First Case of Ebola in U.S. 9/30/14

September 30th, 2014

Background

CDC confirmed on September 30, 2014, 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 West Africa (Liberia). The patient did not have symptoms when leaving West Africa, but developed symptoms approximately five days after arriving in the United States.

The person sought medical care at Texas Health Presbyterian Hospital of Dallas after developing symptoms consistent with Ebola. 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 CDC’s Laboratory Response Network. CDC and the Texas Health Department reported the laboratory test results to the medical center to inform the patient. Local public health officials have begun identifying close contacts of the person for further daily monitoring for 21 days after exposure.

The ill person did not exhibit symptoms of Ebola during the flights from West Africa and CDC does not recommend that people on the same commercial airline flights undergo monitoring, as Ebola is only contagious if the person is experiencing active symptoms. The person reported developing symptoms several days after the return flight.

CDC recognizes that even a single case of Ebola diagnosed in the United States raises concerns. Knowing the possibility exists, medical and public health professionals across the country have been preparing to respond. CDC and public health officials in Texas are taking precautions to identify people who have had close personal contact with the ill person and health care professionals have been reminded to use meticulous infection control at all times.

The U.S. public health and medical systems have had prior experience with sporadic cases of diseases such as Ebola. In the past decade, the United States had 5 imported cases of Viral Hemorrhagic Fever (VHF) diseases similar to Ebola (1 Marburg, 4 Lassa). None resulted in any transmission in the United States.

The CDC will be contacting those who were potentially exposed.

Early recognition is critical to controlling the spread of Ebola virus. Health care providers should be alert for and evaluate any patients with symptoms consistent with EVD and potential exposure history. Standard, contact, and droplet precautions should be immediately implemented if EVD is suspected. Guidance for clinicians evaluating patients from EVD outbreak-affected countries is available at http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html.

TAKE A TRAVEL HISTORY WITH FEVER  TAKE A TRAVEL HISTORY WITH FEVER

Health care professionals in the United States should immediately report to their state or local health department any person being evaluated for EVD if the medical evaluation suggests that diagnostic testing may be indicated. If there is a high index of suspicion, US health departments should immediately report any probable cases or persons under investigation (PUI) to CDC’s Emergency Operations Center at 770-488-7100.

Public Health Terminology for Control of Transmission

Conditional release

Conditional release means that people are monitored by a public health authority for 21 days after the last known potential Ebola virus exposure to ensure that immediate actions are taken if they develop symptoms consistent with EVD during this period. People conditionally released should self-monitor for fever twice daily and notify the public health authority if they develop fever or other symptoms.

Controlled movement

Controlled movement requires people to notify the public health authority about their intended travel for 21 days after their last known potential Ebola virus exposure. These individuals should not travel by commercial conveyances (e.g. airplane, ship, long-distance bus, or train). Local use of public transportation (e.g. taxi, bus) by asymptomatic individuals should be discussed with the public health authority. If travel is approved, the exposed person must have timely access to appropriate medical care if symptoms develop during travel. Approved long-distance travel should be by chartered flight or private vehicle; if local public transportation is used, the individual must be able to exit quickly.

Quarantine

Quarantine is used to separate and restrict the movement of persons exposed to a communicable disease who don’t have symptoms of the disease for the purpose of monitoring.

Self-monitoring

Self-monitoring means that people check their own temperature twice daily and monitor themselves for other symptoms.

Ebola Facts

Transmission

Ebola is spread through direct contact (through broken skin or mucous membranes) with:

  • blood or body fluids (including but not limited to urine, saliva, feces, vomit, and semen) of a person who is sick with Ebola
  • objects (like needles and syringes) that have been contaminated with the virus
  • infected animals

Ebola is not spread through the air or by water, or in general, food. However, in Africa, Ebola may be spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats.

Healthcare providers caring for Ebola patients and the family and friends in close contact with Ebola patients are at the highest risk of getting sick because they may come in contact with infected blood or body fluids of sick patients.

Signs and Symptoms

Symptoms of Ebola include

  • Fever (greater than 38.6°C or 101.5°F)
  • Severe headache
  • Muscle pain
  • Weakness
  • Diarrhea
  • Vomiting
  • Abdominal (stomach) pain
  • Unexplained hemorrhage (bleeding or bruising)

Incubation Period

Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days.

Clinical Course

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.

Diagnosis

Ebola virus is detected in blood only after the onset of symptoms, usually fever. It may take up to 3 days after symptoms appear for the virus to reach detectable levels. Virus is generally detectable by real-time RT-PCR from 3-10 days after symptoms appear.

Ideally, specimens should be taken when a symptomatic patient reports to a healthcare facility and is suspected of having an Ebola exposure. However, if the onset of symptoms is <3 days, a later specimen may be needed to completely rule-out Ebola virus, if the first specimen tests negative.

