ebola travel restrictions uganda

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Update April 12, 2024

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Uganda Travel Advisory

Travel advisory december 28, 2023, uganda - level 3: reconsider travel.

Uganda Level 3 – Reconsider Travel C T O

Reissued with updates to terrorism information.

Reconsider travel to Uganda due to  crime, terrorism , and  anti-LGBTQI+ legislation . Some areas have increased risk. Read the entire Travel Advisory.

Country summary:  There remains a threat of  terrorist attacks  in Uganda and throughout the region. Numerous terrorist attacks have occurred in Uganda, to include religious venues, schools, and areas frequented by tourists, resulting in the deaths of Ugandans as well as foreign visitors.  U.S. citizens should remain alert and avoid large public gatherings. In October 2023, ISIS-Central Africa claimed responsibility for killing two international tourists and a Ugandan driver within Queen Elizabeth National Park.

Violent crime , such as armed robbery, home invasion, and sexual assault, presents a serious threat to those visiting and residing in Uganda and can occur at any time, especially in larger cities, including Kampala, Jinja and Entebbe, in the Karamoja region, and along Uganda’s western and northern borders. Local police may lack appropriate resources to respond effectively to serious crime in most areas.

The May 2023 Anti-Homosexuality Act raises the  risk that LGBTQI+ persons, and those perceived to be LGBTQI+, could be prosecuted and subjected to life imprisonment or death based on provisions in the law , and may be subject to mandatory reporting to the police if they are suspected of committing or intending to commit acts in violation of the law, and could face harassment or attacks by vigilantes. Those perceived to support the dignity and human rights of LGBTQI+ persons (including those of youth under the age of 18) could be prosecuted and imprisoned for multi-year sentences.   Even an unsubstantiated accusation of supporting the LGBTQI+ community can create risks from police and vigilantes.  Read the country information page for additional information on travel to Uganda.

If you decide to travel to Uganda:

• Remain alert and avoid large public gatherings.
• Keep a low profile.
• Be aware of your surroundings.
• Do not display signs of wealth, such as expensive watches or jewelry.
• Use caution when walking or driving at night.
• Remain with a group of friends in public.
• Do not physically resist any robbery attempt.
• Do not open your door for people at your hotel/residence unless you know who it is.
• Do not leave food and drinks unattended in public, especially in local clubs.
• Stay alert in locations frequented by foreign tourists.
• Be extra vigilant when visiting banks or ATMs.
• Carry a copy of your passport and visa (if applicable) and secure originals in your hotel safe.
• Provide your itinerary to a family member or friend.
• Enroll in the Smart Traveler Enrollment Program  (STEP)  to receive Alerts and make it easier to locate you in an emergency.
• Be mindful that any public identification with the LGBTQI+ community, as either a member or supporter, could be grounds for prosecution, and that even private consensual same-sex relations are illegal.
• Follow the Department of State on  Facebook  and  Twitter .
• Review the  Country Security Report  for Uganda.
• Prepare a contingency plan for emergency situations.  Review the Traveler’s Checklist.
• Visit the  CDC page  for the latest Travel Health Information related to your travel.

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Watch CBS News

U.S. restarts airport screening for Ebola as outbreak in Uganda swells

By Alexander Tin

Updated on: October 6, 2022 / 7:06 PM EDT / CBS News

The Biden administration announced Thursday it plans to funnel all passengers flying into the U.S. from Uganda through five international airports for "enhanced screening," in response to a growing Ebola outbreak in Uganda. 

The move, which the State Department said would take effect at midnight on Friday morning, revives a set of measures implemented by federal health authorities in response to previous Ebola outbreaks abroad as recently as 2016 . In 2021, the CDC also rerouted passengers from the Democratic Republic of the Congo and Guinea to collect contact information.

Airlines will be required to route passengers who have been in Uganda during the past three weeks through one of five airports: 

• New York John F. Kennedy International Airport 
• Newark Liberty International Airport
• Atlanta Hartsfield-Jackson International Airport
• Chicago O'Hare International Airport
• Washington Dulles International Airport.

There, passengers will undergo "enhanced screening" measures designed to assess whether they have symptoms of the disease before they are allowed to continue on to their destinations. 

The change applies to all passengers, including U.S. citizens, the State Department said.

Experts say the move might deter travelers who feel sick after recently being in Uganda from trying to fly into the U.S. 

A previous attempt to conduct exit and entry screening for  Ebola , after  a case in 2014 , identified seven travelers with potential symptoms — none of whom were ultimately diagnosed with the disease. One traveler cleared by the screening later developed symptoms and tested positive for the virus  after arriving in the U.S.

Ebola infections typically start with symptoms like fever and fatigue, before leading to more severe vomiting, diarrhea, bleeding and often death. The World Health Organization says the virus can have an incubation period of as long as three weeks after exposure before symptoms begin.

This move comes as the Centers for Disease Control and Prevention has ramped up warnings to doctors and health departments over the outbreak, urging them to immediately screen any suspected cases for their recent travel history. 

The CDC says the risk of the Ebola virus spreading in the U.S. is low. Cases in Uganda have not been spotted in either the country's capital or travel hub.

However, the CDC says "as a precaution" it is hoping to raise awareness about the virus given the swelling case count in Uganda. 

"While there are no direct flights from Uganda to the United States, travelers from or passing through affected areas in Uganda can enter the United States on flights connecting from other countries," the agency said in a health alert published on Thursday .

The Biden administration has touted its response to the outbreak, which includes CDC staff working with health officials on the ground in Uganda. Health and Human Services Secretary Xavier Becerra spoke with his counterpart in Uganda on Tuesday , pledging to support the country's campaign to end the outbreak and expressing sympathy for those killed by the virus so far.

Since the outbreak was first declared on September 20 , the World Health Organization said this week that 63 cases of Ebola were confirmed or probable. At least 29 people have died. 

The strain of Ebola behind the outbreak is known as the Sudan virus, which spreads mostly through close contact with blood or other bodily fluids. 

The World Health Organization says the share of cases in previous outbreaks that died from their Sudan Ebola virus infections ranged between 41% and 100%. 

Unlike some other Ebola viruses, there are currently no licensed vaccines or treatments to curb the Sudan virus. Doses of the Ervebo vaccine in the U.S. Strategic National Stockpile are not expected to work for Sudan virus infections, the CDC said.

A vaccine candidate from Johnson & Johnson backed by the National Institutes of Health that might work against the Sudan virus is still in clinical trials. The WHO said the Johnson & Johnson vaccine "may be effective but has yet to be specifically tested against Ebola Sudan."

On the treatment front, the U.S. Administration for Strategic Preparedness and Response on Tuesday announced it would pour some $110 million into accelerating development of a monoclonal antibody drug for Sudan virus from Mapp Biopharmaceutical.

"If approved this treatment will put the U.S. in a better position to prepare for and respond to future potential ebolavirus incidents. Given the current outbreak of Ebola Sudan in Uganda, this work is now even more important," said Assistant Secretary for Preparedness and Response Dawn O'Connell in a statement.

