Understanding Ebola Precautions

Although outbreaks of the Ebola virus hemorrhagic fever in Africa have occurred sporadically over the years, the latest is the largest to date. In the past, each outbreak was quickly controlled when teams from the United States arrived and instituted very basic infection control practices. This time, however, the outbreak began on the border of three countries: Guinea, Sierra Leone and Liberia. With people traveling between neighboring countries, the disease spread more widely and wasn’t contained to a single village as before.
Basic infection control practices–use of disinfectant solutions, instrument sterilization, clean water, use of personal protective equipment (PPE), and cleaning equipment such as needles and syringes between patients–aren’t in use in many areas of Africa. Most communities don’t have clean running water, let alone disinfection solutions. Syringes and surgical instruments are rinsed out and reused without being properly cleaned. Hospitals have dirt floors and fabric walls. Infection control practices are foreign and viewed with suspicion. 
Village residents lean to local treatment methods, but these rituals play a role in the spread of diseases–especially ones that are blood and body fluid transmitted like Ebola. Families also most often care for ill members in their homes, placing them in direct contact with body fluids.1 Currently, villagers are praying over hot salt water and then bathing in it as a means to protect themselves from Ebola.2 Long-used burial practices also play a role in transmission. There are thousands of tribal healers and very few trained physicians in most of these countries. 
Travel & Quarantine
As with other outbreaks in the past (e.g., avian flu, SARS and measles), concern over travelers from areas at the center of an outbreak coming to the U.S. is high. However, processes are in place to lessen the possibility of disease transmission.
Most international airlines are counting on more rigorous passenger screening as they continue serving the region. Air France has fliers in some cities complete health questionnaires and get checked for symptoms before boarding passes are issued. Delta Air Lines is also checking travelers at the airport in Monrovia, Liberia.
Currently, persons who have been exposed to Ebola are advised not to travel for 21 days after their exposure. Passengers who appear ill will need to be cleared by a health authority.
Most people aren’t aware there are established procedures if a passenger on a commercial airline takes ill. If a passenger is suspected of having a communicable disease, the pilot reports to air traffic control, which facilitates response of any special medical personnel 
and equipment. 
The Centers for Disease Control & Prevention (CDC) will follow up with the passenger. There are many quarantine stations located at U.S. airports. (See Figure 1, p. 30.) In some cases, the ill person will be placed into quarantine at the airport.3,4 If needed, transport will be arranged. Passengers who may have been exposed will be contacted and the public health department will conduct a follow-up assessment.
Many U.S. airports have CDC team members available to evaluate ill passengers. If a person is found to have a communicable disease, other passengers will be asked to complete a “public health passenger location card,” which provides important information when there’s concern of a person with Ebola entering the U.S.2
Why do we become so afraid? Perhaps author Philip Alcabes, in his book Dread: How fear and fantasy have fueled epidemics for the black death to avian flu, summed it up best by comparing current attitudes about Ebola to how people feared leprosy and other diseases that weren’t highly communicable. 
Does our anxiety about a disease overshadow facts that could reduce our comfort level? The fact is, movies and books about outbreaks don’t always match with reality. News media shows the same images over and over again in newscasts and contributes to the escalation of our fears.5 Joanne Liu, MD, from Doctors Without Borders, stated in a recent NPR interview, “The only thing we’re facing is fear. Fear is normal when you don’t understand what is going on.”6
Why Not Moon Suits?
Moon suits were shown on TV when the first two Ebola patients arrived in the U.S. and the media played it up big. But, here are some important points: 

1. The unit at Emory University Hospital, where the first patient was taken, is just one of four in the U.S. designed to care for patients with an unknown disease. (There are also patients at the facility in Nebraska and at the National Institutes of Health in Maryland);

2. Written plans are in place for patient care and transport; and 

3. Although Ebola is a familiar disease with a known method for transmission, this situation presented the perfect opportunity to put the university’s written plan into action and to practice real containment. However, in a more recent document, the CDC has made clear that any medical facility in this country should use the recommended precautions.7 This is now the case in Texas, where the first U.S. patients diagnosed with Ebola is hospitalized.

