Global Ebola—Are We Prepared?

This index case illustrates valuable lessons for all emergency care workers going forward. Ebola virus disease is now global, in the sense that it has proven its ability to present in a community far from its endemic home. Infectious diseases in their early stages present in nonspecific constellations of symptoms, and the key to rapid identification of EVD lies in careful attention to the recent travel history and exposure potential. Since patients may not offer this information for various reasons (eg, degree of symptoms, language barriers, fear, denial), it must be sought out lest more index patients be released into the public. As CDC Director Thomas Frieden related to CNN, “If someone’s been in West Africa within 21 days and they’ve got a fever, immediately isolate them and get them tested for Ebola.”¹³

Concerning the EMS transport of this patient, the ambulance used was disinfected per standard local protocols and remained in service for 2 days after this patient was transported. Though local officials are confident in the disinfection technique, it was pulled from service after the diagnosis was confirmed to ensure its full sterilization from Ebola virus¹⁶ before returning to full service. The rapid and robust public health response in progress will undoubtedly reveal further information over the coming days to weeks. To quote Michael Osterholm, PhD, MPH, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, “We are going to see more cases show up around the world.”¹⁵

In addition to the index patient, it is important to keep in mind that secondary cases may present. If this occurs, the travel question must be altered to reflect the possibility that a secondary patient may not have been the traveler but rather one who was in close contact with an ill person who was in contact with him or her. Such a scenario would have a huge impact if that traveler did not seek treatment and would in turn require ED personnel to seek-out the information and report it to local public health officials.

Quelling the Panic

Even though Ebola is only spread through direct contact with infected bodily secretions, there is still significant public fear of the disease due to the high mortality rate and the graphic nature of symptoms in late stages of the disease. Daily monitoring of contacts of symptomatic Ebola patients for evidence of disease development—mainly fever—is sensible. Asymptomatic persons need not be confined or hospitalized unless fever develops, in which case contact isolation should occur until formal Ebola testing can rule-out the disease. Personal protective equipment, standardized hospital cleaning protocols with meticulous adherence, as well as quickly burying the deceased with adequate contact precautions, can all limit potential exposure and spread of the disease. Public health discussion and education about the virus and methods of transmission are needed so that individuals are not denied proper treatment or scared away from medical centers.

Importantly, communication by public health and medical experts on local and national levels should be with news media that embrace honest and careful reporting to avoid sensationalism and foster appropriate concern—ensuring that content is fundamental to curtailing panic and undue public fear.

For Internationally Traveling Clinicians 

At present, the area endemic for Ebola remains confined to sub-Saharan Africa and West Africa. Clinicians should remain alert when traveling or treating patients in these areas. However, with the ease of international air travel, the potential for the spread of disease is recognized with many bordering nations now screening passengers from affected countries and some closing their borders to travelers from endemic areas. If a clinician encounters febrile patients in endemic areas, the differential diagnosis for any febrile illness must include Ebola, as well as malaria and other more common infectious agents. A thorough history about recent travel, ill contacts, and possible exposures should be sufficient in categorizing the risk of Ebola, but a high index of suspicion is necessary for prompt and proper treatment of those affected and to curtail spread of disease.

Despite the efforts of the national and local health systems and many nongovernmental organizations, including the World Health Organization, this epidemic continues to hold strong in the affected West African countries. Methods of containment of the virus are seemingly simple by modern standards, yet tragically beyond access for many on the ground. Lack of clean water sources in affected communities is a significant barrier to basic personal and environmental hygiene. Inadequate safe food sources and poaching encourages the hunt for primate bushmeat and thus presents a formidable local challenge.¹⁷ Lack of adequate PPE for healthcare workers, for those responsible for facility environmental hygiene, and for family members participating in traditional funeral rites for Ebola victims compounds the problem. Illness and deaths among exposed healthcare workers have led to the loss of significant numbers of nurses and doctors. This has caused legitimate fear in qualified individuals who subsequently decline to accept jobs caring for Ebola patients, which in turn increases the burden on those who remain. Additionally, some nongovernmental organizations have canceled scheduled aid trips to West Africa in response to the epidemic out of concern for the health of their workers. Meticulous management of environmental hygiene including sharps, surfaces, soiled linens, reusable medical equipment, waste products, and the preparations for burial of the deceased pose definite challenges to containment and prevention of transmission. Strict adherence to the use of PPE and hand hygiene is essential for all in contact with Ebola patients, pre- and postmortem. The lack of layperson comprehension and community understanding of the illness itself and the mechanism of viral transmission along with fear and mistrust for healthcare providers and nongovernmental medical missionaries are all serious barriers to the containment of disease spread. In fact, rumors that the virus does not truly exist, and that the illness is a result of biological warfare, cannibalistic rituals, or witchcraft add to the complexity of the situation.¹¹