Ebola in the United States: Education, Training, and Interventions

Mary Beth Nierengarten

doi:10.1177/155989771446001

Summary

Closing the gaps in education and training can ease anxiety about Ebola virus disease (EVD) and help health care workers be more comfortable and better prepared when faced with a patient suspected to have the disease. This article discusses prehospital evaluation and management of patients with serious communicable disease, as well as information on the pathogenesis of EVD.

Environmental & Wilderness Medicine
Viral Infections Critical Care

Environmental & Wilderness Medicine
Viral Infections
Emergency Medicine
Critical Care

In a session devoted to EVD, Alexander Isakov, MD, MPH, Emory University School of Medicine, Atlanta, Georgia, USA, focused on prehospital evaluation and management of patients with serious communicable disease. David C. Pigott, MD, University of Alabama at Birmingham, Birmingham, Alabama, USA, provided up-to-date information on the pathogenesis of EVD.

Dr Isakov focused on the need for health care workers to understand and implement strict infectious control measures to screen, identify, and manage patients with EVD, emphasizing the following key points when dealing with individuals who have returned from one of the affected West African countries:

Asymptomatic patients are not contagious
Risk of transmission increases with the severity of illness
Infection control revolves around preventing exposure to blood and infectious bodily fluid
Personal protective equipment (PPE) should reflect the condition of the patient and operating environment
Special supervision is advised when during decontamination and disinfection procedures and when health care workers doff PPE.

Dr Pigott explained that the Ebola virus typically enters the host through a break in the skin or via mucous membranes. The virus spreads through the lymphatic system to regional lymph nodes, liver, and spleen, infecting and replicating in a variety of cells and causing cytotoxic tissue damage, endothelial injury, increased vascular permeability, and loss of vascular tone [Toner E et al. Disaster Med Public Health Prep. 2014].

Although EVD is very infectious and requires only a few particles (estimates as low as 1–10 virions) to cause infection, Dr Pigott emphasized that transmission requires direct contact with infected body fluids. Vomit, feces, and blood are most infectious, whereas other fluids, such as sweat and saliva, carry lower risk of transmission. Patients with more advanced disease are more highly viremic, and their body fluids contain higher levels of virus. There is risk of transmission via contact with contaminated surfaces. In Dr Pigott's opinion, speculation that EVD could mutate to an airborne form is unsubstantiated. Table 1 lists the risk level by type of exposure to infected patient.

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Table 1.

Risk Level by Type of Exposure to Infected Patient

To educate and train health care workers on EVD, Dr Isakov drew on the experiences and evolving policies developed more than 10 years ago at Emory University Hospital's Serious Communicable Disease Unit. A joint venture between Emory University Hospital and the Centers for Disease Control and Prevention (CDC), this unit is one of the 4 health care facilities identified in the United States that had special provisions in place to care for patients with serious communicable diseases, like Ebola.

Dr Isakov reviewed the algorithm provided by the CDC to screen suspected EVD patients with at the point of entry [Identify, Isolate, Inform: Emergency Department Evaluation and Management of Patients With Possible Ebola Virus Disease. CDC. 2014].

Establishing exposure history is the critical first step that informs the rest of the screening. If a patient has traveled in the previous 3 weeks to one of the 3 West African countries with epidemic EVD (Guinea, Liberia, and Sierra Leone) and has signs or symptoms of illness (fever, severe headache, muscle pain, weakness, fatigue, diarrhea, vomiting, abdominal pain, unexplained hemorrhage), he or she is put in a private room.

Dr Isakov also emphasized the importance of the CDC's recommendation to stratify patients based on their degree of signs and symptoms. For example, when caring for patients with copious diarrhea and vomiting, health care workers need more protection than for patients presenting simply with fever.

PROTECTING HEALTH CARE WORKERS FROM EXPOSURE

Health care workers should avoid contact with any of the patient's vomit or diarrhea or other bodily fluids, which requires adequate PPE. It is critical for health care workers caring for patients to receive training on the proper way to don and doff PPE, whether managing a patient in-hospital or transporting them via ambulance or other forms of transport.

For patients who arrive in ambulances or other forms of transport, decontamination and disinfection of the ambulance or transport are also necessary. Procedures also implemented to facilitate vehicle disinfection include isolating the driver compartment from the patient compartment, and protecting the patient compartment environmental surfaces with impervious barrier drapes.

For all of these measures, Dr Isakov emphasized the need for supervision of the process to ensure no lapse in procedure that could inadvertently expose a health care worker to infectious fluids [Isakov et al. Ann Intern Med. 2014].

Currently, the only established treatment for EVD is supportive care: symptom control, hydration, electrolyte repletion. However, Dr Pigott provided a brief overview of investigational treatment options for EVD and the evidence to date (Table 2).

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Table 2.

Experimental Interventions for EVD

Dr Pigott concluded by highlighting the CDC's 3 major strategies to address the current EVD outbreak: prevention (reducing disease outbreaks), detection (identifying cases and contacts), and response (establishing training and treatment centers) [N Engl J Med. 2014].

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