Alexander Tin is a digital reporter for CBS News based in the Washington, D.C. bureau. He covers the Biden administration's public health agencies, including the federal response to infectious disease outbreaks like COVID-19.

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Global Health

Travelers coming to the u.s. from uganda will face enhanced screening for ebola.

Halisia Hubbard

Doctors walk in the Ebola isolation section of Mubende Regional Referral Hospital, in Mubende, Uganda, on Sept. 29. Ugandan health officials have declared an Ebola outbreak in several regions of the country. Hajarah Nalwadda/AP hide caption

Doctors walk in the Ebola isolation section of Mubende Regional Referral Hospital, in Mubende, Uganda, on Sept. 29. Ugandan health officials have declared an Ebola outbreak in several regions of the country.

Ugandan health officials declared an Ebola outbreak in several regions in late September . Now, travelers who have been to the African country within 21 days of arriving in the U.S. will be subject to enhanced screening, according to a health alert issued Thursday by the U.S. Embassy in Uganda.

So far, cases from this outbreak have only been detected in Uganda.

Passengers from that country will be routed to one of five airports: New York's John F. Kennedy International, Newark Liberty International, Hartsfield-Jackson Atlanta International, Chicago O'Hare International or Washington D.C.'s Dulles International. The Centers for Disease Control and Prevention, the Department of Homeland Security and Customs and Border Protection are adding new screening measures at the airports.

Guinea Faces First Ebola Outbreak In Years

Ebola virus disease, also referred to as EVD, is passed among humans through direct contact with an infected person's bodily fluids or objects and surfaces contaminated with such fluids.

According to the World Health Organization , the average fatality rate for Ebola is about 50%. The WHO says this outbreak appears to have been caused by Sudan virus, which it describes as a "severe, often fatal illness affecting humans." There are currently no approved vaccines or therapeutics for the Sudan ebolavirus.

The Congolese Doctor Who Discovered Ebola

The CDC recommends avoiding unnecessary travel to the affected districts in Uganda, and to avoid contact with sick people and dead bodies. Travelers should also isolate and seek medical help if any symptoms appear, such as fever, muscle pain, sore throat, diarrhea, weakness, vomiting, stomach pain, or unexplained bleeding or bruising.

European Centre for Disease Prevention and Control

An agency of the European Union

• Media centre

Ebola outbreak in Uganda, as of 11 January 2023

On 11 January 2023, Uganda declared that the Ebola disease outbreak caused by the Sudan ebolavirus was over. The declaration was made after 42 days passed without any case reported, since the last case was released from care.

Overall, 142 confirmed cases of Sudan virus disease (SVD) were reported, of which 55 died (CFR: 39%), and 87 recovered. In addition, 22 deaths among probable cases were reported in individuals who died before samples could be taken (overall CFR: 47%). At least 19 healthcare workers were infected, of whom seven died.

Over 4000 contacts were followed up for 21 days ( WHO AFRO News ).

Overall, nine Ugandan districts were affected by this outbreak: Bunyangabu, Jinja, Kagadi, Kampala, Kassanda, Kyegegwa, Masaka, Mubende, and Wakiso.

On 20 September 2022, the Ministry of Health in Uganda, together with WHO AFRO, confirmed an outbreak of SVD in Mubende District, Uganda, after one fatal case was confirmed.  

The index case was a 24-year-old man, a resident of Ngabano village of the Madudu sub-county in Mubende District. The patient experienced high fever, diarrhoea, abdominal pain, and began vomiting blood on 11 September 2022. Samples were collected on 17 September 2022 and SVD was laboratory-confirmed on 19 September. The patient died on the same day, five days after hospitalisation. 

This was the fifth SVD outbreak that occurred in Uganda.

Ebola cases in Uganda, 2022

Disclaimer: This figure is based on the latest available data from different public official sources. Updates are not always available on a daily basis. In addition, please note that there is a delay between the date of disease onset, the date of detection and the date of reporting, resulting in a reporting lag. This should be taken into consideration when interpreting these figures.

Geographical distribution of SVD cases in Uganda, 2022

Ebola virus disease outbreak in Uganda

More on this topic.

Ebola virus disease

Ebola and Marburg haemorrhagic fevers are rare diseases but have the potential to cause high death rates.

Infographics about Ebola virus disease

How does Ebola spread? Ebola - reducing the risk of transmission. View ECDC infographics

U.S. ending arrival Ebola screening for travelers from Uganda

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Uganda’s Ebola responders fret as some people fight measures

People load a coffin onto the back of a motorcycle to transport it to be used for the burial of an Ebola victim, in the town of Kassanda in Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

A man wearing protective clothing washes the interior of an ambulance used to transport suspected Ebola victims, in the town of Kassanda in Uganda, Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

A medical worker gestures to an Ebola patient inside the Ebola isolation center of Madudu Health Center III, in the village of Madudu, in the Mubende district of Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

A father and his baby son suspected of having Ebola sit inside the Ebola isolation center of Madudu Health Center III, in the village of Madudu, in the Mubende district of Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

Medical workers walk inside the Ebola isolation center of Madudu Health Center III, in the village of Madudu, in the Mubende district of Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

A motorcyclist transports a coffin to be used for the burial of an Ebola victim, in the town of Kassanda in Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

An Ebola patient sits inside the Ebola isolation center of Madudu Health Center III, in the village of Madudu, in the Mubende district of Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

Men carry a stretcher used for suspected Ebola victims back to an ambulance after washing it, in the town of Kassanda in Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

A military officers observes traffic at a checkpoint set up to stop motorcycles carrying passengers, in an attempt to limit the spread of Ebola, in Mubende, Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

People await a food distribution from a truck aimed to help those affected by the travel restrictions imposed in an attempt to limit the spread of Ebola, at a football pitch in Mubende, Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

Protective boots are hung up to dry after being disinfected inside the Ebola isolation center of Madudu Health Center III, in the village of Madudu, in the Mubende district of Uganda, Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

People receive a food distribution aimed to help those affected by the travel restrictions imposed in an attempt to limit the spread of Ebola, at a football pitch in Mubende, Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

A medical worker disinfects a tent used for suspected Ebola victims inside the Ebola isolation center of Madudu Health Center III, in the village of Madudu, in the Mubende district of Uganda Tuesday, Nov. 1, 2022. Ugandan health officials say they have controlled the spread of a strain of Ebola that has no proven vaccine, but there are pockets of resistance to health measures among some in rural communities where illiteracy is high and restrictions on movement and business activity have left many bitter. (AP Photo/Hajarah Nalwadda)

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KASSANDA, Uganda (AP) — The recent explosion of Ebola virus cases in a Ugandan rural community began when defiant residents exhumed a body at night, undoing the work of a safe burial team in order to give the deceased man a proper Islamic funeral.

Within days, at least 23 of the mourners had contracted Ebola and three were dead, prompting Uganda’s health minister to say she hoped the members of the farming community in the district of Kassanda had learnt their lesson.

But it seems not everyone had.

