Caring for Ebola Disease Survivors in the U.S.

Note:

All available data on Ebola disease comes from people infected with Ebola virus (species Orthoebolavirus zairense). However, there are other orthoebolaviruses known to cause disease in humans, which include Sudan virus, Bundibugyo virus, and Taï Forest virus. We expect data gathered from people with Ebola disease to be applicable to these other orthoebolaviruses.

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A healthcare provider examines an Ebola disease survivor in Uganda, 2000.

Orthoebolavirus persistence

Orthoebolaviruses can persist for several months after acute infection in organs where the virus is shielded from the immune system. These sites, called "immunologically privileged sites," include the testes, interior of the eyes, placenta, and central nervous system (CNS). Table 1 summarizes data available to date on detection of Orthoebolavirus zairense ribonucleic acid (RNA) by reverse transcription-polymerase chain reaction (RT-PCR) or recovery of viable Orthoebolavirus zairense in viral culture from different clinical specimens.

People who recover from infection with an ebolavirus can experience complications after acute disease. The timing of onset, severity, and duration of complications are variable and can include:

• Non-specific fatigue
• Joint pain
• Muscle aches
• Headaches
• Suppurative parotitis
• Pericarditis
• Orchitis
• Sexual dysfunction
• Hair loss
• Vision loss (including uveitis and permanent blindness)
• Hearing loss or tinnitus
• Paresthesia or dysesthesia
• Memory loss
• Insomnia
• Depression
• Anxiety or post-traumatic stress disorder

Risk of virus transmission due to persistent virus infection

The risk of a health care provider acquiring Ebola disease from patients with persistent infection is unknown but appears to be low and is likely to decrease over time. Appropriate infection control practices, such as those recommended for evaluating patients with a suspect viral hemorrhagic fever, should be adhered to until the patient tests negative.

Neurologic illness or ocular symptoms in a person who recovered from acute disease could indicate persistent orthoebolavirus replication in the central nervous system or eye, respectively. Patients who recovered from an ebolavirus infection and show new or recurrent neurologic or ocular symptoms should be assessed for complications associated with potential virus persistence.

Ebola survivors with fever should be assessed for both common community-acquired infections (e.g., malaria, influenza, common cold, typhoid fever, gastroenteritis, etc.), as well as possible complications related to orthoebolavirus persistence.

Clinical assessment of Ebola disease survivors

Healthcare personnel should not withhold care, when seeing a patient who has recovered from an orthoebolavirus infection. Use Standard Precautions and correct waste management during a clinical evaluation and when caring for a patient who has fully recovered from Ebola disease and is seeking medical care. There is no current evidence that routine clinical care poses risk to healthcare personnel when contact with intact skin, sweat, tears, conjunctivae, saliva, or cerumen is involved.

There is no evidence that people who become pregnant after they recover from Ebola disease pose special risk to healthcare providers. They should receive routine prenatal care with Standard Precautions and correct waste management used during labor and delivery with attention paid to splash prevention.

The absence of neurologic symptoms suggests that the virus is not present in the CNS, and regional anesthesia, like spinal blocks and epidurals, should not pose a risk to hospital staff. Standard Precautions and correct waste management procedures should be followed. Available evidence indicates that people do not manifest orthoebolavirus viremia when they have fully recovered and are not febrile, and they do not pose a risk of exposure through phlebotomy.

Special consideration for immunologically privileged sites

Special considerations are needed when healthcare personnel perform specific procedures on (Table 1) people who have recovered from acute disease that could expose them to certain body fluids and tissues. These procedures may include:

• Obtaining and handling cerebral spinal fluid from patients with CNS symptoms.
• Performing invasive ophthalmologic procedure on an affected eye in a patient with ocular disease (uveitis or cataract).
• Procedures involving exposure to semen or the testes, prostate gland, or seminal vesicles.

For these and other care activities that might involve contact with certain body fluids and tissues, healthcare facilities and clinicians should:

• Arrange expert consultation in advance or on an urgent basis as needed with the state/local health department and/or CDC.
• Assess capabilities of the facility and ability to correctly implement and maintain infection control, including contact precautions, environmental hygiene, and infectious waste management, as needed.
• Assess readiness, training and competence of all staff potentially involved in care, including diagnostic laboratory and imaging personnel, environmental services staff, and care providers, and their willingness to participate knowing the possible risk of virus persistence.
• Determine appropriate personal protective equipment (PPE) needed based on a risk assessment of potential exposure during the procedure(s) and related care and ensure training on its use. Based on assessment, and in consultation with public health authorities, safe care delivery can be arranged either at the original facility or, at the discretion of local and state public health authorities and in consultation with CDC, at an appropriate referral facility.