Primary prevention

The Centers for Disease Control and Prevention (CDC) recommends the following preventive measures for people in an area affected by an outbreak:

  • Practice careful hygiene (e.g., wash hands with soap and water, alcohol-based hand sanitizer, or chlorine solution)

  • Avoid contact with body fluids

  • Do not handle items that have come into contact with an infected person's body fluids (e.g., clothes, medical equipment, needles)

  • Avoid funeral or burial rituals that require handling of the body of someone who has died from confirmed or suspected Ebola virus infection

  • Avoid contact with nonhuman primates and bats, including body fluids or raw meat prepared from these animals

  • Avoid hospitals in West Africa in which infected patients are being treated (unless going there to work)

  • Returning travelers (including healthcare workers) should follow local policies for surveillance and monitor their health for 21 days and seek medical attention if symptoms develop, especially fever.

Healthcare workers who may be exposed to infected patients should follow these steps:

Centers for Disease Control and Prevention (CDC): infection control for viral haemorrhagic fevers in the African health care setting

World Health Organization (WHO): aide-memoire for infection prevention and control in a health care facility

If infection is suspected based on initial screening, immediate isolation is warranted before any further workup is carried out. This is crucial to reduce contact with other patients and healthcare workers while the patient is being investigated. Isolation measures should be continued until the patient has tested negative. [73]

The highest risk facing healthcare workers when looking after infected patients is inadvertently touching their own faces or neck under the face shield during patient care, and removing (doffing) personal protective equipment (PPE). Healthcare workers should understand the following basic principles of using PPE: [73]

  • Donning: PPE must be donned correctly in proper order before entry into the patient care area. Since PPE cannot be modified while in the patient care area, caution should be taken to ensure it is as comfortable as possible before entering the area. No skin should be exposed. Donning activities must be directly observed by a trained observer, and a final check performed before entering the patient care area

  • During patient care: PPE must remain in place and be worn correctly for the duration of exposure to potentially contaminated areas. PPE should not be adjusted during patient care. Healthcare workers should perform frequent disinfection of gloved hands using an alcohol-based hand rub or chlorine solution, particularly after handling body fluids. If there is a partial or total breach in PPE (e.g., gloves separate from sleeves leaving exposed skin, a tear develops in an outer glove, a needlestick) during patient care, the healthcare worker must move immediately to the doffing area to assess the exposure and implement the facility exposure plan, if indicated. The immediate action drills to take in the event of a high-risk exposure (needle stick injury and mucous membrane splash) should be clear to all healthcare workers. After safe doffing, a rapid risk assessment and consideration of post-exposure prophylaxis (PEP) should be undertaken. [74]

  • Doffing: removal of used PPE is a high-risk process that requires a structured procedure, a trained observer, and a designated area for removal to ensure protection. PPE must be removed slowly and deliberately in the correct sequence to reduce the possibility of self-contamination or other exposure. A stepwise process should be developed and used during training and daily practice.

com.bmj.content.model.Caption@2f8c10d3 [Figure caption and citation for the preceding image starts]: Healthcare worker in personal protective equipment at an Ebola treatment center in Sierra Leone, 2014 From the personal collection of Chris Lane, MSc (Public Health England/World Health Organization); used with permission [Citation ends].

The importance of a "buddy" when inside the patient care area and during donning and doffing, to ensure safe practice cannot be overstated, together with guidance from independent monitors if available. Centers for Disease Control and Prevention (CDC): the buddy system

The CDC and World Health Organization (WHO) produce detailed guidance on PPE:

Vaccines:

  • No vaccines have been licensed for use in humans. [75] ┬áSee Emerging section for detail on vaccines in development.

Centers for Disease Control and Prevention (CDC): Ebola prevention

World Health Organization (WHO): Ebola: infection prevention and control

Secondary prevention

Ebola virus infection is a notifiable disease.

If infection is suspected, the patient should be put in isolation and all healthcare workers in contact with the patient should wear personal protective equipment. The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) produce detailed guidance on PPE:

Contact tracing (e.g., family, friends, work colleagues) is essential. People who have been exposed to the Ebola virus within the last 21 days and who are asymptomatic need to be monitored for the duration of the incubation period in order to ensure rapid recognition of symptoms followed by immediate isolation. The WHO has produced guidance on contact tracing:

Healthcare workers suspected of being infected should be isolated and treated the same as any other patient until a negative diagnosis is confirmed. [175] If exposure to body fluids from a patient with suspected infection has occurred, the person should immediately wash affected skin surfaces with soap and water and irrigate mucous membranes with copious amounts of water.

Safe burial practices are essential but are not always culturally accepted, and this continues to be a challenge. [70]

World Health Organization (WHO): how to conduct safe and dignified burial of a patient who has died from suspected or confirmed Ebola virus disease

Post-exposure prophylaxis (PEP):

  • This is a rapidly changing field. [265] A useful framework that takes a stratified approach to exposure risk has been proposed.

  • PEP is recommended in high-risk patients (e.g., people with broken skin or mucous membrane contact with an infected patient (alive or deceased) or their body fluids, a penetrating sharps injury, or contact with contaminated gloves or clothing). It may also be considered in patients with intact skin-only contact with an infected patient (alive or deceased) or their body fluids. Options to consider include passive immunotherapy with monoclonal antibodies (e.g., ZMapp, MIL77), antiviral agents (e.g., favipiravir, remdesivir, BCX4430), or vaccination (e.g., rVSV-ZEBOV) depending on specific patient circumstances. [266]

  • In addition to these interventions, psychological support is needed for healthcare workers exposed to dangerous pathogens. [267]

Centers for Disease Control and Prevention (CDC): Ebola prevention

World Health Organization (WHO): Ebola: infection prevention and control

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