In a recent community discussion of the challenges health teams face in combating the current outbreak of a strain of Ebola with no proven vaccine, the district’s Ebola incident commander cited pockets of resistance to health measures.

Another official spoke of people who hide in the shrines of traditional healers — who are temporarily banned from working amid the outbreak — and another complained about youths unhappy with restrictions on movement who throw stones at patrol vehicles.

Ebola, which can sometimes manifest as a hemorrhagic fever, arrived here from Uganda’s neighboring district of Mubende in October, as patients crossed valleys and hills to seek treatment. Others didn’t even know they were infected. The early symptoms — including fever, fatigue and muscle pain — can often be mistaken for those of malaria or measles. But failing to isolate infectious patients can have fatal consequences.

When Ebola patients or their contacts are highly mobile, it’s harder to trace them and new clusters can emerge. At least two people sick with Ebola traveled 150 kilometers (93) miles from this central Ugandan region to Kampala, the capital, where authorities have voiced serious concern after 15 people there — including six schoolchildren — were infected.

Ebola has infected 130 people and killed 43 in this East African country of 45 million since Sept. 20, when the outbreak was confirmed in Mubende days after local officials first noted a “strange illness.” Official figures don’t include those who died with probable Ebola before the outbreak was confirmed.

There are at least 40 active Ebola cases in Uganda, which has had multiple outbreaks in the past. One in 2000 killed more than 200 people.

Ebola spreads through contact with the bodily fluids of an infected person or contaminated materials. During the current outbreak, the World Health Organization has said the fatality rate is nearly 30%.

Last week, the U.N. health agency revised its formal risk assessment, saying the risk to Uganda had been raised to “very high” and the risk of regional spillover was “high.” Scientists suspect that bats are the natural reservoir of Ebola and say outbreaks are often triggered when people come into contact with infected wildlife including bats, monkeys or antelopes.

Ugandan health officials say most Ebola contacts have been documented by tracers, hoping to reassure people who are worried that further spread of the disease could cause a nationwide lockdown. The Africa Centers for Disease Control and Prevention says the outbreak is under control because of the contact tracers’ efficient work.

But without effective vaccines or medicines, unless everyone cooperates an Ebola outbreak can be hard to end. This is especially so in a remote community with high levels of illiteracy, where some still link Ebola to witchcraft and choose to address it at home rather than call an ambulance.

Ugandan health officials have achieved “a tenuous degree of control” in the outbreak, said Dr. Atul Gawande, a U.S. official responsible for global health at USAID. Just a few errant individuals can cause the outbreak to change rapidly, he said during a visit to Kassanda Tuesday. Scientists do not consider outbreaks to be over until 42 days — twice the maximum incubation period — have passed without new cases detected.

Speaking to the community, Health Minister Jane Ruth Aceng warned that if contacts continue to run away, “there will be an explosion where they run.” She said sometimes villagers “are like children. You tell them, ‘Don’t touch the fire.’ They touch it.”

On Wednesday, the national Ebola incident commander, Dr. Henry Kyobe Bosa, said the outbreak “is entering a phase of potentially sporadic cases” as contacts keep running as was recently seen in Masaka, along the busy highway to western Uganda.

Some residents of Kassanda and Mubende said movement restrictions in place since mid-October seem worse than Ebola itself. Traditional healers complained they had no income. A food vendor who waits on passenger buses said he lost business. Others said even food is hard to come by.

“It has affected us too much because we don’t have customers for buying our booze. We lock ourselves inside at 7 (p,m.) exactly,” said Miria Twijukye, bitter that after two days she was still waiting to get her package of government-supplied food rations. “We are suffering so much.”

Even if the measures are necessary, “we need food,” she said, drawing cheers from others in a crowd waiting for free food in Mubende town.

Some in Mubende are concerned about the risk of new contamination from neighboring Kassanda amid the reports of community resistance.

“This disease escalated from here and it went to the neighboring district. And today I want to report that Kassanda is the one that’s having very many numbers,” said Rosemary Byabasaija, who heads Mubende’s Ebola task force.

In a sign of the shifting epicenter of the outbreak, most of the 24 Ebola patients admitted at Mubende’s regional referral hospital are from Kassanda. Only three are Mubende residents.

“That’s a big problem,” said Byabasaija, talking about the jump in cases from Kassanda after the infected body was exhumed. “I want to appeal to religious ... and cultural leaders that this is not the time to go by our (normal) rules and procedures, because Ebola kills.”

She spoke worriedly of a trail that some people are following to dodge restrictions, creating unwanted traffic from Kassanda that could hurt efforts to eliminate active cases in Mubende.

“For us, we had fought our war and we are succeeding,” she said, “but now we are getting challenges (from) people who are coming from Kassanda.”

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‘Ebola Could Have Wiped Us All’: Slow Lockdown Haunts Uganda

The authorities hesitated to impose restrictions in the epicenter of the Ebola outbreak because of residual trauma from the Covid lockdown. Ebola then spread to the capital, killing dozens of Ugandans.

By Abdi Latif Dahir

Abdi Latif Dahir, The Times’s East Africa correspondent, accompanied by the photographer Esther Ruth Mbabazi, reported this article from Kampala, Uganda’s capital, and Kassanda District, one of the epicenters of the Ebola outbreak.

As an outbreak of Ebola swept through central Uganda in late September, government officials were willing to do anything to contain the virus except take one crucial step: impose a lockdown.

This was radically different from their response during the onset of the coronavirus pandemic, when Uganda introduced some of the most restrictive shutdowns in Africa by closing borders, banning public transportation and shutting schools for two years — one of the longest such shutdowns worldwide .

Officials in Uganda, a landlocked nation in East Africa, now acknowledge that they hesitated to impose similar restrictions in the recent Ebola outbreak because of the lingering anger, resentment and trauma over the strict Covid measures. They worried that another harsh response to an epidemic could spark protests, batter an economy already under strain and alienate a weary population inundated with misinformation about the dangers — and even the existence — of the Ebola virus.

The initial decision not to seal off the epicenter of the Ebola outbreak has come to haunt Uganda. The disease spread to nine districts, including the capital, Kampala. The World Health Organization reported 142 confirmed cases and 55 confirmed deaths, with an additional 22 deaths probably linked to the outbreak.

“We should have done it in a much more aggressive way,” said Henry Kyobe Bosa, an epidemiologist who is managing the Ebola response at the Ministry of Health. But he added, “Remember, we are coming from Covid, and you want not to disrupt people’s lives as much as possible.”

The outbreak, the country’s deadliest in over two decades , has now largely subsided, and no new Ebola infections have been reported recently. But those who were affected are asking whether all the pain could have been avoided.

Among those who died was 12-year-old Ssebiranda Isaiah Victor, whose relatives gathered on a recent overcast afternoon for a memorial service at Nakaziba, their village in the lush hills of central Uganda.

The family lived in Kampala, and the boy’s father, Ssekiranda Fred, said his son had contracted the virus from a neighbor’s child who arrived from Kassanda, one of the districts in the center of the outbreak.

