COMMENTARY

Ebola: A Primary Care Physician's Point of View

Sandra Adamson Fryhofer, MD

Disclosures

September 22, 2014

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Editor's Note: Since the time of taping, the number of Ebola cases has continued to increase. On September 18, 2014, the World Health Organization reported that as of September 14, the total number of probable, confirmed, and suspected cases in West Africa was 5335, with 2622 deaths and an estimated 700 new cases each week. Countries currently affected are Guinea, Liberia, and Sierra Leone, with no new cases reported in Nigeria or Senegal since early September. Additionally, four American patients have now returned to the United States for treatment.

Hello. I'm Dr. Sandra Fryhofer. Welcome to Medicine Matters. The topic: Ebola what you don't know can hurt you. Here is why it matters.

I recently received a travel brochure exploring coastal Africa; cultural and natural diversity of matchless magnitude and unceasing fascination. Inside was a map outlining the journey: Liberia, Sierra Leone. My next thought: Ebola.

Ebola has been designated by the World Health Organization (WHO) as a public health emergency of international concern. This designation was declared for H1N1 in 2009 and the polio resurgence in May of this year. The Centers for Disease Control and Prevention (CDC) has issued a level three travel warning urging all US residents to avoid nonessential travel to Guinea, Liberia, and Sierra Leone. The case of Ebola reported in Nigeria was traced to an infected airline passenger from Liberia. WHO now urges exit screenings at international airports, seaports, and land crossings by countries affected by Ebola.

Ebola is not new. There have been at least 15 outbreaks in sub-Saharan Africa since 1976 but no deaths in West Africa until December 2013 when this current outbreak began.[1]

The incubation period for Ebola is 2-21 days, but CDC says symptoms usually start within 8-10 days after exposure. Early symptoms are nonspecific: fever, headache, sore throat, muscle pain, weakness. Later symptoms include diarrhea, vomiting, and abdominal pain, symptoms that can mimic malaria or typhoid fever. Some that are infected get red eyes and a rash; some patients hemorrhage internally and externally.

There is only one good thing about Ebola. It is not airborne. It is not like flu or tuberculosis. You can only get it from direct contact with infected blood or other bodily fluids, including urine, saliva, feces, vomit, and even semen. An infectious diseases colleague said even exposure to tears should be avoided. You can also get it from contact with contaminated objects, infected animals, bush meat primates, forest antelope, and wild pigs. Fruit bats are known to carry Ebola, but media reports say that doesn't stop some villagers in West Africa from eating them.

Those at highest risk of contracting infection are the family and close friends of those infected and healthcare workers like Dr. Kent Brantly and Nancy Writebol. I have a clinical appointment at Emory, an institution now famous for its Ebola isolation unit. As for the medical status of these missionaries, I only know what I read or have seen on the news. They are no longer infectious, and they have been discharged from the hospital. The fact that they are still alive is a tribute to history lessons learned and remembered from the early 1900s when the magic bullet, antiserum, was used to treat pneumococcal pneumonia. This historical perspective is chronicled in a recent Annals piece.[2]

A recent JAMA viewpoint[3] says National Institutes of Health-supported phase 1 clinical trials of a new experimental vaccine should begin soon. The CDC website says several different therapies are under study,[4] including ZMapp™ (Mapp Biopharmaceutical Inc.; San Diego, California), received by both Brantly and Writebol, a cocktail of three different monoclonal antibodies. A slew of other companies—Crucell, Profectus Biosciences, Tekmira, BioCryst Pharmaceuticals, NewLink—have potential therapies and vaccines in early development.

Ebola has been around in sub-Saharan Africa for nearly 40 years. Why are we just doing this now? There is a lot that is bad about Ebola, including a reported case fatality rate of 55% or higher. Already more than 1400 individuals have died in this current outbreak.

And there are always bad guys ready to take advantage of a bad situation. The US Food and Drug Administration has just released a warning[5] to consumers about fraudulent treatments for Ebola being sold online.

To me, one of the scariest things about Ebola is that initial symptoms are so nonspecific. If you don't know a person is infected, you might not take appropriate precautions. So what you don't know can really hurt you.

CDC recommends negative pressure rooms for patients with suspected or confirmed Ebola. CDC has also issued guidelines[6] for protecting hospital personnel based on 40 years of experience caring for Ebola patients.

Here is what they recommend:

 • A flu-impermeable gown, gloves, a surgical mask, and either goggles or a face mask.

 • Leg and shoe coverings are recommended if caring for a patient with copious secretions.

 • For aerosol-generating procedures, CDC recommends an N95 mask.

A recent Annals article[7] says that many hospitals are going way beyond what CDC recommends and specifying hazmat suits along with N95 mask or powered air purifying respirators in their infection control plans. The authors' concern is that this could hinder patient care and also lead to self-contamination by hospital personnel during removal because they are unfamiliar with this kind of protective gear.

CDC reassures us that Ebola poses no substantial risk to the US general population. Still, it is out there. Many people are dying. We need reliable treatments, and we need a vaccine now.

For Medicine Matters, I'm Dr. Sandra Fryhofer.

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