CONCISE REVIEW FOR CLINICIANS

See also page 15

From the Division ofInfectious Diseases, MayClinic, Rochester, MN.

1710

What Clinicians Should Know About the 2014Ebola Outbreak

96

o

Pritish K. Tosh, MD, and Priya Sampathkumar, MD

CME Activity

Target Audience: The target audience for Mayo Clinic Proceedings is primar-ily internal medicine physicians and other clinicians who wish to advancetheir current knowledge of clinical medicine and who wish to stay abreastof advances in medical research.Statement of Need: General internists and primary care physicians mustmaintain an extensive knowledge base on a wide variety of topics coveringall body systems as well as common and uncommon disorders. Mayo ClinicProceedings aims to leverage the expertise of its authors to help physiciansunderstand best practices in diagnosis and management of conditionsencountered in the clinical setting.Accreditation: Mayo Clinic College of Medicine is accredited by the Accred-itation Council for Continuing Medical Education to provide continuing med-ical education for physicians.Credit Statement: Mayo Clinic College of Medicine designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s).TM

Physicians should claim only the credit commensurate with the extent oftheir participation in the activity.Learning Objectives: On completion of this article, you should be able to(1) summarize the status of the current Ebola outbreak in West Africa; (2)name the precautions recommended to limit transmission of Ebola; (3) pro-vide appropriate care for persons with suspected Ebola virus disease.Disclosures: As a provider accredited by ACCME, Mayo Clinic College ofMedicine (Mayo School of Continuous Professional Development) mustensure balance, independence, objectivity, and scientific rigor in its educa-tional activities. Course Director(s), Planning Committee members, Fac-ulty, and all others who are in a position to control the content of thiseducational activity are required to disclose all relevant financial relation-ships with any commercial interest related to the subject matter of the

Mayo Clin Proc. n December 2014;nn

www.mayoclinicproceedings.org n

educational activity. Safeguards against commercial bias have been put inplace. Faculty also will disclose any off-label and/or investigational use ofpharmaceuticals or instruments discussed in their presentation. Disclosureof this information will be published in course materials so that those par-ticipants in the activity may formulate their own judgments regarding thepresentation.In their editorial and administrative roles, William L. Lanier, Jr, MD, Terry L.Jopke, Kimberly D. Sankey, and Nicki M. Smith, MPA, have control of thecontent of this program but have no relevant financial relationship(s) withindustry.The authors report no competing interests.Method of Participation: In order to claim credit, participants must com-plete the following:1. Read the activity.2. Complete the online CME Test and Evaluation. Participants must achieve

a score of 80% on the CME Test. One retake is allowed.Visit www.mayoclinicproceedings.com, select CME, and then select CME ar-ticles to locate this article online to access the online process. On successfulcompletion of the online test and evaluation, you can instantly download andprint your certificate of credit.Estimated Time: The estimated time to complete each article is approxi-mately 1 hour.Hardware/Software: PC or MAC with Internet access.Date of Release: 11/10/2014Expiration Date: 11/30/2016 (Credit can no longer be offered after it haspassed the expiration date.)Privacy Policy: http://www.mayoclinic.org/global/privacy.htmlQuestions? Contact dletcsupport@mayo.edu.

Abstract

The ongoing Ebola outbreak that began in Guinea in February 2014 has spread to Liberia, Sierra Leone,Nigeria, Senegal, Spain, and the United States and has become the largest Ebola outbreak in recordedhistory. It is important for frontline medical providers to understand key aspects of Ebola virus disease(EVD) to quickly recognize an imported case, provide appropriate medical care, and prevent transmission.Furthermore, an understanding of the clinical presentation, clinical course, transmission, and preventionof EVD can help reduce anxiety about the disease and allow health care providers to calmly and confi-dently provide medical care to patients suspected of having EVD.

ª 2014 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2014;nn(n):1710-1717

T he first recorded Ebola outbreak beganin September 1976 in Zaire (now theDemocratic Republic of the Congo)

after the index case received a chloroquineinjection for malaria at Yambuku MissionHospital.1 Although the patient’s malariasymptoms initially resolved, he then devel-oped an aggressive infection with hemorrhagicsequelae 5 days after the injection. Within aweek, several other patients who had receivedinjections at the clinic or who were closehousehold contacts of patients developed a

similar illness. During a 2-month period, 318cases of viral hemorrhagic fever were identifiedin 55 nearby villages, with 88% mortality.

