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A1 Ebola in the United States: Are We at Risk of an Epidemic?
Student Network Resources
October 27, 2014
The United States is collectively experiencing its worst health scare in over a century, as Americans are panicking about the fact that the deadly Ebola virus has come to the U.S. While there is no doubt that the idea of contracting Ebola is terrifying, given that the survival rate for the disease is only around 50% and that it causes horrific damage to its victims, the level of hysteria about the disease is disproportionate to the actual threat that Ebola currently poses to the U.S. population. While Ebola is an epidemic and threatening to become a pandemic in much of Western Africa, it is important to keep in mind that conditions vary dramatically from Africa to the United States. Western Africa, particularly Liberia, does not have a reliable well-established healthcare service for its citizens, so that treatment of the ill has often been confined to home-based efforts, which increase the risk of exposure to family members and other care providers. These family members and care providers must then interact with the community, spreading the infection. Coupled with that is a general lack of education about Ebola, in general, and infectious diseases, in particular, which can make it difficult to enforce common safety precautions that could halt the spread of the disease. Although Ebola is a frightening disease and has spread from person-to-person in the United States, living conditions in the United States are not conducive to the type of epidemic that is currently plaguing western Africa. A3
A4 What is Ebola?
Ebola is a severe, often fatal illness in humans. It is transmitted from wild animals to people, usually beginning with the consumption of bush meat. The virus can then spread through the human population. The average fatality is around 50%, though fatality has varied from 25% to 90% in past outbreaks A5 (WHO, 2014). The disease has a variable incubation period, which can last from 2 to 21 days, but people are not considered infectious until symptom development (WHO, 2014). Symptoms include fever, fatigue, muscle pain, headache, and sore throat, which can make it difficult to distinguish Ebola from other common illnesses, such as flu or even the common cold. Then the patient develops severe symptoms including vomiting, diarrhea, rash, impaired organ function, and possible internal and external bleeding (WHO, 2014). While symptoms can indicate a possible case of Ebola, they are not diagnostic. Diagnosis can be confirmed using a variety of laboratory tests including: antibody-capture enzyme-linked immunosorbent assay (ELISA), antigen-capture detection tests, serum neutralization tests, reverse transcriptase polymerase chain reaction (RT-PCR) assay, electron microscopy, and virus isolation by cell culture (WHO, 2014).
Human-to-Human Transmission of Ebola
Ebola is considered an infectious disease, not a contagious disease. Ebola is not an airborne disease. Instead, it is spread through direct contact with the blood, secretions, organs or bodily fluid of infected people, whether on the person or on surfaces (WHO, 2014). Ebola patients remain infectious after death, so that handling of dead bodies as well as any surfaces or materials that came into contact with Ebola patients can be a source of infection (WHO, 2014). Moreover, people who recover from Ebola remain infectious for a significant time period after recovery; as long as Ebola remains in the bodily fluids, the person is contagious, and it is transmitted via breast milk and semen (WHO, 2014).
Prevention and Control of Ebola Transmission
In the United States, containment is the primary way to prevent and control the spread of Ebola, since the risk is from human-to-human transmission not animal-to-human transmission, as it is in parts of Africa. If caring for an ill patient at home, all caregivers should wear full protective gear, and engage in regular hand washing. Burial practices that involve touching or handling the corpse should be discouraged. Those exposed to Ebola should be monitored for the 21 day incubation period to ensure that they are not infected.
The biggest challenge for prevention and control is in the healthcare setting. Standard precautions with all patients should help reduce transmission in the healthcare environment, however staff treating Ebola patients should go beyond standard precautions:
Health-care workers caring for patients with suspected or confirmed Ebola virus should apply extra infection control measures to prevent contact with the patient’s blood and body fluids and contaminated surfaces or materials such as clothing and bedding. When in close contact (within 1 metre) of patients with EBV, health-care workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures). Laboratory workers are also at risk. Samples taken from humans and animals for investigation of Ebola infection should be handled by trained staff and processed in suitably equipped laboratories (WHO, 2014).
Treatment of Ebola
At the present time, treatment for Ebola is generally supportive care. Keeping the patient hydrated with oral or intravenous fluids, and treating individual symptoms can increase survival rights. There are no established treatment protocols for Ebola, but there are several experimental treatments and there are currently vaccines in development. Some patients have recovered after treatment with experimental medications or therapies, but these may not be available in sufficient quantities to treat an actual outbreak of the disease.
