Community/ Public / Population Health

Ebola is here: Knowledge, identification, and appropriate infection control are key

Ebola… the word conjures up the thoughts of dark, steamy jungles and grim healthcare providers working feverishly in primitive conditions to battle a deadly—yet geographically isolated—disease. Today, we see Ebola in a different light as patients return from abroad for treatment and we hear of the first case identified on U.S. soil and the subsequent death of the patient. This view includes specialized treatment in a secured isolation unit, manned by battalions of care providers and support personnel to manage patient contact, treatment, medications, contaminated protective gear, and waste. It’s a chilling reminder that any contagious pathogen in the world is a plane ride away from its next host.

As a nurse, you need to be prepared by understanding the nature of the virus, its signs and symptoms, diagnosis, and treatment.

What Is Ebola?

Ebola Virus Disease (EVD) is a severe illness in human beings. Ebola, formerly called Ebola hemorrhagic fever, is often fatal. According to the WHO Ebola Response Team (2014) the current strain has a case fatality rate of 70.8% (95% confidence interval, 69% to 73%) with clinical symptoms for the infection. Dr. Peter Piot, director of the London School of Hygiene and Tropical Medicine and co-discoverer of Ebola in 1976, calls it a “Spectacular Virus.” We still are not positive where the virus hides in nature, but experts feel the most likely source is fruit bats. Ebola is introduced to humans through contact with body secretions, blood, or organs from infected animals such as monkeys, fruit bats, or antelope.

Ebola is transmitted human-to-human through direct contact with blood or body fluids (for example, urine, feces, vomit) of a symptomatic infected person or through exposure to objects contaminated with infected body fluids. Thus, contaminated clothing and hard surfaces are infectious. According to the CDC, several laboratory studies have demonstrated that Ebola virus can be viable on solid surfaces for several days if conditions are favorable (http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html.)
Healthcare workers who have direct unprotected contact to contaminated materials are at high risk for infection. According to the World Health Organization (WHO), in the past 6 months since the outbreak was formally identified in March 2014, 337 health workers have been infected. Of those infected, 181 have died.

Contact with the Ebola virus can occur in settings where healthcare workers have inadvertent exposures because they lack appropriate personal protective equipment (PPEs) or have poor quality equipment such as gloves that break or thin gowns, masks or goggles where fluid may leak through. This problem has been noted in the latest outbreak in West Africa. An additional important point was poignantly made in a recent statement from nursing assistant Teresa Romero, who is now infected with Ebola after caring for a patient who died: “I think the problem was in taking off my PPE (personal protective equipment).” (For more information, see http://crofsblogs.typepad.com/h5n1/2014/10/ebola-in-spain-the-problem-was-in-taking-off-my-ppe.html.)

Recognition of the significant risk that healthcare providers are taking in caring for EVD-infected individuals has spurred U.S. and other governmental agencies across the globe to assist in supplying high-quality PPEs to help protect healthcare personnel. The U.S. Disaster Assistance Response Team (DART) is airlifting 130,000 sets of PPEs for healthcare providers as well as generators to power units where Ebola patients receive care. Canada and other countries are also donating PPEs and laboratory equipment (http://wjcl.com/2014/10/06/white-house-releases-fact-sheet-on-response-to-the-ebola-epidemic-in-west-africa/).


Symptoms

The incubation period from infection to symptomatology is 2 to 21 days, with an average of 8 to 10 days. It’s important to remember that humans aren’t infectious until signs and symptoms appear.

Signs and symptoms include

  • fever (greater than 38.6°C or 101.5°F), fatigue, muscle pain
  • severe headache
  • vomiting, diarrhea, and mild rash that may occur approximately 5 days after infection
  • weakness
  • muscle and abdominal pain
  • impaired liver and kidney function
  • unexplained bleeding or bruising and blood in stool
  • laboratory findings include low white blood cell count, low platelet count, and elevated liver enzymes

Diagnosis

It can be difficult to discern differences in Ebola and other infectious diseases initially. Diseases with similar signs and symptoms include malaria, typhoid fever, and meningitis. Confirmation is particularly important in areas such as Africa that have high rates of these other infectious diseases. Considering that flu season is starting in the United States, it’s important to be aware of possible Ebola infections in those who have recently traveled to areas with EVD.

