Health workers need to understand how to respond to patients with, or at risk of, ebola to ensure any isolated cases occurring in the UK do not result in an outbreak
The outbreak of ebola virus disease in parts of West Africa is outpacing efforts to control it. Although the risk of imported ebola in the UK remains low, health workers must be vigilant for patients who develop symptoms after returning from affected countries. Public Health England has updated guidance on identifying and managing patients with ebola in primary and acute settings. Anyone with suspected or confirmed ebola should be identified early and managed following risk assessment and infection control procedures.
Citation: Dix A (2014) Responding to patients at risk of contracting ebola. Nursing Times; 110: 46, 12-14.
Author: Ann Dix is a freelance healthcare journalist.
- This article has been double-blind peer reviewed
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Ebola virus disease is a severe, often fatal, type of viral haemorrhagic fever (VHF), for which there are currently no licensed treatments or vaccines. Since March 2014, there has been an intense and widespread outbreak in West Africa, primarily in Guinea, Liberia and Sierra Leone.
In October, the World Health Organization reported more than 4,900 confirmed deaths across these countries, making it the largest ever known outbreak of the disease (WHO, 2014). Cases have also occurred in Nigeria (Port Harcourt and Lagos) and Senegal (Dakar), but these outbreaks are now under control.
There have been a small number of cases outside West Africa in the US and Spain, the latter involving a nurse who was in contact with a known ebola patient. The UK has had one repatriated nurse treated in London after returning from working in an ebola treatment centre in Sierra Leone who recovered and returned to West Africa.
Public Health England says the risk of imported cases in the UK remains low, but warns health workers to be vigilant for people developing ebola symptoms who have recently been to an affected area (PHE, 2014a). Ebola has an incubation period of 2-21 days and patients do not become infectious until they develop symptoms, usually after 5-7 days. A WHO study of the West African outbreak published in October estimates the average fatality rate to be around 70% (WHO, 2014).
It is difficult to know in the early stages whether a patient has ebola, as symptoms such as fever, headache and muscle pain are similar to those of many other diseases, including flu, typhoid and malaria. However, the disease progresses extremely rapidly and can cause diarrhoea, vomiting, bruising and bleeding (Box 1).
Box 1. Ebola symptoms
- Sudden onset fever, severe headache, joint and muscle pain, sore throat, weakness
- Diarrhoea, nausea and vomiting, stomach cramps, raised rash, red eyes
- Unexplained bruising and bleeding (eyes, nose, gums, ears, bloody stools)
- Failure of liver or kidneys
Source: PHE (2014a)
Clinicians assess patients’ risk of ebola from their symptoms and history, but the disease can only be diagnosed from laboratory tests. The sooner patients receive care, including rehydration and symptomatic treatment, the greater their chances of survival. Severely ill patients need intensive supportive care, including intravenous fluids or oral rehydration.
Ebola infection is contracted through contact with blood and body fluids from an infected person or animal, including after death; it enters the body through broken skin or mucous membranes. This can happen through touching an infected patient or deceased patient’s body, or cleaning up blood or stools, urine or vomit. It can also happen through contact with environments contaminated with an infected person’s fluids, such as soiled clothing, bed linen or used needles.
The likelihood of contracting ebola is considered low unless there has been this type of specific exposure; there is no evidence of ebola transmission through intact skin or through small droplet spread, such as coughing or sneezing (PHE, 2014a).
To minimise the risk to health workers, PHE has updated guidance on identifying and managing patients with ebola, which should be used with updated guidance on managing VHFs (PHE, 2014a).
Initial risk assessment
Staff should identify patients with suspected ebola as soon as possible by asking:
- Has a patient with a fever of over 38°C, or who has had fever in the last 24 hours, come to the UK from an ebola-affected area in the last 21 days?
- Has a patient with fever cared for or been in contact with body fluids, or clinical specimens, from a live or deceased patient or animal known or strongly suspected to have ebola?
If the answer to either question is yes, the patient should be isolated and staff should take appropriate protection measures while the patient is assessed further. Patients who answer yes to the second question, or who have additional symptoms of bruising or bleeding, are high-risk and must immediately be transferred to a hospital isolation room.
Patients in primary care
If patients telephone a GP surgery, walk-in centre or other primary care service, with history and symptoms suggesting the possibility of ebola, staff should advise them to stay at home and wait for assistance.
Primary care centres should clearly display information requesting patients to tell the receptionist on arrival if they are unwell and have returned from an ebola-affected area within the last 21 days. If any patients come into primary care facilities and ebola is suspected, staff should take them directly to an isolated room, preferably cleared of removable items to reduce contamination, and limit any contact with them. Patient assessment should be undertaken without physical contact if possible. As long as the appropriate isolation and infection control measures are taken, there is no need to close waiting areas or the surgery unless the patient has symptoms such as vomiting, diarrhoea and/or bleeding.
