Perception of the Risks of Ebola, Enterovirus-E68 and Influenza Among Emergency Department Patients

Lauren K. Whiteside, MD, MS; Rosemarie Fernandez, MD; Justin Bammer, MD; Graham Nichol, MD, MPH


Western J Emerg Med. 2016;17(4):391-395. 

In This Article


Introduction: Emerging infectious diseases often create concern and fear among the public. Ebola virus disease (EVD) and enterovirus (EV-68) are uncommon viral illnesses compared to influenza. The objective of this study was to determine risk for these viral diseases and then determine how public perception of influenza severity and risk of infection relate to more publicized but less common emerging infectious diseases such as EVD and EV-68 among a sample of adults seeking care at an emergency department (ED) in the United States.

Methods: We included consenting adults who sought care in two different urban EDs in Seattle, WA in November 2014. Excluded were those who were not fluent in English, in police custody, had decreased level of consciousness, a psychiatric emergency, or required active resuscitation. Patients were approached to participate in an anonymous survey performed on a tablet computer. Information sought included demographics, medical comorbidities, risk factors for EVD and EV-68, and perceptions of disease likelihood, severity and worry for developing EVD, EV-68 or influenza along with subjective estimates of the number of people who have died of each virus over the year in the United States.

Results: A total of 262 (88.5% participation rate) patients participated in the survey. Overall, participants identified that they were more likely to get influenza compared to EVD (p<0.001) or EV-68 (p<0.001), but endorsed worry and concern about getting both EVD and EV-68 despite having little or no risk for these viral diseases. Nearly two-thirds (64%) of participants had at-least one risk factor for an influenza-related complication. Most participants (64%) believed they could get influenza in the next 12 months. Only 52% had received a seasonal influenza vaccine.

Conclusion: Perception of risk for EVD, EV-68 and influenza is discordant with actual risk as well as self-reported use of preventive care. Influenza is a serious public health problem and the ED is an important healthcare location to educate patients.


Ebola virus disease (EVD) and enterovirus (EV-68) are uncommon viral diseases in the United States (U.S.). An EVD outbreak in West Africa in 2014 was associated with four confirmed cases of EVD in the U.S. There was also an outbreak of EV-68 among patients with severe respiratory symptoms, resulting in over 1,000 confirmed cases in 49 states from August 2014, to January 2015. During this same time period, influenza activity increased across the country with high levels of outpatient illness and influenza-related hospitalizations especially in older adults.[1] There is concern for diversion of resources toward preparedness for emerging infectious diseases such as EVD and EV-68 in emergency departments (EDs) within the U.S. that are more likely to see patients with seasonal flu.

Influenza poses a serious threat to public health in the U.S.; it causes over 2,000 deaths per year.[2] In August 2014, the Centers for Disease Control and Prevention (CDC) recommended that all adults without a contraindication get vaccinated for seasonal influenza.[3] The perception of influenza severity predicts vaccination uptake.[4] Influenza-like illness can account for significant ED volume during influenza season. However, perception of risk of EVD, EV-68 and influenza among patients in an ED setting remains unknown. We hypothesized that patient perception of risk of these viral illnesses would not correlate with actual individual risk. Furthermore, worry about EVD would not be correlated with risk for influenza-related complications or self-reported vaccination for influenza.

The overall objective of this brief report is to determine how public perception of influenza severity and risk of infection relate to more publicized but less common emerging infectious diseases such as EVD and EV-68. This study was conducted during the 2014–15 winter season and reflects patient opinion during the EVD outbreak.