Ebola preparedness for ob/gyns

Dr. Hill is with the Human Resources for Health Program Rwanda and the Department of Obstetrics and Gynecology and Maternal-Fetal Medicine at the Duke University School of Medicine, Kigali, Rwanda. 

You have heard the details about the current Ebola virus disease (EVD) outbreak in West Africa; an outbreak that probably began in early 2014 in Guinea and then spread to Liberia and Sierra Leone. These are the 3 countries most affected by EVD. The disease was evidently brought to the United States by a Liberian man visiting family in Dallas in late September. Two heroic healthcare workers at a Texas hospital became infected as a result of caring for him. Thus, Ebola preparedness is on the minds of all ob/gyns and it is the health issue of the moment as we care for our patients. What do we need to know to be safe and how should we inform our co-workers who are genuinely very concerned?

Slideshow: What doctors need to know about Ebola

What is EVD?

EVD is Ebola virus disease or Ebola. It is caused by an RNA virus of which there are 5 species; 4 cause disease in humans, with a case fatality rate of between 25% and 90%.

Why has it infected and killed so many in West Africa?

Weak public healthcare systems and poor infrastructure have facilitated the spread of EVD in close, crowded living conditions. The early signs and symptoms of EVD are also similar to malaria, another infectious disease frequently seen in this part of the world, which has contributed to late diagnoses and rapid spread.

What is the likelihood of our hospital or my practice seeing a case of EVD?

Very, very unlikely, but, in this age of worldwide airline travel, not impossible. But recall what you learned in medical school: Common disorders are common. Most patients presenting to your office, emergency department, OB triage, or labor and delivery suite with fever will have the flu or a urinary tract infection. Some may have chorioamnionitis or other pregnancy complications and require treatment and delivery. Those who have traveled to the West African countries of concern may even have malaria or typhoid. Few if any will have EVD but you must be vigilant.

What information do my coworkers need to know about EVD?

There are several important messages that need to be emphasized and reemphasized. Ebola is not transmitted through casual contact, or in water, air, or food. It is spread by direct body contact only after symptoms appear. Symptoms of EVD include fever, muscle and abdominal pain, vomiting, internal bleeding, and bloody diarrhea. These can appear up to 21 days after exposure to the virus. As the "flu season" approaches, remind coworkers in particular that if their patient has not been to West Africa or they have not taken care of a patient with EVD or touched the body fluids of someone with EVD, they do not have Ebola.

What body fluids are we talking about?

Sweat, saliva, blood, urine, semen, tears, feces, or vomitus.

I am working in my OB emergency care center, triage or Labor and Delivery. When should I suspect a patient might have EVD?

When a patient has suggestive signs and symptoms and has recently been to West Africa or taken care of a patient with EVD or touched the body fluids of someone with EVD.

What should I do then?

Minimize the risk of spreading a potentially serious infection through infection control. You may have a suspected case and must follow your hospital's protocol and the Centers for Disease Control and Prevention (CDC) protocol, which should include immediate isolation of the patient, Ebola testing, infection control, and consultation with infectious disease. It should also include the wearing of personal protective equipment or PPE by those taking care of the patient.

Can't I take Ebola home to my immediate family and friends? I am scared of doing that.

No, not unless you have EVD with some of those signs and symptoms and have been exposed to an EVD patient's bodily fluids, which is most unlikely.

What should my OB emergency care center, triage or Labor and Delivery be doing now in preparation for pregnant or postpartum EVD cases?

When indicated such as for a patient with fever, ask the individual promptly about her travel history. Remember, if an individual has not been to West Africa or taken care of a patient with EVD or touched the body fluids of someone with EVD, he or she does not have EVD.

Know your hospital's infectious disease protocols and stay involved in updating them in case you get a patient. Have signage in your waiting room about Ebola as you did with H1N1. Run simulation drills to pick up gaps on how to care for suspected cases. Practice with assistance putting on and particularly taking off the hazardous materials (hazmat) suit or PPE and providing obstetrical and postpartum care in it. Practice infection control measures with disposables and equipment. Develop a plan of care in your department with your maternal-fetal medicine and infectious disease specialist so you can safely take care of the pregnant and postpartum patient and protect yourself and colleagues.