The virus was found to be related to, butdistinct from, the Marburg virus and wasnamed after the Ebola River, which traversedthrough the affected region. Since that time,there have been approximately 20 identifiedoutbreaks of Ebola virus disease (EVD) thathave occurred sporadically in Africa, mostlyin central and east Africa (Table).2 The 2014outbreak is the first to occur in West Africa.

(n):1710-1717 n http://dx.doi.org/10.1016/j.mayocp.2014.10.010ª 2014 Mayo Foundation for Medical Education and Research

TABLE. Chronology of Ebola Outbreaks in Africa

Year(s) Country(ies) Ebola subtype

Reportedhuman

cases (No.)

Reported deathsamong cases(No. [%])

1976 Zaire (currently Democratic Republic of the Congo) Zaire virus 318 280 (88)1976 Sudan (currently South Sudan) Sudan virus 284 151 (53)1979 Sudan (currently South Sudan) Sudan virus 34 22 (65)1994 Gabon Zaire virus 52 31 (60)1995 Democratic Republic of the Congo (formerly Zaire) Zaire virus 315 250 (79)January-April 1996 Gabon Zaire virus 37 21 (57)July 1996-January 1997 Gabon Zaire virus 60 45 (75)1996 South Africa Zaire virus 2 1 (50)2000-2001 Uganda Sudan virus 425 224 (53)October 2001-March 2002 Gabon Zaire virus 65 53 (82)October 2001-March 2002 Republic of the Congo Zaire virus 57 43 (75)December 2002-April 2003 Republic of the Congo Zaire virus 143 128 (89)November-December 2003 Republic of the Congo Zaire virus 35 29 (83)2004 Sudan (currently South Sudan) Sudan virus 17 7 (41)2007 Democratic Republic of the Congo Zaire virus 264 187 (71)December 2007-January 2008 Uganda Bundibugyo virus 149 37 (25)December 2008-February 2009 Democratic Republic of the Congo Zaire virus 32 15 (47)May 2011 Uganda Sudan virus 1 1 (100)June-October 2012 Uganda Sudan virus 11a 4 (36)a

June-November 2012 Democratic Republic of the Congo Bundibugyo virus 36a 13 (36)a

November 2012-January 2013 Uganda Sudan virus 6a 3 (50)a

February 2014-present Guinea, Liberia, Sierra Leone, Nigeria, Senegal, Spain,United States

Zaire virus 4655a,b 2431 (52)a,b

August 2014-present Democratic Republic of the Congo Zaire virus 68a,b 49 (72)a,b

aLaboratory-confirmed cases only.bAs of October 13, 2014.Adapted from http://www.cdc.gov.2

WHAT TO KNOW ABOUT THE 2014 EBOLA OUTBREAK

As stated by Dr Peter Piot, one of the re-searchers who first identified Ebola virus in1976, “In general, it is an infection that causesepidemics only if basic hospital hygiene is notrespected, and is really a disease of povertyand neglect of health systems.”3

THE 2014 WEST AFRICAN EBOLAOUTBREAKThe ongoing outbreak in West Africa is thelargest Ebola outbreak in recorded history.2,4

The first cases occurred in Guinea in December2013. Cases were identified in neighboringLiberia in March 2014, and in April theoutbreak spread into Sierra Leone. In July2014, EVD was introduced in Nigeria by anill traveler from Liberia, with subsequent trans-mission to health care workers. In September2014, Senegal had an EVD case importedfrom Guinea. On September 30, 2014, the firstcase of EVD was diagnosed in the United States

