Ebola: A Nurse Epidemiologist Puts the Outbreak in Perspective

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

Ebola virus viron

By CDC microbiologist Cynthia Goldsmith, a colorized transmission electron micrograph (TEM) reveals some of the ultrastructural morphology displayed by an Ebola virus virion. CDC image library.

We humans have a knack for taking any newly reported issue of legitimate concern entirely out of context, foregoing all common sense as we transform it into a danger of galactic proportions.

The current case in point is Ebola viral disease. There has been much ranting and raving about closing our borders to people with Ebola infection (as if that were possible), even some misinformed speculation that the virus has been intentionally released.

To me as a nurse epidemiologist, though, the central questions in this tragic outbreak are the same for Ebola as for any other disease:

  • How is the organism transmitted?
  • What is the risk of protected or unprotected exposure to the infected person?

Ebola is a bloodborne pathogen. It’s spread in the same way as HIV, hepatitis B, or hepatitis C: when blood or other body fluids contaminate another person’s non-intact skin or mucous membranes. None of these diseases is spread by casual contact. And unlike HIV or hep B or C, Ebola is not a chronic condition; transmission occurs during acute infection, after the fever begins and the disease progresses. It is virtually impossible to contract the virus by, say, walking past an infected person in the airport, or sharing a bus ride, or shopping in the same grocery store.

Preventing transmission. Unlike for HIV or hep B or C infection, isolation precautions are implemented to prevent transmission of Ebola. This is because bloody secretions, vomit, and diarrhea are typical symptoms as the disease progresses. Because of the resulting probability of exposure to the patient’s blood or bloody secretions/excretions, both contact and droplet precautions are used (i.e., gown, gloves, mask, and eye protection) in order to place a barrier between the infected person’s secretions and the caregivers.

Airborne transmission has not been documented—however, because of the potential for aerosolization of blood or bloody secretions/excretions, most experts recommend airborne isolation precautions as well (negative pressure room, N95 or greater respirators), if possible. (Here’s a CDC table with recommendations regarding transmission precautions for Ebola in various clinical situations.)

Why the rapid spread in West Africa? News reports of unchecked spread of the virus in West Africa have fueled global fears. However, a closer look at what’s happening makes it clear that two main groups of people have been at particular risk for Ebola infection:

  • close family members of those who are already infected
  • health care workers

There are risk factors unique to these groups in this region that have contributed to transmission.

It has been reported that many family members have continued to provide close personal care to their infected loved ones, without using any kind of protective gear. (Don’t attribute this to ignorance. If your two-year-old child were gravely ill, would you be likely to gown, glove, and mask? And even if you thought about doing so, do you have a large stash of these items at home?) Their repeated exposure to blood and body fluids inevitably leads in some cases to the contamination of mucous membranes or non-intact skin.

Postmortem care is traditionally done by families, and this also involves much intimate contact. Added to prolonged, unprotected exposure are health belief systems that can further increase risk. Reportedly, family members in some of the outbreak regions deny the possibility of Ebola infection. They see their loved one’s illness as a curse, not a virus, and believe it can only be cured by a traditional healer.

For health care workers, risk is increased by the difficulties of maintaining full isolation precautions under these particular circumstances. Have you ever complained about suiting up for isolation because the gown, mask, and gloves make you too warm, even in an air-conditioned workplace? Imagine wearing all of this gear for a prolonged period of time in a high-temperature, high-humidity environment.

Western medical professionals who have worked under these conditions have noted how easy it is to unconsciously wipe their faces with their contaminated hands, as they try to keep the sweat streaming into their eyes from blurring their vision. It’s not that personal protective equipment doesn’t work, but that difficult conditions and a high-pressure care situation can compromise the use of personal protective equipment (PPE), sometimes unnoticed.

