Download Ebola Virus Elizabeth Boldon, RN, MSN Elizabeth Boldon is a Nurse

Ebola Virus
Elizabeth Boldon, RN, MSN
Elizabeth Boldon is a Nurse Education Specialist at Mayo Clinic in
Rochester, Minnesota. She received a BSN from Allen College in
Waterloo, Iowa in 2002 and an MSN with a focus in education from the
University of Phoenix in 2008. She has bedside nursing experience in
medical neurology and the neuroscience ICU.
Abstract:
Ebola virus is transmitted by unprotected physical contact with infected
persons. It mostly affects countries outside the U.S. The etiology,
transmission and treatment of Ebola are discussed here. Prevention and
control of the disease include a vigilant public health safety system to
address transmission risks and education of the public regarding personal
hygiene standards and strategies to avoid transmission. Individuals should
be educated on the symptoms of Ebola, and those with an affected family
member informed of methods of protection from disease transmission.
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Continuing Nursing Education Course Director & Planners
William A. Cook, PhD,
Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner
Accreditation Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses.
Credit Designation
This educational activity is credited for 1.5 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this course
activity.
Course Author & Planner Disclosure Policy Statements
It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and
best practice in clinical education for all CNE educational activities. All
authors and course planners participating in the planning or implementation
of a CNE activity are expected to disclose to course participants any relevant
conflict of interest that may arise.
Statement of Need
Eboli is a devastating disease that can be spread through direct unprotected
contact with an infected individual. Preventive measures can help to control
disease spread through an educated healthcare and public sector. Necessary
education includes public sanitization and personal protection to prevent
disease spread.
Course Purpose
To enable nurses to increase their knowledge on the Ebola virus.
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Learning Objectives
1. Describe the etiology of Ebola.
2. Describe the symptoms of the Ebola virus.
3. Explain ways to prevent transmission of the Ebola virus.
Target Audience
Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical
Nurses, and Associates
Course Author & Director Disclosures
Elizabeth Boldon, RN, MSN, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, CGRN, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information:
Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC.
Release Date: 6/17/2015
Termination Date: 6/17/2018
Please take time to complete the self-assessment Knowledge Questions before
reading the article. Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
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1. The following statement is true about diagnosing Ebola:
Diagnosing Ebola in a person who has been infected for only a few
days is difficult because the early symptoms, such as fever, are
nonspecific to Ebola infection.
a. True
b. False
2. The Ebola virus can be spread
a. via insect bites
b. through the air
c. on dry surfaces, such as doorknobs and countertops
d. none of the above
3. On the basis of evidence and the nature of similar viruses,
researchers believe that ________ are the most likely reservoir for
the Ebola virus.
a. humans
b. dry surfaces, such as doorknobs and countertops
c. bodily fluids
d. bats
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4. Healthcare providers should ask patients who present with fever
and/or other symptoms consistent with Ebola virus disease if within
21 days prior
a. they travelled outside North America
b. had contact with a patient with possible Ebola virus disease
c. worked in a hospital setting
d. practice basic hand hygiene
5. Patients who have symptoms consistent with Ebola virus disease
should be evaluated for other possible ______________ diseases
including those that are common in areas where the patient traveled
or resided.
a. hepatitis
b. gastrointestinal
c. electrolyte disturbance
d. febrile
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Introduction
Ebola, previously known as Ebola hemorrhagic fever, is a rare and deadly
disease caused by infection with one of the Ebola virus strains. Ebola can
cause disease in humans and nonhuman primates (monkeys, gorillas, and
chimpanzees).
Ebola is caused by infection with a virus of the family Filoviridae, genus
Ebolavirus. There are five identified Ebola virus species, four of which are
known to cause disease in humans: Ebola virus (Zaire ebolavirus); Sudan
virus (Sudan ebolavirus); Taï Forest virus (Taï Forest ebolavirus, formerly
Côte d’Ivoire ebolavirus); and Bundibugyo virus (Bundibugyo ebolavirus).
The fifth, Reston virus (Reston ebolavirus), has caused disease in nonhuman
primates, but not in humans.1
Ebola viruses are found in several African countries. Ebola was first
discovered in 1976 near the Ebola River in what is now the Democratic
Republic of the Congo. Since then, outbreaks have appeared sporadically in
Africa.
The natural reservoir host of Ebola virus remains unknown. However, on the
basis of evidence and the nature of similar viruses, researchers believe that
the virus is animal-borne and that bats are the most likely reservoir. Four of
the five virus strains occur in an animal host native to Africa.1
What Is Ebola?
The Ebola virus (which is related to the Marburg virus) causes hemorrhagic
fevers and is marked by severe bleeding (hemorrhage), organ failure and, in
many cases, death.
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The Ebola virus lives in animal hosts, and humans can contract the virus
from infected animals. After the initial transmission, the virus can spread
from person to person through contact with body fluids or contaminated
needles.
No drug has been approved to treat Ebola virus. People diagnosed with Ebola
virus receive supportive care and treatment for complications; however,
scientists are coming closer, to developing vaccines for this deadly disease.
The Centers for Disease Control and Prevention (CDC) monitors the United
States for conditions such as Ebola infection, and its laboratories can test for
the Ebola virus.2
People get Ebola by direct contact (through broken skin or mucous
membranes in the eyes, nose, mouth, etc.) with the following:1