Treatment and vaccines

Supportive care—rehydration with oral or intravenous fluids—and treatment of specific symptoms as they appear is vital. Maintaining adequate oxygenation and blood pressure and treating other infections as they develop improves patient survival. For more information about treatment, see the information provided by the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/vhf/ebola/treatment/index.html.

WHO also has provided a wide range of treatment protocols to help facilitate survival of persons infected with EVD. Treatments include blood and blood products, immune therapies, and innovative pharmaceutical therapies. (For more information, see http://www.who.int/mediacentre/factsheets/fs103/en/.)

Although no vaccine is currently available to prevent Ebola infection, in an interview Piot stated that new testing of ZMapp, an experimental Ebola treatment drug, has led to the recovery of 18 monkeys infected with the virus; the control group of monkeys all died. ZMapp was recently used to treat two Americans with EVD, although it’s unclear as to what role it played in their successful recovery. A Spanish priest treated with ZMapp during the same period died. The Centers for Disease Control and Prevention (CDC) notes that at this time two vaccine trials are underway; in addition, several vaccines are in early stages of development and additional vaccine trials may start in early 2015.

The basics

The CDC website has a wealth of resources related to Ebola at http://www.cdc.gov/vhf/ebola. These include a guidance document to help healthcare providers understand Ebola and enhance preparedness (http://www.cdc.gov/vhf/ebola/pdf/healthcare-provider-checklist-for-ebola.pdf). Another CDC resource is a checklist for delivery of emergency services for U.S.-based EMS systems (http://www.cdc.gov/vhf/ebola/pdf/ems-checklist-ebola-preparedness.pdf). This practical checklist provides targeted guidance that supports protection of health responder personnel as they work to detect and identify suspected Ebola cases. Finally, there is an overview link that covers most information that healthcare workers would require in caring for a patient who has Ebola Virus Disease (http://www.cdc.gov/vhf/ebola/hcp/index.html).

In August 2014, the CDC released care guidance recommendations for healthcare workers in the United States (Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals). This document, which is updated as needed, provides vital information and recommendations for persons who may come in contact with EVD infected persons during care or transport. Your facility’s infection control policies should be consistent with these recommendations.

See the box below for a summary of resources available from the CDC.

Ebola resources from the Centers for Disease Control and Prevention

http://www.cdc.gov/vhf/ebola/
http://www.cdc.gov/vhf/ebola/pdf/healthcare-provider-checklist-for-ebola.pdf
• Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals
http://www.cdc.gov/vhf/ebola/symptoms/index.html
http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html
http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
http://www.cste.org/?page=StateEpi
http://www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html
http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitals-mortuaries.html
http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states-html.
http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html

Report any potential EVD case to your facility’s infection prevention staff, who should in turn report it to state and local public health officials. Know whom to contact in the case of an unprotected exposure through patient contact or with direct contact with blood or body fluids from a suspected or confirmed EVD patient. It’s important for all health care providers to note that an unprotected exposure of EVD body fluids or blood for any one is considered to be of high risk (http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html). This would include health care providers. Additionally, an unprotected exposure for a care provider or others would lead to monitoring the health of the individual for 21 days.

Most importantly, know when to wear PPE, take extreme care when removing the equipment, and always apply standard, contact, and droplet precautions for any suspected or confirmed EVD patients.

State and local public health response to Ebola

Local and state health departments routinely practice health surveillance in their communities that includes monitoring for symptoms related to hemorrhagic fevers. This automated electronic surveillance, which captures chief complaints (but not travel history) of patients presenting at local hospital emergency departments, has been in operation for years in many cities. The recent outbreak of EVD has prompted several epidemiologists and programmers in the United States to work on establishing more refined specific terminology to query health systems; the increased specificity would help identify potential Ebola cases more quickly.

The infectivity and virulence of this virus reinforces the importance of not only automated systems that captures patterns of emerging data, but also the critical need for frontline care providers whose knowledge, skills and expertise about EVD will identify the patient who may have been exposed or infected.