It’s also possible that the overuse of PPE was designed to lower public fear about spread of the disease. It’s not helpful that, in many media reports, the actual method for transmission hasn’t been made clear. Ebola is a disease transmitted by direct contact with blood and body fluids, so healthcare workers are protected as long as they practice basic infection control measures. 
Many people have been frightened by movies depicting widespread transmission of diseases such as Ebola. This has led to widespread misunderstanding of the true risk posed. The fact is that no healthcare workers in the U.S. have contracted these diseases from caring for the infected patients. Yes, healthcare workers have sustained exposures while rendering care to these patients, but none became ill because they know how to deal with infection control issues.7 
Patient Assessment
Travel history is important in today’s global society and should be a routine part of patient assessment. Assess patients who have had contact with blood or body fluids of a person known or suspected to have the disease, traveled to an area where there are cases of Ebola, or have handled bats, rodents, or primates from a disease area within the past three weeks.9,10 Assess for temperature greater than 101.5 degrees F, headache, muscle pain, vomiting, diarrhea, abdominal pain or unexplained hemorrhage.
What PPE is needed? 
The World Health Organizations (WHO) and the CDC have published guidelines for the care of persons suspect for or diagnosed with Ebola:
>> Wear gloves when touching the patient and the patient’s immediate environment or belongings;
>> Wear a gown if substantial contact with the patient or their environment is anticipated;
>> Wear protective eyewear to protect from splash/splatter; and
>> Perform hand hygiene after removal of PPE. Use soap and water when hands are soiled with body fluids or after caring for patients with known or suspected infectious diarrhea.
There are three types of isolation precautions that should be used: standard, droplet and contact. Standard precautions are based on the principle that all blood, body fluids, secretions (except sweat), non-intact skin and mucous membranes may transmit infectious agents. Use gloves and wash hands when in contact with patient blood, non-intact skin, mucous membranes and contaminated surfaces. Alcohol-based foams and gels may be used if hands aren’t visibly covered with blood or body fluids.
To take droplet precautions, wear a surgical facemask when coming within three feet of an Ebola patient or upon entering the vehicle or home of a suspect patient, especially if he or she isn’t wearing a mask. Eyewear should be worn to protect from splash/splatter. If substantial spraying of respiratory fluids is anticipated, gloves and gown as well as goggles or face shield should be worn. Instruct the patient to wear a facemask when exiting the ambulance, avoid coming into close contact with other patients, and practice respiratory hygiene and cough etiquette.
For contact precautions, wear gloves and a cover gown when in direct contact with patient or contaminated equipment or surfaces. Perform adequate hand hygiene after removal of PPE, and dispose of medical waste as required by your state regulations.11
Key prevention points include:
>> Avoid aerosol-generating procedures as these should be done in a hospital negative pressure isolation room;
>> Limit the use of and carefully handle sharps;
>> Cleaning can be conducted by using any EPA-registered disinfectant. No special solutions are required;9 and 
>> Only routine laundry procedures are needed. No special washer or solutions are required. 
Unprotected Exposures
The CDC and WHO have developed guidelines for post-exposure evaluation. If an exposure were to occur, remove yourself from care and safely remove PPE. Then, as with 
any exposure: 
1. Perform first aid. If a sharps injury is sustained, wash with soap and water. If a splash or splatter event occurs, rinse with large amounts of water or use an eyewash station. Don’t use bleach or other disinfectants.
