by Susan Dammann RN, Medical Specialist

With the recent presentation of Ebola cases in the United States, many in the health care field, including pregnancy center staff, are seeking to learn more about the virus and even more so, if prevention measures should be put into place. This article is intended as a resource to help you achieve those goals.

Part 1 will familiarize you with information about the Ebola virus, risks of transmission, symptoms of Ebola infection, and the diagnosis and treatment of Ebola victims, not inclusive of hospital protocol. Part 2 will offer recommendations and tools from various sources your center may wish to use to develop guidelines and procedures to screen for and deal with possible Ebola carriers.

Part 1: Information

Ebola, also known as Ebola hemorrhagic fever, is a severe viral illness that is rare and can be deadly. It is caused by an infection with one of the Ebola virus strains. To date, there have been nearly 9,000 reported cases of infection with Ebola in Africa in the recent outbreak, with more than 4,000 of those cases resulting in death.

• "One of the difficulties in identifying potential cases of Ebola infection is the nonspecific presentation of most patients. Fever/chills and malaise are usually the initial symptoms, so all medical personnel should maintain a high index of suspicion in these cases.
• Patients who survive infection with Ebola generally begin to improve around day 6 of the infection.
• There is no cure for Ebola infection; treatment is largely supportive. Therefore, prevention of the spread of Ebola in healthcare facilities is particularly important.
• Patients with fever, even subjective fever, or other symptoms associated with Ebola infection along with a history of travel to an Ebola-affected area within the past 21 days need to be identified in triage.
• If such a patient is identified, she/he needs to be isolated immediately in a single room with access to a bathroom. The door to the room should remain closed." (quoted from MedScape.org)

Transmission

"When an infection does occur in humans, the virus can be spread in several ways to others. Ebola is spread through direct contact (through broken skin or mucous membranes in, for example, the eyes, nose, or mouth) with

• blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with Ebola
• objects (like needles and syringes) that have been contaminated with the virus
• infected fruit bats or primates (apes and monkeys)

Once someone recovers from Ebola, they can no longer spread the virus. However, Ebola virus has been found in semen for up to 3 months. Abstinence from sex (including oral sex) is recommended for at least 3 months. If abstinence is not possible, condoms may help prevent the spread of disease."

(quoted from cdc.gov)

"Persons who have direct contact with infected individuals or their blood and body fluids, such as healthcare personnel without access to appropriate personal protective equipment or other caregivers in hospitals or homes, and persons handling bodies of deceased EVD patients are at high risk for Ebola virus exposure and infection.

Airborne transmission of Ebola virus has been hypothesized but not demonstrated in humans. While Ebola virus can be spread through airborne particles under experimental conditions in animals, this type of spread has not been documented during human EVD outbreaks in settings such as hospitals or households.

CDC infection control recommendations for U.S. hospitals, including recommendations for standard, contact, and droplet precautions for general care, reflect the established routes for human-to-human transmission of EVD and are based on data collected from previous EVD outbreaks in Africa in addition to experimental data."

(quoted from cdc.gov)

Can Ebola Be Transmitted Through a Sneeze?

"The only time that Ebola is in the lungs in sufficient quantities to produce virus in fluid that would be expelled during a sneeze is during extraordinarily advanced disease. A typical Ebola patient doesn't have a lot of virus in the lungs, but a person with advanced disease who is close to death could have a lot of virus in the lungs. During intubation, or when a very sick, infected person coughs or sneezes, an improperly protected healthcare worker could be at risk for being infected.

It would be a stretch to say that someone who is infected but well enough to walk around among other people would have enough Ebola in his or her lungs to be able to spread it by sneezing."

(quoted from MedScape.org)

Part 2: Recommendations and Tools

Pregnancy Center Considerations

If your center is currently serving clients from West African countries where the Ebola Virus has been reported, then you may wish to consider proactively creating a screening policy.

Should Ebola become a serious concern in our nation, the following are recommendations from various sources.  Your board of directors in conjunction with your Medical Director or Medical Advisor may then need to develop the best strategy for your center in screening for Ebola carriers and what protocol your center will follow should such a person be identified.