Ebola in the United States
Though most Americans are focused on Thomas Duncan, the first non-American to come to the United States with an Ebola infection, the reality is that Ebola first came to the United States in August 2014. On July 27, 2014 to U.S. aid workers were infected with Ebola while working with patients in Liberia. On August 2, 2014, Dr. Kent Brantly became the first person to come to the United States with Ebola. On August 5, 2014, Nancy Writebol was also transported to the United States. Both of them were transported to Emory Hospital in Atlanta (New York Daily News, 2014). On August 19, Writebol tested negative for Ebola and on August 21, Brantly tested negative for Ebola; both of them were considered successfully treated and were discharged from the hospital (New York Daily News, 2014). There were no secondary infections at Emory as a result of them being treated at that hospital, and no further introductions of Ebola into the country for another month. However, the Ebola epidemic in Western Africa, which had seemed to be getting under control, experienced a resurgence in early August. On August 8, 2014, the World Health Organization (WHO) declared it the worst Ebola outbreak ever (New York Daily News, 2014).
On September 20, 2014, Thomas Eric Duncan arrived in Dallas from Liberia. He was asymptomatic at the time he got on the plane and upon arrival in the United States. He began to feel ill on September 24, 2014, which is when he became infectious. On September 26, 2014, Duncan went to Texas Health Presbyterian’s (THP) emergency room. He was sent home, although he was running a high fever and informed the nurse he had come from Liberia. However, Duncan did not inform the staff that he had been exposed to Ebola. On September 28, 2014, Duncan is transported by ambulance back to THP. He is diagnosed with Ebola on September 29, 2014.
On October 2, 2014, the family members with whom Duncan stayed during his visit are court-ordered to stay indoors after allegedly ignoring requests to stay indoors. On October 3, 2014 a Haz-Mat crew decontaminates the apartment and the quarantined family members are transported to an undisclosed location. On October 8, 2014, Duncan died of Ebola at THP. No family members or others who may have come into contact with him prior to hospitalization had been diagnosed with Ebola as of October 17, 2014, including a police officer who entered the apartment and later presented with symptoms that were consistent with early Ebola symptoms, but were determined to be caused by another illness.
On October 10, 2014, Nina Pham, a nurse at THP who treated Duncan, reported having a fever. She drove herself to THP and was isolated within 90 minutes of her arrival at the hospital. On October 12, 2014, Pham was diagnosed with Ebola. She was the first person to contract Ebola within the United States. As of October 17, 2014, Pham was receiving treatment at THP and was in stable condition. On October 2, 2014, Pham’s dog was transported to an undisclosed location for monitoring for the 21 day incubation period, although Ebola is not believed to be transmitted from humans-to-pets.
On October 13, Amber Vinson, a nurse who treated Duncan at THP, travels from Cleveland to Dallas on Frontier Airlines, despite having a low-grade fever. She was in contact with the Centers for Disease Control (CDC), which approved her taking the flight. On October 14, 2014, Vinson was admitted to THP and was diagnosed with Ebola on October 15, 2014. Vinson was transferred to Emory Hospital for treatment.
Other Cases of Ebola
On October 2, 2014, Ashoka Mupko, an NBC News cameraman in Liberia was diagnosed with Ebola. Mupko was flown to Nebraska on October 6, 2014. As of October 17, 2014 Mupko was responding to treatment and there had been no secondary infections reported as a result of Mupko’s treatment.
What Went Wrong at THP
While it is impossible to know why Pham and Vinson contracted Ebola during their treatment of Duncan, it seems clear that something went wrong with the protective measures that healthcare workers were using in treating Duncan. First, Duncan was sent home with a high fever, despite telling the emergency room staff that he had come from an area with an Ebola outbreak. Second, nurses report that THP’s Ebola procedures were constantly changing and that nurses were expected to work without adequate protective gear (New York Daily News, 2014).
As of October 17, 2014, there were no additional cases of Ebola contracted in the United States. However, people exposed to either of the patients, including passengers that shared a flight with Vinson, are considered to be at-risk of developing the disease and have been asked to report any symptoms immediately. The fact that two patients were successfully treated at Emory without any secondary infections, while two nurses contracted Ebola at THP, strongly suggests that it was THP’s protective and decontamination procedures, which healthcare workers have criticized as inconsistent and ineffective, which contributed to the disease spread. Most officials seem to believe that there will be additional isolated cases of Ebola, which may result in secondary infections, but that, as long as patients report to hospitals for immediate treatment, that there remains virtually no risk of an Ebola epidemic within the United States.
New York Daily News. A7 (2014, October 16). How Ebola made it to the U.S.: a timeline.
Retrieved October 17, 2014 from New York Daily news website: http://www.nydailynews.com/life-style/health/ebola-made-u-s-timeline-article-1.1976007
World Health Organization. (2014, September). Ebola virus disease. Retrieved October 17,
2014 from WHO website: http://www.who.int/mediacentre/factsheets/fs103/en/