Ebola primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Michael Maddaleni, B.S.; Guillermo Rodriguez Nava, M.D. [2]

Overview

Transmission of ebola virus disease has only been documented to occur during the symptomatic phase but not during the incubation period. If transmission of ebola occurs, steps need to be taken to prevent further infection as well as transmission to other people. It is important to be able to prevent subsequent transmission of ebola. Transmission of ebola can be prevented by isolation of patient, wearing a HEPA or other biosafety mask and by limiting the movement of the patient from the room to other areas.

Primary Prevention

Use Standard Precautions

A patient with a virus hemorrhagic fever (VHF) may come to the health facility at any point in his or her illness,

• When the possibility of exposure is often highest, and
• Before the specific cause of the patient’s illness is known.

Because a health worker cannot always know when a patient’s body fluids are infectious. Standard Precautions should be used with all patients in the health care setting, regardless of their infection status. Standard Precautions are designed to prevent unprotected contact between the health care worker and

• Blood and all body fluids whether or not they contain blood
• Mucous membranes.

When a specific diagnosis is made, additional precautions are taken, based on how the disease is transmitted.

Establish and Maintain a Minimum Level of Standard Precautions

Limited supplies and resources may prevent a health facility from using all the Standard Precautions all the time. However, health facilities should establish and maintain a basic, practical level of Standard Precautions that can be used routinely with patients in their health facility. At a minimum, consider the services in the health facility that present a risk of disease transmission due to potential contact with blood and all body fluids, broken skin or mucous membranes. For health facility staff who work in such areas, establish at least:

• A source of clean water.
• Routine handwashing before and after any contact with a patient who has fever.
• Safe handling and disposal of sharp instruments and equipment, including needles and syringes.

Establish Routine Handwashing

Handwashing is the most important precaution for the prevention of infections. Handwashing before and after contact with a patient who has fever should be a routine practice in the health facility even when VHF is not present. Washing hands with soap and water eliminates microorganisms from the skin and hands. This provides some protection against transmission of VHF and other diseases. In services where health care workers see patients with fever, provide at least:

• Cake soap cut into small pieces.
• Soap dishes. Microorganisms grow and multiply in humidity and standing water. If cake soap is used, provide soap dishes with openings that allow water to drain away.
• Running water, or a bucket kept full with clean water.
• A bucket for collecting rinse water and a ladle for dipping, if running water is not available.
• One-use towels. Sharing towels can result in contamination. Use paper towels. If they are not available, provide cloth towels that can be used once and then laundered. If towels are not available, health care workers and health facility staff can air-dry their hands.

Make sure health facility staff know the steps of handwashing:

1. Place a piece of soap in the palm of one hand.
2. Wash the opposite hand and forearm. Rub the surfaces vigorously for at least 10 seconds. Move soap to the opposite hand and repeat.
3. Use clean water to rinse both hands and then the forearms. If running water is not available, pour clean water from a bucket over the soapy hands and forearms. The rinse water should drain into another bucket.
4. Dry the hands and forearms with a clean, one-use towel. First dry the hands and then the forearms. Or let rinsed hands and forearms air-dry.

Handle and Dispose of Sharp Instruments Safely

• Disease transmission can occur through accidental needlestick injuries. Make sure health facility staff always handle sharp instruments safely. Do not recap needles after use.
• Limit invasive procedures to reduce the number of injectable medications. This will limit the opportunities for accidental needlestick injuries.
• When an injection is necessary, always use a sterile needle and sterile syringe for each injection.
• To discard disposable needles and syringes safely: Disposable needles and syringes should be used only once. Discard the used disposable needle and syringe in a puncture-resistant container. Then burn the container in an incinerator or pit for burning.
• If puncture-resistant containers are not available, use empty water, oil, or bleach bottles made with plastic or other burnable material. Adapt them for use as puncture-resistant containers.

Disinfect Reusable Needles and Syringes Safely

• Reusable needles and syringes are not recommended. If reusable needles and syringes are used, clean, disinfect and sterilize them before reuse, according to your hospital’s policy.
• Needles and syringes used with VHF patients require special care. Cleaning staff should wear two pairs of gloves when handling needles and syringes used with any patient with a known or suspected VHF.

Disinfect Disposable Needles and Syringes That Must Be Reused

• Whenever possible, use disposable needles and syringes only once and then discard them safely.
• In situations when disposable needles and syringes must be reused, make sure they are cleaned and disinfected after each use. Disinfection with bleach will reduce the risk of transmission of VHF and blood-borne diseases, such as HIV infection and viral hepatitis.

Obtain a jar or pan. Clean and disinfect it.

1. Place the disposable needle and syringe in a pan of soapy water after use. Fill the needle and syringe with soapy water. Leave them to soak until they are cleaned.
2. Take the soaking needles and syringes to the cleaning area.
3. Clean them very carefully in soap and water. Remove any blood or other biological waste, especially from the area around the syringe fittings. Blood or other biological products may collect in these small openings.
4. Draw full-strength bleach into the needle and syringe.
5. Soak for 30 seconds, and then expel bleach into a container for contaminated waste.
6. Soak again by once more drawing full-strength bleach into the needle and syringe. Soak for 30 seconds, and then expel bleach into the container for contaminated waste.
7. Let the disinfected needle and syringe air-dry. Store them in a clean jar or pan that has been disinfected.

Use VHF Isolation Precautions

• Isolate the patient.
• Wear protective clothing in the isolation area, in the cleaning and laundry areas and in the laboratory. Wear a scrub suit, gown, apron, two pairs of gloves, mask, headcover, eyewear, and rubber boots.
• Clean and disinfect spills, waste, and reusable equipment safely.
• Clean and disinfect soiled linens and laundry safely.
• Use safe disposal methods for non-reusable supplies and infectious waste.
• Provide information about the risk of VHF transmission to health facility staff. Reinforce use of VHF Isolation Precautions with all health facility staff.
• Provide information to families and the community about prevention of VHFs and care of patients.

Other Transmission-Based Precautions

Airborne Transmission

1. Place the patient in an isolation room that is not air-conditioned or where air is not circulated to the rest of the health facility. Make sure the room has a door that can be closed.
2. Wear a HEPA or other biosafety mask when working with the patient and in the patient's room.
3. Limit movement of the patient from the room to other areas. Place a surgical mask on the patient who must be moved.

Droplet Transmission

1. Place the patient in an isolation room.
2. Wear a HEPA or other biosafety mask when working with the patient.
3. Limit movement of the patient from the room to other areas. If patient must be moved, place a surgical mask on the patient.

Vaccination

Vaccines have been produced for both Ebola and Marburg that were 99% effective in protecting a group of monkeys from the disease. These vaccines are based on either a recombinant Vesicular stomatitis virus or a recombinant Adenovirus carrying the Ebola spikeprotein on its surface. Early human vaccine efforts, like the one at NIAID in 2003, have so far not reported any successes. The biggest problem with the vaccine is that unless the patient is given it near the onset of the virus (1-4 days after the symptoms begin) then there will be too much damage to the human body to repair, ie: ruptured arteries and capillaries, vomiting, and other symptoms which may still cause enough harm to kill or seriously traumatize the patient.