Course Management of Prevalent Infections in Children Following a Disaster

The 2014 Ebola Virus Disease (EVD) outbreak in West Africa underscored the importance of preparedness, pre-planned response, and mitigation of infectious and contagious diseases. EVD demonstrated that poorly-resourced African countries, with unprepared, fragile, and strained healthcare systems, were particularly susceptible and crippled by the outbreak. Repeat outbreaks and a possible global pandemic is still a reality.

Epidemiology

EVD was discovered in the former republics of Zaire and Congo In 1976 by World Health Organization scientists. There have been approximately 20 outbreaks since its discovery, mostly clustered in sparsely populated towns and villages in Central Africa.2 The 2014 EVD West African outbreak occurred in densely populated urban areas in West Africa. Ultimately, EVD caused over 27,000 cases and claimed over 11,000 lives, and nearly cascaded into a global pandemic.1 The overall social, economic, and public health toll were incalculable. It is estimated that the nations of Liberia, Guinea, and Sierra Leone will take approximately 10 years to return to their pre-Ebola state.

Pathogenesis and Transmission

Five species of virus, of the family Filoviridae, have been identified that cause Ebola Virus Disease; Zaire, Bundibugyo and Sudan ebolaviruses have been associated with outbreaks in Africa. Ebolavirus is transmitted through bodily fluids. The natural host of ebolavirus is wild animals, including fruit bats. Traditional practices, i.e. the consumption of undercooked infected bush meat, is believed to be a frequent cause of EVD in humans. Human-to-human transmission is through direct contact in which infected bodily fluids transmit ebolavirus. The mean incubation period is 5 days (range: 2-21 days).4 As the viral burden increases in a human, the human becomes more clinically symptomatic, and more infectious; an infected person is most contagious upon death, and corpses can harbor live ebolavirus for weeks. It should be emphasized that humans are not infectious until they develop symptoms. This places healthcare workers at particularly high risk for EVD during routine patient care. It also places family members, caretakers off ill, and handlers of corpses at highest risk of catching EVD.

Clinical Syndrome

EVD is characterized by a non-specific or constitutional illness, most similar to a viral illness. Its clinical syndrome includes fever (87.1%), fatigue (76.4%), loss of appetite (64.5%), vomiting (67.6%), diarrhea (65.6%), headache (53.4%), and abdominal pain (44.3%).3 EVD symptoms overlap considerably with influenza and malaria, and may be confused with typhoid fever and meningitis. It should be noted that hemorrhage occurs in less than 20% of cases, but is more likely to predict death. Bleeding, if present, occurs mostly in GI and respiratory mucosa, and at the site of intravenous punctures. Hence, it may cause hemoptysis and hematochezia.

Screening and Quarantine

Because Ebola virus is spread through contact with the body fluids of infected, symptomatic patients, transmission can be stopped by a combination of early diagnosis, contact tracing, patient isolation and care, infection control, and safe burial.3 In healthcare settings, it is critical that a form of non-contact screening be performed of all patients arriving at the healthcare facility. In the 2014 West African outbreak, this was best accomplished using infrared no contact temperature sensors and screening questions, performed with a minimum separation of 3-feet between healthcare provider and patient. A positive screen for EVD includes fever, contact with a person with EVD, and/or travel to an endemic area. Ebolavirus may be confirmed by polymerized chain reaction (PCR) or enzyme-linked immunosorbent assay (ELISA) testing. Patients who screen positive should be quarantined to assess development of clinical symptoms, and/or repeat confirmatory testing.\( ^{4} \)

Treatment

As of early 2015, no specific cure, or vaccine exists for ebolavirus infection in humans. The standard and hallmark of care is supportive therapy. This includes basic acute and resuscitative care, including: hydration, electrolyte repletion (if vomiting or diarrhea), fever control, and physical safety for altered patients. It is critical that healthcare workers adhere to strict personal protective equipment guidelines set forth by international health agencies. Further, they should minimize performance of any potentially “risky” procedures e.g. intravenous insertions or blood draws, or avoid spreading ebolavirus through nebulizer treatments, positive pressure ventilation, or leakage of infected bodily fluids.3 Of note, healthcare workers faced disproportionately higher rates of infection and death than the general population, speaking to their particular vulnerability, need for education and personal protection. \( ^{1} \)\( ^{,} \)\( ^{4} \)

Healthcare System Management of Ebola

EVD directly threatens patients, healthcare workers, healthcare systems, communities, and  nations. It is a considerable public health threat, and by all accounts, outbreaks of EVD in low-resource settings are a healthcare disaster in their own right. Healthcare systems need to prepare and plan by developing disease surveillance systems to monitor and contain small outbreaks before they spread. Facilities need to have pre-planned procedures and researched drills for how to secure additional resources, use personal protective equipment, and how to re-configure their physical spaces (to quarantine and observe suspected cases, and separately treat confirmed or probable cases, while protecting healthcare workers and the general public). Outbreak containment measures, such as mandatory safe burials by specialist burial teams, are essential.4 Communication, through sustained community engagement, also proved to be a successful method of disseminating public health information during the West Africa outbreak. \( ^{4} \)