Should we be worried in the U.S.? In this age of global travel, it is inevitable that we will eventually see cases of Ebola in the U.S. Of course the prospect is sobering; though the virus is not spread casually, the mortality rate from Ebola infection is high. (As of August 1, there had been 1603 confirmed or suspected cases in this outbreak, with 887 deaths.) However, given the infection-control resources and expertise of hospitals and health care providers, there is very little risk of the spread of Ebola in the U.S. The take-home points for health care workers are these:

  • This is a bloodborne pathogen. It is transmitted through contact of mucous membranes or non-intact skin with blood or body fluids.
  • Transmission is most likely to occur after fever develops and as the disease progresses.
  • If infection is suspected, ALWAYS inquire about the patient’s travel history. Ebola and other diseases don’t appear out of thin air. Look for a link to outbreak areas.
  • INSTITUTE ISOLATION PRECAUTIONS IMMEDIATELY. Policy in all health care organizations should specify that any clinical staff person can initiate isolation; if your policy limits isolation “orders” to physicians, change it.
  • Wear appropriate PPE.
  • Don and remove PPE as though someone’s life depends on it. Often, someone’s does. Unfortunately, we caregivers can be careless about suiting up because in most situations, we are not the people at risk. But the patient down the hall to whom you’ve just carried MRSA (because of poor hand hygiene, messy glove technique, or a sloppily tied gown) can die from MRSA bacteremia or pneumonia.
  • With a disease like Ebola, or any emerging infectious disease that has not yet been fully defined (e.g., MERS), a “gatekeeper” should be stationed outside of the closed door of the patient’s room. The gatekeeper’s role: to ensure that only essential personnel enter the room, and to supervise the meticulous donning and doffing of protective gear.

For details on the pathogenesis, clinical presentation, epidemiology, and treatment of Ebola virus, see this still very relevant AJN article from several years back, free until the end of September.

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Editor’s note: a new post by Betsy Todd addressing the concerns nurses have been expressing about adequate protective equipment can be found here.

About the Author:

Clinical editor, American Journal of Nursing (AJN), and epidemiologist

30 Comments

  1. Megan Figueroa July 17, 2015 at 1:20 pm

    Hi Betsey Todd,
    Thank you for addressing the Ebola Virus Disease and the major impact it has had on the health care professionals- especially the nursing community. After learning about the death of the nurse in Nigeria, I could not help but panic. As the number of those affected rose, I began to grow more concerned about international relief efforts and the preparations that were being made here in the United States. Almost daily, new information was being broadcasted about how to properly prepare and protect from the Ebola Virus Disease.

    Ebola is a highly contagious virus and I am especially intrigued by the last bullet points you provided. You mentioned the importance of initiated contact precautions, even if a physician does not order it, as we must do everything we can to protect ourselves. I also thought your idea of having a “gatekeeper” present outside the room of a patient with an infectious disease. Having a guard supervise who goes into the room and to ensure staff are properly donning PPE effectively is important to prevent the spread of infectious diseases like Ebola.

    All in all, thank you for your great insight. I find this information very effective in this global issue.

  2. Lauren Suarez April 20, 2015 at 1:38 pm

    Ebola has been a hot button topic in global health over the last year. The information provided in this blog is clear and concise. I believe this will assist in reducing the panic surrounding the spread and making it more likely for preventative policies to be implemented. At the hospital in which I am employed, an infectious disease screening has been implemented on all patients in order to isolate potential carriers as soon as possible. Globally, the burden of controlling the spread of emerging infectious diseases falls on first line health care workers and providing information in this way lessens the chance of spread.

  3. Steven Bock RN CIC October 15, 2014 at 9:52 pm

    Hi Everyone,
    Did you see Dr. Sanjay Gupta’s video on CNN about how he tried to follow the CDC’s PPE guidelines for Ebola pt care and used chocolate syrup as a surrogate contamination on his gloves and gown? DON’T copy his mistakes. He is making several critical errors as he removes his PPE and as a result, not surprisingly, he gets “contaminated” in the process.

