U.S. Physicians Should Be Ready to Recognize, Manage Ebola

FP Infectious Disease Expert Discusses Diagnosis, Treatment Options

August 06, 2014 03:58 pm Chris Crawford

It's virtually impossible to miss the headlines and broadcast reports: As of Aug. 4, the death toll from the worst recorded outbreak of Ebola virus disease (EVD) had reached 932, out of a total of 1,711 cases, according to the World Health Organization(www.who.int) (WHO). That's a jump of 108 cases between Aug. 2 and Aug. 4.

"This is the biggest and most complex Ebola outbreak in history. Far too many lives have been lost already," said CDC Director Tom Frieden, M.D., M.P.H., in a July 31 press release(www.cdc.gov). "It will take many months, and it won't be easy, but Ebola can be stopped. We know what needs to be done. CDC is surging our response, sending 50 additional disease control experts to the region in the next 30 days."

The 1,711 reported cases are distributed as follows:

  • Sierra Leone, 691 cases (576 confirmed, 49 probable and 66 suspected) including 286 deaths,
  • Liberia, 516 cases (143 confirmed, 252 probable and 121 suspected) including 282 deaths,
  • Guinea, 495 cases (351 confirmed, 133 probable and 11 suspected) including 363 deaths, and
  • Nigeria, 9 cases (0 confirmed, 2 probable and 7 suspected) including 2 deaths (one reported on Aug. 6).
Story Highlights
  • The World Health Organization announced that as of Aug. 4, the death toll from the worst recorded outbreak of Ebola virus disease had reached 932, out of a total of 1,711 cases.
  • The CDC website provides extensive up-to-date resources on the Ebola outbreak to health care professionals and the general public.
  • One family physician expert offers insight on detecting and managing the disease.

CDC Provides Useful Resources

In recognition of the fact that any infectious disease outbreak is only a plane ride away from potentially entering the United States, the CDC issued a Health Alert Network advisory on Aug. 1 titled "Guidelines for Evaluation of U.S. Patients Suspected of Having Ebola Virus Disease."(emergency.cdc.gov)

The advisory outlines recommendations for evaluating patients with suspected EVD, including exploring epidemiologic risk factors within the three weeks preceding the onset of symptoms. These include

  • contact with blood or other body fluids of another patient known or suspected of having EVD,
  • travel to -- or residence in -- a country where EVD transmission is active, or
  • direct handling of bats, rodents or primates from disease-endemic areas.

The advisory also lays out recommended isolation and infection control measures to prevent transmission of EVD. Personal protective equipment for health care professionals includes gloves, gown (fluid resistant or impermeable), shoe covers, eye protection (goggles or face shield) and a facemask. Additional protective equipment might be required in certain situations (e.g., in the presence of copious amounts of blood, other body fluids, vomit or feces), including but not limited to double gloving, disposable shoe covers and leg coverings.

Additional information for health care professionals is available on the CDC website(www.cdc.gov).

FP Expert Offers Treatment Advice

Current CDC Advisory Committee on Immunization Practices (ACIP) Chair and family physician Jonathan Temte, M.D., Ph.D., of Madison, Wis., said that although he hasn't yet encountered anyone who has traveled to West Africa during the outbreak, asking patients about recent travel and other potential exposure risks should always be part of the history-taking process in acute and severe illness.

AAFP Member Battled Ebola Overseas and Now Here

Academy member Kent Brantly, M.D., who contracted Ebola virus disease during recent medical missionary work in West Africa, returned to the United States from Liberia on Aug. 2 and is currently isolated at Emory University Hospital in Atlanta. His condition is reported to be improving.

After completing his residency at John Peter Smith Hospital in Fort Worth, Texas, Brantly traveled to Liberia in 2013 to participate in a postresidency program sponsored by the Boone, N.C.-based missionary group Samaritan's Purse. He was working as the medical director for the organization's Ebola Consolidated Case Management Center in Monrovia when he fell ill with the disease.

A fellow medical missionary who had also contracted the disease, Nancy Writebol, was flown to Atlanta on Aug. 5, where she, too, will be treated at Emory University.

"This simple information can greatly narrow differential diagnostic possibilities," he said.

Temte, who also is a professor in the Department of Family Medicine at the University of Wisconsin School of Medicine and Public Health in Madison, said that Ebola is tricky to diagnose because it typically presents with nonspecific symptoms such as fever, headache, arthralgia, myalgia, weakness, diarrhea, stomach pain, vomiting and anorexia. Other symptoms may include rash, red eyes, cough, sore throat, chest pain, difficulty breathing, dysphagia and hemorrhage, he added.

The typical incubation period for Ebola is eight to 10 days but can range from two to 21 days. "If Ebola is suspected based on travel and/or exposure history, patient isolation and immediate communication with public health authorities are key elements of containment," Temte said.

Treatment for Ebola is entirely supportive at this time. According to Temte, the goals of treatment are to replace fluids, electrolytes and blood components lost through hemorrhage, vomiting and diarrhea; support oxygenation and blood pressure; and treat secondary infections.

Experimental Drug Used

One of the more intriguing threads in the Ebola outbreak narrative is that of the experimental drug(www.mappbio.com) that was flown to Liberia to help two infected American aid workers (see sidebar at right). The substance, known as ZMapp, is a serum produced by San Diego-based Mapp Biopharmaceutical. Three vials of ZMapp, shipped at subzero temperatures, were delivered to the two patients in Liberia.

The serum was produced by Kentucky BioProcessing, which conducts research and development for Mapp Biopharmaceutical. The drug, which had not previously been tested on humans, was created using genetically modified tobacco plants in Owensboro, Ky., according to a Lexington Herald-Leader(www.kentucky.com) story.

An August 2013 report from the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) published in Science Translational Medicine(stm.sciencemag.org) examined the serum and found that 100 percent of nonhuman primates that were given the serum one hour after Ebola exposure survived infection. When given the serum 104 to 120 hours after exposure, 43 percent of the primates survived.

Even so, Stephan Monroe, deputy director of the National Center for Emerging and Zoonotic Infectious Diseases at the CDC, pointed out in a July 28 telebriefing on Ebola(www.cdc.gov), that no EVD treatments or vaccines have been evaluated thoroughly or approved for use by the FDA or any other regulatory organization around the globe.

What's Next?

During the CDC telebriefing, Monroe also addressed what is to come in the fight to quell the EVD outbreak in West Africa. He said stopping an outbreak of this magnitude requires breaking the chain of transmission.

First, said Monroe, cases must be identified through active individual case finding, and then investigators backtrack to identify all contacts who were exposed to those patients while the patients were symptomatic. These contacts are at risk for infection and must be monitored daily for 21 days. If they develop symptoms, they must be admitted to isolation facilities.

According to Monroe, the standard for declaring that an Ebola outbreak has been contained is to wait 42 days, two full incubation periods after the last case has been identified. "So, if there was no case identified after today, we would still be committed to waiting 42 days to declare the outbreak fully over," he said.

The problem with this type of disease outbreak, Monroe explained, is that it can be reseeded like a forest fire, with sparks from one tree reseeding it.

"That is clearly what happened in Liberia. Liberia was a situation (where) they did not have any new cases for more than 21 days in the first wave of the outbreak, and they were reseeded by cases coming across the border," Monroe said. "Until we can identify and interrupt every chain of transmission, we will not be able to control the outbreak."

Additional Resources
CDC: Ebola Hemorrhagic Fever(www.cdc.gov)

World Health Organization: Ebola Virus Disease(www.who.int)

American Public Health Association: Ebola-Marburg Virus Diseases(www.apha.org)