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Ebola Virus Disease Transmission November 5, 2014

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Ebola Virus Disease Transmission November 5, 2014 Ebola Virus Disease Transmission November 5, 2014 Key Points: The Ebola virus is transmitted from person to person through close personal contact with an infected individual or their blood or body fluids. Airborne transmission of Ebola virus has not been demonstrated in human studies. Individuals infected with Ebola are not infectious before the onset of symptoms. Individuals at the height of their illness or in the latter stages of fatal disease present the greatest risk for potential transmission. Strict adherence to infection prevention and control precautions, including the use of personal protective equipment, has been shown to be extremely effective in preventing Ebola virus transmission to health care workers. How is Ebola transmitted? The Ebola virus is considered a classic zoonotic pathogen with the suspected reservoir being the African fruit bat, with chimpanzees, apes, and humans being end hosts. Transmission to humans from contact with infected animals through the preparation of “bush meat” has been well documented in Africa1. Person to person transmission of the Ebola virus occurs through close personal contact with an infected individual or their blood or body fluids2. Transmission occurs from direct blood or body fluid exposure to non-intact skin or mucous membranes, or through percutaneous exposure (e.g. needle stick injury). In addition to blood, Ebola virus has been detected in other body fluids following symptom onset, including saliva, stool, semen, breast milk, urine, sweat, and tears3,4, and the World Health Organization has indicated that vomit can also be infectious5. Any body fluid from an infected patient that has blood mixed with it may potentially contain the virus. In studies of Ebola outbreaks, transmission of Ebola from patients to household contacts has required direct contact with an infected patient or their body fluids6,7. In one study, transmission to a household contact occurred in the absence of direct contact with the infected patient, but the infected contact had slept wrapped up in a blanket left by his brother, who had just died of Ebola virus disease6. In another study of 27 primary Ebola cases and 173 household contacts, none of 78 household member contacts who did not touch the infected person during the clinical illness period were infected7. Traditional funeral practices in African countries affected by Ebola outbreaks typically involve the cleaning and rubbing of the deceased body, which may have a high load of Ebola virus8. Contact with the bodies of deceased Ebola patients during such funeral rituals has been shown to be a significant risk factor for Ebola virus transmission7,9. Ebola virus has been detected within the skin when skin biopsy samples have been examined using special antigen staining techniques. Specifically, virus was detected within cells in the deeper layer of the skin (dermis) and in areas surrounding sweat glands where cell breakdown (lysis) had occurred10. Page 1 of 8 Ebola Virus Disease Transmission November 5, 2014 Using electron microscopy, no Ebola virus particles were observed in skin cells closer to the skin surface or within sweat glands10. Ebola virus has been detected in a skin swab from a patient with Ebola virus disease, but there was no microscopic examination to determine if the skin surface had been contaminated with blood or other body fluid3. It is possible that Ebola can be transmitted through contact with environmental surfaces that are contaminated with Ebola virus (i.e. fomites), but this possibility is unlikely if the environmental surface is not visibly contaminated with blood or body fluids. Enveloped viruses such as Ebola are susceptible to a broad range of hospital disinfectants used to disinfect hard, non-porous surfaces11. An environmental sampling study took place on an isolation ward caring for Ebola patients; this isolation ward underwent daily disinfectant cleaning of the floors, as well as disinfectant cleaning of visibly contaminated surfaces as necessary. All environmental samples were negative for Ebola virus, suggesting that the risk of transmission from fomites is low when environmental cleaning practices are followed3. Can Ebola be transmitted by the airborne route? Lung involvement is uncommon in Ebola virus disease12,13. Airborne transmission of Ebola virus has not been demonstrated in human studies. Studies of Ebola outbreaks to date have been consistent with transmission via close personal contact with infected individuals or their blood or body fluids6,7,14,15. For example, in settings where household contacts have shared small confined living spaces (e.g. small and poorly ventilated huts, or slept in the same room as the infected individual) but did not have direct contact with infected individuals, no Ebola virus transmission has occurred14,15. In laboratory settings, non-human primates exposed to aerosolized Ebola virus from pigs have become infected, however, airborne transmission of Ebola