Courtesy of ACEP

If it wasn’t there before, the past two weeks have brought Ebola Virus Disease (EVD) to the world’s center stage. Index cases from outside of West Africa occurred in Spain and the US. There is now transmission of disease outside of West Africa in exposed Healthcare Workers (HCW). HCWs are at significant risk when treating Ebola patients. This post contains general facts as well as information aimed at HCWs, and specifically HCWs in hospitals. The CDC has changed protocol for handling EVD in the US since the outbreak in Dallas.

EVD cases continue to accumulate in the three most affected countries of West Africa: Guinea, Sierra Leone, and Liberia. Ebola in these countries is far from contained, though there remains a remarkable unaffected region of Sierra Leone: Koinadugu. With the help of native Momoh Konte, educated in the U.S. and living in D.C., Koinadugu has so far kept its community safe from EVD by imposing strict surveillance and travel restrictions; strict to the point of discomfort among residents. Surveillance continues in Senegal and Nigeria where cases were confirmed in July. However, there have been no new reported cases, and by October 17 and 20 respectively, reaching 42 days of surveillance without new cases, the outbreaks there will be considered contained according the WHO. This careful surveillance system gives the world hope in containing outbreaks when surveillance, isolation, and management can be performed adequately.

That being said, there are four hospitals in the US that are particularly equipped to manage biohazards like Ebola. They include Emory in Atlanta, where the second Dallas HCW diagnosed with Ebola has been transferred, and the NIH in Bethesda where the first nurse diagnosed in Dallas was transferred. The other two hospitals are St. Patrick Hospital in Montana and University of Nebraska in Omaha. Nebraska and Emory have managed Ebola patients who survived, and notably, there have been no reported cases of Ebola transmission to HCWs in these institutions. One conclusion: hospitals should aim to replicate isolation, management and safety precautions observed at these institutions.

While Ebola currently holds the spotlight, as it should, it’s important to remember that returned traveler’s from abroad have a differential diagnosis that includes malaria, cholera, typhoid, and Dengue, among others. Interestingly, last week there was a confirmed diagnosis of Marburg Virus Disease in Kampala, Uganda. Marburg is in the Filoviridae family, the same family as Ebola and causing similar symptoms, including hemorrhagic fever.

Ebola Recourses I personally find useful:

• Checklist for Evaluating Patients for Ebola
  • Checklists have been shown to improve outcomes in procedures, disasters and MCIs
• Updated (10/21/2014) CDC PPE Recommendations
• Prevention of Ebola
• Q & A on EVD Transmission
• Ebola Algorithm for the Returned Traveler
• WHO Ebola Fact Sheet
• EVD Clinician Fact Sheet
• CDC Updates on this Ebola Outbreak
• American College of Emergency Physicians (ACEP)  resources for preparing for Ebola in your hospital and community.
• The ACCME Provided an Ebola PowerPoint and FAQs to CME providers
• CDC call-in/webinar on Ebola Preparedness on October 14, more to follow
• CDC Response Team to travel to any US hospital providing care for an EVD patient
• Pets and EVD

Ebola Facts:

• Clinical Presentation and Course
  • Symptom onset 8-12 days after exposure (current outbreak mean 9-11d), Incubation period is up to 21 days
  • Patients are not contagious until symptomatic
  • 21 days of surveillance for anyone exposed: twice daily symptom and temperature assessments
  • Most common symptoms
    • fever
    • fatigue and malasie
    • nausea/vomiting/diarrhea, anorexia
    • headache, sore throat
  • Differential Diagnosis: malaria, typhoid, meningococcemia
  • Unexplained Bleeding in 18% of cases in current outbreak, often GI
  • 71% mortality rate W. Africa with risk factors:
    • age > 45
    • unexplained bleeding
    • chest pain, shortness of breath, sore throat, conjunctivitis, confusion, coma
  • Pathogenesis – Direct contact with EBV bodily fluids. NOT airborne
    • Blood, secretions, breast milk, semen
    • Men who have recovered from the disease can still transmit the virus through their semen for up to 7 weeks after recovery from illness
  • High Risk Exposures:
    • Needle-stick or mucous membrane exposure
    • Direct skin contact with bodily fluids of EBV patient without PPE
    • Processing bodily fluids from EBV patient without PPE
    • Handling of dead body without PPE in outbreak region
  • Low Risk Exposures:
    • Household contact with EBV patient
    • Close contact – within 3 feet, prolonged period in patient room without PPE
    • Direct brief contact (shaking hands)
  • PPE Recs for EBV
    • Place patient in single room with private bathroom
    • Personnel at door to ensure all staff use proper PPE
    • Standard, contact and droplet
    • Donning/doffing buddy system
    • Impermeable gown, gloves, eye protection, mask
    • Copious fluids: double glove, impermeable leg and shoe covers
    • Proper PPE Removal
    • Dedicated medical equipment for each patient
  • Labs
    • iSTAT or dedicated medical equipment for each patient
      • NO SPECIMENS GO TO STAT OR ROUTINE HOSPITAL LAB
    • Local Department of Health runs PCR to make the diagnosis – call your ID department of the Department of Health
    • CDC runs confirmatory test

Quoting Dr. Michael Callahan, MGH ID Specialist who kindly provided Wilderness Medicine an interview about the current outbreak back in August of this year, “This outbreak is another example of the “Equal Opportunity Nature of Modern infectious Diseases” and a reminder that in today’s world, the division of travel, tropical and global diseases is increasingly imprecise and misleading.”