blood or body fluids (including but not limited to urine, saliva, sweat,
feces, vomit, breast milk, and semen) of a person who is sick with or
has died from Ebola

objects (like needles and syringes) that have been contaminated with
body fluids from a person who is sick with Ebola or the body of a
person who has died from Ebola

infected fruit bats or primates (apes and monkeys)

possibly from contact with semen (i.e., through oral, vaginal, or anal
sex) from a man who has recovered from Ebola
Symptoms of Ebola
Signs and symptoms typically begin abruptly within days of infection with
Ebola virus. Symptoms may appear anywhere from 2 to 21 days after
exposure to Ebola, but the average is 8 to 10 days.1
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Early signs and symptoms include:

Fever greater than 101.5°F (38.6°C)

Severe headache

Joint and muscle aches

Chills

Weakness

Fatigue

Sore throat

Loss of appetite
Over time, symptoms become increasingly severe and may include:

Nausea and vomiting

Diarrhea (may be bloody)

Red eyes

Raised rash (usually develops by day five to seven and involves the
face, neck, trunk, and arms)

Chest pain and cough

Abdominal or stomach pain

Severe weight loss

Bleeding (people near death may bleed from orifices such as eyes,
ears, nose, mouth and rectum)

Internal bleeding

Unexplained bruising

Vomiting

Neurologic symptoms (such as altered level of consciousness, stiff
neck or seizures, typically present after day ten)

Organ failure
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Recovery from Ebola depends on good supportive clinical care and the
patient’s immune response. People who recover from Ebola infection develop
antibodies that last for at least 10 years.1
Etiology Of Ebola
Ebola virus has been found in African monkeys, chimps and other nonhuman
primates. A milder strain of Ebola has been discovered in monkeys and pigs
in the Philippines. The following section discusses Ebola virus transmission
and how the disease may be spread. This is important for healthcare
workers to understand in order to implement measures of prevention and
control of the spread of disease.
Transmission From Animals to Humans
Experts suspect that the Ebola virus is transmitted to humans through an
infected animal's bodily fluids. Butchering or eating infected animals can
spread the virus. Scientists who have operated on infected animals as part
of their research have also contracted the virus.
Transmission from person to person
Infected people do not become contagious until they develop symptoms.
Family members are often infected as they care for sick relatives or prepare
the dead for burial.
Medical personnel can be infected if they do not use personal protective
equipment (PPE), such as surgical masks and gloves. Medical centers in
Africa are often so poor that they must reuse needles and syringes. Some of
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the worst Ebola epidemics have occurred because contaminated injection
equipment was not sterilized between uses.
There is no evidence that Ebola virus can be spread via insect bites and it is
not spread through the air.2 Ebola virus on dry surfaces, such as doorknobs
and countertops, can survive for several hours. When it is in body fluids
(such as blood), the virus can survive up to several days at room
temperature. Ebola virus is killed with hospital-grade disinfectants or
household bleach.3
Risk Factors for Ebola
For most people, the risk of getting Ebola virus is low. The risk increases if a
person is exposed to the following environmental and situational factors.

Traveling to affected areas of West Africa
There is increased risk for those who visit or work in areas where
Ebola virus outbreaks have occurred. Past Ebola outbreaks have
occurred in the following countries:
o Democratic Republic of the Congo (DRC)
o Gabon
o South Sudan
o Ivory Coast
o Uganda
o Republic of the Congo (ROC)
o South Africa
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The 2014 outbreak in several countries in West Africa (Guinea, Sierra
Leone and Liberia) was the largest in history. The fatality rate for those
with Ebola in this outbreak was close to seventy percent.

