Date: September 30, 2014

Background

Topic: First Case of Ebola in US

CDC confirmed on September 30, 2014, through laboratory tests, the first case of Ebola to be diagnosed in the United
States in a person who had traveled to Dallas, Texas from West Africa (Liberia). The patient did not have symptoms when
leaving West Africa, but developed symptoms approximately five days after arriving in the United States.
The person sought medical care at Texas Health Presbyterian Hospital of Dallas after developing symptoms consistent
with Ebola. Based on the person’s travel history and symptoms, CDC recommended testing for Ebola. The medical facility
isolated the patient and sent specimens for testing at CDC and at a Texas lab participating in CDC’s Laboratory
Response Network. CDC and the Texas Health Department reported the laboratory test results to the medical center to
inform the patient. Local public health officials have begun identifying close contacts of the person for further daily
monitoring for 21 days after exposure.
The ill person did not exhibit symptoms of Ebola during the flights from West Africa and CDC does not recommend that
people on the same commercial airline flights undergo monitoring, as Ebola is only contagious if the person is
experiencing active symptoms. The person reported developing symptoms several days after the return flight.
CDC recognizes that even a single case of Ebola diagnosed in the United States raises concerns. Knowing the possibility
exists, medical and public health professionals across the country have been preparing to respond. CDC and public
health officials in Texas are taking precautions to identify people who have had close personal contact with the ill person
and health care professionals have been reminded to use meticulous infection control at all times.
The U.S. public health and medical systems have had prior experience with sporadic cases of diseases such as Ebola. In
the past decade, the United States had 5 imported cases of Viral Hemorrhagic Fever (VHF) diseases similar to Ebola (1
Marburg, 4 Lassa). None resulted in any transmission in the United States.
The CDC will be contacting those who were potentially exposed.
Early recognition is critical to controlling the spread of Ebola virus. Health care providers should be alert for and
evaluate any patients with symptoms consistent with EVD and potential exposure history. Standard, contact, and
droplet precautions should be immediately implemented if EVD is suspected. Guidance for clinicians evaluating
patients from EVD outbreak-affected countries is available at http://www.cdc.gov/vhf/ebola/hcp/clinician-information-ushealthcare-settings.html.

TAKE A TRAVEL HISTORY WITH FEVER TAKE A TRAVEL HISTORY WITH FEVER
Health care professionals in the United States should immediately report to their state or local health department any
person being evaluated for EVD if the medical evaluation suggests that diagnostic testing may be indicated. If there is a
high index of suspicion, US health departments should immediately report any probable cases or persons under
investigation (PUI) to CDC’s Emergency Operations Center at 770-488-7100.
Public Health Terminology for Control of Transmission
Conditional release

Conditional release means that people are monitored by a public health authority for 21 days after the last known potential
Ebola virus exposure to ensure that immediate actions are taken if they develop symptoms consistent with EVD during
this period. People conditionally released should self-monitor for fever twice daily and notify the public health authority if
they develop fever or other symptoms.
Controlled movement
Controlled movement requires people to notify the public health authority about their intended travel for 21 days after their
last known potential Ebola virus exposure. These individuals should not travel by commercial conveyances (e.g. airplane,
ship, long-distance bus, or train). Local use of public transportation (e.g. taxi, bus) by asymptomatic individuals should be
discussed with the public health authority. If travel is approved, the exposed person must have timely access to
appropriate medical care if symptoms develop during travel. Approved long-distance travel should be by chartered flight or
private vehicle; if local public transportation is used, the individual must be able to exit quickly.
Quarantine
Quarantine is used to separate and restrict the movement of persons exposed to a communicable disease who don’t have
symptoms of the disease for the purpose of monitoring.
Self-monitoring
Self-monitoring means that people check their own temperature twice daily and monitor themselves for other symptoms.
Ebola Facts
Transmission
Ebola is spread through direct contact (through broken skin or mucous membranes) with:

blood or body fluids (including but not limited to urine, saliva, feces, vomit, and semen) of a person who is sick
with Ebola

objects (like needles and syringes) that have been contaminated with the virus

infected animals

Ebola is not spread through the air or by water, or in general, food. However, in Africa, Ebola may be spread as a result of
handling bushmeat (wild animals hunted for food) and contact with infected bats.
Healthcare providers caring for Ebola patients and the family and friends in close contact with Ebola patients are at the
highest risk of getting sick because they may come in contact with infected blood or body fluids of sick patients.
Signs and Symptoms
Symptoms of Ebola include
•Fever (greater than 38.6°C or 101.5°F)
•Severe headache
•Muscle pain
•Weakness
•Diarrhea
•Vomiting
•Abdominal (stomach) pain
•Unexplained hemorrhage (bleeding or bruising)
Incubation Period
Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days.
Clinical Course

Recovery from Ebola depends on the patient’s immune response. People who recover from Ebola infection develop
antibodies that last for at least 10 years.
Diagnosis
Ebola virus is detected in blood only after the onset of symptoms, usually fever. It may take up to 3 days after symptoms
appear for the virus to reach detectable levels. Virus is generally detectable by real-time RT-PCR from 3-10 days after
symptoms appear.
Ideally, specimens should be taken when a symptomatic patient reports to a healthcare facility and is suspected of having
an Ebola exposure. However, if the onset of symptoms is <3 days, a later specimen may be needed to completely rule-out
Ebola virus, if the first specimen tests negative.
CDC cannot accept any specimens without prior consultation.
Treatment
Symptoms of Ebola are treated as they appear. The following basic interventions, when used early, can significantly
improve the chances of survival:

Providing intravenous fluids (IV)and balancing electrolytes (body salts)

Maintaining oxygen status and blood pressure

Treating other infections if they occur

Some experimental treatments developed for Ebola have been tested and proven effective in animals but have not yet
been tested in randomized trials in humans.

