The mainstay of treatment for viral hemorrhagic fevers in the ED begins with initiation of contact isolation of the patient to prevent spread to the healthy. Supportive care involving aggressive intravenous fluid resuscitation to maintain blood pressure, oxygen support as needed, blood products as indicated for DIC, correction of electrolyte abnormalities, including dialysis for renal failure, is the only treatment widely available at this time. In patients who exhibit generalized edema as a result of hypoproteinemia from liver damage and third spacing, serum protein monitoring and replacement is indicated.9
An experimental treatment, ZMapp, which is a monoclonal antibody that is derived from mice and blocks Ebola from entering cells, has recently been used in combination with supportive treatment in six individuals infected with Ebola. However, ZMapp is still in early stages of development and testing is not widely available. No clinical trials have begun, but are planned. Two individuals treated with ZMapp have recovered in the United States; three healthcare workers are recovering in West Africa10,11; and one patient has died. It is not clear whether this medication is responsible wholly or in part for their recovery.
According to Dr Bruce Ribner, Director of Emory University Hospital’s Infectious Disease unit in an interview with Scientific American’s Dina Fine Maron on August 27, 2014, the two patients cared for at Emory have developed immunity to Zaire Ebolavirus.11 Continued outpatient monitoring is allowing study to help understand immunity to Ebola, and may lead to further treatment and vaccination development. Thus far, cross-protection against other Ebola viral strains for these recovered individuals is not as robust, indicating that this family of viruses are different enough that recovery from infection with one species may not be enough to confer immunity to a different species exposure. Blood transfusions from recovered patients have been described, but there is no clinical evidence to support any benefit from this therapy at this time.9
Reporting Cases/Specimen Collection
Personal protective equipment is a mainstay in the collection of specimens for viral-specific testing by the CDC, including full-face shield or goggles, masks to cover nose and mouth, gowns, and gloves. For routine laboratory testing and patient care, all of the above PPE is recommended, along with use of a biosafety cabinet or plexiglass splash guard, which is in accordance with Occupational Safety and Health Administration bloodborne pathogens standards.12
Specimens should be collected for Ebola testing only after the onset of symptoms, such as fever (see Table for supplemental information). In patients suspected of having viral exposure, it may take up to 3 days for the virus to reach detectable levels with RT-PCR. Consultation per hospital procedure with the local and/or state health department prior to specimen transport for testing to the CDC is mandatory. Public health officials will help ensure appropriate patient selection and proper procedures for specimen collection, and make arrangements for testing, which is only available through the CDC. The CDC will not accept any specimen without appropriate local/state health department consultation.
Ideally, preferred specimens for Ebola testing include 4 mL of whole blood properly preserved with EDTA, clot activator, sodium polyanethol sulfonate, or citrate in plastic collection tubes stored at 4˚C or frozen.12 Specimens should be placed in a durable, leak-proof container for transport within a facility; pneumatic tube systems should be avoided due to concerns for glass breakage or leaks. Hospitals should follow state or local health department policies and procedures for Ebola testing prior to notifying the CDC and initiating sample transportation.
The Dallas Index Case
Deplaning a flight from Liberia in Dallas, Texas on September 20, this index patient had no outward signs of illness, and thus no reason to cause any health concern. Joining in the community with friends and family, it was not until 4 days later that he reportedly developed a fever. Yet 2 more days passed before this patient initially sought ambulatory care at Dallas Health Presbyterian Hospital Emergency Department, during which time additional close contacts were exposed to infection. After evaluation, antibiotics were prescribed and the patient was released. Though this case is under investigation, according to a CNN report,13 the patient did inform a member of the ED nursing staff of his travel history, but this information was not communicated to the rest of the healthcare team. The presence and recognition of this patient’s travel history with disease symptoms heightens the level of suspicion for the possibility of EVD, and is the cornerstone of patient selection for Ebola testing.14
After the patient was discharged, another 2 days passed, during which time his condition deteriorated at home. Emergency medical services (EMS) transport was summoned to take the patient back to the hospital, expanding exposure to first responders, who appropriately utilized masks and gloves during transport. During this ED visit, his travel history was obtained and communicated, and he was appropriately isolated, supported, and admitted. These are early reported details of the case, and local public health officials continue to work with a team from the CDC to trace, isolate, and monitor all contacts with this patient (including the transporting emergency medical technicians) for evidence of further cases.15