The 2014 Ebola outbreak was the largest and most deadly in history. The western African countries of Liberia, Sierra Leone, and Guinea were devastated by the spread of the disease and their respective government’s inability to combat the disease. Further, imported cases in the United States and Spain have helped to place Ebola Hemorrhagic Fever on the forefront of popular cultures mind.

Ebola Hemorrhagic Fever (EHF) belongs to one of the only known virus families in which scientists have a severe lack of understanding. The infectious reservoir (the source of the infection) is unknown ¹ . Further, the exact modes of transmission are not always identified and there is no proven cure, vaccine, or treatment for this usually fatal infection. The mortality rates associated with the disease range from 50% to 90% - mortality rates fluctuate based on the specific type of Ebola ¹. In short, health care workers can
only offer palliative care in response to the effects of the Ebola virus and hope that the patient’s immune response becomes sufficient ³.

Ebola is named after a central African river in the Democratic Republic of Congo where it was first identified in 1976 ^{1, 3}. The virus belongs to a family of RNA filoviridae viruses of which there are only two members (Ebola virus and Marburg Virus) ³. Presently, there are five species of the Ebola Virus: Tai Forest, Sudan, Zaire, Reston, and Bundibugyo ^{1, 3, 4}. Interestingly, Ebola-Reston is the only known Filovirus that does not cause a severe disease in humans ⁴. However, the Ebola-Reston virus is still fatal in monkeys and has been found in infected swine in South-east Asia ⁴. 95% of Ebola cases can be linked to two species of Ebola:

• Ebola-Zaire – 80-90% mortality rate ^{1, 3, 4}
  • The 2014 Ebola Outbreak was caused by the Ebola-Zaire species of the virus ⁴.
• Ebola-Sudan – 40-50% mortality rate ^{1, 3, 4}

It is believed that the Ebola virus is zoonotic in nature; meaning that the disease is initially transmitted to humans from ongoing life cycles in animals other than humans ^{1, 4} . Recently, Ebola was identified in African Fruit Bats ¹. Once the Ebola virus has been transmitted to a human, it can then be transmitted from human to human in a variety of ways:

• Transmitted through direct contact with the blood, secretions, organs, or other bodily fluids of infected people ^1-8 .
• Transmitted through indirect contact with the contaminated environment (contaminated bed sheets, clothes, needles, bandages, floors, etc.) ^{6, 7}.
• Transmitted through indirect contact with a contaminated body (such as during burials or funerals) ¹.
• The Ebola virus has been found in deceased animals near the outbreak site (gorillas, monkeys, antelope, porcupine, chimpanzees and fruit bats) ¹. The virus can be spread to humans through the consumption and handling of contaminated game meat ³.
• The Ebola virus was isolated in the semen of a formerly contaminated male 3 months after his full recovery ³. The virus was isolated in the vaginal fluid of a contaminated female 2 months after her recovery ⁹ .
• The virus has been isolated in female breast milk up to one month after patient recovery ⁹. (This has only occurred in one documented case and an exact estimate of when breastfeeding can resume is not currently available ^{8, 9})
• The Ebola Virus is not transmitted through water or air in normal circumstances ⁹.
• The virus has not been found to be transmitted through mosquitos or flies ⁹.

The symptoms can begin to appear anywhere from 2-21 days after exposure: with 8-10 days being the most common ^{7, 8} . The early signs and symptoms of Ebola include ^{1, 7, 8, 9} :

• Fever
• Severe Headache
• Joint and Muscle pain
• Weakness
• Diarrhea
• Vomiting
• Stomach (abdominal) Pain
• Unexplained bleeding (and/or bruising) inside and outside of the body

Symptoms generally appear 8 -10 days after the patient has originally been exposed to the virus 8 . The list of early symptoms are fairly nonspecific and resemble the symptoms of a variety of other diseases that are native to the African region, such as malaria and typhoid fever ⁷ . As such, the disease can be difficult to diagnose early and quarantine the patient – especially in areas without modern medical technology and laboratory testing ¹. Early recognition is crucial for infection control and it is absolutely necessary for health care providers to be alert for and evaluate patients suspected for the Ebola Virus Disease. The CDC has designed the risk factors to include ¹³:

• The symptoms listed above and/or a fever greater than 100.4 Fahrenheit. Symptoms such as headache, vomiting, diarrhea, abdominal pain, and unexplained hemorrhage are early indications ^{12, 13}.

