Ebola is elusive and stealthy, so a medical degree doesn't automatically prepare a health worker to figure out if a new patient is a likely Ebola case.
The symptoms mimic other diseases. Fever, chills and vomiting could also signal malaria or maybe just a heavy night of drinking. If clinicians guess wrong, they might accidentally put an uninfected person into a treatment area with patients who have contracted the virus.
So before volunteer health workers head off to the Ebola treatment units of West Africa, they need training. A manual created by the IMAI-IMCI Alliance, a global health network, has seen heavy demand during the World Health Organization's fall training surge. Groups like the U.S. Department of Defense and nongovernmental organizations like Save the Children have also used it.
The IMAI-IMCI alliance shared the 128-page manual with Goats and Soda, and we'd like to share parts of it with our readers.
One section offers case histories to consider. Here are four samples: Can you figure out how to proceed?
Before we begin, here's a quick review of Ebola.
Transmission: Patients are not contagious until symptoms appear, which can take two to 21 days. Exposure to bodily fluids — blood, spit, semen, breast milk, excrement — can pass on the disease. Fluids must contact a break in the skin or the eyes, nose or mouth.
Early symptoms: hiccups, sudden fever, weakness, headache, muscle pain, joint pain, loss of appetite, throat pain and difficulty swallowing.
Late symptoms: confusion, seizures, chest pain, diarrhea (watery or bloody), vomiting, rash, internal and external bleeding (appears in fewer than half of patients).
Gathering clues: Even if a patient doesn't mention possible exposure, Ebola isn't automatically ruled out. The manual notes that as the outbreak evolves and stigma mounts, the fear of being put in isolation increases. Patients might hide important information. A patient's family, however, might tell a different story.
Case 1: The Woman From Gueckedou
A women in her 60s from Gueckedou town was brought by her older son to the treatment center with a three-day history of fever, abdominal pain and bloody diarrhea.
She reports that the symptoms all started around the same time and that she has had similar episodes in the past. She denied having any other symptoms or recent contact with sick or deceased persons.
The patient is from Gueckedou town, where no EVD [Ebola virus disease] cases have been detected in the past few weeks and denied travel outside the town limits in past months. When asked why she was brought to the treatment center, she responded that her son was concerned that she did not respond to treatment received at the local health facility.
She had high fever (39.5°C) and looked ill but was able to walk. No physical exam could be performed at the screening area.
Do you think she fits the case definition? What would you do next?
The manual says: The patient's symptoms did not completely fit the case definition (acute fever and ≥ 3 symptoms in absence of a history of contact). Also, the start of fever at the same time as diarrhea is not typical. Usually fever precedes diarrhea and vomiting by a few days.
However, the fact that the older son brought her raised suspicions that there was more to her illness than what the family was telling us. She also looked very ill. EVD testing was offered and was positive.
A day later, we heard that she was connected to a [Ebola] cluster in a remote village:
Her youngest son was sent to help a pregnant family member harvest palm nuts. When he arrived at the community, the pregnant woman became sick with EVD. He helped carry her to a very remote community where the woman died. He came back to the first community where a few days later he started to feel unwell and was transferred to Gueckedou town.
The current patient took care of him. He eventually survived but she became ill. After asking again, she was sick with fever for 3-4 days before the diarrhea started.
Teaching point: In areas with high community resistance, patients often do not tell the truth about their symptoms and history. It is important to ask the family member for more information and to keep a high level of suspicion in order to not miss cases. When in doubt, test.
Case 2: The Anxious Young Man With Diarrhea
A young man in his 20s shows up at the treatment center and asks to be tested for EVD. He appears anxious and reports a history of headache, abdominal pain and diarrhea for the past six weeks with a notion of mild fever at the onset for 1-2 days. A thorough review reveals no history of contact with persons with EVD. He is presently afebrile [without fever].
How would you manage this patient?
The manual says: The patient was counseled on the signs and symptoms of EVD and transmission routes for Ebola virus. We explained that his symptoms were not consistent with EVD and that testing is not necessary. Nor would a negative test rule out future EVD.
Teaching point: Never test persons who do not fit the case definition (unless you suspect that the patient is lying).
Case 3: Three Girls Who Walk Into A Clinic
Three girls ages 7, 8 and 12 years from a community severely affected by EVD were followed as contacts of their mother who died of confirmed EVD a week earlier.
They did not directly take care of sick or deceased family members or participate in the burials. When their mother fell sick, the children were placed with another unaffected family member. During the contact tracing period, the 7- and 8-year-olds reported fever since the day before. The 12-year-old felt unwell but denied fever. All three were taken to the treatment center where EVD testing was positive for the two younger girls (now at day 3 of illness) but negative for the 12-year-old. However, the older girl began reporting fever shortly after the testing. All three girls had a positive malaria rapid diagnostic test.
How will you manage the three girls?
The manual says: The 7- and 8-year-old were admitted to the treatment center as confirmed cases, where they received supportive care for EVD, as well as treatment for malaria. The 12-year-old was kept into the suspect case area and treated for malaria. Her fever continued and on day 2 of illness her EVD test was repeated and was positive.
Teaching point: The level of virus in EVD generally parallels the clinical status of the patient. A test can be negative in the very early stages of illness. If contacts or other persons with a high suspicion of EVD test negative, continued monitoring and retesting on day 3 of illness is warranted. Negative tests on very sick persons or after three days of illness reliably rule out EVD.
How were the children infected?
The manual says: Further discussion with family members revealed that, although the three girls did not get close to sick persons, they washed the clothes soiled with vomitus and stool at the river and probably got infected that way.
Although Ebola virus is not particularly stable in the environment (most evidence suggests that it is not viable for more than a few days) and fomite [contaminated surface] transmission is not commonly suspected, contact with fresh blood or bodily fluids, including on soiled clothing, should nevertheless be considered a risk factor.
Case 4: Lady With A Baby
A 9-month-old baby presented with high fever. The father died of EVD three weeks earlier. The mother and the baby have been followed as contacts. The mother has not been sick and has been breastfeeding the baby.
How would you manage the mother and child?
The manual says: The child was referred to the treatment center for EVD and malaria testing. Testing for EVD was negative but a malaria rapid diagnostic test came back positive. The baby received treatment for malaria and the fever resolved in 48 hours.
Teaching Point: Common diseases in the area continue to occur, in particular malaria, but also typhoid fever and many others. Malaria testing is recommended for all persons with acute febrile disease. Had this child not responded to malaria treatment, repeat testing for EVD at day 3 of illness would have been indicated to definitively rule out the disease. Also note that, as malaria is holoendemic in the region [essentially every individual in the population is infected] and many people, especially children, may have asymptomatic parasitemia [malaria infection without symptoms]. A positive malaria test should not be interpreted as excluding EVD. Testing for EVD should still be performed, especially if the child does not respond to anti-malarial drugs.