Out of Africa: Ebola Cases come to U.S.
CDC issues isolation precautions, clinical care guidance
By Gary Evans, Executive Editor
As the first cases of Ebola ever treated in the U.S. were recently admitted to a special containment unit at Emory University Hospital in Atlanta, clinicians and public health officials continued to reassure a jittery public that infection control measures would prevent transmission and contain the virus.
"We are talking about a virus that is spread in a way that we are quite used to — HIV, hepatitis B, hepatitis C. It’s the same algorithm and we use the same kind of precautions on those patients on a daily basis," Bruce Ribner, MD, an infectious disease physician at Emory, said at an Aug. 1 press conference. "All of these viruses are spread by close contact with blood and body fluids. I will be one of the individuals coming into direct contact with the patients. I have no concerns about either my personal health or the health of the other health care workers who will be working in that unit."
This reassurance, while accurate from a medical standpoint, could nevertheless be seen as something of a disconnect when you are admitting patients into a specially designed unit with elaborate and redundant systems to contain any pathogen within. There are a few such units in the country, so the Ebola patients a volunteer American physician and a medical missionary worker infected in the ongoing West African outbreak were hospitalized under extreme infection control precautions that belie Ribner’s business-as-usual tone. The Centers for Disease Control and Prevention often finds itself delivering a similar mixed message with an exotic pathogen, reassuring that there is little threat to public safety while taking extensive measures with the first cases out of an abundance of caution.
CDC surge in Africa, isolation guidelines in U.S.
As of Aug 12, 2014 the CDC reported the Ebola outbreak in West Africa included 1,848 suspected and confirmed cases with 1013 dead, a mortality rate of some 55%. As cases continued to be reported, the CDC dramatically ramped up its presence in the region and activated its Emergency Operations Center in the U.S. As this issue went to press, the CDC had 55 people deployed to West Africa, including 14 in Guinea, 18 in Liberia, 16 in Sierra Leone, and seven in Nigeria. In a painstaking attempt to stop the outbreak, CDC epidemiologists are identifying new Ebola cases and then tracking their contacts for signs and symptoms within a 21-day incubaton period.
Meanwhile, in the U.S., the CDC posted Ebola information for clinicians and recommendations for infection control precautions in hospitals admitting suspected or confirmed casess. (http://1.usa.gov/1kz43R9) The CDC recommends a combination of standard, contact, and droplet precautions for management of hospitalized patients with known or suspected Ebola hemorrhagic fever. The recommendations were based upon the best available information as of July 30, 2014 and took into account the following considerations:1
•High rate of morbidity and mortality among infected patients
•Risk of human-to-human transmission
•Lack of FDA-approved vaccine and therapeutics
The CDC recommends an Ebola patient should be placed in a single patient room containing a private bathroom with the door kept closed. Facilities should maintain a log of all persons entering the patient’s room. Consider posting personnel at the patient’s door to ensure appropriate and consistent use of PPE by all persons entering the patient room. All persons entering the patient room should wear at least, gloves, gown (fluid resistant or impermeable), eye protection (goggles or face shield), and a facemask.
Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment). These would include but are not limited to: double gloving, disposable shoe covers, leg coverings.
Ebola does not spread through the air, but workers should wear respiratory protection at least to the level of an N95 respirator if they are doing procedures on an Ebola patient or fluids that could generate aerosols. The CDC recommends avoiding aerosol generating procedures (AGPs) on Ebola patients if possible. If performing AGPs, use a combination of measures to reduce exposures from aerosol-generating procedures when performed on Ebola HF patients. Conduct the procedures in a private room, ideally in an Airborne Infection Isolation Room (AIIR) when feasible. Room doors should be kept closed during the procedure except when entering or leaving the room, and entry and exit should be minimized during and shortly after the procedure. In addition to a respirator, health care workers performing an AGP on an Ebola patient should wear gloves, a gown, disposable shoe covers, and either a face shield that fully covers the front and sides of the face or goggles.
Dedicated medical equipment (preferably disposable) is recommended, with the use of sharps and needles limited as much as possible. All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers, the CDC recommends.
No asymptomatic transmission
Ebola does not spread in the absence of symptoms while the patient is in the incubation phase. "Ebola is spread as people get sicker and sicker, they have fever and they may develop severe symptoms," CDC director Tom Frieden, MD, said at a press conference. "Those symptoms and the body fluids that may be shed during that time, those are the infectious risk entities."
U.S. hospitals should have no problem isolating Ebola patients, but personnel must be meticulous in following the measures, he added.
"American health care workers are much more familiar with how to isolate patients and how to protect themselves against infection," he said. "In fact, any advanced hospital in the U.S. — any hospital with an intensive care unit — has the capacity to isolate [Ebola] patients," Frieden said. "There is nothing particularly special about the isolation of an Ebola patient other than it’s really important to do it right. So ensuring that there is meticulous care of patients with suspected or confirmed Ebola is what’s critically important."
Seeking a second opinion, we asked an Ebola expert if U.S. hospitals adopting such measures could contain Ebola and protect their health care workers.
"Yes, I think they can," says Thomas Geisbert, PhD, Ebola researcher and professor of microbiology and immunology at the University of Texas Medical Branch at Galveston. "Because there is an understanding and a recognition in the U.S., especially after the anthrax letters and 9/11. There is [heightened] awareness in U.S. hospitals. Most of them have isolation rooms, good barrier precautions and things like that. Quick identification is the key. Identifying that you have a problem quickly — a definitive diagnosis to rule [Ebola] in or out. I think any of the really good hospitals in this country that have good isolation procedures and rooms would have no problem."
The CDC recommends that U.S. health care settings be alert for possible incoming cases of Ebola, emphasizing these basic points:
•Take good travel histories of patients to identify any who have traveled to West Africa within the last three weeks.
•Know the symptoms of Ebola — fever, headache, joint and muscle aches, weakness, diarrhea, vomiting, stomach pain and lack of appetite and, in some cases, bleeding.
•Know what to do if you have a patient who has Ebola symptoms. First, properly isolate the patient. Then, follow infection control precautions to prevent transmission. Most importantly, avoid contact with blood and body fluids of infected people.
Reference
- CDC. Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals. July 30, 2014. http://1.usa.gov/1pvUSQz