CDC cannot accept any specimens without prior consultation.

Treatment

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.

 

Infection Control

Standard, contact, and droplet precautions are recommended for management of hospitalized patients with known or suspected Ebola hemorrhagic fever (Ebola HF), also referred to as Ebola Viral Disease (EVD) (See Table below). Note that this guidance outlines only those measures that are specific for Ebola HF; additional infection control measures might be warranted if an Ebola HF patient has other conditions or illnesses for which other measures are indicated (e.g., tuberculosis, multi-drug resistant organisms, etc.).

In this guidance healthcare personnel (HCP) refers all persons, paid and unpaid, working in healthcare settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or aerosols generated during certain medical procedures. HCP include, but are not limited to, physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual personnel, home healthcare personnel, and persons not directly involved in patient care (e.g., clerical, dietary, house-keeping, laundry, security, maintenance, billing, chaplains, and volunteers) but potentially exposed to infectious agents that can be transmitted to and from HCP and patients. This guidance is not intended to apply to persons outside of healthcare settings.

Full recommendations: http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html  

Evaluation Algorithm

Exposure Level Clinical Criteria Public Health Actions
High Risk
Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of EVD patient Fever OR other symptoms consistent with EVD without fever Consideration as a probable case
Direct skin contact with, or exposure to blood or body fluids of, an EVD patient without appropriate personal protective equipment (PPE) Medical evaluation using infection control precautions for suspected Ebola, consultation with public health authorities, and testing if indicated
Processing blood or body fluids of a confirmed EVD patient without appropriate PPE or standard biosafety precautions If air transport is clinically appropriate and indicated, only air medical transport (no travel on commercial conveyances permitted)
Direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is occurring
Asymptomatic If infection control precautions are determined not to be indicated: conditional release and controlled movement until 21 days after last known potential exposure
Some Risk of Exposure
Household contact with an EVD patient
Other close contact with an EVD patient in health care facilities or community settings
Fever with or without other symptoms consistent with EVD Consideration as a probable case
Medical evaluation using infection control precautions for suspected Ebola, consultation with public health authorities, and testing if indicated
If air transport is clinically appropriate and indicated, only air medical transport (no travel on commercial conveyances permitted)
Asymptomatic or clinical criteria not met If infection control precautions are determined not to be indicated: conditional release and controlled movement until 21 days after last known potential exposure
No Known Exposure
Having been in a country in which an EVD outbreak occurred within the past 21 days and having had no exposures
Fever with other symptoms consistent with EVD Consideration as a person under investigation (PUI)
Medical evaluation and optional consultation with public health authorities to determine if movement restrictions and infection control precautions(http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html) are indicated
If movement restrictions and infection control precautions are determined not to be indicated: travel by commercial conveyance is allowed; self-monitor until 21 days after leaving country
Asymptomatic or clinical criteria not met No movement restrictions
Travel by commercial conveyance allowed
Self-monitor until 21 days after leaving country

 Case Definition for Ebola Virus Disease (EVD)

Person under Investigation (PUI)

A person who has both consistent symptoms and risk factors as follows:

1.Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND

2.Epidemiologic risk factors within the past 21 days before the onset of symptoms, such as contact with blood or other body fluids or human remains of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active*; or direct handling of bats or non-human primates from disease-endemic areas.

Probable Case

A PUI whose epidemiologic risk factors include high or low risk exposure(s) (see below)

Confirmed Case

A case with laboratory-confirmed diagnostic evidence of Ebola virus infection

Exposure Risk Levels:  Levels of exposure risk are defined as follows:

High risk exposures:  A high risk exposure includes any of the following:

  • Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of EVD patient
  • Direct skin contact with, or exposure to blood or body fluids of, an EVD patient without appropriate personal protective equipment (PPE)
  • Processing blood or body fluids of a confirmed EVD patient without appropriate PPE or standard biosafety precautions
  • Direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is occurring*

Low risk exposures:  A low risk exposure includes any of the following

  • Household contact with an EVD patient
  • Brief interactions, such as walking by a person or moving through a hospital, do not constitute close contact
  • Other close contact with EVD patients in health care facilities or community settings. Close contact is defined as
  • being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or care area for a prolonged period of time (e.g., health care personnel, household members) while not wearing recommended personal protective equipment (i.e., standard, droplet, and contact precautions; see Infection Prevention and Control Recommendations)
  • having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended personal protective equipment.

No known exposure

Having been in a country in which an EVD outbreak occurred within the past 21 days and having had no high or low risk exposures

I know this is a lot of info but hope it helps

Questions call Deb McMahan, MD