Mayo Clin Proc. n December 2014;nn(n):1710-1717 n http://dx.doiwww.mayoclinicproceedings.org

in a patient who had recently traveled fromLiberia to Dallas, Texas. He did not have symp-toms when leaving West Africa but developedsymptoms approximately 4 days after arrivingin the United States. He was hospitalized inDallas and despite supportive care, mechanicalventilation, and hemodialysis, he died onOctober 8. Two members of the health careteam caring for this patient have subsequentlybeen diagnosed as having EVD. Similar trans-mission of EVD to a health care worker in Spainhas been reported, where a nursing assistantdeveloped EVD after caring for 2 repatriatedSpanish missionaries who contracted EVD inWest Africa. As of October 21, 2014, theWest African Ebola outbreak had resulted in9216 confirmed or suspected cases, with4555 deaths (Figure 1). Case counts are likelyan underestimate of the true number of casesowing to underdiagnosis and underreportingof cases. A separate outbreak of EVD, unrelated

.org/10.1016/j.mayocp.2014.10.010 1711

1 - 100 cases

101 - 200 cases

201 - 300 cases

301 - 400 cases

401 - 500 cases

501 - 600 cases

601 - 700 cases

701 - 800 cases

801 - 900 cases

901 - 1000 cases

1001 + cases

Sierra910 c

FIGURE 1. Progression o

MAYO CLINIC PROCEEDINGS

1712

to the outbreak in West Africa, is occurring inthe Democratic Republic of the Congo.

Previous Ebola outbreaks have largelyoccurred in rural, isolated villages with limitedaccess to medical care, resulting in outbreakswith high case fatality but limited transmis-sion. With the industrialization and globaliza-tion of commerce, there is now increasedtravel from previously isolated areas, allowingfor spread of the outbreak into densely popu-lated urban areas. Increased access to medicalcare, with amplification of transmission inhealth care facilities, has also likely contrib-uted to the larger outbreak.

Cultural and societal practices havecontributed to the extent of the outbreak inWest Africa.5 Family members are often takingcare of sick relatives at home, putting them-selves at high risk for infection through con-tact with infectious materials: blood, feces,vomit, or other body fluids. Family membersare fearful that it is the hospitals themselvesthat are causing the infections; as a result,EVD cases and their contacts have been hid-den from health authorities. This is com-pounded by the limited availability ofsanitation and public health infrastructure.Burial practices in several parts of West Africainclude preparation of the body for burial andclose contact of family members with thedeceased, further contributing to the propaga-tion of the outbreak.

March 25, 201486 cases, 60 deaths

Guinea86 cases, 60 deaths

May287

Guinea248 cases, 171 dea

Liberia27 cases, 13 de

Sierra Leone12 cases, 0 deaths

August 21, 20142615 cases, 1427 deaths

Guinea607 cases, 406 deaths

Liberia1082 cases, 624 deaths

Nigeria16 cases, 5 deaths

Leoneases, 392 deaths

Septem6263 c

Guinea1022 cases, 635 de

Liberia3280 cases, 16

Sierra Leone1940 cases, 597 deaths

Senegal1 case, 0 deaths

f the 2014 Ebola outbreak in West Africa.

Mayo Clin Proc. n December 2014;nn

VIROLOGYEbola is one of several viruses that cause hem-orrhagic fever, including Marburg, Lassa,Crimean-Congo, Sin Nombre, yellow fever,and Dengue hemorrhagic fever.6 The hallmarkof viral hemorrhagic fever is severe illness,including multiple organ failure and possibledeath, even in previously healthy persons.Sepsis is often induced through cytokinestorm, and hemorrhagic complications occurthrough thrombocytopenia, hepatic necrosis(with resultant reduction in synthesis of coag-ulation factors), disseminated intravascularcoagulation, and endothelial damage.6,7

There are 5 species of Ebola virus, each be-ing a single-stranded RNA virus in the filoviri-dae family. The Bundibugyo, Zaire, andSudan species have been responsible for all ofthe known Ebola outbreaks, with the Zaire spe-cies causing the current outbreak in West Af-rica.2 The other 2 Ebola virus species are theReston Ebola virus, which is limited to thePhilippines and has not caused human diseaseto date, and the Taï Forest Ebola virus, whichcaused a single human infection in a scientistperforming an autopsy on a chimpanzee.

