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Ebola

2 Contact Hours
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Respiratory Care Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Friday, April 25, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of participants will know how to identify specific risk factors for Ebola virus disease, modes of transmission, and proper infection control and mitigation steps.

Objectives

After completing this course, the participant will be able to meet the following objectives:

  1. Summarize modes of transmission of the Ebola virus.
  2. Identify the clinical manifestations of the Ebola virus, including symptomology and laboratory values.
  3. Describe treatment options for patients with suspected or confirmed Ebola virus disease.
  4. Outline strategies to prevent the spread of the Ebola virus.
  5. List long-term complications which may persist after surviving the Ebola virus.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Krystle Maynard (DNP, RN, SANE-A)

Introduction

Ebola virus disease (EVD), previously known as Ebola hemorrhagic fever, is a rare viral hemorrhagic fever in humans and other nonhuman primates caused by ebolaviruses (CDC, 2021d). Outbreaks have been known to occur in humans and primates, commonly on the African continent. Transmission occurs via direct contact with bodily fluids, tissues, and blood of those infected with the virus. Symptoms may include fever, sore throat, body aches, headaches, malaise, diarrhea, vomiting, and hemorrhage (CDC, 2023f).

The disease has a high risk of death, killing an average of about 50% of those infected (WHO, 2021). Death is often due to low blood pressure from fluid loss and typically follows six to sixteen days after symptoms appear.

The Ebola virus is a nonsegmental, negative-sense, single-stranded ribonucleic acid (RNA) virus that resembles rhabdoviruses (e.g., rabies) and paramyxoviruses (e.g., measles, mumps) in its genome organization and replication mechanisms. It is a member of the Filoviridae family, taken from the Latin "filum," meaning thread-like, based upon its filamentous structure.

Classifications

Six virus species have been identified. Of the six, only four cause disease in humans and include the following:

  1. Zaire ebolavirus
  2. Sudan ebolavirus
  3. Taï Forest ebolavirus (originally Côte d'Ivoire ebolavirus)
  4. Bundibugyo ebolavirus

The other two viruses are the Reston and the Bombali ebolaviruses.

Reston Ebolavirus

The Reston virus was discovered in 1989 when monkeys from a research lab were imported from the Philippines to the United States (US). During this time, it was determined that the virus spread via droplets among the monkeys within the facility; this form of transmission has not been proven in humans, but it did give way to the fact that Ebola was not purely confined to Africa (CDC, 2023c).

The Reston virus differs markedly from the others because it is maintained in an animal reservoir in the Philippines and has not been found in Africa. Serologic studies have shown that a small percentage of Philippine pig farmers have IgG antibodies against the agent without developing severe symptoms, proving that the Ebola Reston virus can cause mild or asymptomatic infection in humans (CDC, 2023c).

Bombali Ebolavirus

Bombali ebolavirus is the most recent species to be named and was isolated from Angolan free-tailed bats in Sierra Leone. Bombali ebolavirus can infect human cells, although it has not yet been shown to be pathogenic.

Epidemiology

Viral Reservoirs

The natural reservoir for Ebola has yet to be confirmed; however, African fruit bats (Pteropodidae) are the most likely candidate species. Chimpanzees, gorillas, and other mammals have been other known suspects, though they are considered dead-end hosts, like humans. In other words, once infected with the virus, the organism dies and fails to continue to spread the virus (CDC, 2021d).

Transmission

Transmission occurs when humans come in contact with blood or bodily fluids from infected animals, such as fruit bats, monkeys, and gorillas (WHO, 2021).

Before the epidemic in West Africa, outbreaks of EVD were typically controlled within a few weeks to a few months as the outbreaks occurred in remote regions with low population density, where residents rarely traveled far from home. However, the West African epidemic showed that EVD could spread rapidly and widely due to the extensive movement of infected individuals. The disease is spread by infected individuals who move to densely populated urban areas, the avoidance and lack of adequate personal protective equipment (PPE), and the absence of dedicated medical isolation centers.

Person-to-Person Transmission

Person-to-person transmission is associated with direct contact with the body fluids of individuals who are ill with EVD or have died from the infection. Examples of transmission include (CDC, 2021b):

  • Any contact with bodily fluids, such as saliva, sweat, urine, vomit, feces, semen, breast milk, or blood.
  • Contact with objects contaminated by blood or bodily fluids, such as clothing, blankets, needles, etc.
  • Sexual contact or contact with semen from a male who has recovered from EVD. The virus can remain in the semen even after the person has recovered and is no longer experiencing symptoms.
  • Contact with infected primates or fruit bats.

The likelihood of infection depends, in part, upon the type of body fluid an individual is exposed to and the amount of virus it contains. Transmission is most likely to occur through direct contact of broken skin or mucous membranes with virus-containing body fluids from a person who has developed signs and symptoms of illness (CDC, 2021b).

Acute Infection

According to the World Health Organization (WHO), the most infectious body fluids are blood, feces, and vomitus (WHO, 2021).

The Ebola virus can also be spread through direct contact with a patient's skin, but the risk of developing an infection from this type of exposure is lower than from exposure to blood or body fluids (CDC, 2021b). Viruses on the skin surface might result from viral replication in dermal and epidermal structures, contamination with blood or other body fluids, or both.

The risk of Ebola transmission also depends upon the quantity of virus in the fluid. During the early phase of illness, the amount of virus in the blood may be low, but levels then increase rapidly in severely ill and moribund patients (CDC, 2021b).

Convalescent Period

The infectious virus or viral RNA can persist in some body fluids of patients recovering from EVD even after it is no longer detected in the blood. For example:

  • Follow-up studies of approximately 40 survivors of the 1995 outbreak in Kikwit, Democratic Republic of the Congo, found that reverse transcription-polymerase chain reaction (RT-PCR) could detect viral RNA sequences in the semen of male patients for up to three months and infectious virus was recovered from the semen of one individual 82 days after disease onset.
  • A study of patient samples collected during the Sudan EVD outbreak in Gulu, Uganda, in 2000, detected the virus in the breast milk of a patient even after the virus was no longer detectable in the bloodstream. Two children who were breastfed by infected mothers died of the disease.
  • The percentage of patients with persistent virus and the level of virus detected in semen decreased over time. In a patient treated in the US, the concentration of viral RNA in semen during early recovery was 4 logs higher than in blood during peak infection (Barnes et al., 2017). A modeling study from a 2014 - 2016 outbreak suggests the median time to semen RT-PCR negativity is 47 days after symptom onset, and the probability of shedding at 18 months is <1% (Subtil et al., 2017).

