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Accurate Information on Ebola

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The World Health Organization declared the Ebola outbreak a Public Health Emergency of International Concern (PHEIC) on August 8. The U.S. Centers for Disease Control and Prevention (CDC) promptly began urging health care providers around the country to take precautions to prevent the spread of the disease.

Specialists from the Mount Sinai Health System’s departments of Emergency Management, Infection Prevention and Control, and Infectious Disease have been working with leadership and frontline employees in inpatient and outpatient settings to establish protocols to identify, treat, and monitor patients suspected of having Ebola Virus Disease (EVD).

In addition to providing you with information about these protocols, we want to give you accurate information about EVD to help you communicate with staff and patients. Sources for the following questions and answers include infectious disease experts within the Mount Sinai Health System, the CDC, and WHO.

1. What is Ebola?

Ebola is a type of virus that is highly infectious, meaning that a small amount of virus can make someone severely ill but it is not highly contagious. There is an outbreak in West Africa (Guinea, Sierra Leone, Liberia) which is the largest outbreak of Ebola.

2. What are the symptoms of Ebola?

Symptoms include fever, headache, joint and muscle aches, weakness, diarrhea, vomiting, stomach pain, lack of appetite, and abnormal bleeding. Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola virus, although 8 to10 days is most common.

To be identified as having a potential Ebola virus infection, the patient will have a fever of greater than 38 degrees Celsius or 100.4 degrees Fahrenheit associated with severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or hemorrhage; AND epidemiologic risk factors within 21 days before the onset of symptoms, such as contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active (Sierra Leone, Liberia, Guinea); or direct handling of bats, rodents, or primates from disease-endemic areas.

3. To date, what are the Ebola cases and deaths?

Approximately 8,997 cases have been reported in the West African countries of Guinea, Liberia, Sierra Leone, Nigeria and Senegal. There have been a total of 4,493 deaths. 

4. How can Ebola be transmitted?

Ebola is transmitted through direct contact with the blood or bodily fluids of an infected symptomatic person, or though exposure to objects (such as needles) that have been contaminated with infected secretions.

5. Can Ebola be transmitted through the air?

No. Ebola is not a respiratory disease like the flu, so it is not transmitted through the air.

6. Can I get Ebola from contaminated food or water?

No. Ebola is not a food-borne illness. It is not a water-borne illness.

7. Can the Ebola virus mutate?

Mutation is a change in the structure of a virus.  The Ebola virus is a stable virus and does not easily mutate.  The virus associated with the current outbreak is not a new, mutated virus.

8. When are patients with Ebola potentially infectious?

Patients with Ebola are potentially infectious from the onset of symptoms, such as fever, and as long as the virus is in their blood and body fluids, lasting weeks to months.  They are not infectious prior to the onset of symptoms.

9. What is the take-away message with respect to risk of Ebola virus exposure for U.S. citizens?

Ebola can only be transmitted through direct contact with blood or bodily fluids. The infection cannot be transmitted through casual contact. It is neither transmitted through the air like flu, nor through contaminated food or water.  It is also important to note that persons without symptoms are not considered contagious.

10. What infection control precautions should be in place? 

A potentially infected patient should be placed in a single-patient room with a private bathroom and the door closedFacilities should maintain a log of all people entering the patient’s room.

Patients are considered contagious as soon as they start to show symptoms of the disease, but risk of transmission in the early stage of illness is low.  Because of this fact, staff should wear appropriate personal protective equipment (PPE) while seeing patients at an early stage of illness, but not to the extent that would be necessary when a patient’s illness advances.  As symptoms advance and the patient requires a higher level of medical care, a higher level of PPE is required.  Staff required to wear PPE will receive appropriate training.

Health care workers providing direct patient care in an exam or patient room would wear a higher level of PPE.  That can include   a fluid- impermeable gown, a fluid resistant coverall with foot and leg protection, a hood, eye protection (goggles or face shield), a N95 respirator and double 12” gloves.  Recommendations regarding PPE are being modified by the CDC.  As updates become available, they will be shared on the Mount Sinai Health System Ebola intranet site.  PPE must be put on carefully and also carefully removed without contaminating one’s eyes, mucous membranes, or clothing with potentially infectious materials.  A trained observer or “buddy” must be present when putting on and taking off PPE to ensure this is done correctly.

Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is paramount, as blood, sweat, emesis, feces, and other body secretions represent potentially infectious materials. Health care workers performing environmental cleaning and disinfection should wear recommended PPE as noted above.

Where possible, health care workers should avoid procedures that generate aerosol exposure (aerosol generating procedures or AGPs) and droplets of body fluid from Ebola patients. If performing AGPs, use a combination of measures to reduce exposures from aerosol-generating procedures when performed on Ebola patients. Visitors should not be present during aerosol-generating procedures. Although there are limited data available to define a list of AGPs, procedures that are usually included are bilevel positive airway pressure (BiPAP), bronchoscopy, sputum induction, intubation and extubation, and open suctioning of airways.

For more detail, please see the following CDC guidelines.

11. Does the Mount Sinai Health System have the supplies needed to protect staff from potential exposure to the Ebola virus? 

Yes. Training of staff has occurred and will continue to occur to assure proper use of PPE.

12. What is the United States doing about the Ebola outbreak?

The CDC has mounted its largest response ever to an international outbreak. The U.S. Agency for International Development (USAID) is leading the United States’ overseas response to the Ebola outbreak, while the U.S. Department of Defense, the U.S. Department of State, the CDC, and other U.S. government departments and agencies are supporting our approach to this national security priority.  On September 16, President Obama announced additional U.S. government support for the response in West Africa, including significant U.S. military funding and engagement.

