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An Ebola epidemic is currently underway in equatorial West Africa. Viral outbreaks have occurred sporadically in Africa, but this one is different. It is the first time that the disease has occurred outside of Africa and now for the first time there has been actual transmission of the disease outside the African continent. Clearly, the world is watching to see what happens next and how well our governments and healthcare systems respond to contain this potentially fatal threat.
Ebola is a rare and potentially deadly viral illness caused by one of four Ebola virus strains. It is one of a family of viral diseases referred to as Viral Hemorrhagic Fevers or VHF. VHF is not new to the continent of Africa. Marburg Fever – another VHF, was diagnosed in Africa in 1967 and found to be transmitted by an indigenous bat species. Ebola was first diagnosed in Zaire (now the Democratic Republic of the Congo) in 1976 and was named for the Ebola River in the region where the virus first arose. The natural reservoir host for this virus remains unknown. However, based on evidence and the nature of similar viruses, researchers believe that the virus is animal borne and that bats native to the area where the virus is present are the most likely reservoir. The disease typically affects multiple organs in the body and is often accompanied, particularly in latter stages, by hemorrhage (bleeding).
Dr. John LaPook, CBS Medical Correspondent appearing on Face the Nation addressed the question of what happens if someone sneezes in your face?
“Well, first off – when was the last time that happened? If so, was it a potential case?”
There have been multiple outbreaks since Ebola was first diagnosed, all well contained in the West African region. One laboratory worker died in Russia from a laboratory contamination incident in 1996. The current outbreak is the largest of these outbreaks, with a case count of about 7,500 as of Oct. 3, 2014. One thing makes this disease different is its high fatality rate. This outbreak is also unique in that it has resulted in the first diagnosed case of Ebola within the U.S., in a traveler arriving in Dallas, Texas from West Africa. It has also resulted in the first transmission of Ebola outside of Africa, occurring in a Madrid Emergency Room nurse who had treated an infected patient.
Transmission of Ebola
When an Ebola infection occurs, the virus can be spread to others in several ways. Ebola is spread through direct contact (through broken skin or mucous membranes in the eyes, nose, or mouth) with:
- Blood or body fluids 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, by food. However, in Africa, Ebola may be spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats.
There is no evidence that mosquitos or other insects can transmit Ebola virus. Only mammals (e.g. humans, bats, monkeys, and apes) have shown the ability to become infected with and spread the Ebola virus. Current scientific opinion is that the disease is not spread unless the infected person is exhibiting symptoms. Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days. Symptoms of Ebola include:
- Fever (greater than 38.6°C or 101.5°F)
- Severe headache
- Muscle pain
- Abdominal (stomach) pain
- Unexplained hemorrhage (bleeding or bruising), typically a late symptom
Risks of Infection
Currently it is believed that the only path of transmission for Ebola is direct contact with infected body fluids, as the disease does not follow the airborne transmission pattern typical with influenza. Dr. Anthony Fauci, Director of the National Allergy and Infectious Disease Branch of NIH stated that “our experience with this disease since 1976 provides no information that Ebola is transmitted other than by direct contact with blood and body fluids.” Persons at heightened risk of Ebola include those who live with or care for a patient, those involved in the preparation of an infected body for burial, and healthcare workers treating infected or symptomatic patients.
All scientific evidence points to the fact that the likelihood of contracting Ebola is extremely remote, unless there has been direct contact with blood or body fluids of a symptomatic and infected person. Dr. Fauci stated that the current worries about an outbreak of Ebola in the U.S. are unfounded. If you begin to experience flu-like symptoms in Boston or San Francisco, where no index cases have occurred, and you have no other travel risk factors, the probability that your symptoms are the result of Ebola are practically nonexistent.
Dr. John LaPook, CBS Medical Correspondent appearing on Face the Nation October 5th, addressed the question of what happens if someone sneezes in your face? “Well, first off – when was the last time that happened? If so, was it a potential case?” If fluid droplets were to get into the eyes, nose or mouth from an infected person’s sneeze, transmission might occur, but coughing and sneezing is not a typical Ebola symptom as this is not a respiratory virus. According to Dr. LaPook, exposure from just being in the same room or same airplane with an infected person, based on the evidence to date, is just not possible, without direct contact with body fluids.
