Ebola in Dallas – information for the residents

You have all heard, by now, about the first case of Ebola diagnosed within the United States at Presbyterian Hospital here in Dallas. In order to respond to this event, it is important to understand the ramifications of this diagnosis and its potential implications.

Background (from the CDC):

The Centers for Disease Control and Prevention confirmed today, through laboratory tests, the first case of Ebola to be diagnosed in the United States in a person who had traveled to Dallas, Texas from Liberia. The patient did not have symptoms when leaving West Africa, but developed symptoms approximately four days after arriving in the U.S. on Sept. 20.

The person fell ill on Sept. 24 and sought medical care at Texas Health Presbyterian Hospital of Dallas on Sept. 26. After developing symptoms consistent with Ebola, he was admitted to hospital on Sept. 28. Based on the person’s travel history and symptoms, CDC recommended testing for Ebola. The medical facility isolated the patient and sent specimens for testing at CDC and at a Texas lab participating in the CDC’s Laboratory Response Network. CDC and the Texas Health Department reported the laboratory test results to the medical center to inform the patient. A CDC team is being dispatched to Dallas to assist with the investigation.

Clinical Impact: To expand our understanding of the topic, Dr. Jade Le presented an excellent lecture on Ebola last month. She also notes that we, as healthcare providers, should maintain suspicion for Ebola when evaluating any patient who has been to Liberia, Sierra Leone, Guinea, DRC, or Nigeria within the past 21 days who has symptoms (usually including fever > 101.5F plus other symptoms such as diarrhea, vomiting, rash, HA, myalgias, easy bleeding).  Her talk is summarized below:

  • Incubation Period for EVD
    • 8-10 days (ranges 2-21 days)
    • 6 days with percutaneous exposure
    • 10 days with body fluid exposure
  • Transmission: 
    • EVD Infectious Fluids: blood, urine, saliva, sweat, vomit, feces, tears, breast mild, and semen (up to 3 months)
    • Person-person, NOT airborne
    • Ebola Transmission

 


 

  • EVD Risk Factors
    • Epidemiologic Risk Factors (within past 21 days)
      • Residence in or travel to area where EVD transmission active
      • Contact with blood/other body fluids or human remains of patient known/suspected to have EVD
      • Direct handling of bats/rodents/primates from disease-endemic areas
    • High Risk
      • Percutaneous
      • Mucous membrane (body fluids)
      • Direct care/exposure to body fluids of EVD patient without appropriate PPE
      • Participation in funeral rites without PPE
    • Low Risk
      • Household member or other close contact with EVD patient
      • Patient care/close contact in healthcare facilities in EVD outbreak-affected countries
      • Hunting/processing/consuming infected bushmeat
    • No Risk: Persons who had residence in (or travel to) Guinea, Sierra Leone, Liberia, Nigeria (Lagos) or Democratic Republic of Congo in past 21 days WITHOUT high- or low-risk exposures
  • What is Close Contact with EVD?
    • Being within 3 feet or within room/care area for prolonged period of time without PPE
    • Having direct brief contact (shaking hands) with EVD case without PPE
    • Walking by a person or moving through a hospital DO NOT constitute casual contact
  • Signs and Symptoms
    • Typical: Fever > 38.6°C or >101.5°F, severe HA, myalgias, weakness, diarrhea, vomiting, abdominal pain, anorexia, unexplained bleeding (petechiae, ecchymosis, oozing, mucosal hemorrhage).
    • Other: Rash (25-52%), red eye, cough, sore throat, chest pain, SOB, hiccups, dysphagia
  • Prognosis: If alive on day 14 –> 75% chance of survival (Kortepeter M G et al. J Infect Dis. 2011;204:S810-S816)
  • WHAT TO DO AT UTSW/PMH if you Suspect EVD:
    • Page infection prevention and call Dallas County Health and Human Services
    • Page Lab-on-call BEFORE obtaining any specimens
    • Page ID Consult
  • Clinical Presentation
    • Ebola Clinical course

 
 
 

  •  Work-up of a Patient with Suspected EVD:
    • General Labs: CBC, CMP, PT/PTT/INR, Urinalysis, Malaria smear, Blood cultures (NOT viral cultures)
    • Expected abnormalities:
      • Thrombocytopenia (< 150,000 cells/μL)
      • Leukopenia  –> leukocytosis (2° bacterial)
      • Elevated transaminases
      • Hypoglycemia (day 3-8)
      • Hypocalcemia (< 6mg/dL assoc with fatal illness)
      • Acute renal failure (fatal)
      • DIC (prolonged PT/PTT, elevated D-dimer)
    • EVD-specific testing:
      • Detectable virus by day 3 after symptoms start
      • Maximal detection at days 3-10
      • Call Infection Prevention and Lab-on-call (BEFORE PIV or LAB DRAW!)
      • Ebola Tests

 
 
 

  • Steps to Prevent Transmission of EVD
    • Isolate the patient (standard contact and droplet)
    • Wear appropriate PPE:
      • Consider: double glove, disposable shoe covers, leg coverings
      • Why not the Hazmat suits???: “Exceeding these recommendations may paradoxically increase risk. Introducing new and unfamiliar forms of personal protective equipment could lead to self-contamination during removal of such gear.(Ann Intern Med. Published online 21 August 2014 doi:10.7326/M14-1918)
    • Restrict visitors
    • Avoid aerosol-generating procedures
    • Limit use of needles/sharps, and unnecessary tests/procedures
    • Implement environmental infection control measures
    • PPE

 
 
 
 
 
 

  • Treatment (from the CDC): No specific vaccine or medicine (e.g., antiviral drug) has been proven to be effective against Ebola.
    • Symptoms of Ebola are treated as they appear. The following basic interventions, when used early, can significantly improve the chances of survival:
      • Providing intravenous fluids (IV)and balancing electrolytes (body salts)
      • Maintaining oxygen status and blood pressure
      • Treating other infections if they occur
    • Some experimental treatments developed for Ebola have been tested and proven effective in animals but have not yet been tested in randomized trials in humans.
    • Recovery from Ebola depends on the patient’s immune response. People who recover from Ebola infection develop antibodies that last for at least 10 years, possibly longer.

For more information, visit the CDC’s guidelines on Safe Management of Ebola Virus DIsease in U.S. Hospitals, Graphic Information for Patients, or see the DCHHS Algorithm Testing and Monitoring of Patients with Suspected Ebola Virus Disease (EVD) in Dallas County.