My phone rang at 5 a.m. this morning. A panicked young voice on the other end came through loud and clear: “Noel, can you please tell my doctor that I cannot see the patient in my chair...” The caller was concerned about the possibility of the transmission of the Ebola Virus disease (EVD). She wanted to keep herself and others safe. Her intensions were good, but she needed resources to stay updated on emerging diseases.
Infection control is not a static field. As new information comes forward, we all need to be prepared and informed on all aspects of infection control. When I wrote an article last in August on infection control and Ebola, it focused on the volunteer setting in Africa since that was where risk were associated in that area at that time. Since then, we have had more cases in the United States and transmission modes of this disease have come to the forefront.
In order to empower each of us to serve patients, and yet keep the public and your staff safe, we have to be prepared for changes. The information below is from recognized resources for EVD (see table 1 below).
What is EVD?
EVD is a virus that results in viral hemorrhagic fever disease. Symptoms may not appear until two to 21 days after exposure, commonly from eight to 10 days from exposure.
The CDC lists symptoms to include fever (101.5 f/38.6 C or above), headaches, joint and muscle aches, weakness, diarrhea, vomiting, stomach pain, lack of appetite, and abnormal bleeding. Some patients have also experienced rash, red eyes, hiccups, cough, sore throat, chest pain, difficulty breathing, and difficulty swallowing, as well as bleeding inside and outside of the body.(1) Asymptomatic patients are not contagious. In order to get the virus, direct contract with symptomatic individual is required. It is a severe, often fatal disease with the case fatality rates around 50%. Case fatality rates have varied from 25% to 90% in past outbreaks, according to the World Health Organization.
How is EVD Transmitted?
There are so many conflicting news broadcasts about transmission of EVD. There are multiple ways that this virus could be transmitted to humans by direct and indirect contact. Direct contact occurs when there is physical contact between an infected individual and a susceptible person. Broken skin, nasal, ocular and oral mucous membranes are places where direct contact could occur with this disease. Indirect contact occurs when an object such as the lumen of a needle is contaminated followed then with direct contact with an individual.(3,4)
Areas to be very aware of include:
- Blood or body fluids (including but not limited to urine, saliva, feces, vomit, breast milk, and semen) of a person who is sick with Ebola
- Objects (for example, needles and syringes) that have been contaminated with the virus
- Infected animals
- Ebola is not spread through the air or by water, or by food in general. However, in Africa, Ebola may be spread as a result of handling bush-meat (wild animals hunted for food) and contact with infected bats. There is no evidence that mosquitos or other insects can transmit Ebola virus. Only mammals (for example, humans, bats, monkeys, and apes) have shown the ability to become infected with and spread Ebola virus.(2)
It is clear that health-care providers, family, and friends in close contact with EVD patients are at the highest risk for acquiring the disease. This is because they may come in contact with infected blood or other infectious body fluids and materials.
As we have seen over the past year in clinic and hospital settings, the disease can quickly spread. During outbreaks of Ebola, the disease can spread quickly within health-care settings.
The basic things that we all know about personal protective equipment need to be adhered to strictly. Infection control standards are a must as this disease virus transmission through cross contamination can do more harm than good and non-compliance will spread the disease.
The disease does not necessarily end with the symptoms. General contact will not spread the disease after the symptoms have dissipated, but EVD can be found in semen for up to three months. It is recommended that oral, vaginal, and anal sex be refrained from for at least three months. Condoms may help prevent the disease from spreading.(2)
What are the risk factors and symptoms of this disease?
The CDC has made it clear that we should be on alert. As with all diseases, the key to infection control is treating all patients as if they are infectious and recognizing diseases early.(3). All patients need to be evaluated for the possibility of transmittable diseases. That is nothing new, we all must review health histories with patients every time they sit in the chair.
What do clinicians need to know
With Ebola, the symptoms that you would be looking for are:
- Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage.
- Epidemiologic risk factors within the past 21 days before the onset of symptoms, such as contact with blood or other body fluids or human remains of a patient known to have or suspected to have EVD; residence in or travel to an area where EVD transmission is active; or direct handling of bats or non-human primates from disease-endemic areas.
- Level of exposure risk (see below).
Health History Questions:
- Have you traveled in areas where EVD is present? It is important to include other diseases that the patient may experience symptoms such as persistent cough and tuberculosis, as well as other areas that may have other contagious diseases.
- Do you have any symptoms of diseases such as fever (101.5F/38.6C or above), headache, joint and muscle aches, weakness, diarrhea, vomiting, stomach pain, lack of appetite, and abnormal bleeding. Any patient with symptoms of any contagious disease should defer treatment that is not emergency or palliative.
