How Frontline Health Care Workers Can Prepare for an Ebola Outbreak

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Sudan Ebolavirus Outbreak in Uganda

As of October 5, 2022, the World Health Organization (WHO) is reporting 63 confirmed and probable cases of Sudan ebolavirus, including 29 fatalities, across five districts in Uganda. In neighboring Kenya, a person under investigation (PUI) has tested negative and in South Sudan there are a number PUIs, one of whom has died from hemorrhagic symptoms consistent with Ebola virus disease (EVD).

While there are no suspected U.S. cases of Ebola, the CDC recommends that health care providers be prepared for early identification and care of patients who present with symptoms and have recently traveled from Uganda. See the CDC’s health advisory for October 6, 2022 (CDC, https://emergency.cdc.gov/han/2022/han00477.asp, Accessed 10/7/2022).

Differences and Similarities Among Ebolavirus Species

The Sudan ebolavirus spreading in Uganda is one of four species of Ebolavirus known to cause disease in humans. First identified in 1977, Sudan ebolavirus has led to intermittent outbreaks in central Africa, the largest outbreak occurring in 2000-2001 with 425 cases. Prior to the current outbreak, the virus was last identified in 2012 in Uganda. See the CDC’s history of outbreaks. In previous outbreaks affecting more than 1-2 people, the case fatality rate of Sudan ebolavirus has ranged from 41–65 percent.

More recent outbreaks of Ebola have stemmed from the Zaire ebolavirus species, including the 2014-2015 outbreak that resulted in more than 11,000 deaths. While all Ebolaviruses are lipid-enveloped, single-stranded RNA viruses, the Sudan ebolavirus differs in its genome from the Zaire ebolavirus in ways that make available vaccines ineffective. The Sudan ebolavirus species may also be more difficult to diagnose outside of special laboratory settings. Testing capacity, vaccine strategies, and medical countermeasures are all under review and in development, but infection prevention and control strategies and personal protective equipment remain the same as for other Ebolavirus species.

All Ebola viruses have similar symptoms that may include sudden fever, fatigue, weakness, and muscle/joint pain. Headache and sore throat are common and the initial symptoms may be followed by nausea, vomiting, and diarrhea. Ebola virus disease (EVD) is a viral hemorrhagic fever (VHF), but bleeding is rarely a presenting complaint. Concurrent outbreaks of VHFs , including Crimean-Congo Hemorrhagic Fever (CCHF), Lassa Fever, and Rift Valley Fever, in West Africa may complicate diagnosis as there is significant overlap in symptoms among VHFs.

Care for patients with or suspected of having EVD is largely supportive, with fluid and electrolyte replacement as necessary, but may include the need for frequent monitoring, renal and respiratory support, and aggressive fluid resuscitation. All care of suspected or confirmed patients should be done with extreme caution by healthcare workers (HCW) in appropriate personal protective equipment (PPE). Malaria, typhoid fever, and other infections with similar symptoms may need to be ruled out and can present as concomitant illness.

Identify, Isolate, and Inform

It is important to follow the Identify, Isolate, and Inform process with any contagious pathogen, including viral hemorrhagic fever (VHFs), to limit the spread of the disease and keep healthcare workers and the public safe.

Watch this NETEC webinar to learn more about the identify, isolate, and inform strategy to control transmission of viral hemorrhagic fevers, including Ebola (NETEC, https://repository.netecweb.org/items/show/1509, Accessed 2024).

Identify

The CDC defines a person under investigation (PUI) as a person who has both traveled to a hot spot with a current or recent outbreak and has signs or symptoms consistent with the CDC case definition of Ebola. Symptom screening for fever, cough, nausea, vomiting, diarrhea, rash, fatigue, muscle pain, unexplained hemorrhage, and/or severe headache should be evaluated first. Then any travel history outside the country should be investigated with any person presenting for medical care whether in a hospital or clinic. Ask if the patient has traveled to a country with an ongoing outbreak or if they have had any contact with individuals with confirmed disease. Both the symptoms and the travel information should be documented in the patient’s chart.

Isolate

Isolating the patient starts with ensuring they are wearing a mask and having them perform hand hygiene. Move the patient to a separate isolated area as soon as possible. If family members arrived with the patient they will also need to be isolated. Consider what personal protective equipment (PPE) will be needed for healthcare workers caring for a person under investigation.

While PPE ensembles may differ by facility based on staff role, required patient interaction, and patient condition, mucous membrane coverage (eyes, nose, and mouth), gloves, and meticulous adherence to safety practices are required. Prioritize avoiding any exposure to blood and body fluids, including sweat, urine, saliva, and tears, and preventing sharps or needle-stick injuries while caring for suspected or confirmed Ebola virus disease (EVD) patients. Use this NETEC matrix to figure out the personal protective equipment (PPE) you should use when caring for a patient with a viral hemorrhagic fever.

Training and education on proper PPE use and safe doffing methods is important and the use of a trained observer to ensure health care worker safety is encouraged. See the CDC’s video guides on how PPE training.

Inform

Inform the charge nurse immediately to initiate the notification process. Notification of a person under investigation should include but is not limited to nurse leaders, infection prevention, providers, and public health authorities. Find state, local, tribal, and territorial health department contact numbers.

Infection Control and Waste Management

Due to their lipid envelope, Ebola viruses are susceptible to a number of cleansers and disinfectants. See the CDC’s list of registered disinfectants for use against the Ebola virus on hard, non-porous surfaces. Waste from Ebola virus disease (EVD) patients is considered Category A waste by the U.S. Department of Transportation and must be handled carefully. A plan for waste handling, secure packaging, and treatment or disposal options should be considered along with staff training. Find summary guidance on managing solid waste contaminated with a Category A infectious substance from the Department of Transportation.

Resources for Health Care Workers

NETEC offers free training, resources, and consultation to help ensure that clinicians can safely and effectively care for patients infected with high consequence pathogens like Sudan ebolavirus.