Note: These materials are current as of October 22, 2014. Users should consult the Centers for Disease Control (CDC) or other cited sources on the day they access this information to get the most current information or version that may now be available. If you have specific questions about the information and recommendations contained in the attached material, we ask that you immediately contact the CDC or your local public health authority or infection control officer for the information you seek.

Clinical Context

The Ebola virus epidemic in West Africa is currently a leading headline in both the medical and popular media, and each day seems to bring more ominous news. To date, there have been nearly 9000 reported cases of infection with Ebola in Africa, with more than 4000 of those cases resulting in death. In the United States, the case of the Liberian citizen who eventually died of Ebola infection and the subsequent infection of 2 nurses who cared for him receives constant coverage.

One of the most critical ways to prevent the spread of Ebola is the appropriate use of isolation and personal protective equipment (PPE). However, a study of Canadian pediatric emergency medicine physicians serves as a warning regarding our collective preparedness for a serious infectious disease. This research, which was published in the March 2011 issue of the Canadian Journal of Emergency Medicine, found that 22% of physicians had not received training in the use of PPE and 32% had not been trained in the past 2 years. Nearly half of physicians were uncomfortable with their knowledge of transmission-based isolation practices, a fact which was reinforced by a mean score of less than 50% on a short questionnaire regarding such practices. Finally, given 6 case scenarios in which PPE was recommended by national standards, physicians selected an average of 1 case in which they would actually wear PPE. Another review of infection control practices of healthcare workers published in the American Journal of Infection Control following the SARS (severe acute respiratory syndrome) outbreak revealed that failure to implement appropriate PPE is responsible for most hospital-acquired infections.

This evidence is frightening in a climate that had already witnessed fairly recent outbreaks of H1N1 influenza and SARS. Ebola is another lethal virus that needs to be addressed through diligent and unwavering prevention practices. The current report from the American Hospital Association and the US Centers for Disease Control and Prevention highlights facts regarding Ebola-related disease and its prevention.

Reid SM, Farion KJ, Suh KN, Audcent T, Barrowman NJ, Plint AC. Use of personal protective equipment in Canadian pediatric emergency departments. CJEM. 2011;13:78-78.

Gamage B, Moore , Copes R, Yassi A, Bryce E; for the BC Interdisciplinary Respiratory Protection Study Group. Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature. Am J Infect Control. 2005;33:114-121.

Ebola Slide Presentation

Click here for the PowerPoint presentation on Ebola developed by the AHA.

Highlights

• One of the difficulties in identifying potential cases of Ebola infection is the nonspecific presentation of most patients. Fever/chills and malaise are usually the initial symptoms, so all medical personnel should maintain a high index of suspicion in these cases.
• The most common symptoms of patients in the current outbreak of Ebola include fever (87%), fatigue (76%), vomiting (68%), diarrhea (66%), and loss of appetite (65%).
• Other symptoms may include chest pain, shortness of breath, headache or confusion, conjunctival injection, hiccups, and seizures.
• Bleeding does not affect every patient with Ebola and usually presents as small subcutaneous bleeding vs frank hemorrhage.
• More severe symptoms at presentation with Ebola infection predict a higher risk for mortality. Most patients with fatal disease die between days 6 and 16 of complications.
• The case-fatality rate of the current outbreak is approximately 71%.
• Patients who survive infection with Ebola generally begin to improve around day 6 of the infection.
• Multiple tests can be used to diagnose Ebola provided they are ordered in a timely fashion. Antigen-capture enzyme-linked immunosorbent assay (ELISA), IgM ELISA, polymerase chain reaction, and virus isolation may be employed to make the diagnosis during the first few days of symptoms. Patients identified later during the disease course may be diagnosed with serum antibody levels.
• There is no cure for Ebola infection; treatment is largely supportive. Therefore, prevention of the spread of Ebola in healthcare facilities is particularly important.
• Patients with fever, even subjective fever, or other symptoms associated with Ebola infection along with a history of travel to an Ebola-affected area within the past 21 days need to be identified in triage.
• If such a patient is identified, she/he needs to be isolated immediately in a single room with access to a bathroom. The door to the room should remain closed.
• Hospital infection control and local health departments should be contacted immediately in the case of suspected Ebola disease. Each healthcare site should have a site manager responsible for healthcare worker safety on site at all times during the evaluation and treatment of a patient with Ebola infection.
• Standard, contact, and droplet precautions should be enforced immediately.
• A trained observer should oversee all donning and doffing of PPE in order to maintain safety protocols.
• There has to be a clear separation between areas for donning and doffing PPE. PPE is preferably removed in an anteroom or adjacent vacant patient room rather than in the patient's room.
• PPE must be worn at all times when in the patient's room and must include a powered air-purifying respirator (PAPR) or N95 mask with face shield; a fluid-resistant, single-use gown; a long pair of nitrile gloves covering a shorter pair of gloves; and boot covers.
• No skin should be exposed while wearing PPE. The gown and boot covers may meet at the mid-calf. An apron should be worn over the gown when the patient has vomiting or diarrhea.
• Trained observers should wear essentially the same PPE as personnel entering the patient's room, albeit without the PAPR or N95 mask.
• There is a very precise method for the appropriate donning and doffing of PPE. Frequent decontamination with a disinfectant wipe or alcohol-based hand rub, even while still wearing potentially soiled gloves, is important when disposing of PPE.
• Visibly soiled areas in the patient's room should be cleaned immediately. Physicians and nurses should perform cleaning tasks while engaging in patient care activities in order to limit the number of workers in the patient's room.
• A log should be maintained of all persons entering the room of a patient with suspected Ebola disease.
• Invasive procedures, including phlebotomy, should be limited to what is medically necessary.
• A contact assessment should be performed for all patients with suspected Ebola infection. High-risk contacts include individuals with direct contact with the patient's skin or bodily fluids. Low-risk contacts include household members and others who have had no more than casual contact with the patient. Healthcare workers in the area of a patient with Ebola who do not use PPE are also considered low-risk contacts.

Clinical Implications

• Fever is the most common presenting symptom of the current outbreak of Ebola disease, followed by fatigue and vomiting.
• Measures to reduce the risk of transmission of Ebola in healthcare settings include the identification of suspected cases in triage; immediate patient isolation in a room with access to a bathroom; and PPE featuring PAPR or an N95 respirator with facemask, double gloves, disposable gown, and boot covers.

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