virus has not been demonstrated between non-human primates2,16. Although this has not been demonstrated in human studies, there is a theoretical risk of transmission if one were to inhale aerosolized fluids from an Ebola patient. For this reason, airborne precautions are required when an aerosol generating medical procedure is performed on a patient infected with Ebola virus disease. Airborne precautions are also required when performing laboratory tests on specimens that may contain the Ebola virus, due to the likelihood of aerosolization during processing of samples. How soon after being infected with Ebola can a person potentially infect others? The period between contact with Ebola virus and the development of symptoms (incubation period) ranges from 2 to 21 days (but is usually 4 to 9 days). During the incubation period (prior to the onset of symptoms) transmission of Ebola from an infected person to another individual has not been observed. For example, in a study of household members who had close contact with infected individuals during the incubation period (including direct contact, sharing of meals, sharing a bed, etc) there was no observed risk of Ebola virus transmission7. Page 2 of 8 Ebola Virus Disease Transmission November 5, 2014 Ebola virus is not detectable in the blood prior to the onset of symptoms17. Once symptoms begin, Ebola virus may be detectable in the blood at very low levels. Subsequently, the viral load in blood changes in parallel with the disease course, increasing over the first few days as symptoms escalate, and then decreasing as symptoms settle17. The risk of transmission is correlated with the quantity of circulating virus in blood and body fluids. Patients in the latter stages of fatal disease (including the post-mortem period) have high levels of the Ebola virus in their blood and body fluids, which represents the highest risk for Ebola virus transmission6,7. Is Ebola easily transmissible? Unprotected exposure to blood and body fluids from a symptomatic individual who is infected with Ebola virus carries a risk of disease transmission. However, it has been observed that Ebola virus is not transmitted in the context of casual contact with patients in the early stages of clinical illness, or in health care settings when appropriate infection prevention and control measures are in place. For example: In Gabon, 18 people who had become ill with Ebola after skinning and chopping a chimpanzee cadaver were admitted to hospital. All equipment necessary for barrier nursing and prevention of the spread of disease were provided at the hospital. No Ebola cases occurred among health care personnel, and 191 contacts were traced with no further cases of Ebola virus disease18; An Ebola-infected individual from Guinea travelled to Senegal by seven-person taxi on August 14, 2014. He developed fever, vomiting, and diarrhea on August 16, sought care at a neighbourhood health post on August 18, continued follow-up as an outpatient until August 25, and was admitted to hospital on August 26. Sixty- seven contacts of the patient were identified, including 33 health care workers, and none of the contacts developed Ebola virus disease19; An Ebola-infected individual from Liberia had traveled to Dallas, Texas, on September 20, 2014, and developed symptoms four days later. He presented to a local emergency department on September 25 with fever, abdominal pain, headache, dizziness, and nausea, and was discharged home early on September 26. On September 28, 2014, he was transported to the same hospital by ambulance, was admitted for further assessment, and was diagnosed with Ebola virus disease on September 3020. Of all the people who had close contact with this symptomatic individual in the days prior to his hospital admission - including emergency department staff, EMS workers, his fiancée, and family members - none of them became infected with the Ebola virus20,21. Although transmission did not occur early in his disease, two ICU nurses who had close contact with the Ebola-infected patient in the latter stages of his disease did become infected (both have since recovered from their infections). It is not yet clear how these two nurses acquired Ebola; there is speculation about the adequacy of personal protective measures (in terms of equipment, training, and supervision), but the full details of the events at the Dallas hospital have yet to be formally disclosed. Page 3 of 8 Ebola Virus Disease Transmission November 5, 2014 Why has this Ebola outbreak been so large and widespread? The current Ebola outbreak in West Africa is the largest and most sustained Ebola outbreak in human history. Since 1976, when the Ebola virus was first identified, the largest previous outbreak involved 425 cases22. In comparison, as of October 29, 2014, there have been 13,567 reported Ebola cases, including 4,951 reported deaths23. There are many factors that have contributed to the size and extent of the current outbreak, for example8: Although historical outbreaks have occurred in remote forests of Sub-Saharan Africa, the current outbreak has reached urban areas.
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