For more than thirty years Ebola has been feared as a potentially cataclysmic epidemic. “The Hot Zone” and other sensational books and movies have promoted this fear. Today we finally have an Ebola epidemic and it has has now reached crisis proportions in West Africa. This article explains Ebola from the nurse’s perspective. Positioned on the front lines of medicine, nurses will likely be the first to correctly assess Ebola cases.
The Ebola Virus
Ebola belongs to the obscure Filoviridae Family and includes both the Marburg and Ebola filoviruses. The Ebola virus is simple in design and has only about a dozen genes. It has a filamentous form and can also appear in various shapes that include “U”, “6”, as well as branched filaments. Individual virus filaments can measure up to 14 micrometers in length. In humans, the virus causes Ebola Virus Disease (EVD) also known as Ebola Hemorrhagic Fever (EHF). Five species of Ebola are known so far: Tai Forest (TAFV), Zaire (EBOV), Sudan (SUDV), Bundibugyo (BDBV), and one of apparently Asian origin – Ebola Reston (RESTV).
Filoviridae virus particles are environmentally stable. Research indicate that both Ebola and Marburg are stable in small particle aerosols. Aerial transmission is a possibility.
Suppression of the immunological system is severe and damage to spleen and lymph nodes are notable. Fatal cases have necrotic lesions and extensive bleeding from tissues and organs throughout the body. The virus attacks the vascular system. Both kidney and liver failure are likely outcomes. Once patients are symptomatic viral particles are found throughout the body including the skin.
Recovering survivors generate significant levels of antibodies for Ebola and are immune to further infection. This immunity is believed to last at least ten years.
Understanding the geography of Ebola is important. The current outbreak likely began in Guinea and has spread to neighboring Sierra Leone, Liberia, Senegal and even to more distant Nigeria and Mali. Past known Ebola outbreaks have occurred throughout West Africa including Zaire, Sudan (1979), Republic of the Congo (1977), Uganda, South Africa, and in Reston Virginia (1992 and again in 1996). The Reston outbreaks were vectored by infected research monkeys shipped into the U.S. from the Philippines. The South African outbreak was also “imported” by a traveler who may have actually been exposed in Zimbabwe.
The geography of Ebola is also represented by the following alphabetical list of countries where infection has occurred. Highlighted countries are in the current 2014 West African outbreak.
- Congo (Republic of Congo)
- Ivory Coast (Cote d’Ivorie)
- Sierra Leone
What this distribution clearly illustrates is that modern societies are interconnected by many modes of travel, and contagious persons can quickly cross nations and international borders. This means that new cases and clusters can appear in unexpected places. This happened in Dallas, Texas (2014).
Discovery of Ebola antibodies in local populations now indicates that the disease is more common than previously appreciated. In Gabon 15% of the local population has tested positive for Ebola antibodies. This may indicate that some people are exposed to the virus without suffering serious illness.
The first western outbreak of a filovirus occurred in 1967, in Marburg Germany. A total of 31 human cases resulted from contact with African green monkeys used for research. The resulting human mortality rate from the Marburg Virus was 23%. Reported virulence of Ebola in Africa has ranged from 100% to 50%.
Filovarae are zoonotic and known vectors include humans, monkeys, apes, other primates, Fruit and Rousettus bats, and pigs (recently detected in southeast Asia). Medical personnel who treat Ebola patients or work in emergency rooms, ambulance and first-response personnel, and their family members are also highly susceptible.
Inorganic vectors include physical contact with contaminated hospital equipment, bedding, cleaning materials, patient care products, needles and other sharp objects, as well as objects handled and surfaces contacted by the infected patient or contaminated by the patient’s bodily fluids.
Patients become symptomatic within 2 to 21 days of exposure and commonly within 8-10 days. Patients will present with fever (>38.3C / >100.9F).
The disease initially presents with flu-like symptoms that include malaise, confusion, fever, headaches, abdominal pain, miscarriages, watery eyes, diarrhea, and even hiccups have been reported. At this point, Ebola is infectious for another 14-21 days. Afterwards, the body can continue shedding viral particles but this recovery phase is reportedly not believed to be infectious. However, seminal fluid can remain infectious for 3 months after recovery (no sex for three months).
As the infection advances effects can include cytosis, prevalence of cytokines in the blood, necrosis of organs, rupturing of endothelial cells lining the body’s vascular network, severe kidney and liver damage, and damage to the eyes caused by ruptured capillaries. Bruising, bleeding from bodily orifices, bloody stools, and bloody diarrhea are symptomatic of late stage infection.
The human immunological system is overwhelmed. Severe headaches, severe abdominal pain, diarrhea, swollen lymph nodes, bodily rashes, watery eyes, and mucosal discharges from bodily orifices are symptomatic.
Death occurs from septic shock, loss of blood, vascular and cardiac complications, kidney and liver failure, and complications from severe dehydration.