Mr. Fred said that if the government had taken strict measures to curb the virus, “maybe things wouldn’t have turned out the way they turned out.”

“I miss you, my son,” he said. “He was so brilliant, a dreamer.”

Ebola, a highly contagious disease mostly seen in Africa, causes fever, fatigue and bleeding from the eyes and the nose. The virus kills about half of those it infects. The largest number of deaths, 11,325 people , was recorded during an outbreak in West Africa from 2014 to 2016. An epidemic in the Democratic Republic of Congo in 2018-20 killed 2,280 people .

In recent years, Uganda has suffered through multiple disease outbreaks, including measles, Marburg and polio, that have burdened its health system.

So when Covid-19 hit, the authorities introduced sweeping restrictions, which had devastating effects on the country’s 47 million people. Rights groups and opposition members argued that the measures were part of an effort to suppress dissent ahead of closely contested elections last year and the bloody months that followed .

Ugandan health officials said they were reluctant to issue another blanket lockdown when the Ebola virus was detected, despite recommendations from medical experts and aid groups that urged them to swiftly prevent movement to and from areas where cases appeared.

“This is a public health emergency of international concern, and the government kind of fell behind,” said a senior aid official involved in the emergency Ebola response, who like others, spoke on the condition of anonymity to discuss sensitive matters. “They wanted to give the general impression that the outbreak is under control.”

Finally, on Oct. 15, almost a month after the first Ebola case was reported, President Yoweri Museveni announced a dusk-to-dawn curfew and the restriction of movement in and out of Mubende and Kassanda, the districts where the outbreak was concentrated.

By then, the virus had spread to the capital. People who had contact with Ebola patients from Mubende were evading quarantine . Mr. Museveni said in a speech that one contact concealed his identity and address to seek treatment from a traditional healer in a neighboring district. He later died in Kampala.

“They were really determined on no more lockdowns because they knew that public trust was not there,” said another senior Western health official with knowledge of the emergency response. But with the virus in Kampala, the official said, “they felt pushed into it.”

By then, the United States had issued an order to screen all travelers from Uganda arriving at American airports. Many tourists were also postponing or canceling their trips to Uganda, threatening a tourism industry that was betting on the upcoming holiday season to recover from the staggering losses of the pandemic , said Herbert Byaruhanga, president of the Uganda Tourism Association and the manager of a bird-watching company.

“It is like adding salt to the wound,” said Mr. Byaruhanga.

The Ugandan public’s lack of trust in the government’s Ebola response created fertile ground for misconceptions, including the belief that Ebola is caused by witchcraft and that the burials of Ebola victims are kept closed — not to prevent contagion, but so that their organs can be harvested and sold.

At a motorcycle taxi stop in Kassanda, almost a dozen people congregated on a recent evening to insist to reporters that Ebola did not exist. The lockdown, they said, was meant to punish the district for backing the opposition party led by the musician-turned-politician Bobi Wine in the 2021 elections. They also accused the police of beating them to enforce the overnight curfew.

“Where is Ebola?” Mutumba Alex, a taxi driver, asked. Waving his driver’s license, he said he knew the area well and did not see any proof of sickness or deaths from the disease. “Ebola does not exist.”

But the reality in Kassanda was different for Nantale Rashida, who said she faced stigma and discrimination from her neighbors when her husband, Asadu Matovu, tested positive for Ebola. Mr. Matovu recovered, but lost his mother and two brothers to the virus.

To prevent Ms. Rashida and her their children from going anywhere, the community “tied ropes around our plot,” she said. “I spent all day and night crying.”

Multiple corruption cases related to the coronavirus pandemic have also eroded citizens’ trust in their leaders.

The United States, which has donated more than $22 million to fight Ebola, has been concerned about corruption, too , said Natalie E. Brown, the American ambassador to Uganda. The vast majority of donations from the United States and other donors have gone through aid agencies rather than directly to the Health Ministry — a move that has incensed Ugandan officials, according to interviews with aid officials.

Corruption even struck at Ebola patients. A report prepared by health officials in Kassanda and seen by The New York Times noted that survivors of Ebola complained that the police had impounded their possessions and demanded bribes to release them.

Vaccines exist to prevent Ebola, but there is no approved vaccine or drug treatment for the Sudan strain of the virus, which caused the recent outbreak in Uganda. A clinical trial of three vaccines — made by the Washington-based Sabin Vaccine Institute, the University of Oxford and IAVI, donated by Merck, the American pharmaceutical company — is being prepared . Researchers have also begun a clinical trial of two monoclonal antibodies donated by the United States that can help boost patients’ chances of survival.

Some experts say, however, that with no new Ebola cases being reported in Uganda now, a critical opportunity to advance understanding of the Sudan Ebola strain might have been missed.

For now, families across Uganda are grieving for their loved ones.

Days after he lost his son to Ebola in mid-October, Mr. Fred’s wife of 22 years, Nakku Martha, succumbed to the virus. Mr. Fred was in isolation when both died, and he was unable to attend either of the burials. Even as he mourned, he said, he remained grateful that the virus did not take his three remaining sons.

“Ebola could have wiped us all,” he said, teary-eyed on a recent afternoon, as he walked around the tiled grave of his son, canopied by banana trees. “But we survived and remain hopeful.”

Musinguzi Blanshe contributed reporting from Kampala, Uganda.

An earlier version of this article incorrectly referred to one of the three vaccines being prepared for clinical trials against the Ebola outbreak in Uganda. It is the IAVI vaccine, donated by Merck, not the Merck vaccine, since Merck no longer holds the license to develop the vaccine.

How we handle corrections

Abdi Latif Dahir is the East Africa correspondent. He joined The Times in 2019 after covering East Africa for Quartz for three years. He lives in Nairobi, Kenya. More about Abdi Latif Dahir

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• Queen Elizabeth National Park
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Canadian travellers heading to Uganda urged to take precautions

The Public Health Agency of Canada (PHAC) is warning Canadian travellers entering Uganda to take extra precautions before flying due to an Ebola outbreak that was declared in the nation last month.

The government issued a Level 2 travel health notice on Friday to encourage people travelling to the country to be extra careful.

“Consult a health care professional or visit a travel health clinic at least six weeks before you travel. Make sure your routine vaccines are up to date,” the advisory reads.

There have been four previous Ebola outbreaks in Uganda. The deadliest occurred in 2000, claiming more than 200 lives.

The current Ebola outbreak in central Uganda has a 69 per cent case fatality rate , which the Africa Centres for Disease Control and Prevention’s acting director Ahmed Ogwell called "very high.”

Four health workers are among 10 people confirmed to have died of Ebola. There have been 43 confirmed cases. None have been in the capital, Kampala.

Canada currently recommends all Canadian travellers in Uganda to avoid contact with people infected with the disease along with practicing strict hand-washing routines. Other precautions include avoiding close contact with live or dead animals, and avoiding handling raw or undercooked meat.

