Download Running head: EBOLA EBOLA Ebola: An Emerging Infectious

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Running head: EBOLA
Ebola: An Emerging Infectious Disease
Lori Rosendale
Ferris State University
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Abstract
Ebola virus is an emerging infectious disease as evidenced by the very high mortality rate and
large number of cases. It was first discovered in 1976 and there have been multiple episodes of
outbreaks since that time. Research shows the Ebola virus is transmitted easily between animals
and humans and humans to humans. The clinical presentation will be evaluated as well as the
diagnosis and treatment of the virus. Factors that promote the spread of the virus will be
investigated and possible ways to contain the virus will be evaluated. Knowledge of the Ebola
virus will be gained and the information may be used to help further the prevention of the disease
process.
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Ebola
Ebola is an emerging infectious disease that for many years has been contained to the
African region. It is only recently that it has begun to spread to other areas and multiple
populations have become at risk. Ebola was first recognized in 1976 in Sudan and Zaire and was
"occurred (Ghazanfar, et al, 2015). It is caused by the Filovirus, which can also cause the
Marburg Hemorrhagic Fever (Veenema, 2013).
This paper will examine the transmission and isolation as well as look at the clinical
presentation of the disease. It will discuss how diagnosis is made and the treatment available for
Ebola. It will analyze the evidence available and discuss what the evidence suggests. Finally, it
will evaluate factors that may promote this disease. Upon completion of this paper, the reader
will have a better understanding of the infectious process of Ebola and the risk of the general
population from this emerging infectious disease today.
Descriptive Summary
Transmission/Isolation
Ebola virus is a member of the Filoviridae family and is composed of “linear, nonsegmented, negative-sense, single-stranded RNA viruses” (Stein, 2014). It is believed that it can
be transmitted through African monkeys, chimpanzees and other non-human primates. It is
transmitted to humans through contact with an infected animal’s body fluids (Mayo Clinic,
2015). While it is unsure exactly which animals transmit the disease, these animals are thought
to be the most likely.
The most common way for transmission of the virus between people is direct contact
with body fluids, blood, organs and bodily secretions (Ghazanfar, et al, 2015). Coming into
contact with an infected person’s urine, feces, semen, vomit, breast milk or mucus could lead to
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infection. It is also possible to become infected through infected needles and syringes
(Ghazanfar, et al, 2015). It is common for people to become infected through direct contact of a
deceased person as well during burial rituals (Ghazanfar, et al, 2015).
The incubation period for the Ebola virus is 2-21 days after infection and a person
continues to be infectious as long as the virus is present in their blood and body fluids
(Ghazanfar, et al, 2015). It is believed that the human immune system is overwhelmed due to
the inflammatory factors and cell damage caused by the virus, which can lead to death due to
septic shock (Kilgore, et al, 2015). If a person has been exposed to someone with Ebola, they
should be quarantined for 21 days to ensure they are not carrying the virus and able to infect
others. After 21 days, if they have not developed the virus, they will likely no develop it at this
point.
Clinical Presentation
Ebola presents itself with a high fever initially, followed by headache, fatigue, sore throat
and muscle pain. As symptoms progress, there is anorexia, nausea, diarrhea, vomiting, rash,
abdominal pain, cough, shortness of breath, postural hypotension, edema, headache, confusion,
and coma (Feldmann & Geisbert, 2011). It is also commonly known to cause hemorrhagic
complications (Stein, 2014). Approximately five to seven days after the onset of symptoms,
some patients also display a maculopapular rash on their trunk and shoulders (Stein, 2014).
During the second week, conditions either get dramatically worse with vascular involvement and
coagulopathy or they begin to improve (Stein, 2014).
Death occurs in approximately 60-90% of cases and is usually a result multi-organ failure
and shock (Feldmann & Geisbert, 2011). There are also metabolic disturbances that occur late in
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the disease process and combined with diffuse coagulopathy, often results in death (Feldmann &
Geisbert, 2011).
Diagnosis
Ebola is often times not diagnosed initially, which can lead to exposure to family and
health care workers. Ebola is usually detectable in the blood three days after symptoms first
appear (CDC, 2014). The following tests are used when a person reports to a health care facility
within just a few days of showing symptoms:

IgM enzyme-linked immune-sorbent assay (ELISA)

Antigen-capture ELISA

Polymerase chain reaction (PCR)

Virus isolation
(CDC, 2014)
When the disease is in the later stages or after a person has recovered, then the IgM and IgG
antibodies are used to determine diagnosis (CDC, 2014). When labs are drawn, it is common to
find leukopenia, thrombocytopenia and elevated liver enzymes (Ghazanfer, et al, 2015).