Risk of Transmission through Contact with Contaminated Surfaces

The Ebola virus may be transmitted through contact with contaminated surfaces and objects. The US Centers for Disease Control and Prevention (CDC) indicates that the virus on surfaces may remain infectious from hours to days at room temperature (CDC, 2021a). Disinfection with hospital-grade cleansers should be done to prevent transmission of the virus.

Risk of Airborne Transmission

There are no reported cases of the Ebola virus being spread from person to person by the respiratory route (Dickson et al., 2018). However, laboratory experiments have shown that the Ebola virus released as a small-particle aerosol is infectious for rodents and nonhuman primates (Mattia et al., 2016). Healthcare workers may therefore be at risk of EVD if exposed to aerosols generated during medical procedures.

Nosocomial Transmission

Transmission to healthcare workers may occur when appropriate PPE is not available or used correctly, especially when caring for a severely ill patient who is not recognized as having EVD (CDC, 2023c).

During the epidemic in West Africa, many doctors and nurses became infected with EVD. In Sierra Leone, the incidence of confirmed cases over seven months was approximately 100-fold higher in healthcare workers than in the general population. Several factors accounted for these infections, including:

  • Delayed laboratory diagnoses
  • Inadequate training about the safe management of contaminated waste and burial of corpses
  • Incorrect triage and failure to recognize patients and corpses with EVD
  • Limited availability of appropriate PPE and handwashing facilities

Medical procedures played a significant role in some past Ebola epidemics by amplifying the spread of infection. For example:

  • An iatrogenic point source outbreak occurred in 1976 when an individual infected with the Ebola virus was among the patients treated in a small missionary hospital in Yambuku, Zaire. At this hospital, the medical staff routinely injected all febrile patients with antimalarial medications, employing syringes rinsed in the same pan of water, then reusing them (CDC, 2023c).
  • A different type of iatrogenic amplification occurred in 1995 in Kikwit, Democratic Republic of the Congo, when an infected patient was hospitalized with abdominal pain and underwent an exploratory laparotomy. The entire surgical team became infected, probably through unprotected respiratory exposure to aerosolized blood. Once those persons were hospitalized, the disease spread to hospital staff, patients, and family members through direct physical contact.

Assistance from the international medical community has played an essential role in controlling large epidemics in Africa. Intervention strategies have focused on helping local healthcare workers identify Ebola patients, transfer them to isolation facilities, provide basic supportive care, monitor all persons in direct contact with cases, and rigorously enforce infection control practices. During the West African epidemic, the massive international response made it possible to supplement isolation procedures with more effective supportive care.

Transmission from Animals

Human infection with the Ebola virus can occur through contact with wild animals, such as with hunting, butchering, and preparing meat from infected animals (CDC, 2022a). To help prevent infection, food products should be properly cooked since the Ebola virus is inactivated through cooking. In addition, basic hygiene measures, such as hand washing and changing clothes and boots after touching the animals, should be followed. Unfortunately, some public health messages in West Africa regarding bushmeat consumption have contained incorrect information and may have been counterproductive, increasing the need for additional education (Bonwitt et al., 2018).

Pathogenesis

Because of the difficulty of performing clinical studies under outbreak conditions, almost all data on the pathogenesis of EVD have been obtained from laboratory experiments employing mice, guinea pigs, and nonhuman primates. Case reports and large-scale observational studies of patients in the West African epidemic have provided additional data on pathogenesis. Observations of disease mechanisms from the epidemic have been consistent with findings in animal studies.

Cell Entry and Tissue Damage

After entering the body through mucous membranes, breaks in the skin, or parenterally, the Ebola virus infects many different cell types. Macrophages and dendritic cells are the first to be infected. Filoviruses replicate readily within these ubiquitous "sentinel" cells, causing their necrosis and releasing large numbers of new viral particles into the extracellular fluid.

Rapid systemic spread is aided by virus-induced suppression of type I interferon responses (Basler, 2017). Dissemination to regional lymph nodes results in further rounds of replication, followed by spread through the bloodstream to dendritic cells and fixed and mobile macrophages in the liver, spleen, thymus, and other lymphoid tissues. Necropsies of infected animals have shown that many cell types may be infected, including endothelial cells, fibroblasts, hepatocytes, adrenal cortical cells, and epithelial cells. Lymphocytes and neurons are the only major cell types that remain uninfected. The fatal disease is characterized by multifocal necrosis in tissues such as the liver and spleen.

Gastrointestinal Dysfunction

Patients with EVD commonly suffer from vomiting and diarrhea, resulting in acute volume depletion, hypotension, and shock. It is unclear if such dysfunction in EVD results from a viral infection of the gastrointestinal tract or if circulating cytokines or both induce it.

Systemic Inflammatory Response

In addition to causing extensive tissue damage, EVD also produces a systemic inflammatory syndrome by causing the release of cytokines, chemokines, and other proinflammatory mediators from macrophages and other cells.

Infected macrophages produce tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6, macrophage chemotactic protein (MCP)-1, and nitric oxide (NO). These and other substances have also been identified in blood samples from Ebola-infected macaques and acutely ill African patients. Breakdown products of necrotic cells also stimulate the release of the same mediators.

The systemic inflammatory response may play a role in inducing gastrointestinal dysfunction, as well as the diffuse vascular leak and multiorgan failure seen later in the disease course.

Coagulation Defects

The coagulation defects seen in EVD appear to be induced indirectly through the host inflammatory response. Virus-infected macrophages synthesize cell-surface tissue factor (TF), triggering the extrinsic coagulation pathway. Proinflammatory cytokines also induce macrophages to produce TF. The simultaneous occurrence of these two stimuli helps to explain the rapid development and severity of coagulopathy in EVD.

Additional factors may also play a role in the coagulation defects seen with EVD. For example, blood samples from Ebola-infected monkeys contain D-dimers within 24 hours; D-dimers are also present in the plasma of humans with EVD. In Ebola virus-infected macaques, activated protein C is decreased on day two. Still, the platelet count does not begin to fall until days three or four, suggesting that activated platelets are adhering to endothelial cells. As the disease progresses, the hepatic injury may also cause a decline in plasma levels of certain coagulation factors (Geisbert et al., 2003).

Clinical Manifestations

Incubation Period

The virus has an incubation period of 2-21 days and is spread when individuals become symptomatic (O'Keefe, 2016). Identifying those at risk relies primarily on early recognition of travel history and symptoms. Upon identifying the potentially infected, all healthcare personnel should don appropriate PPE, as standard, droplet, and contact precautions are generally observed (O'Keefe, 2016).

