Update: Ebola, MERS-CoV and Travelers

June 18, 2015

Dear Colleague:

Since October 27, 2014 Virginia Department of Health (VDH) has successfully conducted a post-arrival active monitoring program for over 1,500 travelers arriving from countries with widespread transmission of Ebola virus disease (EVD).  Thank you for your ongoing collaboration in these efforts to prepare and respond to this public health crisis.  No cases of EVD have been identified in Virginia.

The worldwide public health response in West Africa has succeeded in slowing the EVD outbreaks. In the past 21 days, there were only 76 confirmed cases reported from Guinea and Sierra Leone. Liberia was declared Ebola-free by the World Health Organization on May 9 after two full incubation periods (42 days) had passed without a case of the disease being reported in Liberia. This was a significant milestone for the people of Liberia and all the responders who worked to contain the threat. On May 13, the Centers for Disease Control and Prevention (CDC) changed its country classification for Liberia to “a country with “former widespread transmission and current, established control measures.”

Today I want to update you on three items:


Changes to Virginia’s post-arrival active monitoring program for travelers from Liberia

Effective June 17, CDC modified the enhanced Ebola screening and monitoring program for travelers from Liberia. VDH has discontinued active monitoring of travelers who have returned from travel only to Liberia. Although the risk of Ebola is extremely low within Liberia, these travelers are still being screened at their arrival airport and will be advised to watch their health for 21 days after leaving Liberia. VDH will continue to respond to any inquiries from travelers regarding their health, but will not conduct daily, active monitoring of this extremely low risk population. In general, we will encourage these travelers to seek health care as appropriate for their illness, which may include outpatient or urgent care settings. Please continue to consult with your local health department regarding any questions or concerns you may have regarding a specific patient.

Key points of clinical guidance regarding persons whose travel was only to Liberia are:

  • Travelers from Liberia no longer routinely require enhanced Ebola-specific infection control precautions. Healthcare facilities should implement their facility’s routine precautions that are appropriate for the patient’s clinical presentation.
  • Travelers from Liberia with a febrile illness should be evaluated without delay for other causes of travel-related illness, including malaria (primarily Plasmodium falciparum), acute diarrhea and viral respiratory infections. Those with these particular symptoms of concern (fever WITH vomiting, diarrhea, and/or unexplained bleeding) should be placed in a private room until further diagnostic assessments are complete.

The monitoring of and clinical management recommendations for travelers returning from Guinea and Sierra Leone have not changed. Please continue to notify public health immediately if a patient presents with symptoms consistent with EVD and a history of travel within the last 21 days to either Guinea or Sierra Leone. Please continue to use personal protective equipment per CDC guidance and Ebola-specific hospital protocols and procedures for these travelers from Guinea and Sierra Leone.

CDC has summarized these current recommendations in For ED Doctors: Evaluation and management of patients who lived in or traveled to West Africa in the previous 21 days.

MERS-CoV infection and South Korea

Another emerging infection of continued interest is MERS-CoV infection. On May 20, the Republic of Korea (South Korea) reported a laboratory-confirmed MERS-CoV infection in an individual who had recently returned from the Arabian Peninsula. This was the first case in what is now the largest outbreak of MERS-CoV outside of the Arabian Peninsula. All reported cases appear epidemiologically linked to the index case, with transmission limited to other patients, healthcare workers, and visitors in healthcare facilities where case-patients received care. This outbreak is ongoing, although the number of new cases appears to be declining.

On June 11, CDC issued a health advisory with updated information and guidelines for evaluation of patients for MERS-CoV infection. MERS-CoV should be considered in a person presenting with: fever AND pneumonia or acute respiratory distress syndrome (based on clinical or radiologic evidence) AND a history of being in a healthcare facility (as a patient, worker, or visitor) in the Republic of Korea within 14 days before symptom onset. A history of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset remains an exposure risk. The criteria serve as guidance for implementing appropriate infection control precautions (e.g., standard, contact and airborne precautions) and testing; patients should be evaluated and discussed with public health on a case-by-case basis if their clinical presentation or exposure history is uncertain. When indicated, public health will coordinate with the Division of Consolidated Laboratory Services to test for MERS-CoV.

Actions for all health care providers caring for individuals with any possible travel-related infections

  • Take a thorough and detailed travel history of every patient that presents with signs and symptoms that may be consistent with illness acquired during travel.  Collecting travel history information is an important component of any patient’s history to ensure prompt, appropriate diagnosis and care.
  • Use your facility’s standard protocols and procedures to implement infection control and clinical care measures as appropriate for the clinical signs and symptoms of each particular patient.
  • Please continue to report suspect or confirmed reportable conditions to your local health department. Virginia Department of Health will continue to provide public health consultation on any patient with signs and symptoms of illness of public health concern.

The epidemiology of these emerging infectious conditions is fluid and evolving. VDH will provide updates as more information becomes available.

I truly appreciate all of the efforts to provide comprehensive, safe care with dignity to these patients. Thank you for your tremendous partnership with public health to prepare for and respond to the health needs of these patient populations, and to improve our collective ability to address emerging infectious disease threats.


David H. Trump, MD, MPH, MPA
Chief Deputy Commissioner for Public Health and Preparedness