What do we know at this time about the clinical effects of EVD on pregnancy and the fetus and the effect of pregnancy on EVD?

Unfortunately, at this time, we have very little information about pregnancy and this outbreak. As pregnant patients in Africa are diagnosed and treated and data are collected and studied, we will eventually know more. Several small, older studies of earlier outbreaks have shown that infected patients who do not die are at increased risk of first- and second-trimester pregnancy loss and that pregnant women may be more susceptible to EVD. Mortality from EVD is high in both pregnant and non-pregnant patients. We need more data.

Can a patient with EVD breastfeed?

Current recommendations from the CDC are that mothers with suspected or diagnosed EVD not breastfeed or have close contact with their newborn.

Can the treatment for EVD be safe during pregnancy?

There is no specific treatment for EVD, which is one of the reasons there is so much fear of and concern about the disease. The main treatment for EVD is aggressive multidisciplinary supportive care, which includes intravenous fluids, electrolytes, blood products, and hemodynamic monitoring in an intensive care unit setting. The safety of investigative therapies and vaccines at this time during pregnancy is unknown.

What are the most reliable sources to get updates, facts, and science about EVD to decrease fear and share with my colleagues?

It is most important that we be guided by facts and science and not fear or misinformation. Excellent resources include among others the websites of the CDC, National Institutes of Health, World Health Organization, the American College of Obstetricians and Gynecologists, and AWHONN. Regularly check them for updates on protocols and guidelines. Neighbors, "Facebook friends" and most Internet bloggers, however well intended, are not reliable resources. Talk with your hospital's infectious disease experts and epidemiologists and ask them to talk to your service as well. Have a lunch-and-learn with them for your office and Labor and Delivery staff. They are a wealth of accurate information.

What has happened to the pregnant women in West Africa who have EVD during this current outbreak?

To date, there are little or no reported data available on this outbreak.

Why do we have such minimal data today about this disease and pregnancy?

For a number of reasons:

• Few studies were done during past outbreaks in the Democratic Republic of Congo.

• Potential investigators at this time are overwhelmed with taking care of the sick. Reports will come later.

In summary, it is unlikely you will see a patient with EVD, but be vigilant and know the signs and symptoms. When indicated, ask patients about recent travel history. While we continue to have a serious debate about the best preparedness in this country and how best to protect all American citizens, we must continue to allay rational and surely irrational fear. We must also be aware of potential bias when a patient from West Africa shows up in your Labor and Delivery or obstetrics emergency care center. Know your hospital's protocols and stay up to date about current guidelines. They will change and be expanded. In other words, practice and share Ebola preparedness, which will help you to be an informed, prepared leader.

Sources

Centers for Disease Control and Prevention. Ebola (Ebola virus disease): Information for Healthcare Workers and Settings. http://www.cdc.gov/vhf/ebola/hcp/index.html.

Centers for Disease Control and Prevention. Recommendations for breastfeeding/infant feeding in the context of Ebola. http://www.cdc.gov/vhf/ebola/hcp/recommendations-breastfeeding-infant-feeding-ebola.html.

Association of Women’s Health, Obstetric and Neonatal Nurses Ebola: Caring for pregnant and postpartum women in the United States. (AWHONN Clinical Management Guidelines for Women’s Health and Perinatal Nurses Practice Brief No. 3) https://www.awhonn.org/awhonn/binary.content.do?name=Resources/Documents/pdf/2I_Ebola_Practice_Brief.pdf.

Jamieson DJ, Uyeki TM, Callaghan WM, Meaney-Delman D, Rasmussen S A. What obstetrician-gynecologists should know about Ebola: A perspective from the Centers for Disease Control and Prevention. Obstet Gynecol. Epub ahead of print. doi: 10.1097/AOG.000000000000533.

Fauci AS. Ebola: Underscoring the global disparities in health care resources. N Engl J Med. 2014;371:1084–1086.

World Health Organization. Global alert and response: Ebola news. www.who.int/csr/disease/ebola/en/

Centers for Disease Control and Prevention. Ebola (Ebola virus disease). www.cdc.gov/vhf/ebola/.

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