Conducting animal research
People are more likely to contract the Ebola virus if they conduct
animal research with monkeys imported from Africa or the Philippines.

Providing medical or personal care for a person with Ebola
Family members are often infected as they care for sick relatives.
Medical personnel also can be infected if they do not use personal
protective equipment (PPE), such as surgical masks and gloves.

Burial preparation for individuals with Ebola
The bodies of people who have died of Ebola are still contagious.
Helping prepare these bodies for burial can increase the risk of
developing the disease.2
Prevention And Control Of Ebola
Good outbreak control relies on applying a package of interventions, namely
case management, surveillance and contact tracing, a good laboratory
service, safe burials and social mobilization. Community engagement is the
key to successfully controlling outbreaks. Raising awareness of risk factors
for Ebola infection and protective measures that individuals can take is an
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effective way to reduce human transmission. Risk reduction should focus on
several factors:4

Reducing the risk of wildlife-to-human transmission
Avoid contact with infected fruit bats or monkeys or apes and the
consumption of their raw meat. Animals should be handled with gloves
and other appropriate protective clothing. Animal products (blood and
meat) should be thoroughly cooked before consumption.

Reducing the risk of human-to-human transmission
Avoid direct or close contact with people with Ebola symptoms,
particularly with their bodily fluids. Gloves and appropriate personal
protective equipment should be worn when taking care of ill patients at
home. Regular hand washing is required after visiting patients in
hospital, as well as after taking care of patients at home.

Reducing the risk of possible sexual transmission
Because the risk of sexual transmission cannot be ruled out, men and
women who have recovered from Ebola should abstain from all types
of sex (including anal and oral sex) for at least three months after
onset of symptoms. If sexual abstinence is not possible, male or
female condom use is recommended.
Contact with body fluids should be avoided and washing with soap and
water is recommended.
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
Outbreak containment measures
These measures include prompt and safe burial of the dead, identifying
people who may have been in contact with someone infected with
Ebola and monitoring their health for 21 days, the importance of
separating the healthy from the sick to prevent further spread, and the
importance of good hygiene and maintaining a clean environment.
Healthcare workers should always take standard precautions when caring for
patients, regardless of their presumed diagnosis. These include basic hand
hygiene, respiratory hygiene, personal protective equipment use (to block
splashes or other contact with infected materials), safe injection practices
and safe handling of deceased patients.
When caring for patients with suspected or confirmed Ebola virus, healthcare
workers should apply extra infection control measures to prevent contact
with the patient’s blood and body fluids and contaminated surfaces or
materials such as clothing and bedding. Additionally, when in close contact
(three feet) of patients with Ebola, healthcare workers should wear face
protection (a face shield or a medical mask and goggles), a clean, nonsterile long-sleeved gown, and gloves (sterile gloves for some procedures).
More specific information (including videos) on the use and application of
various PPE can be found on the CDC website.1
Laboratory workers are also at risk. Samples taken from humans and
animals for investigation of Ebola infection should be handled by trained staff
and processed in suitably equipped laboratories.
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Complications Of Ebola
The Ebola virus leads to death for a high percentage of people who are
affected. As the illness progresses, it can cause the following conditions:

Multiple organ failure

Severe bleeding

Jaundice

Delirium

Seizures

Coma

Shock
One reason the virus is so deadly is that it interferes with the immune
system's ability to mount a defense. Researchers do not fully understand
why some people recover from Ebola and others do not.2
For people who survive, the recovery is slow. It may take months to regain
weight and strength, and the viruses remain in the body for weeks. These
people may experience:

Hair loss

Sensory changes

Liver inflammation (hepatitis)

Weakness

Fatigue

Headaches

Eye inflammation

Testicular inflammation
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Some patients develop secondary complications related to their disease
and/or the treatments they receive. These include bacterial sepsis,
respiratory failure associated with aggressive fluid resuscitation, and/or lung
and kidney injury.3
Diagnosis Of Ebola
Although there are no approved specific therapies for Ebola virus disease, it
is essential to make the diagnosis as early as possible in order to initiate
supportive measures before the development of irreversible shock, and to
institute infection control procedures. Thus, providers should ask patients
who present with fever and/or other symptoms consistent with Ebola virus
disease whether they have travelled to the epidemic area or had contact
with a patient with possible Ebola virus disease within 21 days prior to the
onset of symptoms.3
Diagnosing Ebola in a person who has been infected for only a few days is
difficult because the early symptoms, such as fever, are nonspecific to Ebola
infection and often are seen in patients with more common diseases, such as
malaria and typhoid fever. However, a person should be isolated and public
health authorities notified if they have the early symptoms of Ebola and
have had contact with the following:

blood or body fluids from a person sick with or who has died from
Ebola

objects that have been contaminated with the blood or body fluids of a
person sick with or who has died from Ebola

infected fruit bats and primates (apes and monkeys)

semen from a man who has recovered from Ebola
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Samples from the patient can then be collected and tested to confirm
infection.
Ebola virus is detected in blood only after onset of symptoms, most notably
fever, which accompany the rise in circulating virus within the patient's
body. It may take up to three days after symptoms start for the virus to
reach detectable levels. Multiple laboratory tests are used in diagnosis,
depending on the stage of the virus and are represented in the table below.1
Timeline of Infection
Within a few days of symptom onset
Diagnostic Tests Available

Antigen-capture enzyme-linked
immunosorbent assay (ELISA) testing

IgM ELISA

Polymerase chain reaction (PCR)

Virus isolation
Later in disease course or after recovery

IgM and IgG antibodies
Retrospectively in deceased patients

Immunohistochemistry testing

PCR

Virus isolation
Patients with Ebola virus disease typically develop leukopenia,
thrombocytopenia, and serum transaminase elevations, as well as renal and
coagulation abnormalities. Other laboratory findings include a marked
decrease in serum albumin and elevated amylase levels.4 Laboratory findings
are outlined below.
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
Leukopenia
Leukopenia usually presents as lymphopenia, followed by an elevated
neutrophil count. Immature granulocytes and abnormal lymphocytes
may be seen in blood smears.

Thrombocytopenia
Platelet counts are usually in the range of 50,000 to 100,000/microL.
Platelet counts typically reach a nadir around day six to eight of
illness.

Transaminase elevations
Because Ebola virus can cause multifocal hepatic necrosis, blood
chemistry tests usually demonstrate elevated serum aspartate
aminotransferase (AST) and alanine aminotransferase (ALT) levels. As
an example, among 39 patients with confirmed Ebola virus disease in
Sierra Leone, the mean AST and ALT levels were 793 U/L and 257 U/L,
respectively.

Coagulation abnormalities
Prothrombin (PT) and partial thromboplastin times (PTT) can be
prolonged, and fibrin degradation products elevated, consistent with
disseminated intravascular coagulation (DIC). These changes are most
prominent in severe and fatal cases.

Renal abnormalities
Proteinuria is a common finding and renal insufficiency with elevated
blood urea nitrogen and creatinine occurs with progression of illness.
When these findings occur early in the course of illness, they are
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largely due to excessive fluid loss from diarrhea and vomiting without
adequate volume replacement.

Electrolyte abnormalities
Patients may develop significant electrolyte disturbances (i.e.,
hyponatremia, hypokalemia, hypomagnesemia, and hypocalcemia)
secondary to the gastrointestinal manifestations of the disease. Such
individuals may require frequent repletion of electrolytes to prevent
cardiac arrhythmias.
Treatment of Ebola
No U.S. Food and Drug Administration (FDA) approved vaccine or medicine
(i.e., antiviral drug) is available for Ebola. Symptoms of Ebola and
complications 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

