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Ebola Virus Disease

Reporting Information

Class A

Report a case, suspected case, and/or positive laboratory result immediately via telephone to the local public health department in which the patient resides.  If patient residence is unknown, report immediately via telephone to the local public health department in which the reporting healthcare provider or laboratory is located.  Local public health departments should report immediately via telephone the case, suspected case, and/or a positive laboratory result to the Ohio Department of Health (ODH).

Reporting Form(s) and/or Mechanism

Immediate telephone reporting is required.

The local public health department should enter the case into the Ohio Disease Reporting System (ODRS) within 24 hours after the telephone report.

The Ebola Virus Disease (EVD) Consultation Record (CDC 55.64) is available for use by the local public health department when following up with cases.  Information collected from the form should be entered into ODRS where fields are available, and the form should be uploaded in the Administration section of ODRS.

Key Fields for ODRS Reporting

  • Import status (whether the infection was travel-associated or Ohio-acquired).
  • Date of illness onset.
  • All fields in the Epidemiology module.

Agent

Ebola virus disease (EVD) is a severe, often fatal disease in humans and nonhuman primates (monkeys, gorillas, chimpanzees) that has appeared sporadically since its initial recognition in 1976.  The disease is caused by infection with Ebola virus, named after a river in the Democratic Republic of the Congo (DRC, formerly Zaire) in Africa, where it was first recognized.

The virus is one of two members of a family of RNA viruses called the Filoviridae.  A major outbreak of >28,000 cases occurred in West Africa in 2014-2016.  The three main countries involved were: Guinea, Liberia, and Sierra Leone.  In August 2018, an Ebola outbreak was reported in northeastern DRC.  As of Sept. 23, 2019, 3,157 cases and 2,108 deaths have been reported, making it the second largest Ebola outbreak on record.

Case Definition

Clinical Description

An illness with acute onset with ALL of the following clinical findings:

  • A fever > 40°C (104°F).
  • One of more of the following clinical findings:
    • Severe headache.
    • Muscle pain.
    • Erythematous maculopapular rash on the trunk with fine desquamation 3-4 days after rash onset.
    • Vomiting.
    • Diarrhea.
    • Pharyngitis (arenavirus only).
    • Abdominal pain.
    • Bleeding not related to injury.
    • Retrosternal chest pain (arenavirus only).
    • Proteinuria (arenavirus only).
    • Thrombocytopenia.

Laboratory Criteria for Diagnosis

One or more of the following laboratory findings:

  • Detection of VHF viral antigens in blood by enzyme-linked Immunosorbent Assay (ELISA) antigen detection.
  • VHF viral isolation in cell culture for blood or tissues.
  • Detection of VHF-specific genetic sequence by Reverse Transcription-Polymerase Chain Reaction (RT-PCR) from blood or tissues.
  • Detection of VHF viral antigens in tissues by immunohistochemistry.

Epidemiologic Linkage

One or more of the following exposures within the 3 weeks before onset of symptoms:

  • Contact with blood or other body fluids of a patient with VHF.
  • Residence in or travel to a VHF endemic area.
  • Work in a laboratory that handles VHF specimens.
  • Work in a laboratory that handles bats, rodents, or primates from endemic areas.
  • Exposure to semen from a confirmed acute or convalescent case of VHF within 10 weeks of that person's onset of symptoms.

Case Classification

Suspected

Case meets the clinical and epidemiologic linkage criteria.

Confirmed

Case meets the clinical and laboratory criteria.

Comments

VHF refers to viral hemorrhagic fever caused by Ebola, Lassa, Lujo, or Marburg virus, a new world arenavirus, or Crimean-Congo hemorrhagic fever.

Early recognition is critical to controlling the spread of Ebola virus.  Healthcare providers should evaluate the patient’s epidemiologic risk factor, including a history of travel to a country with widespread Ebola virus transmission or cases in urban settings with uncertain control measures or contact within the preceding 21 days with a person with Ebola while the person was symptomatic.  CDC has an evaluation algorithm to determine if testing for Ebola is indicated.

If a diagnosis of Ebola is being considered, the patient should be isolated in a single room (with a private bathroom), and healthcare personnel should follow standard, contact and droplet precautions, including the use of appropriate personal protective equipment (PPE).  Infection control personnel should be contacted immediately.

If Ebola is suspected, the local or state health department should be immediately contacted for consultation to assess whether or not testing is indicated and the need for initiating identification of contacts.

Signs and Symptoms

Ebola hemorrhagic fever symptoms include abrupt onset of fever, severe headache, muscle pain, fatigue, and weakness followed by diarrhea, vomiting, and stomach pain.  A rash, red eyes, hiccups, and internal and external bleeding may be seen in some patients.  Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days.  The fatality rate in the 2014-2016 West Africa outbreak was 39%.

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.

Diagnosis

Ebola virus disease is diagnosed through virus isolation, antigen-capture enzyme-linked immunosorbent assay (ELISA) testing, IgM ELISA, and polymerase chain reaction (PCR).  Virus isolation can be used to diagnose a case of EVD within a few days of the onset of symptoms.  Persons tested later in the course of the disease or after recovery can be tested for IgM and IgG antibodies.  The disease can also be diagnosed retrospectively in deceased patients by using immunohistochemistry testing, virus isolation, or PCR.