Treatment
Treatment for Ebola virus is mainly focused on supportive therapy. Supportive therapy is
usually focused on “oral medication, oral fluid rehydration, nutritional supplementation, and
psychosocial support” (Roddy, et al, 2011, p. 792). The oral medications are used to treat
nausea, dyspepsia, anxiety/agitation and pain if needed. If available, intravenous (IV) fluids,
medications and nutrition through a nasogastric (NG) tube are utilized as better options to treat
symptoms and dehydration (Roddy, et al, 2011). In the African countries, it is not unusual for
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malaria and oral antibiotics to be given as well due to not always knowing the exact diagnosis
initially (Roddy, et al, 2011).
While supportive care is essential to recovery, there are some treatments that are being
worked on by researchers to hopefully provide a better treatment option with less of a mortality
rate. These would include using disease-modifying agents and inhibitors of viral replication
(Roddy, et al, 2011). These options are currently being worked on; however, it could be years
before these therapies are available to patients. One factor that poses a problem is with the
disease-modifying agents. They would need to be given within a very short time span of
exposure. This would be feasible with health care workers who would have a better idea of
when they were exposed, but would not be very beneficial in the African countries where
families are not aware of when they were first exposed. Health care workers in this area are also
not always aware soon enough that they have been exposed (Roddy, et al, 2011).
In the United States, there are currently 55 hospitals with Ebola treatment centers (CDC,
2014). There is not an FDA approved medication or vaccine, although these are also in the
process of being researched (CDC, 2014). During an outbreak in Africa during the 1990’s, they
attempted to give a blood transfusion to a person currently experiencing severe symptoms with
blood from a person who had recovered from the virus. This blood contained IgG antibodies, but
not Ebola antigens. All but one person who received the transfusion survived (Mupapa, et al,
1999). It is not completely understood how or why this works, but is also still used as a
treatment option today if it is detected in an area that is capable of providing this level of
treatment (Mupapa, et al, 2011).
One of the main problems with treatment of Ebola, besides the fact that there is not a
vaccine or medication to treat it, is that is often times occurs in areas that are not equipped to
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safely and properly handle the disease. Africa has the fastest rate of spread of the disease
(Yamin, et al, 2015), yet they have poor conditions to treat these patients in. Often times they
are cared for by family members who are not able to take the proper precautions to prevent the
spread of the disease. This contributes to the wide spread that occurs in poverty stricken
countries (Yamin, et al, 2015).
Analysis of Evidence
Critical Appraisal of the Evidence
The evidence showing that Ebola has become an emerging infectious disease is very
strong. The most recent outbreak started in 2014 and as of February 4, 2015, there have been a
total of 22,500 confirmed or suspected cases of Ebola with over 9,000 deaths (World Health
Organization, 2015). These numbers show the devastating effects that this disease can have on
the general population.
Reviewing the evidence for the transmission of Ebola, it is not as clear cut as the other
evidence. While it is known that Ebola can be passed between people through infected body
fluids, it is not known exactly where the original source comes from. It is suspected that it
comes from monkeys, chimpanzees and other non-human primates (Mayo Clinic, 2015), but it
has not been confirmed exactly how they contract the disease to spread it. There is very strong
evidence showing the type of virus it is and it has been isolated in the laboratory setting. By
having this information, it allows researchers the ability to work on creating vaccines and
medications that will hopefully one day be able to treat Ebola.
The clinical presentation for Ebola is very well presented in the research. Studies have
been done on many Ebola patients and it has been noted the main symptoms as well as the main
cause of death. From the research provided by many different scientists, the knowledge of the
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disease process can assist health care workers when treating patients with Ebola and allow them
to better meet their needs. Since it is known of the hemorrhagic capabilities of this disease,
providers can be better prepared and attempt to keep the patient hemodynamically stable and
hydrated at the same time. The anticipated loss of fluids and metabolic shift can be treated
before it even happens.