AND

• Epidemiologic risk factors within the past 21 days before the onset of symptoms. This could include contact with the blood or bodily fluids of a known/suspected Ebola patient, living in/traveling to an area with a known Ebola situation (within the last 21 days), or the direct handling of bats, rodents, or primates from a disease endemic area ^{12, 13} .

In short, successful screening methods will include a patient interview in which the patient is asked about their travel history/personal contact information and at the same time their temperature is also taken and their symptoms are recorded ¹³ . In regards to epidemiologic risk factors, the exposure risks can be segmented as High-Risk, Moderate risk, Low (but not no) risk, and no identifiable risk ¹⁸.

• Mucous membrane contact or percutaneous (needle stick for example) with the blood or body fluids from an Ebola patient ^{12, 13, 18} .
• Direct skin contact with, or exposure to blood or body fluids of, an Ebola patient ^{13, 18}.
• Processing blood or body fluids from an Ebola patient without appropriate personal protective equipment (PPE) or biosafety precautions.
• Direct contact with a dead body (funeral rites or burials for example) in a country with wide-spread Ebola transmission without the appropriate PPE ^{2, 13, 18}.

Patients with a high-risk exposure factor and either a fever of 100.4F or any of the above listed symptoms should be immediately isolated, all applicable health departments should be notified, and transport to an appropriate health care facility for Ebola testing should be coordinated ^{12, 13, 18} . Medical evaluation is necessary and should air travel be necessary this should only be performed by qualified air medical transport.

Patients with a high-risk exposure factor but who are asymptomatic (none of the above listed symptoms are present) or who have been tested and do not have Ebola should still be directly monitored (for at least 21 days) and travel and contact with other people should be limited ¹⁸ . Public transport of any time should be avoided and the patient should be monitored in an uninterrupted fashion for the duration of the health order ¹⁸.

• The patient has been in a country with widespread Ebola Virus Transmission and had direct contact, while using the appropriate PPE, with a symptomatic Ebola patient ¹⁸.
• The patient was in close contact (households, health care facilities, community settings, within 3 feet) of a person with Ebola (while the person was symptomatic) for a prolonged period of time ^{12, 18}.

Patients with a moderate-risk exposure factor and either a fever of 100.4F or any of the above listed symptoms should be immediately isolated, all applicable health departments should be notified, and transport to an appropriate health care facility for Ebola testing should be coordinated ¹⁸. Medical evaluation is necessary and should air travel be necessary this should only be performed by qualified air medical transport.

Patients with a moderate-risk exposure factor but who are asymptomatic (none of the above listed symptoms are present) or who have been tested and do not have Ebola should still be directly monitored (for at least 21 days) and travel and contact with other people should be limited ¹⁸ . Public transport of any time should be avoided and the patient should be monitored in an uninterrupted fashion for the duration of the health order.

• Having traveled to a country with a widespread Ebola outbreak within the past 21 days and having no known exposures.
• Brief physical contact (shaking hands, hugging, etc.) while not wearing PPE with a person with Ebola in the early stages of the disease.
• Working within countries that do not have a widespread Ebola virus outbreak and coming into direct contact with a symptomatic Ebola Patient while using the appropriate PPE ¹⁸.
• Traveled on an airplane, bus, or other form of public transportation with a person with Ebola while the person was symptomatic.

Patients with a Low (but not zero) risk exposure factor and either a fever of 100.4F or any of the above listed symptoms should be immediately isolated, all applicable health departments should be notified, and transport to an appropriate health care facility for Ebola testing should be coordinated ^{17, 18} . Medical evaluation is necessary and should air travel be necessary this should only be performed by qualified air medical transport.

Patients with a Low (but not zero) exposure factor but who are asymptomatic (none of the above listed symptoms are present) or who have been tested and do not have Ebola should still be actively monitored (for at least 21 days). Direct, continuous, monitoring is applicable for health care professionals who cared for an Ebola patient and travelers who may have been within 3 feet of a symptomatic Ebola patient.

• Having been in a country with widespread Ebola Virus Transmission more than 21 days previously.
• Having contact with an asymptomatic person who had contact with a person with Ebola ¹⁸.
• Contact with a person with Ebola before the person developed symptoms.
• Having traveled to or lived in a country without a widespread Ebola outbreak and not having any other exposures.

Should any symptoms appear, routine medical evaluation and management of symptoms is on an as needed basis. No actions are needed for an asymptomatic person.

Hospitals should consider developing a process for managing the monitoring of any potentially infected personnel or patients. This would include documented twice daily temperature checks for a duration of 21 days and discussions on potential symptoms ¹⁴.