The natural reservoirs and vectors of Ebolaviruses are not completely understood, butEbola is clearly a zoonotic disease.2,8,9 Fruitbats have been implicated in transmissionbecause Ebola viruses can replicate in bats andhave been cultured from bat guano. Monkeys

24, 2014 cases, 184 deaths

ths

aths

July 31, 20141323 cases, 729 deaths

Guinea460 cases, 339 deaths

Liberia329 cases, 156 deaths

Nigeria1 case, 1 death

Sierra Leone533 cases, 233 deaths

ber 26, 2014ases, 2917 deaths

aths

77 deaths

Nigeria20 cases, 8 deaths

October 21, 20149216 cases, 4555 deaths

Guinea1519 cases, 862 deaths

Liberia4262 cases, 2484 deaths

Nigeria20 cases, 8 deaths

Sierra Leone3410 cases, 1200 deaths

Senegal1 case, 0 deaths

(n):1710-1717 n http://dx.doi.org/10.1016/j.mayocp.2014.10.010www.mayoclinicproceedings.org

WHAT TO KNOW ABOUT THE 2014 EBOLA OUTBREAK

and other nonhuman primates may serve asintermediate hosts. Increased human-animalinterface in parts of Africa and the black marketbush meat trade have been implicated inbringing this zoonotic disease into humanpopulations.

CLINICAL COURSEPatients with EVD have abrupt onset of symp-toms 8 to 10 days after exposure (range, 2-21days).2,10,11 These symptoms are oftennonspecific initially, with fever, chills, myalgia,malaise, and possibly a maculopapular rash.12

After approximately 5 days, patients will oftendevelop abdominal pain, severe watery diar-rhea, nausea, and vomiting. Hemorrhagicsequelae may develop, including hematoche-zia, petechiae, ecchymosis, and mucosal hem-orrhage. Fatal cases develop severe clinicalsigns and symptoms earlier in their course,and death typically occurs 6 to 16 days aftersymptom onset. Nonfatal cases typically haveresolution of fever between days 6 and 11, fol-lowed by a prolonged period of recovery withsustained weakness, fatigue, poor appetite,and failure to regain weight that was lost dur-ing the acute illness.

Laboratory abnormalities associated withEVD2,11 include thrombocytopenia, hemocon-centration due to increased vascular perme-ability, and initial lymphopenia followed byneutrophilia with a left shift. There is oftenelevation in transaminase levels, along with ev-idence of fibrin degradation products and pro-longation of prothrombin time and partialthromboplastin time (evidence of dissemi-nated intravascular coagulation).

Diagnostic tests for Ebola include poly-merase chain reaction, viral culture, and IgMand IgG enzyme-linked immunosorbent assaytests. Owing to the need for special biosafetyprecautions for specimen handling, testingfor Ebola in the United States is performedonly at the Centers for Disease Control andPrevention (CDC) and some state healthdepartment laboratories.2 Ebola testing shouldbe coordinated through local and regionalpublic health authorities.

TREATMENTTreatment for EVD is largely supportive andincludes blood product transfusion, electrolytereplacement, and fluid resuscitation, pressors,

Mayo Clin Proc. n December 2014;nn(n):1710-1717 n http://dx.doiwww.mayoclinicproceedings.org

and ventilatory support as needed. It is impor-tant that patients with suspected EVD are alsoevaluated for and, if necessary, treated empir-ically for malaria and typhoid fever. Limitedexperience with treating EVD in resource-rich settings suggests that the availability ofsupportive care likely improves patient out-comes substantially. There are no licensedmedications available for the treatment ofEVD, but there are several investigationalagents.13,14 ZMapp (Mapp Biopharmaceutical)is a combination of 3 monoclonal antibodiesthat has been used in a handful of patientsduring the 2014 West Africa Ebolaoutbreak.2,4,15 Similarly, brincidofovir (Chi-merix Inc) is an antiviral medication devel-oped for the treatment of cytomegalovirusand adenovirus that has been used as an inves-tigational agent in patients with EVD.Although the initial reports of use of theseinvestigational medications are promising,there have not been clinical trials to assesstheir safety or efficacy in humans, and supplyis extremely limited at this time. Blood andserum from persons who have recoveredfrom EVD have been used in several cases ofEVD, but the efficacy of this approach remainsunproved.16

