including unnecessary implementation of infection control precautions suitable for MVD or delayed recognition and management of other potentially life-threatening conditions (e.g., malaria, typhoid) while ruling out MVD
  • For any patient whose illness and exposure history meet the definition of suspect case of MVD:
    • Designate an appropriate healthcare facility that has capacity to provide an appropriate level of care for and safely manage a patient with suspected MVD
    • Communicate in advance with emergency medical services and the healthcare facility to ensure appropriate infection control precautions are in place during transport, and at the healthcare facility

CDC does not recommend that all people who have been in Rwanda and subsequently develop symptoms compatible with MVD be tested for Marburg virus infection, regardless of their risk level or recommended post-arrival monitoring strategy. Rather, such decisions should be based on the public health risk assessment, taking into account the person's clinical presentation and reported exposure risk factors, and be made in consultation with CDC subject matter experts. CDC has resources around the world that can be leveraged to provide context and additional clarity on a patient's travel, activities, and other epidemiological risk factors.

Previous updates

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.

On October 25, 2024:

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

On October 23, 2024:

  • Limited the interim recommendations for daily monitoring and avoidance of nonessential visits to a U.S. healthcare facility to travelers who have been present in the past 21 days in patient care areas of specified Rwandan healthcare facilities with known Marburg virus transmission risk (previously applied to all Rwandan healthcare facilities)
  • Defined an outbreak area for which travelers are recommended to have intermittent monitoring if they have a history of being in certain situations with exposure potential
  1. These occupational exposure situations assume correct and consistent use of recommended personal protective equipment (PPE). Correct and consistent use of PPE during situations with occupational exposure risk is highly protective and prevents transmission to healthcare or other personnel. However, unrecognized errors during the use of PPE (e.g., self-contaminating when removing contaminated PPE) may create opportunities for transmission to personnel.
  2. Traveler contact information available to CDC includes information air passengers provide to airlines as required by a CDC Order or provide directly to CDC during the public health entry screening process.