As the literature suggests, diagnosing Ebola can be more difficult in poverty stricken
countries. As research shows, many of the areas do not have adequate hospital settings or
laboratories to run the test in. Often times, they are treated with malaria drugs also, since they
can’t differentiate initially. Research has been done to try and find ways to better diagnose
Ebola and improve treatment time. As discussed in a study by Issah, et al (2015), 17 cases
presented to the hospital and not one of them was immediately detected as Ebola. They were not
treated as Ebola until after many health care workers had been exposed to the body fluids. This
research shows the need for improvement in diagnostic techniques at many hospitals. Based on
this research, it was determined that an effective disease surveillance system is needed to prevent
and respond to Ebola cases (Issah, et al, 2015).
Research has proven that treatment of Ebola has improved and even poverty stricken
countries are improving the care they are able to provide to the patients. Research has provided
evidence that supportive care has recently been improved to include intravenous therapy (Roddy,
2011). Prior to research showing the importance and benefits of IV therapy, many clinicians
were reluctant to utilize this as it has the potential to put them an in increased risk of contracting
Ebola in the event of a needle stick or exposure to blood. Based on research, by using proper
isolation techniques, providers have decreased their risk of infection and improved the overall
outcome for patients.
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What Does This Evidence Suggest?
This evidence suggests that the diagnostic techniques used in some African countries
need to improve and take place at a more rapid rate. The facilities need to be able to run the tests
and have the proper equipment available to perform the diagnostic testing. There needs to be
improved facilities in these areas and improved health care conditions. There are many foreign
workers going into these areas which help provide more resources, but without the improved
facilities, they are still struggling to improve the outcomes.
The research also shows that improved treatment has improved the outcome of the
disease. “The provision of intravenous volume replenishment is a cornerstone of effective sepsis
treatment” (Roddy, et al, 2011). There needs to be continued research to determine the
relationship between supportive care and clinical outcome and ways to improve the overall
outcomes.
One major area the research reflects on is the lack of knowledge regarding the
transmission of the disease from the original source. It has been proven how it can be transferred
from animals to humans and from humans to humans, but it still lacks the original source of the
animals becoming infected. Without this information, this is limited knowledge to stop this
disease process. It is crucial to determine the original source in order to suppress this emerging
disease.
Factors that May Promote Ebola
Biological
Ebola presents as a very real, yet scary disease to use as a biological weapon. Due to the
high infection rate, being easily transmittable, ability to risk public health and the high mortality
rate, it has the possibility of being utilized as a biological weapon (Veenema, 2013). It could be
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spread through droplet or aerosol and there have been reports of both the Soviet Union and the
United States studying and working with these as potential weapons (Veenema, 2013). At this
point, Ebola has not been used as a biological weapon although the threat of it is very real.
Environmental
Environmental factors are more difficult to determine with the Ebola virus. One of the
biggest environmental risks would be if a laboratory that is working with this virus had some
type of environmental accident that resulted in the virus being released into the air. This would
most likely on affect those working within the area and not necessarily the general public.
Although, once a person became infected as a result of this accident, it would put others at risk
due to exposure to the infected person.
Societal
Societal factors are a major risk for promoting the Ebola virus. In areas where the
disease is widespread, living in close physical contact and caring for infected individuals is a
major way for the disease to be spread and promoted. The lack of personal protective equipment
in households has many people becoming contaminated. The burial rituals also pose a risk and
many have become infected as a result of handling a deceased body for the burial rituals (Stein,
2014). According to research done by Yamin, et al (2015), it has been shown that the number of
secondary cases that have resulted from caring for an infected individual varies depending on the
phase of the disease and the outcome of the infected individual. It was shown that contact with
an infected person who did not survive resulted in the highest incidence of spreading the disease
(Yamin, et al, 2015).
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Behavioral
Behavioral factors can play a large role in promoting the Ebola virus. Often, people who
have been exposed to an infected individual continue to travel and leave the area in which they
currently reside. Many people travel from one area to another and this promotes the spread of
the disease. According to research, “2-8 patients are exported from the three major Ebolainfected countries in Africa monthly” (Ghazanfar, et al, 2015). This prevents a great risk to other
countries when these patients are exported. It is believed that there should be screening at all the
export portals of these three countries to help contain the Ebola virus (Ghazanfar, et al, 2015).