    His removal process was reckless and incorrect. Please work with your local facility’s Infection Prevention & Control practitioner on PPE use and removal, or contact a local APIC chapter (find one at http://www.apic.org/Member-Services/Chapters/Chapter-Map) and find an IPC professional who can give you sound advice. But beware – Dr. Gupta’s demonstration was really wrong!
    Steve Bock RN CIC, Infection Control Practitioner

  4. Steven Bock RN CIC October 15, 2014 at 9:47 pm

    Hi Jen,
    Actually, Hep B &C and HIV are transmitted by blood and OPIM (using an OSHA term) – other potentially infectious material. OPIM includes body fluids such as semen, vaginal secretions, pericardial fluid, pleural fluid, ascites fluid, amniotic fluid, and body fluids of unknown origin (e.g. a specimen you are not familiar with but are transporting to the lab). Common body fluids, such as sweat, tears, saliva, urine, tears, and stool are not infectious for HIV/HBV/HCV. In sharp and critical contrast, these latter body substances can transmit Ebola. Thus, the patient management becomes substantially different as all body excretions and secretions are potentially infectious.
    Also, Ebola survives on inanimate surfaces only for a few hours, not days or weeks. See http://www.cdc.gov/vhf/ebola/transmission/qas.html for more info. Thus, don’t get too concerned about paper money or the handle on a gas station pump that was handled by a person who has early symptomatic Ebola (remember that only symptomatic persons are infectious). If an early symptomatic person sneezes on the paper money or another inanimate surface and then I touch that surface with broken skin or mucous membranes, transmission is theoretically possible. However, people in the early stage of symptomatic Ebola infection are shedding far less virus in their body fluids than persons who are much more ill (and now in a hospital somewhere, at least in most parts of the world). So, while this fomite transmission is theoretically possible, your chances of getting hit by a falling meteorite are much, much greater.
    Hope this helps!!
    Steve Bock RN CIC (Infection Control Practitioner)

  5. Harriette Carr RN, MSN October 15, 2014 at 9:05 pm

    Jen, One major reason is dose. It takes a much smaller dose (innoculum) of this virus to transmit disease than it does for either of those diseases. The second reason is outcome. We have treatment regimens that have greater success rates with both of the before mentioned diseases than we have with Ebola. Lastly is latency. You can live a lifetime with both of the diseases you mentioned, but that is not the case with Ebola.

  6. Betsy October 15, 2014 at 8:10 pm

    Thank you for the information. I read the virus can live without a host for 6 days. So hypothetically, pt has fever goes to gas station and pays in cash, sneezing on the money. If it can live without a host, can anyone who touches that money transfer to other objects and so on? That’s my concern.

  7. Jen Bruce October 15, 2014 at 6:06 pm

    If Ebola has the same transmission modes as does Hep C and HIV, why aren’t we also putting pts with those 2 conditions in strict isolation?

  8. Harriette Carr RN, MSN October 15, 2014 at 3:59 pm

    There are varing qualities of isolation gowns available for your use. It is important that you evaluate what your hospital has available to use. Without naming a commercial products you do need to do an investigation to make sure that you have a good product available to use. Next you MUST make sure that you are using your PPE properly and removing it so that contamination of yourself does not occur. This is where the exposure to this virus is anticipated to occur. The second observer is there to help us all remain vigilant in our own practices.

  9. Diana Dlukasiewicz October 15, 2014 at 2:01 pm

    A “gatekeeper”! Most hospitals barely have the staff to care for the patients. If someone needs a sitter because they are unsafe to be alone we have to work down an aide or nurse putting the whole floor at risk.

  10. Nancy Nelson BSN, CNM, ANP October 15, 2014 at 1:07 pm

    Thank you for this great article and information. As a Nurse Practitioner I was wondering if anyone has thought about using Homeopathic medicines that were used with great success during the last Great Ebola/flu Pandemic during the early 1900s.

