Guidance for Management of Survivors of Ebola Disease in U.S. Healthcare Settings
This guidance may be updated based on new data if indicated.
All available data on Ebola disease comes from people infected with Ebola virus (species Zaire ebolavirus). However, we expect this data to be applicable to all ebolaviruses known to cause disease in people (Ebola virus, Sudan virus, Bundibugyo virus, Taï Forest virus).
In the wake of the largest outbreak of Ebola disease in West Africa from 2014 to 2016, and with the improvements seen in supportive care delivery in field settings, there are now many survivors of Ebola disease, including those experiencing sequelae of the disease. Of the eleven patients with Ebola disease who were managed in U.S. healthcare facilities during 2014-2015, nine survived. It is possible that some Ebola disease survivors could seek medical care in the U.S. The purpose of this document is to provide:
- Information about sequelae and ebolavirus persistence in Ebola disease survivors.
- Infection prevention and control recommendations for U.S. healthcare providers when evaluating a patient who is a survivor of Ebola disease.
Data on the pathogenesis of sequelae in Ebola disease survivors and complications related to viral persistence are very limited; few data are available from animal models.
Survivors can experience complications after surviving acute Ebola disease. The timing of onset, severity, and duration of complications among Ebola disease survivors are variable. Reported complications among survivors 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, tinnitus, paresthesia or dysesthesia, memory loss, insomnia, depression, anxiety, and post-traumatic stress disorder1-10).
Ebola virus (EBOV; species Zaire ebolavirus) can persist for several months after acute infection in organs that are considered “immunologically privileged sites” – sites that are shielded from the survivor’s immune system (e.g., testes, eye, central nervous system). EBOV was isolated from a semen specimen collected 82 days after acute onset of Ebola disease from a male survivor13. Molecular evidence suggested sexual transmission of EBOV from an asymptomatic male survivor to a female partner 179 days after the survivor’s disease onset14. The potential for residual infectious risk from EBOV persistence is further highlighted by recovery of infectious EBOV in cerebrospinal fluid collected at 282 days after onset of Ebola disease from a survivor who experienced late onset of meningoencephalitis signs and symptoms1, and isolation of EBOV from an intraocular fluid specimen of an eye affected by panuveitis collected at 14 weeks after onset of Ebola disease16. It is unknown whether EBOV can persist in synovial fluid with or without accompanying arthritis. Table 1 summarizes data available to date on detection of EBOV RNA by reverse transcription-polymerase chain reaction (RT-PCR) or recovery of viable EBOV in viral culture from different clinical specimens.
Patients who recover from acute Ebola disease and later become ill with neurologic or ocular symptoms might have persistent ebolavirus replication in the CNS or eye respectively. The risk of infectivity from patients with persistent infection in immune privileged sites 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 suspect Ebola disease, should be adhered to until testing is negative. This includes any time there could be potential contact with spinal fluid, semen, or ocular contents (e.g., lumbar puncture, spinal anesthesia, prostate or testicular surgery, and intraocular procedures).
Ebola disease survivors who have any new or recurrent ocular or neurologic symptoms should seek care for complications associated with potential virus persistence. 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 virus persistence.