Signs and Symptoms

Most cases of EVD begin with sudden fever, malaise, muscle aches, headache, and sore throat. Other symptoms that may follow include (WHO, 2021; CDC, 2023f):

  • Diarrhea
  • Vomiting
  • Signs of liver and kidney dysfunction
  • Rash
  • Bleeding (internally and externally, such as bloody stools and oozing from the gums)
  • Lab findings may indicate low blood counts and increased liver enzymes

Rash

  • A diffuse erythematous, nonpruritic maculopapular rash may develop by days 5 to 7 of illness.
  • The rash usually involves the face, neck, trunk, and arms and can desquamate. It is generally easier to see in light-skinned persons.
  • During the outbreak in Sierra Leone, the rash was reported as rare. It was, however, clearly described in case reports of infected healthcare workers.

Gastrointestinal

  • Gastrointestinal signs and symptoms are common and usually develop within the first few days of illness. These include:
    • Abdominal pain
    • Nausea
    • Vomiting
    • Watery diarrhea (can be excessive and quickly lead to dehydration, hypotension, and shock if not controlled)

Hemorrhage

  • Case series from the West African epidemic indicate that many patients develop some degree of bleeding during their illness, most commonly manifested as:
    • Blood in the stool
    • Ecchymoses
    • Mucosal bleeding
    • Oozing from venipuncture sites
    • Petechiae
  • Clinically significant hemorrhage may be seen in the terminal phase of illness and pregnancy

Neurologic

  • Patients occasionally develop meningoencephalitis, with findings such as:
    • Altered level of consciousness
    • Gait instability
    • Hyperreflexia
    • Myopathy
    • Seizures
    • Stiff neck
  • These clinical manifestations typically develop around days 8 to 10 of illness

Cardiac

  • Pulse-temperature dissociation with relative bradycardia may be observed during acute illness.
  • In addition, retrosternal chest pain attributed to pericarditis has been reported.
  • Myocarditis has also been described.

Respiratory

  • Tachypnea and shortness of breath may represent hypoxia or hypoventilation due to respiratory muscle fatigue, contributing to impending respiratory failure. These symptoms were observed in nearly one-third of patients treated in Europe and the US in the setting of intravenous fluid resuscitation.

Ocular

  • Patients may develop conjunctival injection and signs and symptoms of uveitis (blurred vision, photophobia, blindness) during the acute phase of the illness.
  • In addition, uveitis has been documented during convalescence.

Laboratory Findings

Patients with EVD typically develop leukopenia, thrombocytopenia, serum transaminase elevations, and renal and coagulation abnormalities. Other laboratory findings include a marked decrease in serum albumin, hypoglycemia, and elevated amylase levels (CDC, 2023b).

Leukopenia

  • Leukopenia usually presents as lymphopenia, followed by an elevated neutrophil count (Mulangu et al., 2018). Immature granulocytes and abnormal lymphocytes, including plasmacytoid cells and immunoblasts, may be seen in blood smears.

Thrombocytopenia

  • Platelet counts decrease during the acute phase of illness but generally do not fall below 50,000 to 100,000/mcl. Platelet counts typically reach their low point around days 6 to 8 of illness.

Abnormal hematocrit

  • Patients with EVD may present with an increased or decreased hematocrit. For example, in one cohort study that evaluated 100 patients, 15 had an increased hematocrit upon presentation, and 36 were anemic.

Transaminase elevations

  • Because the virus can cause multifocal hepatic necrosis, blood chemistry tests usually demonstrate elevated serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels.

Coagulation abnormalities

  • Prothrombin (PT) and partial thromboplastin times (PTT) can be prolonged, and fibrin degradation products are elevated, consistent with disseminated intravascular coagulation (DIC). These changes are most prominent in severe and fatal cases.

Renal abnormalities

  • Proteinuria is a common finding, and renal insufficiency with elevated blood urea nitrogen (BUN) and creatinine can be seen in the early and late stages of the disease.
  • Acute kidney injury is exacerbated by excessive fluid loss from diarrhea and vomiting without adequate volume replacement. Still, it may also develop due to direct viral-mediated tissue injury without severe volume loss.

Electrolyte abnormalities

  • Patients may develop significant electrolyte disturbances (e.g., hyponatremia, hypokalemia, hyperkalemia, hypomagnesemia, and hypocalcemia) secondary to the gastrointestinal manifestations of the disease. Such individuals may require frequent repletion of electrolytes to prevent cardiac arrhythmias.

Disease Course

Patients who survive EVD typically begin to improve during the second week of illness (CDC, 2023b). The fatal disease has been characterized by more severe clinical signs and symptoms early during infection, progressing to multiorgan failure, with death typically occurring in the second week.

Some patients develop secondary complications related to their disease and the treatments they receive (Tozay et al., 2020). These include bacterial sepsis, respiratory failure associated with aggressive fluid resuscitation, and lung and kidney injury.

Convalescence

The convalescent period of EVD is prolonged and can persist for more than two years. Patients may suffer from weakness, fatigue, insomnia, headache, and failure to regain the weight lost during illness, resulting in significant disability. Other clinical manifestations include:

  • Acute arthralgias may result from the formation of antigen-antibody complexes during recovery.
  • Extensive skin sloughing and hair loss may result from virus-induced necrosis of infected sweat glands and other dermal structures.
  • Retro-orbital pain, uveitis, and hearing loss are possible (Jagadesh et al., 2018).

Diagnosis

Whether EVD is considered in the differential diagnosis of a patient with fever and flu-like symptoms will vary markedly depending upon the circumstances, mainly whether a recognized Ebola epidemic is occurring. In addition, clinicians should remember that the acute onset of a febrile illness in a person who lives in or has recently been to West or Central Africa can result from various local infectious diseases, including malaria, typhoid fever, and meningitis (WHO, 2021).

