On Ebola

Medscape on Ebola for US Clinicians, October 2014

• 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 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.
• Standard, contact, and droplet precautions should be enforced immediately.
• PPE must be worn at all times when in the patient room and must include a gown, facemask, eye protection, and gloves. Shoe or leg covers should be worn if there is a high risk of soiling on the ground, and an N95 respirator is necessary for procedures with possible airborne contact.
• A "buddy system" (application and removal of PPE with a witness) should be employed to ensure that PPE protocols are carried out appropriately.
• PPE should be discarded with the utmost caution to avoid contamination, and hand hygiene is necessary after PPE is removed.
• 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 a gown, facemask, eye protection, and gloves.