  11. mark fogleman October 8, 2014 at 10:35 pm

    how did those highly trained doctors get it then

  12. Bill Janet Muldoon October 1, 2014 at 3:27 pm

    The article in concise, direct, and to the point which is outstanding.
    As a retired public health nurse, I would have added and emphasized that this is also a sexually transmitted disease. If it is contacted that way it has a higher risk for immediate death than HIV. That is why unprotected sex in any manner, vaginal, oral, rectal is a very high risk mode of transmission along with sharing needles with drug use. The research says that the virus has been found in semen up to 2 months following contracting the disease. I will be bold enough to suggest that considering the promiscuous mores adopted in the culture we live in, we have a good chance of E-Boli becoming much worse that we might ever want to admit. We, in the USA, have not been able to control HIV and likely will not ever, considering the mode of infection and the political power of those most affected. I fear that if the same HIV standards are applied to those with E-Boli, it has the capability of becoming the worst world wide deadly epidemic in modern history. by Janet Y Muldoon RN, PHN. MN certified- retired

  13. thomapl September 29, 2014 at 11:21 am

    Well done, Ms. Todd…

  14. monika sychra September 5, 2014 at 4:17 am

    very informative and well written, thanks for the much needed info.

  15. Betsy August 12, 2014 at 8:56 am

    Re the virus outside of the body: Some sources estimate that it can survive on surfaces for several days. See, for example, Public Health Canada’s excellent “Pathogen Safety Data Sheet” on Ebola:(http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/ebola-eng.php) The good news: this virus is easily killed by readily-available disinfectants, including bleach.

  16. Kathryn Rexrode August 11, 2014 at 5:33 pm

    is anyone that you know of mobilizing nurses to help provide PPE for the nurses in the affected countries? We need to make sure our colleagues have what they need.

  17. […] given the current Ebola crisis in West Africa, you might want to check out our recent blog post that cuts through the media hype about Ebola and provides a fact-based summary that will help you answer patients’ […]

  18. Steven Bock RN CIC August 10, 2014 at 3:28 pm

    Smooth, clear, concise, detailed, helpful, and accurate! Well written!! I hope this makes it into the print edition of AJN too so that a wider audience can read it! Can’t wait to share w/my colleagues.

  19. terry August 9, 2014 at 6:02 pm

    How long does the virus live outside of the body?

  20. Tammy Zellmann August 9, 2014 at 4:59 pm

    Very well written, thank you for the information

  21. Michèle Rafferty August 8, 2014 at 11:36 pm

    Yes, this article does put it in perspective, and well balanced views that does not judge.
    Thank you

  22. Eileen Koeberg August 7, 2014 at 1:59 pm

    What a good article so agree with this part >>Western medical professionals who have worked under these conditions have noted how easy it is to unconsciously wipe their faces with their contaminated hands, as they try to keep the sweat streaming into their eyes from blurring their vision. It’s not that personal protective equipment doesn’t work, but that difficult conditions and a high-pressure care situation can compromise the use of personal protective equipment (PPE), sometimes unnoticed.

  23. JoAnne August 7, 2014 at 11:19 am

    Well written article that dispels the media frenzy and hysteria about Ebola.

  24. Mary-Jane Sackett August 7, 2014 at 10:41 am

    Very helpful info to share. Especially for some of my FB friends who feel that the POTUS should have closed our borders to anyone coming from Africa, especially. Some people are very strongly reacting to all the media hype, so this should hopefully inform them.

  25. mracovita August 7, 2014 at 5:46 am

    Reblogged this on monica1r and commented:
    A nurse’s take on Ebola

  26. Kelly Barton August 7, 2014 at 12:29 am

    Thank you for such a well written, logical, truthful, balanced article. Why aren’t these sorts of articles the ones that are all over the news?

  27. Anand E. Holtham-Keathley, R.N. August 6, 2014 at 8:45 pm

    PPE may want to include sweat bands to help prevent accidentally wiping the sweat from ones eyes.

  28. Peggy August 6, 2014 at 6:39 pm

    Excellent post!! Thank you!
    I read the book “The HotZone” approximately 18 year ago about this virus and found it very interesting. Your post is calm, practical, and should be shared.

  29. anniecam August 6, 2014 at 1:33 pm

    Thank you for the clear information. The pictures of the caretakers in masks and goggles raised the question about airborne disease. You explained that they were to protect against sprays of body fluids.

  30. Katheren Koehn August 6, 2014 at 11:47 am

    Thank you so much for your practical advise. It has been difficult to sort through all of the media reports and commentary. This is very helpful.

Comments are moderated before approval, but always welcome.