Symptomatic patients

  • Even though there are no approved specific therapies for EVD, it is essential to make the diagnosis as early as possible so that infection control procedures can be implemented to reduce the transmission of the virus and supportive measures can be initiated before the development of irreversible shock.
  • Patients with signs and symptoms consistent with EVD (fever and severe headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage) should be assessed to determine the likelihood of recent exposure to the Ebola virus (table 2). In particular, they should be asked if they traveled to an area with a recognized Ebola epidemic or had contact with a patient with possible EVD within 21 days before the onset of symptoms (CDC, 2023b).
Table 2: EVD Case Definition Box
A person under investigation (PUI) for EVD meets the following criteria.
1. Signs or symptoms compatible with EVD (subjective fever/elevated body temperature, headache, fatigue, muscle pain, vomiting, diarrhea, etc.).
AND
2. An epidemiology risk factor for EVD within 21 days of symptom onset (e.g., travel to a country with widespread Ebola virus transmission or close proximity to a person with symptomatic EVD).

CDC, 2022f

A confirmed case of EVD requires laboratory-confirmed diagnostic evidence of Ebola virus infection.

Infection control precautions should be used for all symptomatic patients who may have been exposed to the Ebola virus (i.e., those who have had a high, moderate, or low-risk exposure). Infection control precautions should also be used for patients whose risk of exposure is unclear at the time of their initial presentation until a medical evaluation can be performed.

Persons under investigation for EVD should undergo testing for the Ebola virus by RT-PCR facilitated by local and state health officials. Persons under investigation for EVD should also be evaluated for other possible febrile diseases, including those common in areas where the patient traveled or resided (e.g., malaria, typhoid, or influenza).

The specific triage system used during the initial assessment of a patient with possible EVD may vary depending on the setting (e.g., emergency department, ambulatory clinic) and the known history of transmission in the community (CDC, 2022b).

For example, medical facilities, especially those with widespread EVD transmission, should designate areas for screening patients (CDC, 2022b).

In addition, the types of PPE recommended for healthcare personnel caring for a patient depend upon the patient's clinical symptoms. The PPE used when caring for patients whose condition is associated with a high risk of direct contact with body fluids (e.g., presence of vomiting, diarrhea, bleeding) are different from those used when evaluating a patient who does not present a hazard due to body fluid exposure (CDC, 2023e). Only essential personnel trained in proper donning and doffing PPE should interact with the patient.

Asymptomatic individuals

  • Asymptomatic individuals with possible exposure to EVD generally do not require strict isolation precautions. Such patients should be monitored so that they can be isolated if fever or other signs or symptoms occur. However, additional restrictions may be required depending on the type of exposure (CDC, 2023e).

The risk of exposure to the Ebola virus helps guide the evaluation and management of symptomatic and asymptomatic individuals. Patients are at risk for EVD if exposed within 21 days before the onset of symptoms. However, the level of exposure risk ranges from high, moderate, and low to no known identifiable risk. Healthcare workers' exposure risk level increases with the number of patients with known EVD they care for. Individuals may also be at risk if they have handled bats or nonhuman primates from endemic areas of Africa.

Initial Assessment for EVD

Symptomatic Patients with Identifiable Risk

  • Clinical findings consistent with EVD include fever, severe headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage (CDC, 2023b). Infection control precautions should be used for all symptomatic patients with an identifiable risk for EVD. In addition, the hospital infection control program and other appropriate staff should be notified, as well as local and state health departments.
  • Such patients should be isolated in a single room with a private bathroom and a closed door to the hallway. All healthcare workers should also use standard, contact, and droplet precautions. PPE is recommended for the care of patients with EVD.
  • In patients suspected of having EVD, phlebotomy and laboratory testing should be limited to tests essential for diagnosing or ruling out the disease, assessing for an alternative or concurrent infection (e.g., malaria), and emergency care. In consultation with local and state health officials, evaluation for other potential causes of their illness may also be indicated, particularly for those individuals whose recent history suggests a low risk of exposure to the virus (CDC, 2023b).
  • In the US, certain hospitals have been designated as "Ebola assessment hospitals." They are prepared to evaluate and care for patients with possible EVD until a diagnosis can be confirmed or ruled out (CDC, 2022f).

Asymptomatic Individuals with Identifiable Risk

  • Monitoring for signs and symptoms of EVD should be performed for asymptomatic persons exposed to the Ebola virus at any risk level (i.e., high, moderate, or low risk).
  • Such individuals should be monitored for 21 days after the last known exposure and immediately report the development of fever or other clinical manifestations suggestive of EVD (CDC, 2023b). The type of monitoring (e.g., self-monitoring and reporting versus direct observation by a designated health official), the need for travel restrictions, restricted movement within the community, and quarantine depend in part upon the type of exposure. Public health authorities typically dictate specific guidelines for managing asymptomatic individuals exposed to the Ebola virus.

Patients with No Identifiable Risk

  • If patients are determined to have no identifiable risk for infection after initial evaluation, monitoring or diagnostic testing for EVD is not warranted. However, if patients have a fever and other signs or symptoms of illness, they should be evaluated for other causes of febrile disease (e.g., malaria, Lassa fever, influenza). Appropriate infection control precautions will depend upon the patient's clinical findings, as well as the specific pathogens that are being considered.

Diagnostic Testing

Indications

  • All patients with suspected EVD should be evaluated in conjunction with local and state health departments (CDC, 2022c).
  • Testing for EVD is performed in symptomatic patients with any possible risk of exposure to the Ebola virus (high, moderate, or low risk).
  • Testing is not warranted for patients with an identifiable risk but no signs or symptoms of EVD. These patients should be monitored and tested if they become ill.
  • Testing is not warranted for patients without any identifiable risk of exposure.

The Ebola virus is generally detectable in blood samples by RT-PCR within three days after the onset of symptoms. Repeat testing may be needed for patients with symptoms for fewer than three days (CDC, 2022c). According to CDC guidelines for discharging a person under investigation for EVD, a negative RT-PCR test collected ≥72 hours after the onset of symptoms excludes EVD (CDC, 2022b).

Patients who have confirmed EVD should be transferred to specialized Ebola treatment centers.

Diagnosing an Ebola virus infection may be challenging to differentiate from other diseases such as typhoid fever, malaria, and meningitis (WHO, 2021). Diagnostics are based on detecting specific RNA sequences by RT-PCR in blood or other body fluids. Viral antigens can also be detected using immunoassays. Any presumptive positive Ebola test in the US should be confirmed at the CDC (CDC, 2022e).

The local or state health department should be contacted immediately if testing is indicated. Clinicians, nurses, and laboratory workers need to be aware that CDC regulations apply to handling patient specimens confirmed to contain infectious Ebola viruses (CDC, 2022e). Additional details on collecting and handling specimens from patients with suspected EVD can be found in the CDC documents that guide laboratories and submission information (CDC, 2022c). For clinicians outside the US, the WHO has also issued guidance for diagnosing, safely collecting, and shipping samples from patients with suspected EVD (WHO, 2021).

