Ebola: Hot Zone arrives in the Lone Star State

The 1st ever documented case of Ebola in the United States was announced on September 30, 2014 by the Centers for Disease Control & Prevention (CDC) and the Texas Department of State Health Services.  

Ebola virus (Image courtesy dailytech.com)

Dallas, We have an Infection

Thomas Eric Duncan, a 42 year old Liberian national, who was traveling to the US for the 1st time to visit family in Dallas arrived in Texas on September 20, 2014.  He had traveled to Dallas via flights from Brussels to Washington, DC then to Dallas.  Mr. Duncan, initially showed signs of a low-grade fever and abdominal pain beginning on September 24th and was seen at Texas Health Presbyterian Hospital Dallas on September 26th. Although his family had informed the healthcare workers of his recent arrival from Liberia, the hospital personnel decided he did not meet the criteria for Ebola suspicion since he did not have a temperature greater than 101.5 degrees Fahrenheit. He was discharged home. On September 28th, Mr. Duncan’s symptoms worsened, and he was transported by Dallas County EMS back to Presbyterian Hospital and was placed into isolation.  On September 30th, lab tests from the State of Texas and the CDC confirmed the patient has Ebola. He is currently in critical condition in the ICU. The C.D.C. has sent a team to Dallas to identify others who may have contracted the illness.

Texas Health  Presbyterian Hospital. Image courtesy of NPR

Texas Health Presbyterian Hospital. (courtesy of NPR.com)

It is important to remember that Ebola does not have respiratory transmission. The disease is only spread through exchange of bodily fluids and is only contagious when symptoms appear. Thus, only those who interacted with Mr. Duncan on or after September 24th are at risk.  The Director of the CDC, Dr. Thomas Frieden has stated there is “zero risk of transmission” to fellow passengers on his flights because he was not showing signs of symptoms while traveling.

Epidemiology in Action: Contact Tracing

This video from the Washington Post provides a great review of how EVD works.
http://www.washingtonpost.com/posttv/c/embed/257d57d4-19c3-11e4-88f7-96ed767bb747

The authors of the accompanying article note that EVD is not the most transmissible virus – Measles currently holds that title. In fact, it is hypothesized that healthcare workers only need to stop 50% of infectious contacts via effective isolation to stem the epidemic. While isolation techniques have been hard to put into place in West Africa, it should be easy to do here in the United States. Therefore, there is very little risk of seeing an epidemic on a scale such that as that in Africa here in the US. The video below describes how the CDC uses Contact Tracing to try to stem outbreaks such as EVD.

Community-Based Surveillance

Remember, here is what you should be looking out for in patients who report recent contact with EVD patients or recent travel from West Africa:

Signs & Symptoms of EVD. Image courtesy of the CDC

Signs & Symptoms of EVD. Image courtesy of the CDC

While symptoms can appear anywhere from 2-21 days after exposure, the average is 8-10 days. Those who recover from EVD will retain antibodies to the disease for at least 10 years.

The CDC recommends physicians be alert when the following is true:

  1. A fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit
  2. Additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage;AND
  3. Risk factors within the past 3 weeks before the onset of symptoms, such as contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active; or direct handling of bats or nonhuman primates from disease-endemic areas. Malaria diagnostics should also be a part of initial testing because it is the most common cause of febrile illness in persons with a travel history to the affected countries.

If you suspect a patient has EVD, the following diagnostic tests are available:

  • Within a few days of appearance of symptoms:
    • Antigen-capture ELISA testing
    • IgM ELISA
    • EVD PCR
    • Virus Isolation
  • Later in disease course or after recovery:
    • IgM and IgG antibodies
  • In deceased patients:
    • Immunohistochemistry
    • PCR
    • Virus Isolation

The CDC recommends an individual be tested if the following are true:

  • percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of EVD without appropriate personal protective equipment (PPE),
  • laboratory processing of body fluids of suspected or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or
  • participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate PPE.

For persons with a high-risk exposure but without a fever, testing is recommended only if there are other compatible clinical symptoms present and blood work findings are abnormal (i.e., thrombocytopenia <150,000 cells/µL and/or elevated transaminases).

If you have any suspicion of EVD, contact the CDC! The infographic below details exactly how to collect samples for testing.

ebola-lab-guidance-page-001

 

Healthcare Providers: Protect Thyself

In order to protect yourself and your fellow healthcare providers, proper PPE protection from all bodily fluids is crucial. This includes blood, emesis, sweat, feces, semen, etc. Use the guide below to ensure you are protected.

Instructions on Putting On PPE

Instructions on Putting On PPE

Instructions on Removing PPE

Instructions on Removing PPE

 

Additional precautions are listed below. Medscape has put together an excellent video which details many of these precautions as well.

Additional information specific for EMS personnel and dispatchers, Hospital Preparedness Teams and Mortuary workers are available online.

Report Written by Vidya Eswaran, MD

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