Local hospitals and laboratories should not attempt to culture any specimens.  These viruses are highly pathogenic and require handling in special laboratory facilities designed to contain them.  The hospital should hold on to any blood, serum, CSF, respiratory secretions, and other tissue collected.  The local health department and ODH will coordinate the shipment of all laboratory specimens for testing.  The ODH Bureau of Infectious Diseases (614) 995-5599 will follow up on the laboratory specimens.

Epidemiology

Occurrence

Ebola virus disease was first identified in 1976 near the Ebola River in Zaire, now known as the Democratic Republic of the Congo.  Since then, isolated human outbreaks have occurred in central African countries such as Côte d’Ivoire (Ivory Coast), the Democratic Republic of the Congo, Gabon, the Republic of the Congo, Sudan, and Uganda.

In March 2014, the largest outbreak of Ebola virus disease in history began in West Africa, with widespread transmission occurring in Guinea, Liberia and Sierra Leone.  A total of 28,616 cases were reported when the outbreak ended in April 2016.  Infected travelers contributed to limited transmission in several other countries as well: Nigeria, Mali, Senegal, Spain, and the United States.

Mode of Transmission

People can be exposed to Ebola virus from direct contact with the blood and/or secretions, organs, or semen of an infected person.  Thus, the virus is often spread through families and friends because they come in close contact with such secretions when caring for infected persons.

People can also be exposed to Ebola virus through contact with objects, such as needles, that have been contaminated with infected secretions.

Ebola can also be acquired while handling infected dead mammals in Africa, or through contact with the blood or organs of infected cynomolgus monkeys.

Nosocomial transmission is common in African healthcare facilities through the previously stated contact means.

Period of Communicability

Growing information suggests Ebola virus can persist in some survivors for more than 18 months (CDC).

Incubation Period

2-21 days, average 8-10 days.

Public Health Management

Case

Investigation

The patient should be kept in strict isolation.  Obtain information about the patient's occupation, history of travel outside the United States, contact with wild animals or lab animals, contact with a suspected or confirmed case of EVD, or close contact with an ill individual who traveled to an EVD endemic area.

Treatment

There is no standard treatment for Ebola virus disease.  Patients receive supportive therapy.  This consists of balancing the patient's fluids and electrolytes, maintaining oxygen status and blood pressure, and treating for any complicating infections.  There is currently no antiviral drug licensed by the U.S. FDA to treat Ebola in people.

Isolation

Ohio Administrative Code (OAC) 3701-3-13 (DD) states:

"Viral hemorrhagic fever (VHF): a person with confirmed or suspected viral hemorrhagic fever shall be placed in airborne isolation until no longer considered infectious."

Clinicians evaluating suspected cases should use standard (e.g., hand hygiene), airborne droplet (e.g., N-95 respirator), and contact (e.g., gowns and gloves) precautions.

Standard, contact, and droplet precautions are recommended for management of hospitalized patients with known or suspected Ebola virus disease (EVD).

Sequelae

Data on the pathogenesis of sequelae in EVD survivors and complications related to viral persistence are very limited.  U.S. healthcare providers should be aware that in most cases, persons who have completely recovered from EVD do not experience a relapse of Ebola virus associated with systemic illness.  However, survivors can experience complications after surviving acute EVD.  The timing of onset, severity, and duration of complications among EVD survivors are variable.  Reported complications among EVD survivors include non-specific fatigue, joint pain, muscle aches, headaches, suppurative parotitis, pericarditis, orchitis, sexual dysfunction, hair loss, vision loss (including uveitis and permanent blindness), hearing loss, tinnitus, paresthesia or dysesthesia, memory loss, insomnia, depression, anxiety, and post-traumatic stress disorder.  The Ebola virus can persist for several months after acute infection in organs that are considered "immunologically privileged sites" - sites that are shielded from the survivor's immune system (e.g., testes, eye, central nervous system).  The risk of infectivity from patients with persistent infection is unknown but appears to be low and is likely to decrease over time.  Because patients who recover from acute EVD and later become ill with neurological or ocular symptoms might have persistent viral replication, appropriate infection control practices such as those recommended for evaluating persons under investigation for EVD, should be adhered to until Ebola testing is negative.

EVD survivors who have any new or recurrent ocular or neurologic symptoms should seek care for complications associated with potential viral persistence.  EVD survivors with fever should be assessed for both common community-acquired infections (e.g., malaria, influenza, common cold, typhoid fever, gastroenteritis) as well as possible complications related to EBOV persistence.

There is additional guidance available for the clinical assessment of EVD survivors.

Contacts

Investigation

Identify all close contacts in the three weeks after the onset of illness.  Initiate quarantine and active surveillance of contacts by having contacts take and maintain a record of body temperature twice a day for three weeks after last exposure.  If temperature is greater than 100.4°F (38°C), hospitalize patient immediately and initiate appropriate isolation precautions.

When a suspected case is reported, the local health department needs to start identifying close contacts.  Often this starts with the family.  The emergency room chart or the medical record may provide names of emergency contacts or family members.

The local health department needs to identify all persons who had "close contact" with the patient for the 21 days prior to the onset of the patient’s illness, and thereafter until the patient is released from isolation.

Prevention and Control

Vaccination

There is currently no vaccine licensed by the US FDA to protect people from Ebola virus.

Prophylaxis

Currently there is no post-exposure prophylaxis available for individuals exposed to these agents.

Special Information

Consult the CDC website for the latest information about Ebola virus disease.

Revised 9/2019.