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 SAFETY IN HANDLING HEALTH CHALLENGES 

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                     SAFETY IN HANDLING HEALTH CHALLENGES 

What causes Ebola hemorrhagic fever?

The cause of Ebola hemorrhagic fever is Ebola virus infection that results in coagulation abnormalities, including gastrointestinal bleeding, development of a rash, cytokine release, damage to the liver, and massive viremia (large number of viruses in the blood) that leads to damaged vascular cells that form blood vessels. As the massive viremia continues, coagulation factors are compromised and the microvascular endothelial cells are damaged or destroyed, resulting in diffuse bleeding internally and externally (bleeding from the mucosal surfaces like nasal passages and/or mouth and gums and even from the eyes [termed conjunctival bleeding]). This uncontrolled bleeding leads to blood and fluid loss and can cause hypotensive shock that causes death in many Ebola-infected patients.

What are risk factors for Ebola hemorrhagic fever?

The risk factors for Ebola hemorrhagic fever are travel to areas with reported Ebola infections (see current CDC travel advisories for African countries). In addition, association with animals (mainly primates in the area with reported Ebola infections) is potentially a health risk factor according to the Centers for Disease Control and Prevention. Another potential source of the virus is eating or handling “bush meat.” Bush meat is the meat of wild animals, including hoofed animals, primates, bats, and rodents. Evidence for any airborne transmission of this virus is lacking. During Ebola hemorrhagic fever outbreaks, health care workers and family members and friends associated with an infected person (human-to-human transfer) are at the highest risk of getting the disease. Researchers who study Ebola hemorrhagic fever viruses are also at risk of developing the disease if a laboratory accident occurs. Caring for infected patients who are near-death or disposing of bodies of individuals that have recently died of Ebola infection is a very high-risk factor because in these situations, the Ebola virus is highly concentrated in any blood or bodily secretions. Caregivers should wear appropriate full-length personal protective equipment (See the CDC site

What types of health care professionals treat Ebola hemorrhagic fever?

Because Ebola infections can spread rapidly to others and because patients can easily infect health care workers, the CDC and other agencies recommend that only highly trained personnel treat Ebola patients. This treatment involves high-level barrier techniques to protect all health care professionals (hospital care workers, nurses, doctors, lab technicians, janitors, and hospital infectious-disease-control personnel). Unfortunately, these trained individuals and resources are often not available in the Ebola high-risk areas. Ideally, individuals diagnosed with Ebola in the U.S. should be treated in specific designated treatment centers and treatment monitored by the CDC. Types of specialists who may treat Ebola-infected patients are emergency medicine specialists, infectious disease specialists, critical care doctors and nurses, pulmonologists, hematologists, hospitalists, and hospital infection-control personnel.

What is the contagious period for the Ebola virus?

For those patients who survive infection, they may remain contagious for approximately 21-42 days after symptoms abate. However, health care professionals can remove the viruses from semen, breast milk, spinal column, and ocular fluids. It is unclear, according to the CDC, if these fluids can transmit viruses, although the CDC suggests that Ebola can be spread by semen and suggest male survivors of the disease abstain from sex or use a condom for all sexual activity.

What is the incubation period for the Ebola virus?

Ebola virus disease symptoms and signs may appear from about 2 to 21 days after exposure (average incubation period is e8 to 10 days). It is unclear why some patients can survive and others die from this disease, but patients who die usually have a poor immune response to the virus. Patients who survive have symptoms that can be severe for a week or two; recovery is often slow (weeks to months) and some survivors have chronic problems such as fatigue and eye problems.

How do health care professionals diagnose Ebola hemorrhagic fever?

Physicians preliminarily diagnose Ebola hemorrhagic fever by clinical suspicion due to association with other individuals with Ebola and with the early symptoms described above. Within a few days after symptoms and signs develop, tests such as ELISA (enzyme-linked immunosorbent assay based on antigen capture), RT-PCR (reverse transcription polymerase chain reaction), and/or virus isolation can provide definitive diagnosis. Later in the disease or if the patient recovers, it’s possible to detect IgM and IgG antibodies against the infecting Ebola strain. Similarly, health care professionals usually perform studies using immunohistochemistry testing, PCR, and virus isolation in deceased patients for epidemiological purposes. 

According to the CDC and others, standard treatment for Ebola hemorrhagic fever is still limited to supportive therapy. Supportive therapy is balancing the patient’s fluid and electrolytes, maintaining their oxygen status and blood pressure, and treating such patients for any complicating infections. Any patients suspected of having Ebola hemorrhagic fever should be isolated, and caregivers should wear protective garments. Currently, there is no specific medical treatment for Ebola hemorrhagic fever according to the CDC. The CDC recommends the following medical treatments for Ebola-infected patients:

  • Providing intravenous fluids (IV) and balancing electrolytes (body salts)
  • Maintaining oxygen status and blood pressure
  • Treating other infections if they occur

Health care professionals transport patients diagnosed with Ebola in the U.S. to special hospitals certified to treat Ebola patients. (Contact the CDC immediately for information for experimental vaccines, treatment protocols, and patient care and/or transfer to an appropriate facility.) The special hospitals were certified because of the problems experienced in a Texas hospital where the first patient in the U.S. was diagnosed with Ebola and subsequently spread the disease to hospital workers. Experimental medical treatments of Ebola infections include immune serum, antiviral drugs, possible blood transfusions, and supportive care in an intensive care hospital facility approved by the CDC to treat Ebola infections.

What are complications of Ebola hemorrhagic fever?