Another example of a behavioral factor would be not taking the proper precautions when
caring for an infected individual. The importance of using proper personal protective equipment
is vital and needs to be followed when caring for an infected individual. Behavioral factors such
as “disorganized health systems, poor personal hygiene practices and false beliefs and stigma
related to EVD” (Ghazanfar, et al, 2015) have attributed to the promotion of the Ebola virus as
well. With improved healthcare, improved resources and improved knowledge of the disease,
the Ebola disease could potentially be managed and outcomes improved.
Conclusion
Ebola virus is an emerging infectious disease as evidenced by the increased number of
cases and the severe mortality rates. The original route of transmission is unknown, although it
can be transmitted from animals to humans and between humans. It presents with severe clinical
symptoms and often ends in death. It can be diagnosed through a variety of lab tests, but is
generally not detected until at least day three of symptoms. Treatment consists of supportive
treatment only and there is not a medication or vaccine that is successful at curing Ebola.
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Ebola is easily transmitted and there are multiple factors that promote the spread of the
disease. Until there are more resources available to help the underdeveloped countries diagnose
and treat the disease, it will continue to be a wide spread disease. Many areas do not have the
resources available to them to effectively treat Ebola patients and as a result, the disease is
spread to many others through lack of proper treatment or handling of Ebola infected patients.
Obtaining more resources and better health facilities will provide a way to contain the
spread of Ebola. Funding needs to be given to researchers who continue to work to study the
disease process and develop medications or vaccines to treat and prevent the infection. Until that
becomes a reality, education needs to be a main priority to underdeveloped areas and assistance
provided to help them better treat and contain the disease. As long as there are areas that do not
have the proper resources to handle this disease, Ebola will continue to be an emerging infectious
disease.
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References
Centers for Disease Control and Prevention (2014). Ebola diagnosis. Retrieved from:
http://www.cdc.gov/vhf/ebola/diagnosis/index.html
Centers for Disease Control and Prevention (2014). Ebola treatment. Retrieved from:
http://www.cdc.gov/vhf/ebola/diagnosis/index.html
Feldmann, H & Geisbert, T.W. (2011). Ebola haemorrhagic fever. Lancet, 849-862
Ghazanfar, H, Orooj, F, Abdullan, M.A, Ghazanfar, A. (2015). Ebola, the killer virus. Infectious
Diseases of Poverty, 4(15). Doi: 10.1186/s40249-015-0048-y
Issah, K, Nartey, K, Amoah, R, Bachan, E.G, Aleeba, J, Yeetey, E & Letsa, T. (2015).
Assessment of the usefulness of integrated disease surveillance and response on
suspected Ebola cases in the Brong Ahafo Region, Ghana. Infectious Diseases of Poverty,
4(17). Doi: 10.1186/s40249-015-0051-3
Kilgore, P.E, Grabenstein, J.D, Salim, A.M, & Rybak, M. (2015). Treatment of the Ebola virus
disease. Pharmacotherapy, 35, 43-53. Doi: 10.1002/phar.1545
Mayo Clinic (2015). Ebola virus & Marburg virus: causes. Retrieved from:
http://www.mayoclinic.org/diseases-conditions/ebola-virus/basics/causes/con-20031241
Mupapa, K, Massamba, M, Kibadi, K, Kuvula, K, Kupasa, M, Colebunders, R & MuyembeTamfum, J. (1999). Treatment of Ebola hemorrhagic fever with blood transfusions from
convalescent patients. The Journal of Infectious Diseases, 179. Doi: 10.1086/514298
Roddy, P, Colebunders, R, Jeffs, B, Palma, P.P, Van Herp, M & Borchert, M. (2011). Filovirus
hemorrhagic fever outbreak case management: a review of current and future treatment
Stein, R.A. (2014). What is Ebola? The International Journal of Clinical Practice, 69 (1), p. 4958. Doi: 10.1111.ijcp.12593
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Veenema, T.G. (2013). Disaster Nursing and Emergency Preparedness: For Chemical,
Biological and Radiological Terrorism and Other Hazards. New York, NY: Springer
Publishing Company
World Health Organization (2015). Ebola situation report. Retrieved from:
http://apps.who.int/iris/bitstream/10665/151311/1/roadmapsitrep_4Feb15_eng.pdf?ua=1
&ua=1
Yamin, D, Gertler, S, Ndeffo-Mbah, M.L, Skrip, L.A, Fallah, M, Nyenswah, T.G, Altice, F.L,
Galvani, A.P. (2015). Effect of Ebola progression on transmission and control in Liberia.
Annals of Internal Medicine, 162 (1), p. 11-18