There are currently no licensed vaccinesfor the prevention of Ebola infection. Twocandidate recombinant vaccines, a chimpanzeeadenovirus and vesicular stomatitis virus,which express Ebola surface glycoprotein,have shown promising results in nonhumanprimates. The National Institutes of Health isexpecting to start a phase 1 vaccine trial in hu-man volunteers in Fall 2014.2,13,17-19

TRANSMISSIONInitial introduction of EVD into human popu-lations likely occurs through contact with aninfected animal, such as a bat or monkey. Sub-sequent human infections, however, occurbecause of direct contact of mucous mem-branes or broken skin with blood or bodyfluids of an infected person.2,4 Patients arecontagious only when they are ill and do nottransmit the infection during the incubationperiod. During severe illness with Ebola,blood, sweat, feces, and vomit are highly infec-tious. Health care workers and household careproviders who come in close contact with pa-tients with EVD without proper personal

.org/10.1016/j.mayocp.2014.10.010 1713

MAYO CLINIC PROCEEDINGS

1714

protective equipment (PPE) are at highest riskfor secondary infection.

INFECTION CONTROL IN HEALTH CAREFACILITIES IN THE UNITED STATESThe first case of EVD diagnosed in the UnitedStates, and the transmission of EVD to mem-bers of his health care team, has raised publicawareness of the Ebola outbreak. It has alsoresulted in fears that the outbreak couldspread widely in the United States. For sus-tained transmission of EVD, there needs tobe direct contact with blood or body fluidsfrom an infected person while he or she isill. Owing to standard infection control prac-tices in health care facilities in the UnitedStates, along with robust sanitation and publichealth infrastructures, it is very unlikely thatwidespread community transmission of EVDwill occur in the United States. It is, however,important for health care facilities to be pre-pared to see imported cases of EVD in recenttravelers from affected countries or in contactsof patients with known EVD and to take im-mediate steps to limit further transmission.

Early recognition is critical for infectioncontrol. Health care providers should be alertfor EVD and obtain travel and exposure his-tory in persons presenting with febrile illness(Figure 2). Before transmission of EVD tohealth care workers in Dallas, the CDC’s posi-tion was that patients with EVD could becared for safely in any hospital in the UnitedStates.2 The fact that 2 health care workerstaking reasonable precautions acquired EVDin a US hospital has resulted in a paradigmshift. There is a new realization that althoughall health care facilities should be prepared torecognize and perform initial stabilization ofa patient with EVD, subsequent care of the pa-tient is extremely resource intensive and is bestperformed at a specialized center. The otherlesson that we have learned from the Dallasexperience is that although PPE is an impor-tant component of patient care, just havingPPE available is not enough. Health careworkers need extensive training in donningand safely removing PPE. Newly releasedguidelines (http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html) from the CDC stress3 important principles: (1) the use of fluid-resistant PPE that covers all exposed skin, (2)the importance of training and demonstrated

Mayo Clin Proc. n December 2014;nn

competency in PPE use, and (3) supervision ofthe PPE donning and removal process by atrained monitor.

All PPE should be single use. Either alcohol-based hand sanitizers or soap and water remainacceptable choices for hand hygiene after PPEremoval. The guidelines provide detailed in-structions on PPE choices and use. Individualinstitutions may need to adapt these guidelinesbased on the physical layout of their facilityand on availability of specific PPE (Supple-mental PPE Checklist; available online athttp://www.mayoclinicproceedings.org).

Given the extensive training needs, hospi-tals should consider training a core team tocare for patients with EVD. Emergency depart-ment staff, intensivists (adult and pediatric), in-fectious diseases physicians, nurses, respiratorytherapists, and environmental services and lab-oratory staff should be considered for inclusionon this core team. The number of health careworkers who enter the room and provide directcare to a patient with suspected/confirmed EVDshould be minimized. A plan should be formu-lated by the health care team early on in thepatient’s hospital course about invasive proce-dures and escalation of care.