|Anatomic compartment||Body fluid(s) or tissue(s)||Longest time from illness onset that Ebola virus RNA or infectious virus was detected in clinical specimens after illness onset, days [reference]|
|Ebola virus RNA detected by RT-PCR or viral antigens detected by other assays||Infectious Ebola virus recovered|
|Eye||Aqueous humor||14 weeks after illness onset by RT-PCR16||14 weeks after illness onset by virus isolation16|
|Conjunctival swab||22 days after illness onset by RT-PCR13
|No published data|
|Central nervous system||Cerebrospinal fluid||10 months after illness onset by RT-PCR1||No published data|
|Testes||Seminal fluid||40 months after illness onset by RT-PCR15||82 days after illness onset by virus isolation13|
|Breast||Breast milk||16 months (500 days) after discharge from treatment center by RT-PCR21||15 days after illness onset by virus isolation11|
|Urinary tract||Urine||64 days after illness onset by RT-PCR17||26 days by virus isolation18|
|Genito-urinary tract||Vagina||36 days after illness onset by RT-PCR12||No published data|
|Joints||Synovial fluid||No animal model data, very limited Ebola Disease patient data, unknown|
|Gastrointestinal tract||Rectal swab||29 days after illness onset by RT-PCR13||No published data|
|Saliva||8 days after illness onset by RT-PCR11||4-8 days after illness onset by virus culture11|
|Vomit||No published data||No published data|
|Feces||12 days after illness onset by RT-PCR11||No published data|
|Lower respiratory tract||Viral antigens detected in alveolar macrophages; viral inclusions observed in intra-alveolar macrophages, with free virus particles within alveolar spaces in fatal cases20||No published data|
|Other||Sweat (underarm)||44 days after illness onset by RT-PCR17||No published data|
|Skin (on the hand)||6 days after illness onset by RT-PCR11||No published data|
|Amniotic fluid||>=32 days after disappearance of virus from maternal blood by RT-PCR19||No published data|
|Placenta||>32 days after disappearance of virus from maternal blood by RT-PCR19||No published data|
|Cord blood||>32 days after disappearance of virus from maternal blood by RT-PCR19||No published data
|Nasal blood||10 days after illness onset by RT-PCR11||No published data|
Guidance for Clinical Assessment of Ebola Disease Survivors
Healthcare personnel should not withhold any care from survivors of Ebola disease. All patient care delivery (i.e., in patients both known and not known to be Ebola disease survivors) should be performed using Standard Precautions. These constitute the minimum set of infection control practices used to ensure that healthcare personnel do not contract infections from patients, whether or not they are known to be infectious, and that personnel do not spread infectious material to other patients during routine medical care.
For patients who fully recover from Ebola disease and subsequently seek medical care (Ebola disease survivors who recover and are discharged after their acute disease clinical course):
- Standard Precautions and correct waste management should remain in effect while appropriate clinical evaluation and care is performed. Based on observations during the 2014 West African Ebola disease outbreak and previous outbreaks, there is no current evidence that the routine clinical care of Ebola disease survivors poses any special risk to healthcare personnel when this care involves contact with intact skin, sweat, tears, conjunctivae, saliva, or cerumen.
- 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.
- In the absence of neurologic symptoms, regional anesthesia should not pose a risk to hospital staff. (For those pregnant survivors with neurologic symptoms who require spinal anesthesia during delivery, see below).
- Available evidence indicates that people who have fully recovered from Ebola disease and are not febrile, do not manifest ebolavirus viremia and do not pose a risk of exposure through phlebotomy.
- Specific procedures that create the opportunity for contact with body fluids from immunologically protected sites merit special consideration. Although data are limited, there is recognized potential for virus persistence in certain body fluids and tissues as summarized in Table 1. Examples include: obtaining and handling CSF from an Ebola disease survivor with CNS symptoms; performing an invasive ophthalmologic procedure on an affected eye in a patient with ocular disease such as uveitis or cataract; and procedures involving exposure to semen, such as infertility evaluations, or performing invasive procedures on the testes, prostate gland, or seminal vesicles. It is unknown whether ebolavirus may persist in synovial fluid of survivors. For these, and any other care activities that might involve contact with such body fluids (including lumbar puncture, spinal anesthesia), healthcare facilities and clinicians should:
- Arrange expert consultation in advance or on an urgent basis as needed (i.e., through the state 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 (including in consultation with CDC in advance or on an urgent basis)
- Assess the readiness, training and competence of all staff potentially involved in care, and their willingness to remain part of the care team knowing the possible risk of virus persistence (this should include any diagnostic laboratory and imaging personnel, environmental services staff, and care providers)
- Determine appropriate personal protective equipment (PPE) based on a risk assessment of potential exposure during the procedure(s) and related care and ensure training on its use. Based on these assessments, 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.
*Healthcare personnel should use precautions when there is potential contact with blood, body fluids or broken skin, and any potential for splashing or exposure to a soiled surface during care, for which non-sterile gloves, disposable gowns, and face protection to prevent mucosal exposure should be used based on the expected risk.
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