Opinion

VIEWPOINT Disease and Children What Pediatric Health Care Professionals Need to Know

4,5 Georgina Peacock, The largest outbreak of Ebola virus disease (EVD) in his- estimated at 11.4 days (typical range, 2-21 days). A per- MD, MPH tory is occurring in West Africa. On August 8, 2014, the son with infection is not contagious until Centers for Disease World Health Organization (WHO) declared this out- symptoms are present. Currently,no specific therapeu- Control and break to be a Emergency of International tics or are approved for EVD, and clinical man- Prevention, Atlanta, 1 Georgia. Concern. As of October 8, 2014, 8399 EVD cases (in- agement is focused on supportive care of complica- cluding 416 in health care personnel) with 4033 deaths tions (eg, hypovolemia and electrolyte abnormalities). Timothy M. Uyeki, were reported, although reported cases are likely a sub- Several investigational therapeutics are in develop- MD, MPH, MPP stantialunderestimateoftheoutbreakmagnitude.2 Most ment and some may be available for compassionate use Centers for Disease EVD cases have been reported in Guinea, Liberia, and or through enrollment in clinical trials in the future. Two Control and Prevention, Atlanta, Sierra Leone, with fewer cases in Nigeria and a single case investigational EVD vaccines are in Phase I trials in Georgia. in Senegal. Although the suspected index case for this healthy adults. outbreak is believed to be a 2-year-old child who died in Sonja A. Rasmussen, Guinea in December 2013, limited information is avail- What Is Known About EVD in Children? MD, MS 3 Centers for Disease able on the impact of this outbreak on children. Cases Control and of EVD were also identified in the Democratic Republic Transmission of Ebolavirus to Children Prevention, Atlanta, of the Congo, but analyses of suggest that the Because EVD outbreaks have typically occurred in low- Georgia. Democratic outbreak is not linked resource settings, detailed information about pediatric to the wider epidemic. As of October 15, 2014, 3 EVD cases has not been systematically collected. Based on cases, including 2 health care personnel, had been iden- available data, children and adolescents often com- tified in the United States and 5 EVD cases, including 4 prise a small percentage of EVD cases. For example, in health care personnel, were identified in West Africa and an outbreak in Zaire in 1995 in which more than half medicallyevacuatedtotheUnitedStatesforfurthercare. of the population was younger than 18 years, only 9% This situation is rapidly evolving, and new information of the 315 EVD cases were younger than 18 years.5 Simi- will be posted to the Centers for Disease Control and Pre- larly,147 of 823 (18%) reported EVD cases reported from vention (CDC) (http://www.cdc.gov/vhf/ebola/index thecurrentoutbreakinGuineawerechildren,6 and13.8% .html) and WHO (http://www.who.int/mediacentre of cases from 4 affected countries were younger than /factsheets/fs103/en/) websites as it becomes available. 15 years.4 Investigators have suggested that the low Our report is intended to complement information on number of pediatric EVD cases may be owing to cul- the CDC webpages, with a focus on what pediatric health tural practices in which children are kept away from care professionals need to know. sick members, resulting in reduced ebolavirus transmission.4 Background Ebola virus disease is a rare zoonotic disease caused by Manifestations of EVD in Children infection with 1 of 5 of Ebolavirus. Zaire ebola- A unique challenge facing pediatricians is being able to virus, the species responsible for the current outbreak, distinguish EVD signs and symptoms from features of was first discovered in 1976 near the in Zaire much more common pediatric infectious diseases. Typi- (now the Democratic Republic of the Congo). Since then, cally, children may present with nonspecific signs and a number of EVD outbreaks have been recognized, pri- symptoms of EVD similar to those in adults, which ini- marily confined to remote areas of East and Central tially include fever, headache, myalgia, abdominal pain, Africa. The animal reservoir of ebolavirus is believed to and weakness, followed several days later by vomiting, be fruit . Zoonotic transmission can occur through diarrhea, and, less commonly, unexplained bleeding or direct contact with bats, primates, and duiker ante- bruising. However, data are very limited. This high- lopes that have died from ebolavirus infection. Ebola- lights the key issue of eliciting a history of exposure to virus can spread among primarily through un- Zaire ebolavirus including a travel history and espe- Corresponding protected direct contact of skin (through breaks or cially any recent direct contact with the blood or bodily Author: Georgina Peacock, MD, MPH, microabrasions) or mucous membranes with blood or fluids of a person who was sick or died from suspected 1600 Clifton Rd, MS body fluids (eg, feces, saliva, urine, and vomit) of a per- or confirmed Zaire ebolavirus infection. E-88, Centers for son who is ill with EVD, or the corpse of a deceased pa- In the 2000-2001 outbreak in Disease Control and tient who had EVD, or possibly with objects contami- Uganda,allchildrenwithlaboratory-confirmedEVDwere Prevention, Atlanta, GA 7 30333 (gpeacock@cdc natedwiththebloodorbodyfluidsofaninfectedperson. febrile, while only 16% had hemorrhage. Respiratory .gov). The mean incubation period in the current outbreak is (eg, cough and dyspnea) and gastrointestinal symp-