Differential Diagnoses

When evaluating a patient for possible EVD, it is essential to consider alternative and concurrent diagnoses, including infectious and noninfectious disorders.

The differential diagnosis depends, in part, upon the individual's symptoms, where they have traveled or resided, if they have had close contact with someone who is ill, their vaccination history, and their age and comorbid conditions (CDC, 2023b).

Since most patients suspected of possible EVD will have traveled to and reside in West or Central Africa, the following disorders should be considered:

  • Influenza
    • Influenza often presents with the abrupt onset of fever, headache, myalgia, and malaise, like the presenting signs and symptoms of EVD. However, with influenza, these manifestations are usually accompanied by respiratory signs and symptoms, such as nonproductive cough, sore throat, and nasal discharge, which are not typically part of EVD. Direct fluorescent antibodies or other rapid assays are used to diagnose influenza.
  • Lassa Fever
    • Lassa fever is restricted to West Africa, though infected travelers have become ill in countries of Europe, as well as in the US. Although symptoms may be mild, approximately 20% of patients develop a severe clinical syndrome that can progress to fatal shock. Transmission to humans occurs primarily through exposure to the aerosolized excretions of local multimammate rats, or in rare cases, through contact with the body fluids of infected individuals. Diagnosis is made by RT-PCR testing and serology (CDC, 2023a).
  • Malaria
    • Travelers who develop a febrile illness after returning from West or Central Africa should be evaluated for malaria, which can present with similar findings to EVD and may occur concurrently (CDC, 2022b). Microscopic examination of blood smears and rapid antigen testing is typically used to diagnose malaria.
  • Marburg Virus Disease
    • Marburg virus causes clinical manifestations like EVD. Cases have been identified in Central Africa but not in West Africa. The diagnosis is typically made by RT-PCR testing.
  • Measles
    • The prodromal phases of measles and EVD are similar and are characterized by fever, malaise, and anorexia. However, in measles, this is followed by conjunctivitis, coryza, cough, and a characteristic maculopapular, blanching rash that begins on the face. The diagnosis of measles is typically established via antibody or PCR testing.
  • Meningococcal Disease
    • Patients infected with Neisseria meningitidis can present with meningitis and bacteremia, and specific signs and symptoms (headache, fever) may overlap with those seen in EVD.
  • Travelers' Diarrhea
    • The condition develops during or within ten days after returning from travel, most commonly from resource-limited regions. Patients typically present with malaise, anorexia, and abdominal cramps, followed by the sudden onset of diarrhea. Nausea, vomiting, and low-grade fever may also occur. When attempting to distinguish between travelers' diarrhea and diarrhea in EVD, clinicians should note whether the condition appears to be part of a systemic illness or is mainly confined to the gastrointestinal tract. A patient who develops diarrhea in the setting of EVD is likely to have a several-day history of fever, myalgia, fatigue, and other signs of a rapidly progressive systemic disease.
  • Typhoid
    • Typhoid fever is a systemic illness characterized by fever and abdominal pain. The organism responsible for enteric fever syndrome is Salmonella Typhi (formerly S. typhi). Worldwide, typhoid fever is most prevalent in impoverished and overcrowded areas with poor access to sanitation. The diagnosis is typically made by identifying the organism in blood cultures.

Treatment

Approach to Therapy

All healthcare workers caring for patients with suspected or confirmed EVD should rigorously observe infection control precautions, including the proper use of PPE.

Two monoclonal antibodies (Inmazeb and Ebanga) were approved in 2020 by the US Food and Drug Administration for treating Ebola. These have only been proven effective against the Zaire ebolavirus thus far (WHO, 2021). Also approved by the FDA in 2020 was the Ervebo vaccine, shown to be effective in protecting people against the Zaire ebolavirus (WHO, 2021).

The mainstay of treatment for EVD involves supportive care to maintain adequate organ function (e.g., cardiovascular, respiratory, renal). At the same time, the immune system mobilizes an adaptive response to eliminate the infection (CDC, 2021c). Whenever possible, such patients should receive care in designated treatment centers and by clinicians trained to care for such patients (CDC, 2023d).

Supportive Care

Fundamental aspects of supportive care involve preventing intravascular volume depletion, correcting profound electrolyte abnormalities, and avoiding the complications of shock.

During the outbreak in West Africa, 27 patients with EVD were treated in the US or Europe, receiving aggressive supportive care (Uyeki et al., 2016). Among those patients, 82% survived. Specific lessons learned from the care of patients with EVD during the outbreak include the following: (CDC, 2023b).

Patients may lose significant amounts of fluid through vomiting and diarrhea, requiring rapid volume replacement to prevent shock. Antiemetic and antidiarrheal agents may also be beneficial. Careful attention to the volume of fluid losses and intake will assist with fluid repletion targets.

When available, patients will benefit from hemodynamic monitoring and intravenous fluid repletion. However, patients in the early phase of illness who respond to oral antiemetic and antidiarrheal therapy may be able to take in sufficient fluids by mouth to prevent or correct dehydration (Kortepeter et al., 2016).

Patients may develop significant electrolyte disturbances (e.g., hyponatremia, hypokalemia, hypomagnesemia, and hypocalcemia) and require frequent electrolyte repletion to prevent cardiac arrhythmias.

Intensive care nursing may be required to respond to the patient's changing clinical situation.

Fluid and Electrolyte Replacement

Patients who experience fluid loss from vomiting and diarrhea may require a balanced crystalloid solution of five or more liters daily. Fluid and electrolyte replacement can be administered orally (WHO-recommended oral rehydration salts) or intravenously (0.9% sodium chloride solution). The approach largely depends upon the stage of illness and the clinical presentation. For example, in resource-limited settings, oral therapy to prevent or correct dehydration may be suitable for patients in the early phase of illness who respond to oral antiemetic and antidiarrheal therapy (Kortepeter et al., 2016). However, patients in shock and those unable to tolerate or manage self-directed oral replacement therapy will require intravenous fluids.

In resource-limited areas with little or no monitoring and laboratory capacity, qualitative assessments of urine frequency, volume, and color and evaluation of skin turgor and mucous membranes may assist in guiding volume replacement without more accurate measures.

In areas with more significant resources, careful attention to the volume of fluid losses and intake and indirect assessments of intravascular volume status (e.g., vascular ultrasound and indwelling catheters for central venous pressure monitoring) will assist with fluid repletion targets. Plasma values should guide electrolyte replacement since patients can present with various abnormalities.