Infection Control
Standard, contact, and droplet precautions are recommended for management of hospitalized patients with known or
suspected Ebola hemorrhagic fever (Ebola HF), also referred to as Ebola Viral Disease (EVD) (See Table below). Note
that this guidance outlines only those measures that are specific for Ebola HF; additional infection control measures might
be warranted if an Ebola HF patient has other conditions or illnesses for which other measures are indicated (e.g.,
tuberculosis, multi-drug resistant organisms, etc.).
In this guidance healthcare personnel (HCP) refers all persons, paid and unpaid, working in healthcare settings who have
the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical
supplies and equipment, contaminated environmental surfaces, or aerosols generated during certain medical procedures.
HCP include, but are not limited to, physicians, nurses, nursing assistants, therapists, technicians, emergency medical
service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees,
contractual personnel, home healthcare personnel, and persons not directly involved in patient care (e.g., clerical, dietary,
house-keeping, laundry, security, maintenance, billing, chaplains, and volunteers) but potentially exposed to infectious
agents that can be transmitted to and from HCP and patients. This guidance is not intended to apply to persons outside of
healthcare settings.
Full recommendations: http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

Evaluation Algorithm
Exposure Level
High Risk
Percutaneous (e.g., needle stick) or mucous
membrane exposure to blood or body fluids of
EVD patient

Clinical Criteria
Fever OR other
symptoms consistent
with EVD without fever

Public Health Actions

Consideration as a probable case

Direct skin contact with, or exposure to blood or
body fluids of, an EVD patient without appropriate
personal protective equipment (PPE)

Medical evaluation using infection control precautions for
suspected Ebola, consultation with public health
authorities, and testing if indicated

Processing blood or body fluids of a confirmed
EVD patient without appropriate PPE or standard
biosafety precautions

If air transport is clinically appropriate and indicated, only
air medical transport (no travel on commercial
conveyances permitted)

Direct contact with a dead body without
appropriate PPE in a country where an EVD
outbreak is occurring

Asymptomatic

If infection control precautions are determined not to be
indicated: conditional release and controlled movement
until 21 days after last known potential exposure

Some Risk of Exposure
Household contact with an EVD patient
Other close contact with an EVD patient in health
care facilities or community settings
Fever with or without
other symptoms
consistent with EVD

Consideration as a probable case
Medical evaluation using infection control precautions for
suspected Ebola, consultation with public health
authorities, and testing if indicated
If air transport is clinically appropriate and indicated, only
air medical transport (no travel on commercial
conveyances permitted)

Asymptomatic or
clinical criteria not met

If infection control precautions are determined not to be
indicated: conditional release and controlled movement
until 21 days after last known potential exposure

No Known Exposure
Having been in a country in which an EVD
outbreak occurred within the past 21 days and
having had no exposures
Fever with other
symptoms consistent
with EVD

Consideration as a person under investigation (PUI)
Medical evaluation and optional consultation with public
health authorities to determine if movement restrictions
and infection control
precautions(http://www.cdc.gov/vhf/ebola/hcp/infectionprevention-and-control-recommendations.html) are
indicated
If movement restrictions and infection control precautions
are determined not to be indicated: travel by commercial
conveyance is allowed; self-monitor until 21 days after
leaving country

Asymptomatic or
clinical criteria not met

No movement restrictions
Travel by commercial conveyance allowed
Self-monitor until 21 days after leaving country

Case Definition for Ebola Virus Disease (EVD)
Person under Investigation (PUI)
A person who has both consistent symptoms and risk factors as follows:
1.Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional
symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND
2.Epidemiologic risk factors within the past 21 days before the onset of symptoms, such as contact with blood or other
body fluids or human remains of a patient known to have or suspected to have EVD; residence in—or travel to—an area
where EVD transmission is active*; or direct handling of bats or non-human primates from disease-endemic areas.
Probable Case
A PUI whose epidemiologic risk factors include high or low risk exposure(s) (see below)
Confirmed Case
A case with laboratory-confirmed diagnostic evidence of Ebola virus infection
Exposure Risk Levels: Levels of exposure risk are defined as follows:
High risk exposures: A high risk exposure includes any of the following:
•Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of EVD patient
•Direct skin contact with, or exposure to blood or body fluids of, an EVD patient without appropriate personal protective
equipment (PPE)
•Processing blood or body fluids of a confirmed EVD patient without appropriate PPE or standard biosafety precautions
•Direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is occurring*
Low risk exposures: A low risk exposure includes any of the following

Household contact with an EVD patient

Brief interactions, such as walking by a person or moving through a hospital, do not constitute close contact

Other close contact with EVD patients in health care facilities or community settings. Close contact is defined as

a. being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or care area for a
prolonged period of time (e.g., health care personnel, household members) while not wearing recommended
personal protective equipment (i.e., standard, droplet, and contact precautions; see Infection Prevention and
Control Recommendations)

b. having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended
personal protective equipment.

No known exposure
Having been in a country in which an EVD outbreak occurred within the past 21 days and having had no high or low risk
exposures
I know this is a lot of info but hope it helps
Questions call Deb McMahan, MD
403-3435