Local health department staff, with assistance from state and federal governments, are responsible for conducting any initial contact tracing needed in the community to help contain the spread of Ebola in the community. Hospitals engage in internal tracing of client contacts. State health departments have legal authority to enact quarantine orders for persons suspected of having certain communicable diseases, including Ebola. Patients who are quarantined are responsible for checking their own temperatures each day and reporting to identified local public health staff by phone for the duration of the quarantine. Teams of public health staff interview patients infected with Ebola to determine possible sources of exposure so that epidemiologists can determine the contact sources and identify which populations are most affected in hopes of curtailing the spread and preventing new cases.

Public health officials also help coordinate the movement of clinical samples to state and federal labs for confirmation of cases. Since Ebola and malaria can both present with similar symptoms, timely lab work is a cornerstone of the response. Maintaining infection prevention techniques is paramount. Broken skin contact with infected EVD contaminated materials may lead to infection. Additionally, any specimens from EVD patients are considered to be highly infectious and should be treated as such. Local health departments may help coordinate supplies such as PPE for the response community, as needed. Some cities have created coalitions to help organize and direct this work.

Anticipating the risk from air travel of patients infected with Ebola but not yet symptomatic, the CDC has provided protocols for airlines on stopping ill travelers from boarding as well as managing and reporting onboard sick travelers. In addition, information for airline crews has been developed to help protect crew and passengers from infection. Finally, additional information on cleaning and disinfecting planes has been provided, and new temperature and health screening of passengers arriving from Ebola-affected countries in West Africa will be started soon at selected international airports.

The key to successful control of outbreaks is engagement of the community. As the teams in West Africa have seen, outbreak control relies on case management, surveillance of the disease state of the population, tracing contacts, reliable and supportive laboratory services, appropriate disposal of contaminated waste materials, engagement and collaboration within the community, and culturally appropriate burials that maintain infection control procedures

Current status and projections for 2015

As of October 8, the West Africa Ebola outbreak death toll has reached 3,865 out of 8,033 total cases (4,461 laboratory confirmed cases), with Guinea, Liberia, and Sierra Leone being the hardest hit.

The latest forecasting tool developed by the CDC paints a grim picture for 2015. Estimates of new cases between 550,000 to 1.4 million are thought to be possible by January 2015. However, CDC Director Tom Frieden says these estimates may be moderated or lessened with planned actions being initiated by the United States and the world community. It’s important to note that the EVD is a fluid and dynamic health crisis. All healthcare providers must continue to remain informed and vigilant, as well as consult experts in the field as this critical outbreak continues.

Final thoughts

Recovery from Ebola often depends on patients’ immune response, and those who recover develop antibodies that last for at least 10 years. These antibodies have potential for treatment of EVD. As treatment and prevention options are being explored, nurses and other clinicians should focus on understanding the basic epidemiology of Ebola. Awareness of infected persons who are symptomatic is critical in preventing the spread of the disease. We all need to be vigilant ambassadors in the prevention, recognition, and treatment of Ebola.

Juanita Ebert Brand is an assistant professor and Debra Siela is an associate professor in the School of Nursing at Ball State University in Muncie, Indiana. Virginia A. Caine is an associate professor in the division of infectious disease at Indiana University School of Medicine in Indianapolis. She is also director of public health Marion County Indiana; Brand is a nurse practitioner, and Shandy Dearth is an epidemiologist at the Marion County Public Health Department in Indianapolis, Indiana.

Note: The final date for downloaded information from websites for this article was October 8, 2014.

Additional references
Centers for Disease Control. Ebola guidance for airlines. Oct. 2, 2014. http://www.cdc.gov/quarantine/air/managing-sick-travelers/ebola-guidance-airlines.html
Co-discoverer of ebola virus, Prof Peter Piot take on outbreak. https://www.youtube.com/watch?v=qqX4kxWwbKk.
Smith-Spark L, Falcon M, Christensen J. CDC: Ebola cases could reach 550,000 by 2015. http://www.cnn.com/2014/09/23/world/africa/ebola-outbreak/index.html.
Trossman S. Outbreaks emphasize need for prevention. The American Nurse. Oct. 10, 2014. http://www.theamericannurse.org/?p=6448.
WHO Ebola Response Team. Ebola virus disease in West Africa—The first 9 months of the epidemic and forward projections. New Eng J Med. Sept. 23, 2014.
World Health Organization. Six months after the Ebola outbreak was declared: What happens when a deadly virus hits the destitute? March-September 2014. http://www.who.int/csr/disease/ebola/ebola-6-months/en/.

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