If a patient is suspected to have the Ebola Virus certain protocols should be implemented as soon as possible:

• The patient must be isolated. This must be a single patient room, with a locking door, and with aprivate bathroom ^{15, 17, 18}.
  • The facility should maintain a log that details everyone who enters the patient’s room ¹⁸.
  • Posting personnel at the patient’s door can help to ensure that anyone entering the room is wearing the appropriate PPE ^{14, 18}.
• Implement standard, contact, and droplet precautions ¹⁸.
• Notify your organization’s infection control program or the pre-determined appropriate staff.
• Evaluate for any risk exposures within the organization for Ebola.
• Immediately report the case to the health department.

For a helpful visual diagram click here to open a handy CDC produced infographic on Ebola screening and
procedure. http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf

Due to the high risk of human-to-human transmission, the high rate of morbidity and mortality of the disease, and the lack of any FDA approved vaccine standard, contact, and droplet precautions must be implemented immediately once an Ebola patient is identified ¹⁸ .

As listed above, the patient must be isolated, in a single patient room, with a door that closes, and a private bathroom. This room should not be carpeted and any blinds or other porous fixtures should be removed ¹⁸. A log should be maintained of all visitors and all visitors must adhere by the personal protective equipment standards ^{14, 18}.

In regards to PPE, all health care providers should be trained and have practiced donning, working with, and doffing the appropriate PPE ⁹. At the most basic level, the goal for the PPE is to not have any skin exposed while working with an Ebola patient ¹⁴. At all times PPE donning, work, and doffing should be monitored by a trained supervisor and should be performed in a separate area that can be easily disinfected ¹⁴. Only health care providers who have demonstrated competency in donning and doffing the full body PPE should be allowed to interact with an Ebola patient. Full body PPE includes:

• Either a PAPR (Powered Air Purifying Respirator) or N95 Respirator. These should be OSHA compliant and fit tested, and the health care worker should be medically evaluated and trained prior to use ¹⁴.
• PAPR’s will include a full face shield, helmet, or headpiece. All reusable helmets or headpieces must be covered in a single-use disposable hood that covers the shoulders and neck and is compatible with the selected PAPR ¹⁴.
  • A designated process and assigned personnel should be in place for ensuring the equipment is correctly decontaminated and that the batteries are fully charged prior to reuse¹⁴. All reusable parts must be decontaminated in accordance with the manufacturer’s guidelines on safe multi-use use ¹⁴.
• If using a N95 Respirator, use a surgical hood extending to the shoulders and a single-use disposable full face shield ¹⁴.
• A single-use disposable fluid resistant or impermeable gown (that extends to at least the health care worker’s mid-calf ¹⁴. Coveralls can be with or without integrated socks.
• Ideally, a gown should have thumb hooks that allow for the sleeves to be secured over the inner gloves ¹⁴. If this is not available, then the sleeve of the gown or coverall can be taped over the inner glove to prevent potential skin exposure. However, current evidence suggests that taping can make the doffing process more difficult, cumbersome, and therefore potentially more risky ¹⁴.
• Single use disposable nitrile examination gloves with extended cuffs. Two pairs should be worn. The outermost glove should have the cuff extended ¹⁴.
• Single use disposable fluid resistant or impermeable boot covers that extend to mid-calf (single use disposable shoe covers can also be used as long as they are in combination with a coverall and integrated socks). These should allow for ease of movement and not present a slip hazard to the health care worker ¹⁴.
• In the event that the patient is vomiting, bleeding, or has diarrhea - an apron (single use, disposable, fluid-resistant, or impermeable) should be used to prevent exposure to any contaminated body fluids ¹⁴. The apron must cover the torso and reach the mid-calf level.

Whenever a health care professional is putting on (donning) PPE this process should be in a designated area and under the supervision of a trained observer ¹⁴. A mirror can be helpful too for self-inspection and the health care professional should be able to comfortably move in a wide range of motions in the PPE.

Also, a designated PPE storage and donning area as well as a PPE removal area should be identified prior to receiving an Ebola patient. These could be adjacent rooms or possibly an anteroom. If a facility must use a hallway outside for the patient’s room, then a physical barrier of some sort could close the hallway to through traffic (thus creating a temporary anteroom). Be careful to check that this new hallway space confirms with local fire-codes. The removal area should contain leak proof containers for the disposal of items and should be cleaned as often as necessary ¹⁴.