VISITORSVisitors should be limited. If a visitor isconsidered essential for the well-being of a pa-tient with EVD, the visitor should be educatedabout modes of transmission of EVD andappropriate PPE use. The visitor should usethe same PPE as health care workers. Visitorswho have had contact with the patient withEVD before and during hospitalization are apotential source of EVD for other patients, vis-itors, and staff. Their movement within the fa-cility should be restricted, and they should bescreened for EVD symptoms before each visitto the facility. Virtual visits by family andfriends should be considered instead of in-person visits.

LABORATORY TESTINGTo reduce the risk of health care worker expo-sure, blood collections for laboratory testsshould be minimized and laboratory testinglimited to tests that are essential for the pa-tient’s medical care. The clinical laboratoryshould be contacted before any samples areobtained and sent for testing so that the

(n):1710-1717 n http://dx.doi.org/10.1016/j.mayocp.2014.10.010www.mayoclinicproceedings.org

Travel to affected countries (Sierra Leone, Guinea, Liberia) in past 3 wk?

Contact in past 3 wkwith a known case of Ebola or an ill person

from affected countries?

Care for patient as perroutine

Yes

Yes Yes

No

No

No

Fever >38°Cor

one of the following:Severe headache

Vomiting Diarrhea

Unexplained bleeding

Outpatient area:• Mask the patient immediately, arrange for transfer to the hospital• If patient is not actively vomiting, bleeding or incontinent of stool, care for patient using fluid-resistant gown, gloves, face and eye protection• If patient is vomiting/bleeding or is incontinent of stool, more extensive PPE is needed for patient contact

• Care for patient as per routine• Monitor patient for symptoms of EVD while in

health care facility• At dismissal from facility, contact public health

authorities to arrange for active or active direct monitoring of patient for 21 d after last exposure

• Provide essential care• Delay non-essential medical tests until 21days after last exposure• Notify public health authorities so that arrangements can be made for direct active monitoring patient for symptoms for 21 d after last exposure

In hospital:• PIace in a single room• Health care workers entering room should have

appropriate PPE, be trained in PPE use, be observed by trained monitors when donning and removing PPE

• Limit blood draws, collect samples in plastic tubes• Notify laboratory before sending any samples • Do not use pneumatic tube system to transport

samples• Contact local or state health department for

assistance with EVD testing and to facilitate transfer to a regional center

Some or low-riskexposure

Some or high-riskexposure

High-risk exposure • Percutaneous (eg, needlestick) or mucous membrane exposure to body fluids of EVD patient• Direct care of a patient with EVD or exposure to body fluids without appropriate PPE• Laboratory worker processing body fluids of confirmed EVD patients without appropriate PPE or biosafety precautions • Direct exposure to human remains in affected countries without appropriate PPE• Household contact who provided direct care to a symptomatic EVD patient

Some risk exposure• Direct contact with a symptomatic EVD person with appropriate PPE

Low-risk exposure• Travel to affected country but no contact with a sick individual• Brief direct contact, eg, shaking hands or being in the same room as an EVD patient who is in early stage of the disease

FIGURE 2. Ebola screening algorithm for patients presenting for care. Direct active monitoring ¼ monitoring that includes directobservation. Active monitoring ¼ daily communication with patient to assess symptoms. EVD ¼ Ebola virus disease; PPE ¼ personalprotective equipment. Modified from Centers for Disease Control and Prevention guidance available at http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html.

WHAT TO KNOW ABOUT THE 2014 EBOLA OUTBREAK

Mayo Clin Proc. n December 2014;nn(n):1710-1717 n http://dx.doi.org/10.1016/j.mayocp.2014.10.010www.mayoclinicproceedings.org

1715

MAYO CLINIC PROCEEDINGS

1716

laboratory staff can take appropriate precau-tions while handling specimens.

The move to regional centers caring for allpatients with EVD would enable these centersto plan for dedicated laboratory instruments toprocess specimens and also expand the menuof tests available to these patients. Patientswith EVD can have profound electrolyte im-balances, and the available point-of-care testsmay be inadequate for optimum care.

In the event that the patient dies, handlingof the body after death should be minimized.All medical devices should be left in situ, au-topsy should be avoided, and burial or crema-tion needs to occur promptly.