Medscape interviewed Arjun Srinivasan, MD (CAPT, USPHS), Associate Director of CDC's Division of Healthcare Quality Promotion, asking some key questions about the Ebola crisis. They began with the upcoming influenza season and the worries that primary care clinicians may have about symptomatic patients who also have concerns about Ebola.

"Medscape: How should clinicians handle patients who present with symptoms of fever, nausea, and vomiting, in light of current Ebola recommendations?

Arjun Srinivasan, MD (CAPT, USPHS): It's important to remember that the telephone can be one of the tools that can help keep us safe from Ebola. When people call for appointments, it's an opportunity to ask them the screening questions about whether they might have risks for Ebola. Important in that is a travel history or potential exposure to a patient with Ebola. A checklist for patients being evaluated for Ebola is available on the CDC website.

Medscape: If there is no positive travel or exposure history in the past 21 days, can a clinician rule out Ebola?

Dr Srinivasan: Yes. The exposure or travel history is a key to identifying patients who might be infected with Ebola. There is an algorithm you can use to help you determine who might be at risk for Ebola, available at cdc.gov."

(quoted from MedScape.com)

The CDC Checklist for Patients Being Evaluated for Ebola Virus Disease (EVD) in the United States (linked to above) may offer some initial steps upon arrival of a possible carrier and initial assessment.

Below are three protocols and a questionnaire from the Franklin County, Ohio Health Department website. (Heartbeat International is located in Franklin County, Ohio) You may also want to look on the health department websites in your county for their recommendations.

Protocol for Assessing Possible Ebola Exposure in Healthcare Settings

Protocols for Dispatch and First Responders to Limit Exposure to Ebola

Protocol for Assessing Possible Ebola Exposure in Work Settings

Travel History and Exposure Screening Questionnaire

From the following document by the American Hospital Association the following may be of importance:

• Implement triage protocols to identify potential patients and institute precautions
• Designate site managers overseeing implementation of safety precautions

.

The following statements from the CDC may be helpful as you consider what steps to take.

"When a patient possibly infected with the Ebola virus appears in a hospital emergency department (ED), clinicians need not necessarily cover themselves from head to toe with personal protective equipment (PPE), according to new guidelines from the Centers for Disease Control and Prevention (CDC).

The CDC also emphasizes that ED patients with an unconfirmed Ebola infection are not contagious unless they are vomiting, bleeding, having diarrhea, or otherwise producing body fluids associated with an advanced stage of the disease and a healthcare worker comes in direct contact with them.

"If you're not at risk of being exposed to blood or body fluids, then you're not at risk of transmission," said Arjun Srinivasan, MD, associate director of the healthcare-associated infection prevention programs of the CDC's National Center for Emerging and Zoonotic Infectious Diseases. "When that risk exists — the patient is throwing up, for example — then you choose PPE that provides full-scale protection."

The first step in the CDC's algorithm for ED clinicians is determining the patient's exposure history: Has he or she lived in or traveled to a country with widespread Ebola disease or had contact with an infected person in the previous 21 days? If so, then the identification of Ebola signs or symptoms comes next. One sign is fever, either subjective or 100.4°F and higher. Other signs include headache, weakness, and muscle pain, as well as the red-alert symptoms of vomiting, diarrhea, abdominal pain, and hemorrhage, as in bleeding gums or nose bleeds.

A patient with these signs and symptoms along with a definite exposure history should be isolated immediately, either in a private room or a separate enclosed area with a private bathroom or a covered bedside commode. The CDC guidance states that only essential healthcare workers with designated roles should care for the patient and should log in and out of the room.

More information on the new Ebola guidance from the CDC is available on the agency's website.

(quoted from MedScape.com)

For additional or ongoing information, the CDC has a wealth of information available here.

Above all, we must look in faith to God Almighty for His wisdom and protection. Psalm 91 is a magnificent promise of protection and there is no better time for daily meditation in this Psalm, as we rest in faith in the One who is able to keep us safe in times of trouble.