Primary care clinicians will work with local infection specialists on further assessment and referral of at-risk patients to the local acute hospital. If ebola or other VHF is suspected, staff should urgently contact the ambulance service to take the patient to hospital, warning both ambulance and hospital staff to take appropriate precautions and take the patient directly to a hospital isolation room.
Hand hygiene is an important infection control measure; ebola virus is not a robust virus, and is readily inactivated, for example, by soap and water or by alcohol.
Staff should prevent use of any rooms occupied by patients with suspected ebola - or any other potentially contaminated areas such as toilets and high-contact surfaces such as door handles - until they are cleaned and decontaminated on the advice of the health protection team, or hospital tests have excluded the possibility of ebola or other VHF.
All waste, including used cleaning equipment, should go into impermeable waste bags. If ebola or another VHF is confirmed, staff should dispose of bags on the advice of the health protection team, who will also review staff contacts with the patient and advise accordingly (PHE, 2014a).
Patients in hospitals
Patients at risk of ebola may be referred to hospital by primary care, transferred by ambulance or walk into accident and emergency. Triage arrangements must quickly identify patients at risk so they can be isolated and assessed, led by a member of the senior medical team (Box 2).
Box 2. Managing Ebola in hospitals
- Patient presents whose symptoms and travel and exposure history suggest ebola
- Isolate in a single room immediately (acute healthcare facilities will have identified the most appropriate rooms in which to manage suspected cases)
- Review VHF risk assessment algorithm and take full history, including travel history, symptoms and contact with persons known or suspected to have ebola (PHE, 2014b). This must be done by a clinician trained in use of and wearing appropriate personal protective equipment (hospitals will have identified and trained groups of staff in use of the necessary PPE, including fluid-resistant coveralls/gowns, gloves, facemask/ respirator and full face protection)
- If ebola is suspected, discuss with local infection specialists. Do not delay relevant diagnostic tests while awaiting test result
- If necessary, the infection specialist should contact imported fever service to discuss testing and further management (PHE, 2014b)
- Contact local health protection team if a patient is being tested for ebola, or there are other public health concerns
Source: Summary guidance for acute trust staff: identifying and managing patients who require assessment for ebola virus disease (PHE, 2014c)
Staff should know their lead for risk assessment and local arrangements. All staff in contact with the patient should wear appropriate personal protection equipment (PPE). Staff must be trained in using and wearing PPE, including how to don and remove it in the correct order and what to do with it after removal.
Based on a VHF risk assessment and the patient’s history and symptoms, clinicians will decide whether ebola is unlikely, or if the patient has a high or low possibility of ebola (PHE, 2014b). This determines the management of the patient, although this can change quickly according to symptoms and the results of diagnostic tests.
If ebola is suspected, samples should be taken for an urgent malaria screen and other diagnostic investigations, as well as sent to a specialist laboratory to test for ebola. A needle-free IV system should be considered to prevent needlestick injuries. Clinical specimens should be transported in suitably sealed containers, and laboratory staff alerted to the possibility of ebola. Specimens should be kept until it is known whether they are VHF positive, in which case they should be autoclaved on site or incinerated as category A waste.
The number of staff in contact with the patient should be restricted, and staff fully informed of all the risks. All staff entering the room must wear suitable PPE and respiratory protective equipment.
If tests are positive, the patient should be immediately transferred to a specialist high-level isolation unit (HLIU). If the result is negative for VHF, testing for other diseases such as malaria should continue (PHE, 2014b).
If VHF is unlikely
Staff should reassess the possibility of VHF if a patient with the relevant exposure history does not improve or develops new symptoms, including:
- Nose bleed;
- Bloody diarrhoea;
- Sudden rise in aspartate transaminase;
- Sudden rise in platelets;
- Clinical shock;
- Rapidly increasing oxygen requirements in the absence of another diagnosis.
If malaria tests are negative and symptoms continue without another diagnosis, the infection consultant may arrange for a VHF screen (PHE, 2014b).
Patients with confirmed VHF
The lead clinician should arrange immediate transfer of the patient to the HLIU by ambulance (unless, in exceptional circumstances, the patient is too ill to be moved). The infection control team should be notified and full public health actions launched. Personal protection worn by HLIU specialist staff depends on arrangements for isolating the patient.