In resource-rich areas, clinicians may employ standard supportive measures for critically ill patients in shock, including invasive blood pressure and continuous pulse-oximetry monitoring. Hypotension may persist despite adequate volume resuscitation, requiring vasopressor infusions such as norepinephrine. Aggressive volume resuscitation may contribute to developing pulmonary edema, and acute lung injury in the setting of shock may necessitate supplemental oxygen therapy (e.g., nasal cannula or face mask).

Respiratory Support

Invasive mechanical ventilation (intubation) may be the best option for patients with progressive respiratory failure. When considering the management of such patients with EVD, clinicians should recognize that some types of respiratory support present a hazard of generating infectious aerosols. Noninvasive mechanical ventilation or high-flow oxygen therapy (e.g., Vapotherm) is generally not recommended, given the potential for continuous aerosol production.

Additional Supportive Measures

Additional supportive measures may be needed depending on the patient's clinical presentation. These include:

  • Analgesic agents to manage pain (e.g., abdominal, joint, muscle).
  • Antiemetic medications to control nausea and vomiting.
  • Anticonvulsant medications for those with seizures.
  • Antimotility agents (e.g., loperamide) to control diarrhea and decrease fluid and electrolyte losses (Kortepeter et al., 2016).
  • Antipyretic agents (e.g., acetaminophen) to decrease fever associated with EVD. A dose reduction of these agents may be needed for patients with progressive hepatic dysfunction. Nonsteroidal anti-inflammatory agents are generally avoided to help minimize the risk of renal failure, which can contribute to fatal disease.
  • Blood products (e.g., packed red blood cells, platelets, fresh frozen plasma) for patients with coagulopathy and bleeding.
  • Renal replacement therapy to manage severe multifactorial acute kidney injury. If dialysis is required, clinicians should refer to the CDC guidelines on safely performing acute hemodialysis in patients with EVD (CDC, 2021g).

Antimicrobial Therapy

As with other severely ill patients, persons with EVD may require evaluation and treatment of other concomitant or possible infections (e.g., malaria).

In addition, empiric antimicrobial treatment should be administered to patients with clinical evidence of bacterial sepsis, which may be a late complication.

  • The choice of agent should provide adequate coverage for gram-negative pathogens.
  • Empiric gram-positive therapy should be added in certain patients, such as those with hospital-acquired pneumonia or indwelling central venous catheters.

In some cases from the Ebola epidemic in West Africa, empiric antimicrobial therapy was given to patients at the time of initial presentation or to patients with gastrointestinal dysfunction, even if clinical evidence of bacterial sepsis was absent. However, data to justify this approach are lacking.

Considerations during Pregnancy

EVD is associated with a high risk of fetal death and pregnancy-associated hemorrhage (CDC, 2022d). Those who are pregnant or breastfeeding should have access to early supportive care measures. Vaccines and monoclonal antibodies should be offered if healthcare professionals feel the risk versus benefit warrants the treatments (CDC, 2022d).

The CDC and the American College of Obstetrics and Gynecology have issued recommendations for caring for pregnant women with EVD (CDC, 2022d). However, no data suggests whether cesarean or vaginal delivery is preferred or when the baby should be delivered. Thus, decisions regarding obstetrical care must be made on a case-by-case basis.

Recovery and Discharge from the Hospital

Patients who survive EVD typically begin to show signs of clinical improvement during the second week of illness (CDC, 2022b). In these patients, viremia also resolves during the second week, associated with the appearance of virus-specific IgM and IgG.

RT-PCR testing is used to help determine when a recovering patient can be discharged from a hospital. According to the WHO, individuals who no longer have signs and symptoms of EVD can be discharged if they have two negative RT-PCR tests on whole blood separated by at least 48 hours (WHO, 2016).

Regardless of when an individual is discharged from the hospital, patients should receive information to help minimize the risk of transmission in the community (e.g., counseling on safe sexual practices) since the virus can persist in a variety of body fluids (e.g., urine, semen) for up to several months after the plasma tests negative for Ebola virus by RT-PCR.

Follow-Up Care

Patients should be informed that clinical sequelae, including mental health issues, may persist after recovering from the illness. A comprehensive plan should be developed to support EVD survivors and reduce the risk of transmitting the disease to others. EVD has been reported to remain in some sites of humans after recovery, such as the central nervous system, testicles, and eyes. After infection in pregnant or breastfeeding women, the virus may remain in breast milk or amniotic fluid (WHO, 2020).

All survivors should be educated to refrain from sexual activity (or practice safe sex) until their semen has tested negative twice for the virus. Initial semen testing should be scheduled three months after the virus onset and every month for those continuing to test positive.

The WHO suggests that patients be seen for follow-up two weeks after discharge, monthly for six months, and then every three months to complete one year (WHO, 2016).

  • Males should have semen testing during these visits until they test negative for virus RNA.
  • If fever develops, patients should be tested for Ebola RNA by RT-PCR and be evaluated for other causes of infection (e.g., malaria).
  • Uveitis and meningitis may be suggestive of an EVD relapse. If meningitis is suspected, a lumbar puncture should be performed (using appropriate PPE), even if the blood tests are negative for Ebola RNA.

EVD survivors with ocular findings also require follow-up for vision care (CDC, 2019).

Prevention

Several concurrent strategies should be employed to prevent the spread of EVD. During acute illness, strict infection control measures and the proper use of PPE are essential to prevent transmission to healthcare workers. In addition, individuals exposed to the Ebola virus should be monitored to quickly identify if signs and symptoms develop. Community engagement and cooperation are vital (WHO, 2021a).

  • Reduce the risk of human transmission by animals. All infected animals should be handled with proper PPE, and animal products (meat) should be cooked thoroughly.
  • Adopt outbreak containment measures. Educate on proper prevention methods and enforce safe burials for the dead that keeps all parties free from harm. Quickly identify those exposed to EVD and quarantine and monitor them for 21 days. Educate on the importance of handwashing and cleanliness.
  • Reduce sexual transmission risk. Male EVD survivors should be educated on the importance of safe sexual practices. The EVD can remain in their semen long after they have been considered recovered. Regular testing will be necessary, as their semen must test negative twice before being considered safe; this could take up to 24 months.
  • Patients who have recovered from EVD may continue to have infectious viruses in urine, vaginal secretions, and breast milk during early recovery when the virus is no longer present in the blood. Long-term persistence of the virus in semen, ocular fluid, and cerebrospinal fluid may also occur and is related to the "immune privilege" of these sites. Certain precautions should be taken to reduce the risk of transmission during convalescence.