Above: The CDC's guidelines for personal protective equipment (PPE)
So where are we now? The more things change…
The Center for Disease Control and Prevention (CDC) and the America Dental Association (ADA), have advised that, “Ebola is not considered contagious until symptoms appear. Due to the virulent nature of the disease, it is highly unlikely that someone with Ebola symptoms will seek dental care when they are severely ill.
However, according to the CDC and the ADA Division of Science, dental professionals are advised to take a medical history, including a travel history from their patients with symptoms where a viral infection is suspected. This is the same advice that has been given for years on other diseases such as tuberculosis. All staff should be educated on the common symptoms of communicable disease and deferring elective treatment, this has not changed. Following the guidelines that the CDC has provided can make all the difference.
Ebola is not in all areas of Africa. To date, there are no cases of the disease reported in South Africa and many other areas of Africa. On the other hand, we need to be aware of patients that may be returning from West Africa within 21 days. Patients from specific countries such as Sierra Leone, Guinea, and Liberia need to be closely evaluated.(5)
Who NOT to treat
The DHCP has been advised not to treat patients if they have the signs and symptoms for Ebola. If a patient arrives feverish and their travel history indicates they may be at risk of Ebola, do not treat them. It is recommended at this time that dental care professionals delay routine dental care until 21 days have passed with no symptoms. In treating patients with symptoms for serious oral health conditions such as dental infections and pain, palliative care can be provided if necessary after consulting with the patient’s physician and confirming standard precautions and physical barriers as specified for prevention of transmission of EVD.(4)
Dental professionals and staff in contact with the patient should:
- Immediately protect themselves by using standard precautions with physical barriers (gowns, masks, face protection, and gloves)
- Immediately call 911 on behalf of the patient
- Notify the appropriate state or local health department authorities
- Ask the health department to provide you and your staff with the most up-to-date guidance on removing and disposing of potentially contaminated materials and equipment, including the physical barriers(4)
Staying up to date on infection control is the responsibility of all dental health care professionals.
Table 1: Resources For Staying Updated
Here are some resources to help the dental office stay up to date. It is important to not just go to the news but to go to the resources that have the accurate information.
Center for Disease Control and Prevention:
This page explains the CDC health advisory and the Evaluating Patients for Possible Ebola Virus Disease: Recommendations for Healthcare Personnel and Health Officials.
This page has the health provider checklist for treating patients that may have a communicable disease such as Ebola.
These are the core guidelines that we should all be following to prevent emerging diseases.
Risk factors for acquiring the disease
Personal protective equipment, great PowerPoint on personal protective equipment and poster on personal protective equipment removal
Current maps of areas that Ebola is active
OSAP is dedicated to keeping both the clinician and the patient safe. They keep their information up to date and have on going news releases. They put everything out in a manner that can be applied to the dental setting. They have reliable and accurate information.
This page has the regulations, guidelines, instructional resources and patient resources.
This page has current news releases and up to date information for compliance
Levels of exposure risk are defined as follows:
High risk exposures
A high risk exposure includes any of the following:
• Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of EVD patient
• Direct skin contact with, or exposure to blood or body fluids of, an EVD patient without appropriate personal protective equipment (PPE)
• Processing blood or body fluids of a confirmed EVD patient without appropriate PPE or standard biosafety precautions
• Direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is occurring*
Low risk exposures
A low risk exposure includes any of the following
• Household contact with an EVD patient
• Other close contact with EVD patients in health care facilities or community settings. Close contact is defined as
a. being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or care area for a prolonged period of time (e.g., health care personnel, household members) while not wearing recommended personal protective equipment (i.e., standard, droplet, and contact precautions; see Infection Prevention and Control Recommendations)
b. having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended personal protective equipment.
• Brief interactions, such as walking by a person or moving through a hospital, do not constitute close contact
No known exposure
Having been in a country in which an EVD outbreak occurred within the past 21 days and having had no high or low risk exposures. (1, 2, 3, 4)
NOEL BRANDON KELSCH, RDHAP, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists’ Association.
- http://www.cdc.gov/vhf/ebola/diagnosis/index.html accessed 10.16.14
- http://www.cdc.gov/vhf/ebola/transmission/ accessed 10.16.14
- http://www.cdc.gov/vhf/ebola/hcp/case-definition.html accessed 10.16.14
- http://www.ada.org/en/member-center/oral-health-topics/ebola-resources?nav=rotator accessed 10.16.14
- http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html#areas accessed 10.16.14