2. Immediately report the incident after first aid is initiated. The exposed person should be medically evaluated and receive any needed follow-up care.
3. Monitor temperature twice a day for 21 days. If the exposed individual is suspect for infection, he/she will be placed on isolation/quarantine for 21 days. This is covered by workers compensation.
4. Contact all persons who were in contact with the exposed individual.12   
If transport of an exposed healthcare worker is deemed appropriate, the CDC recommends air transport to lower exposure to others and increase chances of transport to a containment unit. 
U.S. Case
On Sept. 30 a patient was transported to a medical facility in Texas. He presented with symptoms of Ebola five days after returning from West Africa. He was admitted to a local medical facility, placed in isolation, tested and officially diagnosed. Three EMS crew members were also tested, but were negative. However, they were placed on 21 days of home observation as a precaution.13 In response, the CDC released EMS guidelines for handling patients suspected of having Ebola on Oct. 1, including a detailed checklist.7
1. Our Africa. (n.d.) Health. Retrieved Sept. 12, 2014, from www.our-africa.org/health. 
2. International Commercial Air Transport. ICAO health-related documents, chapter 8, Section E, implementation of international health regulations and related provisions [white paper]. 2005.
3. Centers for Disease Control and Prevention. (March 10, 2014.) Protecting travelers’ health from airport to community: Investigating contagious diseases on flights. Retrieved Sept. 12, 2014, from www.cdc.gov/quarantine/contact-investigation.html.
4. Centers for Disease Control and Prevention (Sept. 5, 2014.) Ebola guidance for airlines. Retrieved Sept. 12, 2014, from www.cdc.gov/quarantine/air/managing-sick-travelers/ebola-guidance-airlines.html.
5. Smith S. (Aug. 7, 2014.) The roots of our Ebola fears. CNN Health. Retrieved Sept. 12, 2014, from www.cnn.com/2014/08/06/health/ebola-epidemic-fears/.
6. NPR Staff. (Aug. 14, 2014.) Doctors Without Borders: What we need to contain Ebola. NPR. Retrieved Sept. 12, 2014, from www.npr.org/blogs/goatsandsoda/2014/08/19/341639702/more-ngos-need-to-be-in-the-fied-to-contain-ebloa-outbreak.
7. Centers for Disease Control and Prevention. (Oct. 1, 2014.) Interim guidance for EMS systems and 9-1-1 public safety answering points (PSAPs) for management of patients with known or suspected Ebola virus disease in the United States. Retrieved Oct. 2, 2014, from www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html.
8. Silver M. (Aug. 12, 2014.) Pray over hot salt water, then bathe in it: An anti-Ebola ritual. NPR. Retrieved Sept. 12, 2014, from www.npr.org/blogs/goatsandsoda/2014/08/12/339638348/pray-over-hot-salt-water-then-bathe-in-it-an-anti-ebola-ritual.
9. Centers for Disease Control and Prevention. (Sept. 5, 2014.) Safe management of patients with Ebola virus disease (EVD) in U. S. hospitals. Retrieved Sept. 12, 2014, from www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html. 
10. Centers for Disease Control and Prevention (Aug. 13, 2014.) Transmissions. Retrieved Sept. 12, 2014, from www.cdc.gov/vhf/ebola/transmission/index.html
11 Centers for Disease Control and Prevention. (Aug. 19, 2014.) Infection prevention and control recommendations for hospitalized patients with known or suspected Ebola hemorrhagic fever in U.S. hospitals. Retrieved Sept. 12, 2014, from www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html. 
12. World Health Organization. (August 2014.) Interim infection prevention and control guidance for care of patients suspected or confirmed filovirus hemorrhagic fever in health-care settings, with focus on Ebola. Retrieved Sept. 12, 2014, from http://apps.who.int/iris/bitstream/10665/130596/1/WHO_HIS_SDS_2014.4_eng.pdf?ua=1&ua=1.
13 Centers for Disease Control and Prevention. (Oct. 1, 2014.) CDC and Texas Health Department confirm first Ebola case diagnosed in the U.S. Retrieved Oct. 2, 2014, from www.cdc.gov/media/releases/2014/s930-ebola-confirmed-case.html.
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