Infection Control Precautions during Acute Illness

When caring for patients with confirmed or suspected acute EVD, healthcare personnel should follow infection prevention and control recommendations from the CDC and the WHO (CDC, 2022f). These guidelines provide control measures to manage patients known or suspected to be infected with the virus or other highly pathogenic agents.

Infection control recommendations for patients who present with acute infection include:

  • Correct use of appropriate PPE
  • If possible, aerosol-generating procedures should be avoided. However, if they must be performed, patients should be placed in an airborne infection isolation room (CDC, 2022f)
  • Isolation of hospitalized patients with known or suspected EVD
  • Proper hand hygiene
  • Use of standard, contact, and droplet precautions

Personal Protective Equipment (PPE)

The type of PPE used and its careful placement and removal are critical to preventing nosocomial transmission of the Ebola virus. During the 2014 - 2016 epidemic, several patients were cared for in the US. The staff at Emory University used full-body suits. It powered air-purifying respirators (PAPR) to help staff work for extended periods, decrease the physical discomfort of working in multi-component PPE, and avoid difficulties like fogged face shields. The donning and doffing of PPE were constantly observed by another staff member.

The PPE used for EVD depends partly upon the patient's clinical presentation (e.g., presence or absence of diarrhea, vomiting, bleeding). Clinicians should refer to the CDC and WHO guidelines when caring for patients. The CDC has also released a video that demonstrates donning and doffing of PPE.

Highlights from these guidelines include the following:

  • Rigorous and repeated training of health care workers in correct donning and doffing of PPE. In addition, healthcare workers should demonstrate competency in performing Ebola-related infection control practices and procedures.
  • PPE should cover all clothing and skin, protecting mucous membranes. Such PPE includes gloves, boot covers, fluid-resistant gowns or coveralls, single-use disposable hoods that cover the head and neck, single-use disposable full-face shields, and PAPR or N95 respirators. Additional measures, such as waterproof aprons, may also be required depending on the patient's symptoms. The healthcare facility providing care should determine the combination of PPE used.
  • Healthcare workers should frequently disinfect gloved hands using an alcohol-based hand rub, particularly after touching body fluids.
  • A trained monitor should actively observe and supervise each worker donning and doffing PPE. Monitors should not serve as an assistant in taking off PPE.

Using the recommended PPE for healthcare workers caring for patients with EVD for extended periods can potentially result in heat-related illness, which was of particular concern in West Africa (CDC, 2022f). Recommendations to help prevent such complications include staying hydrated, working short shifts until the healthcare worker can adjust to the heat, taking time to rest and cool down, and watching for signs of heat-related illness.

Pregnancy

Healthcare workers who are pregnant should not provide care for patients with EVD. In addition to the increased maternal and fetal risks of EVD during pregnancy, PPE may not be well-suited for pregnant healthcare workers.

Labor and Delivery

Strict infection control precautions must be used when caring for pregnant patients with EVD. PPE is recommended for providers at high risk of exposure to bodily fluids. These precautions should be used even if the mother has recovered from the infection since data suggest that the fetus of a mother who survived EVD while pregnant may continue to harbor the virus and be infectious (WHO, 2020).

Environmental Infection Control

Suppose a patient with suspected or confirmed EVD is cared for in a healthcare setting. In that case, specific precautions should be taken to reduce the potential risk of virus transmission through contact with contaminated surfaces. Frequent cleaning of the floor in the doffing area is necessary (CDC, 2021b)

In a study that surveyed EVD treatment centers in Sierra Leone, viral RNA was frequently detected on materials in direct contact with patients (Poliquin et al., 2016). For example, Ebola virus RNA was detected on four of six gloves tested, despite a lack of visible soiling. However, after gloves were rinsed with a chlorine solution, viral RNA was no longer detected.

The CDC has guided medical waste management and specific recommendations for environmental infection control in hospitals, healthcare settings, and laboratories.

Additional Considerations

Sexual transmission

  • The CDC and WHO suggest that patients with EVD refrain from sexual activity (oral, anal, vaginal) and that condoms should be used if abstinence is impossible. In addition, hand hygiene is recommended following contact with semen (CDC, 2019).
  • It is not known when unprotected sexual activity can be safely resumed. For men, the WHO has suggested that the semen be tested for the Ebola virus by RT-PCR three months after the onset of the disease. Further recommendations are as follows:
    • For those men who test negative, the test should be repeated with an interval of one week between tests. Sexual activity can be resumed if their semen has tested negative for the Ebola virus twice by RT-PCR.
    • For those men who test positive for the Ebola virus at three months, testing should be repeated every month until their semen tests negative. Sexual activity can be resumed if the semen has tested negative for the Ebola virus twice by RT-PCR.
    • The WHO recommends that if semen testing is unavailable, men should practice safe sex for at least 12 months from the onset of illness.
  • Studies evaluating the persistence of the Ebola virus have detected viral RNA in vaginal fluids for up to 33 days and in semen for up to two years after the onset of EVD.

Breastfeeding and infant care

  • The Ebola virus can be transmitted through close contact between an infected mother with her children. The CDC recommends that most who are under investigation for EVD, have confirmed infection, or have recently recovered should avoid breastfeeding (CDC, 2021a).
  • Where available, breast milk testing can guide when it is safe for mothers who have survived EVD to resume breastfeeding. If Ebola virus RNA is detected, the breast milk should be retested every 48 hours until two consecutive negative results are obtained.
  • In resource-limited settings, the risk of virus transmission during breastfeeding must be weighed against the risk of the infant becoming malnourished or developing a diarrheal or respiratory disease or other infections if safe alternative options for feeding are not available.

Monitoring and travel restrictions

  • Persons who have had possible exposure to the Ebola virus should be monitored for signs and symptoms of the disease. Monitoring should continue for 21 days after the last known exposure. The development of fever and other clinical manifestations suggestive of EVD should be reported immediately.
  • During the West African epidemic, the CDC and WHO provided information about restrictions on the travel and transport of asymptomatic persons exposed to EVD.