Recommended lab diagnostics include the antigen-capture Enzyme-Linked ImmunoSorbent Assay (ELISA) and IgM ELISA; Polymerase Chain Reaction (PCR); and, microscopy to visually identify the virus. Testing should be limited as the presence of any patient samples increases the risk of virus transmission and infection. However, symptomatic patients should be tested at least daily. Patients in early stages of infection have sometimes tested false-negative. Again, daily testing should be performed on symptomatic patients.
Malarial infections present in a similar manner during the early infectious stage. Other tropical diseases including – but not limited to – Chikungunya, Yellow Fever, Typhoid, Cholera, and Dengue may also present symptoms similar to early stage Ebola infections.
Diagnosis should include a clear understanding of the patient’s recent travel history in known Ebola regions (see occurrence section above) and possible contact with known Ebola vectors. Other indications may include any bloody bodily fluid discharges or bloody stools.
Symptomatic patients are highly contagious. Effective isolation is absolutely required. Nursing must be delivered through isolation barriers by staff wearing full body personal protection equipment (PPE). No portion of the body can be exposed. Mucosal lined passages of the mouth and nose should be properly protected by appropriate masking in accordance with the hospital’s protection management standards for highly infectious diseases.
Isolation wards must be routinely disinfected and protective materials replaced. Resulting waste is a biological hazard and should be disposed of by high temperature incineration into ash, or by carefully following hospital approved autoclave procedures for highly infectious diseases.
Contact with their bodily fluids can transmit Ebola. Bodily fluids include blood, plasma, perspiration, saliva, sputum, breast milk, tears, feces, seminal fluid, and vaginal discharges. Coughing and even talking could present infection risks from sputum aerosols. Especially vulnerable entry points would include the eyes and surrounding tissue, mouth and nostrils, and exposed cuts or abrasions on the skin. Full body covering including full-face protective masks are absolutely required. All personal protection equipment (PPE) should be disposable and discarded after single use. Reuse of PPE increases the possibility of accidental infection.
Aggressive rehydration is recommended by Dr. Adaora Igonoh who is a physician practicing in Nigeria. As an Ebola survivor Dr. Igonoh drank daily at least 5 liters (1.3 gallons) of water fortified with saline and glucose. Her illness had already progressed to mouth sores, sore throat, vomiting and malaise when she began aggressively rehydrating. Maintaining electrolyte balance is also important.
Oxygen should be administered throughout the treatment phase.
Anti-inflammatory drugs must be avoided as these suppress an already over-taxed immune system.
Avoid Aerosol Generating Procedures (AGP) and any contact with aerosols as sputum aerosols may transmit the virus.
The US CDC (Centers for Disease Control) recommends only using EPA registered hospital-grade disinfectants specifically approved for non-enveloped viruses. These would specifically include disinfectants approved for adenovirus, norovirus, polio, and rotavirus.
For field disinfection CDC recommends strong solutions of 0.5% (5000 ppm) hypochlorite (bleach), and a skin-safe 0.05% (500 ppm) solution for hand washing and cleaning of chlorine-sensitive tools and equipment. Hospital-grade alcohol-based disinfectants are also recommended.
A number of new anti-viral medicines are appearing and the status of these changes frequently. Guidance should be sought daily to best understand the current outcomes for these experimental drugs.
Survivors generate antibodies for at least 10 years and during this time are not likely to become reinfected. It is not yet known if this immunity lasts for life. It is not known if acquired immunity for one filovirus species will extend to others. So reinfection could happen if the survivor is infected with a different filovirus species.
Long term complications from the disease include joint pain, vision complications, vascular, kidney and liver problems.
Survivors should abstain from sex and any form of intimate contact that includes exchange of bodily fluids for at least 3 months after clinical discharge.
CDC Guidance Help Line: 1-800-CDC-INFO (1-800-232-4636)
EPA-registered disinfectant lists: http://www.epa.gov/oppad001/chemregindex.htm/
- Detain and Isolate the symptomatic patient.
- Don appropriate full-body PPE. Use disposable PPE and discard after single use.
- Notify Hospital Staff and Management
- Ensure that the County Health Department is also notified
- Notify the State Health Department and CDC
- Isolate Patient in a Contained Environment suitable for highly infectious diseases.
- The room should include an attached/dedicated bathroom.
- The isolation room should also have a door, air micro-filtration, and a pressure differential that prevents air from leaking out of the room and into adjacent hospital work spaces.
- Clearly mark the outside of the door as RESTRICTED ACCESS.
- Post a guard to control access to the patient, using the access list.
- Limit staff and restrict visitors to minimize exposure.
- Maintain an access list.
- Identify and list all persons who have had recent physical contact with the patient.
- Immediately remove all soiled bedding and other material
- Clearly label and carefully handle waste as a bio-hazard
- Avoid Aerosol Generating Procedures (AGP)
- Administer aggressive rehydration and monitor electrolytes
- Administer oxygen
- Treat secondary infections
- Minimize lab testing to reduce transmission risk
- Perform ELISA and PCR testing to confirm filovirus. Retest at least daily to ensure negative tests are not false-negative.
- Avoid anti-inflammatory drugs as these may suppress patient’s immune system