There are two options:
- Completely isolating the patient in a negative pressure chamber (Trexler) within a negative pressure isolation suite. Staff should access the patient through a porthole in a flexible film barrier wearing basic PPE, but no respiratory protective equipment; or
- Isolating the patient within a negative pressure isolation suite with appropriate ventilation system. The risk of exposure to blood and body fluids requires enhanced PPE, including respirator, face visor or goggles, water-repellent coveralls also protecting the head and neck, double gloves and waterproof boots or foot covers.
Specimens should be kept to a minimum and testing undertaken in a dedicated laboratory at the HLIU. Waste must be autoclaved on site or incinerated (category A).
A patient who cannot be moved to the HLIU must be housed in an enhanced single room, preferably with ventilated lobby and en-suite toilet, and away from other patients. Advice on management should be sought from HLIU specialist staff (PHE, 2014b).
Cleaning and decontamination
Staff should follow standard procedures for general cleaning and decontamination of areas used by low-risk patients, and areas used by high-risk or VHF-confirmed patients where there is no visible contamination by blood or body fluids. Otherwise, special procedures should apply (Box 3).
Box 3. Dealing with contaminated areas
The procedure for decontaminating areas contaminated by blood or body fluids of suspected or confirmed VHF patients is as follows:
- Spillages: clean and disinfect wearing appropriate PPE (wear protective footwear for larger spillages)
- Eating utensils and laundry: ideally use disposables
- Toilet facilities: clean and disinfect at least once a day and ideally after each use. Use dedicated commodes with disposable bowls, and disposable bedpans. Solidify contents with high absorbency gel before disposal
- Incinerate or autoclave all waste
Source: PHE (2014b)
Following discharge of patients with VHF, wards must be fumigated after cleaning and disinfecting any visibly contaminated areas. Fumigation must be undertaken by specially trained staff, and the room should be sealed beforehand and nearby patients moved away.
Air outside the room must be monitored to ensure the room is properly sealed. After fumigation, no one should enter the room until levels of fumigant are safe. If this is not possible without opening windows, staff in appropriate PPE, including respiratory equipment, should do this (PHE, 2014b).
Exposure to body fluids
In the case of needlestick injuries, or other accidents where the skin is punctured, staff should encourage bleeding by squeezing and immediately wash with soap and water. Soap and water should also be used where contamination comes into contact with broken skin.
If there is contamination of the eyes, nose or mouth, staff should immediately irrigate the area. Any incident should be reported and the staff member referred urgently to a local infectious disease specialist and occupational health provider (PHE, 2014b).
Caring for deceased patients
If a patient with suspected ebola dies without a definitive diagnosis, diagnostic tests may be needed. If the deceased is in a Trexler isolator, staff with appropriate PPE should take specimens before transferring the body to a leak-proof body bag. If tests are negative for ebola, a post mortem may be required.
Post mortems should not be undertaken on patients known to have died from ebola. If the patient is in an isolator, the body should be transferred into a sealable plastic body bag fitted to the port of the bed isolator. The bag should be sealed, separated from the isolator, labelled high risk and placed in a robust coffin with sealed joints. It should be kept in a separate and identified cold store ready for prompt cremation or burial, and only opened in exceptional circumstances.
If the body of a confirmed or suspected VHF patient is not in an isolator, staff wearing suitable personal and respiratory protection should place it in a double body bag, with absorbent material between each layer. The bag should be sealed, disinfected and labelled high risk, before being placed in a robust coffin with sealed joints.
In all cases, an infection control sheet should be filled out for the funeral director (PHE, 2014b).
Although a serious outbreak of ebola in the UK is considered to be unlikely, it is possible that cases may arise in health workers returning from ebola centres, or asymptomatic travellers from West Africa. All healthcare providers should follow latest guidance to minimise the risk of spread and ensure patients have the best possible chance of survival.
- Ebola is a severe, often fatal, viral haemorrhagic fever, for which there are no licensed treatments or vaccines
- The outbreak in West Africa has resulted in over 4,900 confirmed deaths this year
- Ebola is only transmitted through contact with an infected person’s blood and body fluids; strict infection control procedures can contain the virus
- Anyone with a fever over 38°C, who in the last 21 days has visited ebola-affected countries or had contact with body fluids of an infected person should be isolated
- Nurses should know infection prevention and control measures should ebola be suspected
Public Health England (2014a) Ebola Virus Disease: Managing Patients who Require Assessment in Primary Care.
Public Health England (2014b) Viral Haemorrhagic Fever: ACDP Algorithm and Guidance on Management of Patients.
Public Health England (2014c) Ebola Virus Disease: Identifying and Managing Patients for Assessment in Acute Trusts.
World Health Organization (2014) Ebola virus disease in West Africa - the first 9 months of the epidemic and forward projections. New England Journal of Medicine; 371: 1481-1495.