Case Study

Sister Marie Jones and Sister Anna Cortez arrive at an urgent care center adjacent to a community hospital. Both complain of fever, abdominal pain, lack of appetite, myalgias, and arthralgias. They wait in the waiting room until called for triage by the registered nurse (RN). Both sisters insist upon being triaged at the same time. Both sisters returned from mission work ten days ago after spending the last six months traveling to outlying areas around the capital city of Kinshasa in the Democratic Republic of the Congo. Their job was to try to identify suspected cases of EVD, arrange transport to the nearest healthcare facility if necessary, and educate villagers in preventing the spread of EVD. Both sisters related that other sisters in the convent in which they reside here in the US have similar symptoms but not as severe as themselves.

Interventions/Strategies

The registered nurse phones the main desk to relay the information she has obtained. She requests that the physician gown up and wear gloves and a mask before he enters the triage room. Meanwhile, since she has been inadvertently exposed to the suspected Ebola virus, the triage RN uses her cell phone to contact the hospital infection control professionals/resources. After being informed of the ongoing situation, the infection control professional immediately closed down the urgent care center for the time being, diverting arriving patients to the hospital emergency room. She follows protocol which usually includes informing the administration and the local and state health departments. All patients exposed to the two sisters were asked to be patient and remain in the waiting room for the time being. All patients in the other examination rooms in the urgent care center were either discharged home or transported to the main emergency room.

A hazmat/public health team arrives at the urgent care center to assess the other waiting room patients and admission secretaries as PUIs. Another hazmat/public health team visits the convent where the two sisters reside to evaluate the other sisters as PUIs and any other contacts they may have had.

All suspected PUIs in the urgent care center and convent were immediately isolated to prevent the possible spread of suspected EVD. Federal, state, and local healthcare agencies were immediately notified and responded promptly. Levels of risk assessment were ongoing.

Summary and Recommendations

The family Filoviridae contains three genera, Ebolavirus and Marburgvirus, which cause severe disease in humans, and Cuevavirus, which has only been detected as viral RNA in bats in Spain.

The Zaire species of Ebola virus, the causative agent of the 2014 -2016 West African epidemic, is among the most virulent human pathogens known. The case fatality rate in past outbreaks in Central Africa reached 80 to 90%, but the overall fatality rate in West Africa was approximately 40%.

In the past, the Ebola virus was classified as a "hemorrhagic fever virus." However, that term is no longer used because only a small percentage of patients develop significant bleeding, usually occurring in the terminal phase of illness.

Until the 2014 - 2016 epidemic in West Africa, all outbreaks of EVD had occurred in Central Africa or Sudan. The West African epidemic was the largest filovirus outbreak on record. It started in Guinea in late 2013 and was confirmed by the WHO in March 2014. The countries with widespread transmission included Guinea, Liberia, and Sierra Leone. EVD occurred in hundreds of healthcare personnel who were caring for patients. Several patients with EVD (e.g., doctors and nurses infected in West Africa, returning travelers from the region) were treated in hospitals in the US and Europe.

The reservoir host of the Ebola virus is unknown. Evidence is accumulating that various bat species may be a source of infection for humans and wild primates. Person-to-person transmission is associated with direct contact with body fluids from patients with EVD or cadavers of deceased patients. Transmission to healthcare workers may occur when appropriate PPE is not available or properly used, especially when caring for a severely ill patient.

Human infection with the Ebola virus can also occur through contact with wild animals (e.g., hunting, butchering, and preparing meat from infected animals). Almost all data on the pathogenesis of EVD have been obtained from laboratory experiments employing mice, guinea pigs, and nonhuman primates. Case reports and large-scale observational studies of patients in the West African epidemic have provided additional data on pathogenesis consistent with findings in animal studies.

The incubation period of EVD is typically 6 to 12 days but can range from 2 to 21 days. Patients with EVD usually have an abrupt onset of nonspecific signs and symptoms such as fever, malaise, headache, and myalgias. As the illness progresses, vomiting and diarrhea may develop, often leading to significant fluid loss. Patients with worsening disease display hypotension and electrolyte imbalances leading to shock and multiorgan failure, sometimes accompanied by hemorrhage.

For patients with clinical findings consistent with the disease (i.e., fever and severe headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage), healthcare personnel should obtain a careful history to determine if the patient has had a possible exposure. All patients who have or are suspected of having EVD should be promptly isolated. Infection control precautions, including hand hygiene, standard contact, droplet precautions, and appropriate PPE, should be initiated. Hospital infection control staff and the local or state health department should be contacted immediately.

Monitoring for signs and symptoms of EVD should be performed for asymptomatic individuals with exposure. Medical evaluation of symptomatic patients may include laboratory testing. Whether laboratory testing should be performed depends, in part, upon the relative likelihood that a patient was exposed to the virus and the presence of compatible clinical symptoms.

Diagnostic tests for EVD are based on detecting specific RNA sequences by RT-PCR. The Ebola virus is generally detectable in blood samples within three days after the onset of symptoms. Repeat testing may be needed for patients with symptoms for fewer than three days.

EVD should be considered as a differential diagnosis for certain conditions. The differential diagnosis will vary markedly with the clinical and epidemiologic circumstances. For example, travelers from West or Central Africa should be evaluated for illnesses commonly seen in those areas, such as malaria.

Because of its virulence and high infectivity, the Ebola virus is classified as a Category A bioterror agent.

Effective treatment of EVD requires aggressive supportive care to correct volume losses from vomiting and diarrhea, correct electrolyte abnormalities, and prevent shock. Patients may also require evaluation and treatment of concomitant infections. Several investigational antiviral therapies were used to treat patients during the 2014 - 2016 outbreak in West Africa, but their efficacy is unclear, and the availability of these drugs is limited.

EVD is associated with a high risk of fetal death and pregnancy-associated hemorrhage. Decisions regarding obstetrical care must be made on a case-by-case basis.

Early diagnosis and prompt initiation of care increase the likelihood that a patient with EVD will survive. Patients who survive EVD typically show signs of clinical improvement during the second week of illness. After discharge from the hospital, patients should be monitored for at least one year.

To prevent transmission of the Ebola virus, healthcare personnel should follow infection prevention and control recommendations from the CDC and the WHO:

  • When caring for a patient with acute illness, precautions should include isolation of hospitalized patients with known or suspected EVD, hand hygiene, the use of standard, contact, and droplet precautions, and the correct use of appropriate PPE.
  • For most survivors, only standard precautions are needed for clinical evaluation and care. However, additional precautions are needed for those who present with late-stage manifestations of EVD, such as acute neurological or ocular symptoms.
  • Additional strategies to prevent the spread of EVD include carefully monitoring individuals after possible virus exposure, educating patients on reducing the risk of transmission through sexual contact or breastfeeding, and potentially vaccinating high-risk populations.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

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