One of the best prevention actions everyone can take, especially travelers, is to get an annual flu vaccination, preventing potential confusion and alarm over any flu-like symptoms that might occur without the vaccine.
What is unique about this outbreak is that it has resulted in the first cases of Ebola in the U.S. The first were aid workers who developed disease in West Africa and were returned to U.S. facilities for treatment. The first case to be diagnosed on U.S. soil, occurred in a person who had traveled to Dallas, Texas from West Africa. The patient did not have symptoms when leaving West Africa, but developed symptoms approximately five days after arriving in the United States. Later information revealed that he was apparently untruthful regarding contact with suspected cases on his exit declaration, prior to departure. That Dallas traveler has now died.
This outbreak has also resulted in the first transmission of the disease outside of Africa. It was reported on October 6th that a nurse in Madrid, Spain who had treated a Missionary repatriated from Sierra Leone for treatment has tested positive for Ebola. Her contacts have now been isolated and are under quarantine. The missionary died September 24th.
Governments are stepping up their surveillance and communication programs. Healthcare facilities are revisiting and strengthening their plans. But is it enough?
Several prominent missteps occurred in both the Dallas and Madrid cases. The most public case occurred in Dallas where the patient was initially sent home with antibiotics, due to miscommunication and failure to comply with the Institution’s infectious disease protocol. The case in Spain was also blamed on a protocol failure; this time on the lack of availability and improper use of protective equipment.
These early missteps have focused a laser-like attention on the issues of Pandemic preparation. Governments are stepping up their surveillance and communication programs. Healthcare facilities are revisiting and strengthening their plans. But is it enough?
President Obama said on Oct 6th that the U.S. government would increase passenger screenings in the United States and Africa to detect the Ebola virus, even as he resisted calls to impose a ban on those traveling from the three countries most affected by the outbreak. Neither the President nor White House officials elaborated on exactly what those new screenings would entail. At the moment, passengers leaving the three nations most affected by the virus — Liberia, Guinea and Sierra Leone — are screened for symptoms at the airport before departing. A federal official familiar with the discussions, who spoke on the condition of anonymity because plans have not been finalized, indicated that new screening possibilities being considered by the administration include taking the temperature of travelers from affected countries upon their arrival at major U.S. airports and more-closely tracking travel histories for international travelers arriving in the United States.
The Dallas case, and the potential issues raised by the events leading up to the diagnosis, have generated intense debate regarding national strategy, resulting in some government officials calling for bans on all flights or passport holders from affected countries. Infection Control 101 instructs us to identify and isolate. Already other African countries, and even some in Europe and the Middle East, have banned travelers from affected countries. Suspending travel to the U.S. of persons from countries where the outbreak is occurring is a possible strategy. Announcing the ban and denying boarding to travelers holding passports from the affected region could be implemented quickly and might provide time for US agencies to gauge the needed response to this new threat. Detractors say a ban like this would limit support and aid to the affected countries. Clearly, charter and military flights could fill this void, even while providing better security to those providing aid. Perhaps this is an avenue worth considering, until it is clearer where this outbreak is headed.
Currently, U.S. health officials are downplaying this possibility for the time being, based on the differences in ebola virus transmission pathways. We are being toId daily that this virus cannot be spread through airborne transmission. In addition, medical science has proven that these organisms change rapidly, particularly when they are propagating. Who is to say that a mutation could not occur that would change the characteristics of this organism? Centers for Disease Control and Prevention (CDC) Director Tom Frieden said October 7th, “The Ebola virus becoming airborne is a possible, but unlikely outcome in the current epidemic.” Being overly cautious and protective, at least until the knowledge base on this risk is better understood, might be worth consideration. Rest assured that if additional cases begin to appear, the dynamics of this debate will change quickly.
Bookmark this page for Mr. Cook’s next blog entry regarding Business Continuity Planning in the face of an Epidemic.