T he U.S. Embassy in Uganda announced on Thursday that all U.S.-bound airline passengers who have been in the country in the 21 days before their arrival will be screened for Ebola.

There are no cases of Ebola in the United States at this time, and “the risk of Ebola domestically is currently low,” the embassy said.

Ebola manifests as viral hemorrhagic fever and is spread through contact with the bodily fluids of an infected person or contaminated materials. Ebola symptoms include fever, vomiting, diarrhea, muscle pain and at times internal and external bleeding.

Those who develop symptoms while in flight to Canada are instructed to tell a flight attendant or border services agent who will notify a quarantine officer.

With files from The Associated Press, CNN and The Canadian Press

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Travel and Border Health Measures to Prevent the International Spread of Ebola

Supplements / July 8, 2016 / 65(3);57–67

Nicole J. Cohen, MD 1 ; Clive M. Brown, MBBS 1 ; Francisco Alvarado-Ramy, MD 1 ; Heather Bair-Brake, DVM 1 ; Gabrielle A. Benenson, MPH 1 ; Tai-Ho Chen, MD 1 ; Andrew J. Demma, MS 1 ; N. Kelly Holton 1 ; Katrin S. Kohl, MD 1 ; Amanda W. Lee, MPH 1 ; David McAdam, MA 1 ; Nicki Pesik, MD 1 ; Shahrokh Roohi, MPH 1 ; C. Lee Smith, MA, SS 1 ; Stephen H. Waterman, MD 1 ; Martin S. Cetron, MD 1 ( View author affiliations )

CDC’s Role: Working with Partners

Cdc contributions and impact, acknowledgments.

• pdf icon [PDF]

During the 2014–2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC implemented travel and border health measures to prevent international spread of the disease, educate and protect travelers and communities, and minimize disruption of international travel and trade. CDC staff provided in-country technical assistance for exit screening in countries in West Africa with Ebola outbreaks, implemented an enhanced entry risk assessment and management program for travelers at U.S. ports of entry, and disseminated information and guidance for specific groups of travelers and relevant organizations. New and existing partnerships were crucial to the success of this response, including partnerships with international organizations, such as the World Health Organization, the International Organization for Migration, and nongovernment organizations, as well as domestic partnerships with the U.S. Department of Homeland Security and state and local health departments. Although difficult to assess, travel and border health measures might have helped control the epidemic’s spread in West Africa by deterring or preventing travel by symptomatic or exposed persons and by educating travelers about protecting themselves. Enhanced entry risk assessment at U.S. airports facilitated management of travelers after arrival, including the recommended active monitoring. These measures also reassured airlines, shipping companies, port partners, and travelers that travel was safe and might have helped maintain continued flow of passenger traffic and resources needed for the response to the affected region. Travel and border health measures implemented in the countries with Ebola outbreaks laid the foundation for future reconstruction efforts related to borders and travel, including development of regional surveillance systems, cross-border coordination, and implementation of core capacities at designated official points of entry in accordance with the International Health Regulations (2005). New mechanisms developed during this response to target risk assessment and management of travelers arriving in the United States may enhance future public health responses.

The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners ( http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html ).

Before the 2014–2016 Ebola virus disease (Ebola) epidemic in West Africa, reports of Ebola virus exportation to other countries were rare, a fact partially attributed to the remote, rural locations of previous outbreaks of Ebola. When Ebola spread in 2014 to the capital cities of Guinea, Liberia, and Sierra Leone, where infected persons and their contacts had greater access to international airports, concerns arose about the potential for further international spread. These concerns were heightened in July 2014, after a Liberian-American businessman with symptomatic Ebola traveled from Monrovia, Liberia, via Togo to Lagos, Nigeria. This event triggered an outbreak in Nigeria that spread to a second city by air travel, infected 20 persons (confirmed and probable cases), resulted in the deaths of eight persons, and exposed almost 900 persons ( 1 ). On August 8, 2014, an emergency committee convened by the Director-General of the World Health Organization (WHO) under the International Health Regulations (2005) declared the Ebola epidemic in West Africa a Public Health Emergency of International Concern ( 2 ). Among the recommendations of the emergency committee were that countries with Ebola transmission should conduct exit screening at international airports, seaports, and major land crossings and that other countries should not generally ban travel or trade.

CDC’s initial response to the Ebola epidemic in West Africa included communication to travelers (e.g., travel notices on CDC’s website, messaging displayed in airports) and enhancement of existing mechanisms to detect sick travelers entering the United States. Recognizing the importance of preventing further isolation of, and economic impact to, the countries with Ebola outbreaks and maintaining the essential flow of humanitarian aid workers and supplies, CDC sent teams to these countries in August 2014 to provide technical assistance with border health measures. The teams initially focused on training and capacity building to rapidly implement effective exit screening (i.e., screening of departing travelers for acute illness or possible exposures) at international airports ( 3 ). Although not routinely recommended, exit screening might be considered an important mechanism of source containment during an infectious disease outbreak to prevent international spread. Because the primary benefit of exit screening is protection of the international community, assisting in its effective implementation is a shared international responsibility.

In late 2014, two imported cases of Ebola were identified in the United States, one of which resulted in two domestic cases and extensive contact investigations in the community and for travelers on two domestic flights ( 4 – 7 ). Demands increased from some political leaders and members of the public to strengthen the domestic response, including banning air travel between the United States and the three countries with widespread transmission ( 8 ). Many public health professionals cautioned that such a ban would cause greater harm than good to the public health response by hampering travel of responders and delivery of supplies into the region and paradoxically could increase the risk for spread via covert and circuitous travel routes ( 9 , 10 ). To build on the exit screening already in place, CDC collaborated with the U.S. Department of Homeland Security (DHS) to initiate an enhanced entry risk assessment and management program for travelers from countries with Ebola outbreaks. This unprecedented operation required coordination across multiple U.S. government agencies, as well as with airport authorities and health departments in all U.S. states and territories ( 3 ).

CDC’s travel and border health–related response to the Ebola epidemic comprised three goals: 1) prevent international spread of disease, 2) educate and protect travelers and communities, and 3) minimize disruption of international travel and trade. This report discusses specific measures, considerations for their implementation, and their potential use in response to future outbreaks of international public health concern ( Table ).

International Response

In August 2014, after Ebola spread from Liberia to Nigeria by air travel, concerned airlines canceled flights to Guinea, Liberia, and Sierra Leone, and multiple countries closed their borders to travelers from these countries ( 11 ); the shortage of commercial flights caused delays to the provision of humanitarian aid, resulting in shortages of medical supplies, personal protective equipment, and food ( 12 ). The few airlines that continued to fly to the countries with Ebola outbreaks insisted that departing travelers be screened before boarding ( 11 ). CDC Border Health teams in Guinea, Liberia, Nigeria, and Sierra Leone, and later Mali and Senegal, helped airport and health authorities implement airport exit screening measures that included administering an exposure-and-symptom questionnaire and at least one temperature check with a handheld noncontact thermometer to all departing passengers. Health screeners were trained to conduct secondary assessments of travelers who reported possible exposures or who had symptoms compatible with Ebola. Symptomatic or exposed travelers were denied boarding and referred for further medical and public health assessment. As national databases of known contacts became more robust, they were matched against passenger manifests for departing flights. These measures helped countries with Ebola outbreaks meet WHO recommendations and ensured that some commercial air carriers continued to fly to these countries, serving as vital conduits for supplies and response personnel.

