Health Advisory- Ebola Outbreak in the Democratic Republic of the Congo

Recommendations for Healthcare Personnel and Health Officials Evaluating Patients for Possible Ebola Virus Disease

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The purpose of this Health Advisory is to provide healthcare personnel and health officials with current recommendations regarding evaluation of patients who may have been exposed to Ebola virus, and:

(1) for any patient presenting with fever and other symptoms consistent with Ebola virus disease (such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage), increase vigilance in establishing potential travel history to the Democratic Republic of the Congo in the 21 days before illness onset;

(2) isolate patients who report travel to the Democratic Republic of the Congo and are exhibiting Ebola symptoms in a private room with a private bathroom, and implement standard, contact, and droplet precautions (gowns, facemask, eye protection, and gloves); and

(3) immediately notify the local health department. (Find your local health department at: http://www.dshs.state.tx.us/idcu/investigation/conditions/ contacts/)

Please disseminate this information to urgent and emergency care providers, infectious disease specialists, intensive care physicians, primary care physicians, and infection control specialists, as well as to emergency departments, urgent care centers, and microbiology laboratories.

Background

The Democratic Republic of the Congo is experiencing an Ebola outbreak. According to the World Health Organization, from April 4, 2018 through May 17, 2018, a total of 45 cases of Ebola virus disease (EVD) were reported, resulting in 25 deaths. Fourteen of the 45 cases have been confirmed. Three cases have been in healthcare workers. Cases have been reported from three health zones: Bikoro, Iboko, and Wangata (See map on page 5).

Most of the cases have been from the Bikoro health zone, which is remote and difficult to reach. There has been at least one confirmed case in Mbandaka, though, which is a city of 1.2 million people. There is concern that spread to this urban area increases the risk of international spread.

EVD is a rare and deadly disease caused by infection with one of four viruses (Ebolavirus genus) that cause disease in humans. Ebola infection is associated with fever and additional symptoms, such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage. Ebola is spread through direct contact (through broken skin or mucous membranes) with blood or body fluids (including but not limited to urine, saliva, feces, vomit, sweat, breast milk, and semen) of a person who is sick with Ebola or through contact with objects (such as needles and syringes) that have been contaminated with these fluids. Persons at highest risk of developing infection are those who have had direct contact with the blood and body fluids of an individual diagnosed with EVD. This includes any person who: 1) provided care for an Ebola patient, such as a healthcare provider or family member, who did not adhere to recommended infection control precautions (e.g., not wearing recommended personal protective equipment); 2) those who have had close physical contact with an individual diagnosed with EVD; or, 3) those who lived with or visited an Eboladiagnosed patient while he or she was ill. The main source for spread is human-to-human transmission. Avoiding contact with infected persons (as well as potentially infected corpses) and their blood and body fluids is of paramount importance.

Persons are not contagious before they are symptomatic. The incubation period (the time from exposure until onset of symptoms) is typically 8-10 days, but can range from 2-21 days. Additional information is available at http://www.cdc.gov/vhf/ebola/index.html.

Recommendations

Early recognition is critical to controlling the spread of Ebola virus. Consequently, healthcare personnel should elicit the patient’s travel history and consider the possibility of EVD in patients who present with fever, muscle pain, severe headache, abdominal pain, vomiting, diarrhea, or unexplained hemorrhage, in the setting of recent travel to a region with active Ebola transmission, which currently is the Democratic Republic of the Congo. Should the patient report a history of recent travel to the Democratic Republic of the Congo and exhibit such symptoms, immediate action should be taken. A patient evaluation algorithm is available at (https://www.dshs.texas.gov/idcu/disease/ebola.aspx).

Patients in whom a diagnosis of EVD is being considered should be isolated in a single room (with a private bathroom), and healthcare personnel should follow standard, contact, and droplet precautions, including the use of appropriate personal protective equipment (PPE). Infection control personnel and the local health department should be immediately contacted for consultation.

Healthcare personnel in the United States should immediately contact their local health department regarding any person being evaluated for EVD if the medical evaluation suggests that diagnostic testing may be indicated. Diagnostic testing for Ebola is only available at select laboratories in the U.S. The CDC, Texas DSHS, and certain Texas Laboratory Response Network laboratories offer Ebola PCR testing. Consultation with DSHS and the CDC are required before submitting specimens for testing. Further information about diagnostic testing for Ebola can be found at http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collectionsubmission-patients-suspected-infection-ebola.html.

More Information

The following references provide additional information about case definition, clinical presentation and clinical course of EVD, infection control, and patient management:

  • Guidelines for clinicians in U.S. healthcare settings are available at http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcaresettings.html.
  • Guidelines for infection prevention and control for hospitalized patients with known or suspected Ebola in U.S. hospitals are available at http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-controlrecommendations.html.
  • Guidelines for safe management of patients with Ebola in U.S. hospitals are at http://www.cdc.gov/vhf/ebola/hcp/patientmanagement-us-hospitals.html.
  • Texas DSHS clinical case definitions and case classifications for EVD are as follows:
    • Clinical Case Definition (frequently referred to as Person Under Investigation or PUI):
      • Fever and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND
      • Epidemiologic risk factors within 21 days prior to the onset of symptoms, such as contact with blood or other body fluids or human remains of a patient known to have or suspected to have EVD, residence in – or travel to – an area where Ebola transmission is active, or direct handling of bats or non-human primates from disease-endemic areas.
    • Case Classifications
      • Confirmed: A clinically compatible illness that is laboratory confirmed.
      • Suspect: A clinically compatible illness that meets one or more of the following exposures within 21-days before onset of symptoms:
        • Contact with blood or other body fluids of a patient with EVD, OR
        • Residence in – or travel to – an EVD-endemic area or area currently classified by the CDC as experiencing an Ebola outbreak, OR
        • Handling EVD specimens in a laboratory setting, OR
        • Work in a laboratory that handles primates, bats, or rodents from endemic areas, OR
        • Exposure to semen or breast-milk of an individual who had EVD within the last 9 months.

For more information, healthcare providers can contact their local health department or call the DSHS/Infectious Disease Control Unit at 512-7767676 or 1-800-252-8239.