Infection reflections


Ebola has raised its ugly head. According to the World Health Organization, there are 58 reported cases in Africa with 27 deaths: a 46.5% fatality rate. The last major outbreak of Ebola in Africa resulted in 28,000 people infected and 11,310 killed: a 41% fatality rate. Although the likelihood of Ebola in the United States is minimal (there was a case in Dallas in 2014), the CDC has taken precautions. 6,500 customs and border protection officers have received pre-shift briefings about Ebola. Twenty electronic signs advising travelers of the symptoms of Ebola have been posted from Seattle to San Juan, Puerto Rico. EMS providers now routinely ask patients about their travel histories in an attempt to ascertain potential exposure to Highly Infectious Disease (HID).

The most common international definition of HID is that developed by the European Network for Infectious Diseases: “A disease transmissible from person-to-person that causes life-threatening illness, and presents a serious hazard in health care settings and in the community, requiring specific control measures.” Hemorrhagic fevers, smallpox, severe acute respiratory syndrome, and other conditions caused by dangerous pathogens are examples of HIDs. Let’s focus our attention on Ebola.

What is Ebola?

Ebola is a simple virus. It consists of seven genes wrapped in two layers of protein. This is packaged by a polymerase (enzyme) and wrapped in a membrane studded with glycoproteins. Once inside the cell, the enzyme makes copies of the Ebola genes and takes control of the host cell causing it to make the proteins Ebola needs. Two of the proteins are particularly sneaky. VP35 blocks the production of interferons, which knocks out the immune system radar. VP24 is a stealth bomber which makes the remaining immune system less effective. Ebola attacks the immune system and spreads via the liver, spleen and lymph nodes. The resultant cytokine storm initiates the pathologic response in which a patient can lose 10 liters of fluid a day.

Ebola is spread through direct contact with blood or body fluids (including, but not limited to feces, saliva, urine, vomit and semen) of an infected person. Transmission via semen has been demonstrated seven weeks after clinical recovery. It enters another person’s body through non-intact skin or mucous membranes. It can be transmitted by contact with objects. Ebola may remain intact on solid surfaces for several days. In one series of Ebola infected needle-sticks, there were no survivors. Ebola is not spread through air or water, but there is some controversy about spread through aerosolization. The incubation period ranges from 2 to 21 days with an 8 to 10 day average. Signs of Ebola include fever greater than 101.5 F or 38.6 C, headache, myalgia, vomiting, diarrhea, abdominal pain or unexplained hemorrhage. Given the high case fatalities of Ebola and other HIDs and the fact that they are easily transmissible, it follows that a combination of medical, public health and community measures are necessary to control them. How do we determine if we have the requisite training and education to safely function in this joint effort? Fortunately, a recent gap analysis survey gives a great starting point.

A collaboration among twelve EMS, Infection Control and academic institutions performed a survey to discover where education and training can be strengthened to enhance occupational safety when dealing with HIDs. The survey was directed at both lead-level and front-line personnel. Their responses were compared for similarity. The study was used to create recommendations to mend deficiencies. They include: “Changes to governmental and primary national organization websites that more effectively educate EMS practitioners on HID transmissibility and containments, as has been provided to healthcare workers for years; organizational changes that foster increased communication of HID training, knowledge and available resources between administrators and leads with frontline responders, and between practitioners with differing certification levels; adhering to and expanding upon existing OSHA and CDC training guidelines and recommendations through increased volume of HID-specific training, including proper PPE use and decontamination techniques; implementing and/or increasing the volume of regular HID trainings that focus on the epidemiology of re-emerging and emerging HIDS; and, utilizing existing national resources, like training programs, that specifically provide free HID training to specific worker populations.”

Stagnation and institutional inertia are not viable options. On March 11 of this year a group of 21 organizations from four European and nine African countries formed a group to address clinical research, identifying and tracking (surveillance) processes, diagnostic tools, and treatment for ”disease X”. They want to catch the next infectious agent capable of causing a global pandemic before it strikes. Given that about 1.3% of standard national EMSi curricula address infection, we have a lot of work to do.


  • “Prepping for disease X”, “Science”, 10 March 2018, Vol 359, Issue 6381, p.1198.
  • “CDC officials take precautions as Ebola outbreak spreads. Accessed May 29, 2018
  • “CDC: Ebola for Healthcare Providers” www.cdc./gov/vhf/ebola Accessed May 29,2018
  • Le AB, Buehler S, , “Determining training and educations needs pertaining to highly infectious disease preparedness and response: A gap analysis survey of US emergency medical services practitioners.” American Journal of Infection Control” 46 (2018) 246-252
  • Isakov A, Jamison A, et. al., “Safe management of patients with serious communicable diseases: recent experience with Ebola virus. Annals of Internal Medicine 161 (2014) 829030
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