Ebola hemorrhagic fever often has many complications; organ failures, severe bleeding, jaundice, delirium, shock, seizures, coma, and death (about 50%-100% of infected patients). Those patients fortunate enough to survive Ebola hemorrhagic fever still may have complications that may take many months to resolve. Survivors may experience weakness, fatigue, headaches, hair loss, hepatitis, sensory changes, and inflammation of organs (for example, the testicles and the eyes). Some may have Ebola linger in their semen for months and others may have the virus latently infect their eye(s).

Male patients may have detectable Ebola viruses in their semen for as long as six months after they survive the infection. Researchers consider the chance of being infected with Ebola from semen is very low; however, they recommend utilizing condoms for six months; some experts suggest a longer time.

It is apparent that we don’t know everything about how to cure Ebola infections. A physician thought to be cured of Ebola, Dr. Ian Crozier, in fall 2014 developed burning light sensitivity in his eyes. He returned to Emory University where he was treated and after several tests, he was found to have Ebola infection in his eyes. However, only the fluid removed by needle from his eyes showed viable virus; his tears and the outer membrane of his eyes had no detectable virus. Consequently, health care professionals considered the patient not to be able to spread the virus. One of the complications was that his blue eye color turned green. Fortunately, for Dr. Crosier, treatment with steroids and antiviral agents allowed his eyes to return to normal. This unusual circumstance has suggested that follow-up eye exams are likely to be important in patients who survive Ebola infections.

What is the prognosis of Ebola hemorrhagic fever?

The prognosis of Ebola hemorrhagic fever is often poor; the death rate of this disease ranges from 25%-100%, and those who survive may experience the complications listed above. However, early diagnosis and treatment of Ebola may greatly increase the patient’s chance for survival. Unfortunately, this disease has been mainly located in countries where medical care is often difficult to obtain, especially in rural areas of Africa. Statistics available on the ongoing 2014-2016 outbreak of Ebola are summarized below:

  • Total suspected, probable, and confirmed infections worldwide equal 28,616, and total deaths equal 11,310 for a death rate or death toll of approximately 41%. An occasional new infection (at a low level) and deaths of current patients are unlikely to change these numbers substantially as the epidemic outbreak has ended according to the CDC. Fortunately, this epidemic of 2014-2016 did not become a pandemic but did show how rapidly a relatively rare disease like Ebola can rapidly infect a large number of individuals in this modern-day society.

Is it possible to prevent Ebola hemorrhagic fever? Is there an Ebola vaccine?

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The main way to prevent getting Ebola hemorrhagic fever is to not travel to areas where it is endemic and by staying away from any patients who may have the disease. Medical caregivers may protect themselves from infection by strict adherence to barriers to the virus (wearing gloves, gowns, goggles, and a mask). People can disinfect surfaces with alcohol-based (70%) wipes.

The following are the recommendations from the CDC to prevent getting Ebola (EVD) from an infected person. Avoid the following:

  • Contact with blood and body fluids (such as urine, feces, saliva, sweat, vomit, breast milk, semen, and vaginal fluids)
  • Items that may have contacted an infected person’s blood or body fluids (such as clothes, bedding, needles, and medical equipment)
  • Funeral or burial rituals that require handling the body of someone who died from EVD
  • Contact with bats and nonhuman primates or blood, fluids, and raw meat prepared from these animals (bushmeat) or meat from an unknown source
  • Contact with semen from a man who had EVD until you know the virus is gone from the semen

In addition, after leaving an area affected by EVD, individuals should monitor their health for 21 days; if a person develops any symptoms, he or she should immediately seek medical care and inform the medical caregivers of his or her exposure to Ebola.

Fortunately, in December 2016, researchers reported on a human clinical trial of rVSV-ZEBOV vaccine that was apparently effective and relatively safe for vaccination against Ebola disease. The researchers used people (contacts) exposed to Ebola patients during the outbreak in a trial following similar procedures (“ring of exposure”) used to eliminate smallpox. Researchers randomly assigned the Ebola case exposure patient to get the vaccine at day 0 or 21 days later after being identified as a new case exposure. Although many vaccinated people developed side effects of injection-site pain, mild headache, fatigue and muscle pain, most individuals recovered within a few days and none develop long-term problems. The study involved 11,841 people. The vaccine was 100% effective in patients who obtained the vaccine at day 0 and those day 0 individuals who had no symptoms within 10 days (due to the approximate average incubation period of Ebola). There were 23 new cases of Ebola in patients who got the vaccine 21 days later. Three adverse events occurred in the vaccinated population; one had a febrile reaction to the vaccine, one experienced anaphylaxis and one experienced flu or flu-like symptoms but all recovered and remained healthy. Consequently, many investigators consider this vaccine to be a safe and effective vaccine. There is a stockpile of 300,000 doses in reserve for future outbreaks. The vaccine is in limited supply and not licensed by the FDA. Health care professionals use this vaccine in the same way to limit the spread of Ebola in the DRC in the 2018-2019 outbreak. Time will tell if the “ring of exposure” method of vaccination will stop the outbreak.

 

What is the latest research on Ebola hemorrhagic fever?

Although a relatively safe and effective vaccine is now available to clinicians under certain conditions, research goes on. One problem is that the antibody generated against the glycoprotein in the vaccine may only be effective against one strain of Ebola, but not against the other strains. Readers should expect additional vaccines to become available in the not-too-distant future.

Where can people find more information about Ebola?

The following are several references that we update periodically to provide recent information about Ebola viruses and Ebola disease:

  • World Health Organization: http://www.who.int/csr/don/13-may-2017-ebola-drc/en/
  • Centers for Disease Control and Prevention: https://www.cdc.gov/vhf/ebola/index.html
  • Centers for Disease Control and Prevention — 2014-2016 West Africa outbreak: https://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/

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