During August 2014–January 2016, approximately 300,000 travelers were screened in Guinea, Liberia, and Sierra Leone. Only four cases of Ebola were exported through air travel to other countries (United States [two cases], United Kingdom [one case], Italy [one case]) after exit screening was implemented; none of the infected travelers were overtly symptomatic at the time of travel ( 4 , 7 , 13 , 14 ). No Ebola cases were reported to have been detected during exit screening.

To support the international response, CDC developed Ebola communications tools, job aids for airline and airport staff, and messages specific to different organizations and populations. Information also was provided through webcasts and trainings, and some materials were made available on the CDC website as templates to assist other countries in developing their own communications resources.

Countries in West Africa, including Guinea, Liberia, and Sierra Leone, rely heavily on commercial maritime transport to deliver food and other critical commodities and to export supplies that sustain national economies ( 15 ). Keeping these supplies moving was critical to avoiding further strain on the countries’ already fragile systems. CDC assisted national seaport and maritime authorities by evaluating health security measures at major seaports and training staff how to recognize and respond to Ebola. Port authorities established temperature checkpoints for port access; reviewed and practiced emergency medical response procedures; established onsite isolation facilities; implemented personal protective equipment requirements for staff required to board vessels; and restricted access to vessels in port and disembarkation of seafarers, including cancellation of shore passes and crew transfers.

Land Borders

Ebola initially spread at the land borders of Guinea, Liberia, and Sierra Leone, and frontiers between these countries and their neighbors posed the most difficulties for the border health component of the response. Movement across land borders also resulted in the introduction of Ebola into neighboring Senegal and Mali causing an outbreak in Mali that resulted in eight cases and six deaths; international sharing of information about contacts led to interventions that prevented transmission and contributed to successful containment in Senegal without further spread ( 16 ).

The origin of the epidemic highlighted weaknesses in routine and cross-border disease surveillance. In the border regions of West Africa, tribal and ethnic kinship affiliations rather than geopolitical boundaries define village communities. Official border points of entry (those where travelers are inspected by border officials) are sparse, understaffed, and underresourced; dozens of informal border crossings exist for every official point of entry; and travel volumes are high. For all of these reasons, land borders are porous and applying screening procedures at official land border crossings similar to those used at airports is impractical and probably ineffective. CDC, together with ministries of health, WHO, the International Organization for Migration, nongovernment organizations, and other international partners, strengthened disease surveillance in border communities and sharing of information across borders; implemented simple, sustainable measures (e.g., visual screening for illness at designated official border crossings); and developed clearly articulated plans for isolation, communication, assessment, referral, and transportation on the basis of existing and nearby resources. These organizations also coordinated improved mapping of geopositional landmarks, including official and informal border crossings, villages, and markets and other areas of congregation, as well as mapping of population movement patterns. This approach aimed to improve cross-border operations and situational awareness and engage community members in the public health response.

Domestic Response

Travel and border health measures within the United States evolved over time in response to changing needs, newly identified risks, and public concern. At the start of the epidemic, CDC strengthened coordination with U.S. port-of-entry and community partners to identify and assess risks for symptomatic or potentially exposed travelers. Communications materials supported a strategy that relied on educating travelers to self-monitor and seek health care if they developed symptoms.

In August 2014, CDC issued interim guidance that provided a standard for public health measures in the United States on the basis of clinical criteria and exposure risk ( 17 ). Measures ranged from monitoring (primarily self-monitoring) to controlled movement (e.g., preclusion from long-distance travel on commercial conveyances such as aircraft, ships, buses, or trains) and aimed to apply the least restrictive measures necessary to protect communities and travelers.

CDC issued revised interim guidance in October 2014 ( 17 ) after the first imported case of Ebola in the United States was identified (and initially diagnosed as presumed sinusitis) in Dallas, Texas ( 4 ); an infected U.S. health care worker (HCW) flew on two domestic commercial flights, causing panic among U.S. travelers and disrupting the travel industry ( 6 , 18 , 19 ); and an infected humanitarian aid worker was reported to have been in public areas, including the New York City subway, during the early stages of his illness ( 7 , 20 ). CDC’s guidance was revised in response to assertions that self-monitoring was insufficient; growing concerns about infected HCWs in Spain, the United States, and the West African countries with Ebola outbreaks ( 4 , 7 , 21 , 22 ); and renewed calls for travel bans ( 8 ). Demands to restrict movement of HCWs caring for patients with Ebola were countered by predictions that stringent restrictions would discourage HCWs from supporting the response in West Africa or taking care of patients with Ebola at designated facilities in the United States ( 23 , 24 ). The revised guidance recommended that state or local public health authorities assume responsibility for monitoring all potentially exposed persons for the duration of the 21-day incubation period (active monitoring); established a higher standard of monitoring (direct active monitoring that included daily direct observation by public health officials) for persons with greater potential risk for exposure, including HCWs; and provided guidance for possible application of movement restrictions within communities. Although CDC’s guidance represented a minimum standard, states could, and in many cases did, apply more restrictive measures (e.g., temporarily quarantining HCWs returning from West Africa) ( 25 ). Many of these measures were enacted before CDC issued the updated guidance.

To facilitate postarrival management of travelers, in October 2014, CDC and DHS’s Customs and Border Protection (CBP) began an enhanced entry risk assessment and management program for travelers arriving in the United States from countries with Ebola outbreaks ( 3 ). To implement this program with maximum efficiency and minimal disruption to travel, CBP limited entry of air travelers from Guinea, Liberia, and Sierra Leone (and for several weeks from Mali, during the outbreak in that country) to five airports: Hartsfield–Jackson Atlanta International Airport, Newark Liberty International Airport, Washington Dulles International Airport, John F. Kennedy International Airport (New York City), and Chicago O’Hare International Airport.

Enhanced entry risk assessment at U.S. airports included processes to identify travelers from countries with Ebola outbreaks, either through scheduled flight itineraries or during customs and immigration inspections. CBP officers and other U.S. Department of Homeland Security staff collected contact and locating information, administered an exposure-and-symptom questionnaire, checked travelers’ temperatures with noncontact thermometers, and observed travelers for signs of illness. Data were entered electronically through an online interface and transmitted securely to CDC’s database and then to states. Travelers who were symptomatic or who reported possible exposures were referred to CDC for an in-depth public health risk assessment. Symptomatic travelers who met predefined criteria were referred for medical evaluation to designated assessment hospitals, in consultation with the health department with jurisdiction for the airport.