CLEANING, LINEN, AND WASTEMANAGEMENTThe Ebola virus is a nonenveloped virus and assuch is susceptible to a broad range of hospital-gradedisinfectants.However, as an addedprecau-tion, the CDC recommends using disinfectantseffective against the more resistant nonenvelopedviruses (eg, norovirus, rotavirus, adenovirus, andpoliovirus) to disinfect environmental surfaces inrooms of patients with EVD. The product label’sinstructions for wet contact time should beadhered to strictly to ensure inactivation of the vi-rus. Environmental services staff should be pro-vided PPE training. Disposable cleaning cloths,mops, and wipes should be used, and theyshould be placed in leakproof bags after use.Used cleaning cloths and all linens from the pa-tient room should be handled as regulatedmed-ical waste. Sanitary sewers may be used for thesafe disposal of patient waste because sewage-handling processes in the United States aredesigned to inactivate infectious agents.

STOPPING THE EBOLA OUTBREAKThe current EVD outbreak in West Africa hasbeen the largest, most prolonged outbreak todate. In addition to the direct effects of EVD onpopulations, there has been disruption of stan-dard medical care for common communicablediseases, such as malaria, that are endemic inthe region and huge economic losses and socialdisruption in a region where the infrastructureis already significantly weakened by years ofwar andcivil unrest. TheWorldHealthOrganiza-tion has declared the Ebola epidemic to be a Pub-lic Health Emergency of International Concern.The international community, the World Health

Mayo Clin Proc. n December 2014;nn

Organization, and the World Bank have com-mitted to a coordinated international responseand funding for the relief efforts.4

With the first imported EVD case in theUnited States and subsequent health careworker transmission, all the health care facilitiesin the United States are actively planningfor EVD recognition and containment. Lessonslearned from Dallas are being incorporatedinto EVD health care facility preparedness.

On October 22, the CDC announced thatpublic health authorities will begin active post-arrival monitoring of travelers whose traveloriginates in Liberia, Sierra Leone, or Guinea.Travelers identified as arriving from thesecountries by Customs, Border Protection, andtheCDCwill receive aCARE (CheckAndReportEbola) kit at the airport that includes a pictorialdescription of symptoms, a thermometer, andinstructions on who to contact if they developsymptoms. They will be followed up daily bystate and local health departments for 21 daysfrom the date of their departure from West Af-rica. Any traveler who develops symptoms dur-ing this period will be directed to a local hospitalthat has been trained to receive patients with po-tential EVD. This should limit the number of pa-tients who arrive unexpectedly at emergencydepartments and also allay public anxiety aboutdelayed diagnosis and potential communitytransmission.

CONCLUSIONThe 2014 West African Ebola outbreak hasincreased the awareness of the disease amonghealth care providers and the general public inthe United States. It is important that healthcare workers understand themodes of transmis-sion and the clinical course to recognize a poten-tial EVD case. Preventing transmission in thecommunity setting requires early recognitionand isolation of patients with EVD in a healthcare facility that has adequate capabilities forinfection control and supportive care. Contacttracing and quarantine of people who mayhave been in contact with patients with EVDare essential. Finally, efforts to contain theoutbreak in West Africa through funding,ensuring the availability of necessary supplies,training, and education need to be pursuedaggressively. The global community has beencriticized for a slow and inadequate responseto theEVDcrisis inWest Africa so far, butwe still

(n):1710-1717 n http://dx.doi.org/10.1016/j.mayocp.2014.10.010www.mayoclinicproceedings.org

WHAT TO KNOW ABOUT THE 2014 EBOLA OUTBREAK

have the chance to avert a global crisis. Nigeriaand Senegal are now officially Ebola free, givingus reassurance that EVD control can be achievedeven in resource-limited settings.

SUPPLEMENTAL ONLINE MATERIALSupplemental material can be found online athttp://www.mayoclinicproceedings.org.