In regards to cleaning, the environmental services staff must wear the recommended PPE in order to protect themselves against exposure ¹⁴. All cleaning should use an EPA registered hospital disinfectant with a label claiming that the product is intended for a non-enveloped virus (norovirus, rotavirus, adenovirus, poliovirus, etc.) ¹⁴. The Ebola virus itself is an enveloped virus; however, using a product intended for a much more resistant virus is an added safety precaution. It is important to note that any wastes that are generated during the care of an Ebola virus infected patient should be packaged and transported in accordance to the US DOT hazardous materials regulation (this should be a policy that the hospital organization already has in effect) ¹⁴.

There are several patient care factors that must be taken into consideration when caring for a patient with Ebola. One of the most cost prohibitive factors is that dedicated medical equipment (preferably disposable) should be used for the provision of patient care ¹⁴. Any non-dedicated medical equipment should be cleaned and disinfected according to the manufacturer’s instructions and hospital policies. As such, phlebotomy and laboratory testing can become extremely costly, and should be limited to the minimum amount necessary for essential diagnostic evaluation and medical care. Most state health departments, working in conjunction with the CDC, have identified regional locations for which Ebola testing is to take place.

Also, the use of needles and other sharps should be limited as much as possible. Current PPE technology is not able to effectively prevent a needle stick puncture and this remains a particularly dangerous part of Ebola patient care ¹⁴. Needles and other sharps should be treated with extreme care and disposed of in a puncture-proof and sealed container ¹⁴.

In the event that an aerosol generating procedure must be performed, the absolute minimum necessary amount of health care providers should be in the room and the room should ideally be an Airborne Infection Isolation Room (AIIR) ¹⁴. Aerosol generating procedures include: Bilevel Positive Airway Pressure (BiPAP), bronchoscopy, sputum induction, intubation and extubation, and open suctioning of airways ¹⁴.

Click here for a helpful CDC produced checklist of necessary steps for patients being evaluated with Ebola in the U.S. http://www.cdc.gov/vhf/ebola/pdf/checklist-patients-evaluated-us-evd.pdf

Currently, the treatment options available for Ebola patients are palliative and supportive in nature. They include:

• Checking and treating them for any complicating infections ^{9, 21}.
• Maintaining the patient’s oxygen status and blood pressure.
• Balancing the patient’s fluids and electrolytes.
• There are currently several experimental vaccines in production that have shown promise in animals. However, none are FDA regulated and the testing on humans has only occurred in very extreme cases ¹⁹.

Recovery depends completely on consistent supportive care and the patient’s ability to develop an immune response. It is currently not clear why some individuals are able to develop an immune response while others are not ^{11, 21}. Interestingly, patients who are able to develop an immune response will develop antibodies that will last for at least 10 years. It is currently not clear whether these antibodies will last for life or if the patient is susceptible to another strain of Ebola.

In the event of a patient’s death, only personnel trained in the handling of infectious remains should touch the body while wearing full PPE 2 . The patient’s body is extremely contagious and as such autopsies should be avoided (if one does need to be performed, the CDC should be contacted to perform the autopsy).

The overall risk for a widespread Ebola outbreak in the United States or throughout Western Europe is fairly low, despite the constant media pressure. It is important to understand that the outbreaks in Western Africa have stressed the internal health care systems of those countries tremendously and the environmental differences between US health care facilities and the African Health Care facilities are tremendous and cannot be overstated. Many rural clinics that are on the front lines of Ebola outbreaks do not have a tiled floor for easy cleaning or adequate protective gear for all of the nurses and health care volunteers ¹. Areas often do not have running water, or bleach, and as such disinfection methods are severely limited. Often times the local nurses and physicians in the field are not even receiving continuous pay from the government ¹.

Throughout each of the widespread Ebola outbreaks, nursing pay in these remote areas is often withheld for months and the local nurses and physicians continue to show up to work out of a sense of civic duty and obligation to their patients and communities. Further, local knowledge about infection control methods is severely limited and as such family members may continue to come into close contact with patients until an effective quarantine can be implemented. Local nurses and physicians have historically faced severe stigmatizations from the local community. There are numerous cases of the homes, crops, and property of health care providers being burned down by locals who believe that the health care workers may have the virus ¹.

Considering the points listed above, the difficulties facing African nurses and health care teams is serious. Many African nurses and health care volunteers are truly heroic in their efforts to treat and serve their communities. In an effort to help combat the 2014 Ebola Outbreak many governments donated both financially, and in terms of personnel, to the afflicted nations.

For health care workers working in a country that has not had a severe Ebola outbreak, the screening, treatment, and personal protective guidelines outlined above are capable of preventing the spread of the Ebola Virus and are capable of allowing health care providers to provide safe care to afflicted patients.

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