COMMENTARY

After Ebola: Updated Clinical Guidance for US Healthcare Settings

Barbara Knust, DVM, MPH

Disclosures

May 11, 2016

Editorial Collaboration

Medscape &

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Hello. I am Dr Barbara Knust from the Centers for Disease Control and Prevention's (CDC's) Viral Special Pathogens Branch. I am here today to talk to US clinicians about screening patients with possible Ebola virus disease (EVD) and clinical care for patients who have recovered from EVD (also known as EVD survivors).

Screening for EVD

The Ebola situation has changed dramatically for the better in West Africa. Although we have seen sporadic flare-ups in recent months, widespread transmission is now over. This means that we can adjust our screening of patients with recent travel to West Africa. At this time, healthcare facilities in the United States should adjust screening practices for acutely ill patients and do not need to screen patients specifically for EVD. Healthcare facilities should continue to obtain a travel history in triage before completing a full patient evaluation so that appropriate infection control precautions and patient placement can begin promptly.

Signs and symptoms associated with EVD are nonspecific and are similar to many other common causes of febrile illness in returning travelers. In addition to Ebola virus exposure, acutely ill patients who have been in Guinea, Liberia, or Sierra Leone during the previous 21 days should be assessed for conditions listed on the CDC Travelers' Health website (such as Lassa fever, yellow fever, and particularly malaria, which is the most common diagnosis in a febrile traveler returning from West Africa).

EVD Survivors

Let's talk about EVD survivors. There are now thousands of EVD survivors who were discharged after their acute EVD illness and have fully recovered. With the ease of international travel, it is possible that some EVD survivors from West Africa could seek medical care in the United States. Although it is unlikely that most clinicians in the United States will treat EVD survivors, everyone should understand how to safely care for survivors who might present to their practices.

During recovery from EVD, the infection clears from the blood, after which special precautions are no longer needed for patient care. Some survivors, however, have experienced new complications after surviving acute EVD and have reported a range of symptoms, including ocular disease, joint and muscle pain, neurologic symptoms, and extreme fatigue.

Ebola virus can persist for several months after acute infection in organs that are considered "immunologically privileged sites," such as the testes, eye, or central nervous system. In most of these cases, infectious virus has not been found in the blood, meaning virus persistence in these fluids and tissues is unlikely to pose a risk for systemic Ebola virus infection.

Ebola virus or virus RNA have also been detected in the semen of many asymptomatic male survivors for several months after recovery.[1] Testing of semen for the presence of Ebola virus RNA and use of condoms or abstinence are recommended until virus RNA is no longer detected.

In rare cases, survivors have experienced a relapse (recrudescence) of infectious EVD associated with systemic illness. This has been documented in two patients in whom the virus was detected in immunologically privileged sites. One survivor developed symptoms of meningitis many months after recovery from EVD, and Ebola virus was detected in the cerebrospinal fluid (CSF) and to a lesser extent in the blood.[2] Another survivor developed ocular disease after recovery from EVD, and infectious virus was detected in the ocular fluid of the affected eye.[3]

Most people who have completely recovered from EVD can be treated using standard precautions. There is no current evidence that the routine clinical care that involves contact with intact skin, sweat, tears, conjunctivae, saliva, or cerumen of EVD survivors poses any special risk to clinicians. Survivors who do not have neurologic symptoms and who require regional spinal anesthesia or any other lumbar puncture should not pose a risk to clinical staff.

However, survivors with neurologic symptoms who require lumbar puncture or invasive procedures in locations in the body where persistent virus may be present call for extra precautions. Extra precautions are determined on a case-by-case basis and should include:

  • Arranging for expert consultation through the state health department and/or CDC;

  • Assessing the capabilities of your facility to correctly implement infection control precautions;

  • Assessing the readiness of all staff potentially involved in patient care; and

  • Determining appropriate personal protective equipment for the procedure.

Procedures that might result in contact with these body fluids include:

  • Obtaining and handling CSF from an EVD survivor with neurologic symptoms;

  • Performing an invasive ophthalmologic procedure on an affected eye in a patient with ocular disease (such as uveitis or cataract); and

  • Procedures involving exposure to semen, such as infertility evaluations, or performing invasive procedures on the testes, prostate gland, or seminal vesicles.

It is unknown whether Ebola virus may persist in the synovial fluid of survivors. The risk for infectivity from patients with persistent Ebola virus infection in an immunologically privileged site is unknown but appears to be low and is likely to decrease over time. Appropriate infection control practices based on consultation with the state health department and/or CDC should be adhered to until Ebola virus testing is negative.

This guidance will be updated as more information becomes available.

Web Resources

Frequently Asked Questions on Screening for Ebola Virus Disease for Providers, Healthcare Facilities and Health Departments

Interim Guidance for Management of Survivors of Ebola Virus Disease in U.S. Healthcare Settings

Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care

Standard Precautions

Travelers' Health

Ebola Virus Disease: Risk of Exposure

Ebola-Associated Waste Management

Ebola Survivors

World Health Organization Clinical Care for Survivors of Ebola Virus Disease

Ministry of Health and Sanitation, Republic of Sierra Leone: Ebola Virus Disease

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