13. Who was the first patient to die from Ebola in the United States?  

On September 30, 2014, the CDC confirmed that the nation’s first case of Ebola was diagnosed in in a person who had traveled from Liberia to Dallas, Texas. Thomas Eric Duncan had no symptoms when leaving West Africa, but developed symptoms approximately four days after arriving in the United States on September 20.  He was admitted to Texas Health Presbyterian Hospital in Dallas on September 28, requiring intensive care. Despite aggressive medical management, including dialysis, he died.

14. What is the status of the Texas health care workers who tested positive for Ebola?

As many of you are aware, health authorities in Texas confirmed two  healthcare worker in Dallas who treated the man from Liberia, who traveled to the United States and subsequently died from the disease, have tested positive for Ebola through suspected secondary transmission. Both healthcare workers are currently in isolation and under treatment. Transmission to healthcare workers is concerning to us all. It is why we must remain vigilant with our in-servicing and educational efforts.

15. What is the United States doing for travelers?

The CDC has issued a Warning Level 3 (the highest level) travel notice for Guinea, Liberia and Sierra Leone where the Ebola outbreak is most severe.  U.S. Citizens should avoid all nonessential travel to those countries. 

Exit screening efforts in West Africa help prevent sick travelers or those exposed to Ebola from getting on flights, ships, trains, or buses. In addition, all travelers returning to the United States from West African countries with Ebola outbreaks are advised to monitor their health for 21 days.  If they develop symptoms, they should immediately seek medical care. Travelers are also being screened at a variety of airports including Newark Liberty and John F. Kennedy airports.

16. Are there any treatments for Ebola?

There are no vaccines or medicines (e.g. antiviral drugs) approved by the U.S. Food and Drug Administration for the treatment of Ebola. Experimental vaccines and treatments are under development, but they have not yet been fully tested for safety or effectiveness. Treatment is supportive with airway support, IV hydration, and care in an intensive care unit.

ZMapp is an experimental treatment, a combination of three different monoclonal antibodies that bind to Ebola virus proteins. It is too early to know if ZMapp will benefit Ebola patients because the drug has not yet been tested in humans for safety or effectiveness in a clinical trial. Two companies, Tekmira and BioCryst Pharmaceuticals, have received funding from the U.S. Department of Defense to develop potential Ebola drug treatments as well.

In addition, the National Institutes of Health on Aug. 28 announced that human testing to assess safety and immune response of an investigational vaccine to prevent Ebola virus disease began in September.

Should a case of Ebola infection occur at Mount Sinai, the treatment for any individual patient will be decided by that patient and his or her doctor. Mount Sinai would, as appropriate, seek access to experimental medications and other therapies such as transfusion of serum from Ebola survivors.

17. Why have some patients recovered from Ebola, while others have not?

Recovery from Ebola depends upon good supportive clinical care and the patient’s immune response. Available evidence shows that people who recover from Ebola infection develop antibodies that last for at least 10 years, and possibly longer. It is not known whether people who recover are immune for life or if they can become infected with a different species of Ebola.

18. What are health care workers at Mount Sinai doing to identify possible patients with Ebola?

Providers have been instructed to ask patients with fever about their travel histories to determine if they have traveled to West Africa within the last three weeks. For patients with fever and travel to West Africa, Ebola should be considered. The patient would then be isolated and PPE would be donned. Infection Control personnel would be called immediately.

Protocols for Personal Protective Equipment

As frontline health care providers, we play an essential role in protecting the health and well-being of each other, our patients, our city, and ultimately, our country. We want to share our updated protocols regarding personal protective equipment (PPE) for Ebola. The current protocols follow guidelines from the World Health Organization (WHO) and the recently updated U.S. Centers for Disease Control and Prevention (CDC) guidelines.

Adherence to good infection control and prevention practices when delivering patient care, including the consistent and correct use of PPE, frequent hand washing, and proper decontamination of surfaces and equipment, are key to reducing and eliminating the transmission of Ebola and other communicable diseases. These practices will protect you, your colleagues, and other patients from exposure.

Please note that we are updating training schedules for our staff and will disseminate them on a regular basis. Many of our staff who work in clinical areas will continue to be trained on how to put on and take off their PPE, which includes full-cover body protection with a hood, eye and face protection, and double-gloving with extra-long gloves. The safe removal of PPE is essential to prevent us from infecting ourselves. Additionally, we will continue to conduct drills in many areas across the Mount Sinai Health System to evaluate our readiness and improve practices, where needed.

Updated Recommendations for PPE:

  • N95
  • Eye and face protection
  • Fluid resistant coverall with foot and leg protection
  • Fluid impenetrable gown over the fluid resistant coverall with a hood
  • An extra hood (shroud)
  • Double gloves with 12” gloves

Mount Sinai is using WHO’s protocol for doffing and donning [PDF] the suits which can also be found on the intranet at http://intranet1.mountsinai.org/ebola. This includes having a trained observer present to ensure doffing and donning are done correctly. Donning and doffing will be done in designated areas.

A large number of our clinical staff will be taught how to put on and take off PPE. Gloves will be ordered in small, medium, and large sizes. Par levels will be determined by involving areas that care for these patients. We are working on ordering supplies that will enable at least five people to be readily available at all times.

In addition to inpatient settings, PPE will be available in the outpatient areas. Par levels will be determined by involved practices. Supplies for at least three people should be readily available at all times. Upon presentation, the patient should quickly be placed in an exam room with the door closed. Staff would wear gloves, at a minimum, when taking the patient to the exam room at presentation.

WHO’s Protocol for Doffing and Donning [PDF]