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toms were common among children, while central nervous system ferential diagnosis of a febrile pediatric traveler from West Africa. signs were rare.7 Information on high- and low-risk exposures and case definitions for The overall case-fatality proportion in the current outbreak is the United States are available at http://www.cdc.gov/vhf/ebola estimated at 70.8%, including 73.4% in children younger than 15 /hcp/case-definition.html.IfEVDissuspected,appropriateinfection- years, 66.1% for those aged 15 to 44 years, and 80.4% for those older control precautions (eg, standard, droplet, and contact) should be than 44 years.4 However, in the Sudan ebolavirus outbreak in Uganda implemented immediately and the state health department should during 2000-2001, children younger than 5 years were reported to be promptly notified. The CDC developed an algorithm to evaluate be at increased risk for illness and death.6 The authors hypoth- travelers returning from areas with cases of EVD (http://www.cdc esized that this was owing to more prolonged contact with ill care- .gov/vhf/ebola/pdf/ebola-algorithm.pdf). Laboratory specimens givers (in this outbreak, young uninfected children were often ad- should be processed according to CDC guidance (http://www.cdc mitted to EVD treatment unit isolation wards with their ill parents .gov/vhf/ebola/pdf/ebola-lab-guidance.pdf). because of the reluctance of other adults to care for them).7 Given the impact of this EVD outbreak on the health care infra- Conclusions structure in the most severely affected countries, the health of Health care professionals, including those who care for children, children is likely to be seriously impacted because of challenges to should be familiar with the clinical features of EVD and should in- providing routine care (eg, immunizations and hospitalizations for quire about recent travel to affected West African countries when common illnesses) in affected countries. assessing patients with compatible illness. Prompt implementa- tion of recommended infection-control measures and appropriate Considerations for the Pediatric Health Care Professional reporting to state health departments are essential to prevent Pediatric health care professionals should have a high index of sus- further transmission. Based on previous outbreaks and limited data picion for EVD if the child has compatible signs and symptoms and from the current epidemic to date, children may be at lower risk for a history of travel from an affected country within the past 21 days. EVD than adults. Therefore, health care professionals should also It is essential that health care professionals take a detailed travel his- consider other common infectious diseases prevalent in West Africa tory. , measles, typhoid fever, and other infectious diseases when evaluating ill children from this region, while maintaining a are also endemic in West Africa and should be included in the dif- high level of suspicion for EVD.

ARTICLE INFORMATION /mediacentre/news/statements/2014/ebola 5. Dowell SF. Ebola hemorrhagic fever: why were Published Online: October 17, 2014. -20140808/en/. children spared? Pediatr Infect Dis J. 1996;15(3): doi:10.1001/jamapediatrics.2014.2835. 2. World Health Organization. Ebola response 189-191. Conflict of Interest Disclosures: None reported. roadmap update: 10 October 2014. 6. United Nations International Children's http://apps.who.int/iris/bitstream/10665/136161/1 Emergency Fund. UNICEF Guinea: Humanitarian Disclaimer: The findings and conclusions in this /roadmapupdate10Oct14_eng.pdf. Accessed Situation Report, 29 August 2014. September 5, 2014. report are those of the authors and do not October 10, 2014. http://reliefweb.int/report/guinea/unicef-guinea necessarily represent the official position of the -humanitarian-situation-report-29-august-2014-0. Centers for Disease Control and Prevention. 3. Baize S, Pannetier D, Oestereich L, et al. Emergence of Zaire Ebola virus disease in Guinea. Accessed September 11, 2014. REFERENCES N Engl J Med. 2014;371(15):1418-1425. 7. Mupere E, Kaducu OF, Yoti Z. Ebola 4. WHO Ebola Response Team. Ebola virus disease haemorrhagic fever among hospitalised children 1. World Health Organization. WHO statement on and adolescents in northern Uganda: epidemiologic the Meeting of the International Health Regulations in West Africa: the first 9 months of the epidemic and forward projections [published online and clinical observations. Afr Health Sci. 2001;1(2): Emergency Committee regarding the 2014 Ebola 60-65. outbreak in West Africa. http://www.who.int September 22, 2014]. N Engl J Med. doi:10.1056 /NEJMoa1411100.

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