The enhanced entry risk assessment and management program enabled CDC to educate travelers individually about Ebola and the postarrival monitoring process. Screened travelers received a CDC CARE (Check and Report Ebola) kit containing information and tools (including a thermometer and prepaid cell phone) to facilitate monitoring and reporting to health departments ( Figure 1 ).

Enhanced entry risk assessment was discontinued for travelers from Liberia on September 21, 2015; for travelers from Sierra Leone on December 22, 2015; and for travelers from Guinea on February 19, 2016. Of the approximately 38,000 travelers assessed at U.S. ports of entry during October 11, 2014–February 18, 2016, only one was subsequently determined to have Ebola. The infected humanitarian aid worker arrived during the brief period between initiation of enhanced entry risk assessment and implementation of postarrival monitoring. He was asymptomatic upon arrival, and his illness was detected through self-monitoring and reporting to the local health department as recommended at the time ( 7 ).

To help enforce recommendations that travelers with certain exposures to Ebola should not travel on commercial conveyances and to further reduce the risk for Ebola spread through air travel, in March 2015 CDC revised criteria for use of federal travel restrictions to prevent travel by persons possibly exposed to Ebola or other communicable diseases but not yet considered contagious ( 26 ). The updated criteria gave CDC greater flexibility to control the movement of persons who might pose a public health threat during travel and to apply federal travel restrictions in support of outbreak control.

Communication

Throughout the response, CDC disseminated messages to inbound and outbound travelers through the CDC website, traditional and social media, partner outreach, and printed materials. Messages displayed in U.S. airports and in airports in countries with Ebola outbreaks reminded travelers to avoid travel while symptomatic, monitor themselves for illness, and seek health care should symptoms develop ( Figure 2 ) ( Figure 3 ) ( Figure 4 ).

To provide international travelers with information to protect their health and, ultimately, the health of their communities, CDC regularly posts travel notices about disease outbreaks and international events. Notices are assigned a risk level ( 27 ) on the basis of the situation and available health recommendations and are escalated or deescalated as the analysis of risk to travelers changes (e.g., status of the outbreak or ability to access health care facilities). The highest risk level is Level 3 (i.e., warning), used only for situations in which the risk is so great that CDC recommends against nonessential travel to a destination. When considering issuance of Level 3 travel notices, CDC takes into account the health risk and impact to travelers and the potential for economic harm to the destination country and the travel industry.

During the 2014–2016 Ebola epidemic in West Africa, CDC initially posted Level 2 (i.e., alert) notices, which recommended enhanced precautions for travelers to Guinea (March 2014), Liberia (April 2014), and Sierra Leone (June 2014); later, Level 2 notices were added for Nigeria (August 2014) and Mali (November 2014) when Ebola outbreaks occurred in those countries. The notices for Guinea, Liberia, and Sierra Leone were subsequently elevated to Level 3 in July 2014 to advise U.S. residents to avoid nonessential travel to these countries and enable their governments to respond most effectively to the epidemic by reducing the potential for difficulties posed by nonessential travelers. As the situation improved in Liberia and extensive control measures were put into place, CDC downgraded the notice for this country to Level 2 in May 2015, then to Level 1 (i.e., watch) in September 2015. Similarly, CDC downgraded the notices for Sierra Leone to Level 1 and Guinea to Level 2 in November 2015, and the notice for Guinea was downgraded to Level 1 in December 2015. CDC removed all three notices on February 19, 2016, coinciding with the discontinuation of enhanced entry risk assessment at U.S. ports of entry.

CDC also issued guidance for specific groups of travelers most at risk. Because humanitarian aid was essential to managing the epidemic, CDC posted guidance for aid workers and organizations to help ensure safe travel to and from the region. In contrast, CDC considered education-related travel to be nonessential and advised postponing travel in its guidance for colleges, universities, and students. CDC also published guidance for airlines, cruise ships, and cargo ships to help crew members manage sick travelers onboard when Ebola was suspected.

As CDC’s response to the Ebola epidemic ends, travel and border health measures can be reviewed to assess whether they met the stated goals: 1) prevent international spread of disease, 2) educate and protect travelers and communities, and 3) minimize disruption of international travel and trade. These measures fall into four broad categories: 1) risk determination and characterization, 2) risk communication, 3) risk assessment of persons, and 4) risk management on the basis of individual assessment. Although spread of Ebola through air travel is an inherently low-probability event, the consequences of such spread would be high, including potential for disruption of travel and trade to a highly vulnerable region. Thus, any consideration of travel and border health measures must balance public health risk against the perception of such risk by travelers, the travel industry, and government decision makers. These measures demand constant assessment and refinement to adjust to changing epidemic characteristics. When recommending and implementing such measures, CDC aims to protect civil liberties through the use of least restrictive means.

Although WHO declared the end of the Public Health Emergency of International Concern and recommended discontinuation of exit screening on March 29, 2016 ( 28 ), exit screening continued in Guinea, Liberia, and Sierra Leone in response to a cluster of cases in Guinea with limited spread to Liberia. As of June 6, 2016, when this report went to press, no new cases had been reported and exit screening was expected to end shortly. Exit screening successfully addressed vulnerabilities that enabled exportation of Ebola to Nigeria by an actively symptomatic traveler, minimizing the number of exported cases and preventing travel by overtly symptomatic persons ( 29 ). Separating the effectiveness of exit screening at airports from other public health measures (e.g., identifying and managing cases and exposed persons at the community level or educating travelers) or the deterrent effect of the screening process is difficult. However, these collaborations contributed meaningfully to controlling the epidemic. Exit screening was challenging for the affected countries because resources and staffing needs for these activities competed with other priorities. These difficulties most likely were offset by intangible benefits, including reassurance of airlines and travelers of the continued safety of air travel that no doubt contributed to the willingness of some airlines to maintain flight schedules within the region throughout the epidemic ( 11 ).

Operationally, the U.S. enhanced entry risk assessment and management program succeeded as a mechanism to assess individual risk, educate travelers, and facilitate postarrival management of travelers including active or direct active monitoring by public health authorities. Funneling of travelers from countries with Ebola outbreaks to selected airports rather than diverting airplanes was substantially less disruptive to the travel industry. The ability to track and monitor travelers in any U.S. state or territory, including their movement among states, resulted in rapid identification and evaluation of approximately 1,400 symptomatic travelers, none of whom had Ebola diagnosed. However, the operation was not without costs (e.g., high resource demands), much of which have been borne by the federal government, as well as the subsequent burden to health departments in the United States and inconvenience to airlines and travelers. The opportunity costs of diverted public health resources must also be taken into account.

The more difficult task of preventing, detecting, and responding to the spread of Ebola across highly porous land borders in West Africa resulted in a multisector collaboration, greater awareness of population movement, enhanced procedures and resources to manage sick travelers in remote border locations, and improved binational and multinational communication and cooperation. Border officials and residents of border communities were trained to recognize sick travelers as sentinel events, contributing to more integrated surveillance and response systems that could help prevent unrecognized cross-border spread during future epidemics. However, much work remains to build and maintain these nascent border health systems as part of the broader public health infrastructure.