Abbreviations and Acronyms: CDC = Centers for DiseaseControl and Prevention; EVD = Ebola virus disease; PPE =personal protective equipment

Editor’s Note: The content of this article was current as ofOctober 23, 2014, the date of acceptance. The journal rec-ognizes that this is a rapidly evolving field, and we will pro-vide updates in the electronic and print versions of thejournal as appropriate. e Thomas J. Beckman, MD, Asso-ciate Editor for Concise Reviews.

Correspondence: Address to Priya Sampathkumar, MD,Associate Professor of Medicine, Division of Infectious Dis-eases, Mayo Clinic, 200 First St SW, Rochester, MN 55905(sampathkumar.priya@mayo.edu).

REFERENCES1. Ebola haemorrhagic fever in Zaire, 1976. Bull World Health

Organ. 1978;56(2):271-293.2. Ebola (Ebola virus disease): 2014West Africa outbreak. Centers

for Disease Control website. http://www.cdc.gov/vhf/ebola.Accessed August 22, 2014.

3. Piot P. Ebola outbreaks: I discovered this virus in 1976. I’ts frus-trating that we still know too little to treat it effectively. The Inde-pendent, Thursday March 27, 2014. http://www.independent.co.uk/voices/comment/ebola-outbreaks-i-discovered-this-virus-in-1976-its-frustrating-that-we-still-know-too-little-to-treat-it-effectively-9218620.html. Accessed October 30, 2014.

Mayo Clin Proc. n December 2014;nn(n):1710-1717 n http://dx.doiwww.mayoclinicproceedings.org

4. Ebola virus disease, 2014. World Health Organization website.http://www.who.int/csr/disease/ebola/en. Accessed August 25,2014.

5. Osterholm MT. What we need to fight Ebola. The WashingtonPost. August 1, 2014.

6. Viral hemorrhagic fever. Center for Infectious Disease Researchand Policy website. http://www.cidrap.umn.edu/infectious-disease-topics/vhf. Accessed August 25, 2014.

7. Paessler S, Walker DH. Pathogenesis of the viral hemorrhagicfevers. Annu Rev Pathol. 2013;8:411-440.

8. Leroy EM, Kumulungui B, Pourrut X, et al. Fruit bats as reser-voirs of Ebola virus. Nature. 2005;438(7068):575-576.

9. Olson SH, Reed P, Cameron KN, et al. Dead or alive: animalsampling during Ebola hemorrhagic fever outbreaks in humans.Emerg Health Threats J. 2012;5.

10. Feldmann H, Geisbert TW. Ebola haemorrhagic fever. Lancet.2011;377(9768):849-862.

11. Kortepeter MG, Bausch DG, Bray M. Basic clinical and labora-tory features of filoviral hemorrhagic fever. J Infect Dis. 2011;204(suppl 3):S810-S816.

12. Nkoghe D, Leroy EM, Toung-Mve M, Gonzalez JP. Cutaneousmanifestations of filovirus infections. Int J Dermatol. 2012;51(9):1037-1043.

13. Friedrich BM, Trefry JC, Biggins JE, et al. Potential vaccines andpost-exposure treatments for filovirus infections. Viruses. 2012;4(9):1619-1650.

14. Kondratowicz AS, Maury WJ. Ebolavirus: a brief reviewof novel therapeutic targets. Future Microbiol. 2012;7(1):1-4.

15. ZMapp. Mapp Biopharmaceutical website. http://www.mappbio.com. Accessed August 25, 2014.

16. Mupapa K, Massamba M, Kibadi K, et al. Treatment of Ebolahemorrhagic fever with blood transfusions from convalescentpatients: International Scientific and Technical Committee.J Infect Dis. 1999;179(suppl 1):S18-S23.

17. Fausther-Bovendo H, Mulangu S, Sullivan NJ. Ebolavirus vac-cines for humans and apes. Curr Opin Virol. 2012;2(3):324-329.

18. Hoenen T, Groseth A, Feldmann H. Current ebola vaccines.Expert Opin Biol Ther. 2012;12(7):859-872.

19. Ebola/Marburg. National Institute of Allergy and InfectiousDiseases website. http://www.niaid.nih.gov/topics/ebolamarburg/pages/default.aspx. Accessed August 25, 2014.

.org/10.1016/j.mayocp.2014.10.010 1717