Maintaining oxygen status

Maintaining adequate blood pressure

Treating other infections if they occur

Blood transfusions
Patients who present with signs and symptoms consistent with Ebola virus
disease should be immediately assessed to determine their risk of exposure
to Ebola virus.
Infection control precautions should be used for all symptomatic patients
who may have been exposed to Ebola virus. Infection control precautions
should also be used for patients whose risk of exposure is unclear at the
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time of their initial presentation, until a medical evaluation can be
performed.
Testing for Ebola virus should generally be performed for patients who have
symptoms consistent with Ebola virus disease and have had an exposure
that puts them at risk. In addition, they should be evaluated for other
possible febrile diseases including those that are common in areas where the
patient traveled or resided (i.e., malaria, typhoid, influenza).3 By
comparison, asymptomatic individuals who have had a possible exposure to
Ebola should be monitored so that they can be isolated if signs or symptoms
occur; additional restrictions may also be required, depending upon the type
of exposure.3
The specific triage system and type of personal protective equipment (PPE)
used during the initial assessment of a patient with possible Ebola virus
disease may vary depending upon the setting (i.e., emergency department,
ambulatory clinic), risk of transmission in the community (i.e., low versus
high risk), and the patient's clinical symptoms. As examples, medical
facilities, especially those in areas with widespread Ebola transmission,
should designate areas for screening patients. In addition, the types of PPE
that are recommended for healthcare personnel caring for a patient whose
condition is associated with a high risk of direct contact with body fluids
(i.e., presence of vomiting, diarrhea, bleeding) are different from those used
when evaluating a patient who does not present a hazard due to body fluid
exposure. In all settings, only essential personnel who are trained in proper
donning and removal of PPE should interact with the patient.3
In response to the 2014-2015 outbreak in West Africa, the United States
CDC, the World Health Organization (WHO), and other international
organizations provided recommendations for the evaluation and
management of persons who may have been exposed to Ebola virus. Their
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approaches depend upon when the exposure occurred, if the exposure was
high risk or low risk, and whether or not the individual is displaying signs
and symptoms consistent with Ebola virus disease.3
Experimental vaccines and treatments for Ebola are under development, but
they have not yet been fully tested for safety or effectiveness. Recovery
from Ebola depends on good supportive care and the patient’s immune
response. People who recover from Ebola infection develop antibodies that
last for at least 10 years, possibly longer. It is not known if people who
recover are immune for life or if they can become infected with a different
species of Ebola. Some people who have recovered from Ebola have
developed long-term complications, such as joint and vision problems.1
Patients who survive Ebola virus disease typically begin to improve during
the second week of illness. More severe clinical signs and symptoms have
characterized fatal disease early during infection, with progression to multiorgan failure with death typically occurring in the second week.4
Ebola Research and Vaccine Trial
The Sierra Leone College of Medicine and Allied Health Sciences (COMAHS),
the Sierra Leone Ministry of Health and Sanitation (MoHS), and the CDC are
working together on a candidate Ebola vaccine trial in Sierra Leone, which
launched in April 2015.
This study, called the Sierra Leone Trial to Introduce a Vaccine against Ebola
(STRIVE), is designed to assess the safety and efficacy of a candidate Ebola
vaccine (rVSV-ZEBOV) among health and other frontline workers.1
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Summary
In summary, Ebola is a serious and often fatal infection, caused by a virus,
which causes fever, body aches, diarrhea, and sometimes bleeding. The risk
of contracting or coming in contact with someone with the Ebola virus is very
low for anyone outside of West Africa. There is no vaccine for Ebola yet and
no specific treatment, other than supportive care, for the patient’s
symptoms.
Please take time to help the NURSECE4LESS.COM course planners evaluate
nursing knowledge needs met following completion of this course by completing
the self-assessment Knowledge Questions after reading the article.
Correct Answers, page 23.
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1. The following statement is true about diagnosing Ebola:
Diagnosing Ebola in a person who has been infected for only a few
days is difficult because the early symptoms, such as fever, are
nonspecific to Ebola infection.
a. True
b. False
2. The Ebola virus can be spread
a. via insect bites
b. through the air
c. on dry surfaces, such as doorknobs and countertops
d. none of the above
3. On the basis of evidence and the nature of similar viruses,
researchers believe that ________ are the most likely reservoir for
the Ebola virus.
a. humans
b. dry surfaces, such as doorknobs and countertops
c. bodily fluids
d. bats
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4. Healthcare providers should ask patients who present with fever
and/or other symptoms consistent with Ebola virus disease if within
21 days prior
a. they travelled outside North America
b. had contact with a patient with possible Ebola virus disease
c. worked in a hospital setting
d. practice basic hand hygiene
5. Patients who have symptoms consistent with Ebola virus disease
should be evaluated for other possible ______________ diseases
including those that are common in areas where the patient traveled
or resided.
a. hepatitis
b. gastrointestinal
c. electrolyte disturbance
d. febrile
Correct Answers:
1. a
2. c
3. d
4. b
5. d
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REFERENCE SECTION
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1. Ebola (Ebola Virus Disease) (2015). Centers for Disease Control and
Prevention. Retrieved June 11, 2015 from www.cdc.gov
2. Ebola Virus and Marburg Virus. (2014). Mayo Foundation for Medical
Education and Research. Retrieved June 11, 2015 from
www.mayoclinic.org
3. Bray, M. & Chertow, D.S. Clinical manifestations and diagnosis of Ebola
virus disease in Hirsch, M.S. (Ed.), UpToDate. Waltham, Mass.:
UpToDate. Retrieved from www.uptodate.com
4. Ebola Virus Disease. (2015). World Health Organization. Retrieved June
11, 2015 from www.who.int
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