Travel and border health measures applied in the countries with Ebola outbreaks, domestically in the United States, and through various communications mechanisms might have averted a breakdown of global interconnectedness that would have damaged the Ebola response and severely disrupted international travel and trade to a highly vulnerable region. A new model was developed that replaced single-point screening at borders with a continuum of measures that started with pretravel information for travelers and ended with monitoring through the end of the potential incubation period. These measures provided an alternative to more stringent options (e.g., travel bans or widespread use of quarantine) and calmed the concerns of political leaders and the public. This experience managing a public health threat from a relatively remote area elevated interagency cooperation at the federal, state, local, and international levels and led to development, revision, and validation of new and old tools that were effective and might prove invaluable in the future.

The Ebola epidemic devastated Guinea, Liberia, and Sierra Leone. However, the reconstruction process presents a unique opportunity to build sustainable public health infrastructure by leveraging resources and systems put in place to combat the epidemic, including helping countries comply with core capacities at designated official points of entry in accordance with the International Health Regulations (2005) ( 30 ) and developing systematic cross-border communication as part of plans to establish a West African surveillance network. Moving forward, the Global Health Security Agenda ( 31 ) presents an opportunity to reduce the risk for global spread of disease through migration and travel and to meet the crucial need for enhanced border health security in vulnerable regions of the world. In the United States, new mechanisms for targeted risk assessment and management of travelers can improve the efficiency of border health measures aimed at preventing the introduction and spread of high-consequence communicable diseases into the United States and enhance the public health response to future outbreaks involving travelers.

Yusra Ahmad, Andre Berro, Sena Blumensaadt, Denise Borntrager, Gary Brunette, Michelle Calio, Michelle Canady, Blanche Collins, Terrence Daley, Christopher de la Motte Hurst, Pamela Diaz, Annelise Doney, Onalee Grady-Erickson, Bruce Everett, Reena Gulati, Harlem Gunness, Yoni Haber, Christa Hale, Erin Hawes, Ronald Henry, Yonette Hercules, Jonathan Hill, Heather Joseph, Phyllis Kozarsky, Adam Langer, Laura Leidel, Susan Lippold, Carolina Luna-Pinto, Charlene Majersky, Ashley Marrone, Brian Maskery, J. Todd Mercer, Rebecca Merrill, Rebecca Myers, Pamela Nonnenmacher, Tina Objio, J. Miguel Ocana, Gabriel Palumbo, Kate Pearson, Joanna Regan, Alfonso Rodriguez Lainz, Kimberly Rogers, Erin Rothney, Lisa Rotz, Derek Sakris, Dana Schneider, Kate Shaw, Erica Sison, Ronald Smith, Amra Uzicanin, S. Sadie Ward, James Watkins, Erika Willacy, Racquel Williams, Kelly Winter, and the many other Division of Global Migration and Quarantine and CDC staff who supported the domestic and international activities of the Global Migration Task Force; CDC Ebola response staff in Atlanta and in affected countries.

Corresponding author: Nicole J. Cohen, Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, CDC. Telephone: 404-498-0743; E-mail: [email protected] .

1 Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, CDC

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TABLE . Timeline of key travel-related events and CDC border health measures during the 2014–2016 Ebola epidemic in West Africa

Abbreviations : ATL = Hartsfield–Jackson Atlanta International Airport; CBP = Customs and Border Protection, U.S. Department of Homeland Security; Ebola = Ebola virus disease; EOC = Emergency Operations Center; EWR = Newark Liberty International Airport; HCW = health care worker; IAD = Washington Dulles International Airport; JFK = John F. Kennedy International Airport (New York City); ORD = Chicago O’Hare International Airport; WHO = World Health Organization. * CDC travel notice definitions are available at http://wwwnc.cdc.gov/travel/yellowbook/2016/introduction/planning-for-healthy-travel-cdc-travelers-health-website-and-mobile-applications .

FIGURE 1 . CDC CARE kit distributed to travelers to facilitate monitoring and reporting to health departments during the 2014–2016 Ebola epidemic in West Africa

Abbreviations: CARE = Check and Report Ebola; Ebola = Ebola virus disease.

FIGURE 2 . Example of CDC messages displayed on posters at U.S. airports for travelers going to West Africa during the 2014–2016 Ebola epidemic

Abbreviation: Ebola = Ebola virus disease.

FIGURE 3 . Example of CDC messages displayed on posters at airports in Sierra Leone* for departing travelers during the 2014–2016 Ebola epidemic in West Africa

*Similar posters were displayed in airports in Guinea, Liberia, Mali, Nigeria, and Senegal.

FIGURE 4 . Example of information displayed on electronic message boards at U.S. airports for travelers arriving from West Africa during the 2014–2016 Ebola epidemic

Suggested citation for this article: Cohen NJ, Brown CM, Alvarado-Ramy F, et al. Travel and Border Health Measures to Prevent the International Spread of Ebola. MMWR Suppl 2016;65(Suppl-3):57–67. DOI: http://dx.doi.org/10.15585/mmwr.su6503a9 external icon .

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U.S. issues travel alert for Uganda due to Ebola outbreak

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The U.S. Centers for Disease Control (CDC) has issued a travel alert for Uganda, where authorities are scrambling to contain an outbreak of an Ebola strain for which there’s no vaccine.

Ebola tracker: Click here for daily updates

The CDC issued a Level 2 Alert, meaning travelers should take enhanced precautions, for all of Uganda. A Level 3 Warning, which urges against non-essential travel, was issued for five districts.

“Travelers should avoid contact with sick people and avoid contact with blood or body fluids from all people,” the CDC said in the alert. “Travelers should avoid contact with dead bodies, including participating in funeral or burial rituals.”

A travel warning, which discourages against all non-essential travel, was issued for Mubende, Kassanda, Kyegegwa, Kagadi and Bunyangabu. Those are the five districts where cases have been found so far.

“Travelers should isolate immediately and seek medical care if they develop signs and symptoms like fever, muscle pain, sore throat, diarrhea, weakness, vomiting, stomach pain, or unexplained bleeding or bruising during or for up to 21 days after travel,” the CDC said.

Uganda declared an Ebola outbreak on September 20 after a 24-year-old man from Mubende District tested positive for Sudan ebolavirus, which is one of six species of the ebolavirus genus. The strain had not been found in humans since 2012.

Uganda has reported 62 cases so far, including 28 deaths. Only four people have recovered.

“CDC and the World Health Organization (WHO) are working with local health authorities to identify sources of transmission, conduct case investigations, and strengthen local laboratory capacity,” the CDC said in Tuesday’s statement.

There have been seven previous outbreaks of Sudan ebolavirus, with four occurring in Uganda and three in Sudan. Those outbreaks showed an average mortality rate of 57%, which is high but lower when compared to Zaire, which kills about 70% on average.

Current evidence suggests that the ERVEBO vaccine, which is used to control outbreaks with the Zaire variant, is not effective against the Sudan strain. Six vaccine candidates are in different stages of development.

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