By Gail E. Thomas, M.D., Ph.D., FACS; Consultant to Smart Training
As a surgical oncologist with an abiding interest in tropical medicine, I spent considerable time in Africa overseeing surgical projects for the Atlanta-based Carter Center. After attending the 2014 conference of the American Society for Tropical Medicine and Hygiene (ASTMH) in early November, I came away with the view that only a few medical practices in the United States are prepared to deal with the Ebola virus at any level.
More to the point, only a handful of dental practices are prepared to encounter an Ebola patient or to deal with Ebola on any clinical basis. Ebola is well covered in mainstream news, but the coverage is often either incomplete or directly misleading. Dental professionals and staff should understand the disease, its limitations, and what their practices should do to be prepared for it. In this article, I’ll provide a brief summary of the background and symptoms of the disease. I’ll also highlight safety measures your practice should take regarding Ebola.
Ebola, Its Symptoms and Treatment
Ebola is a very infectious, often fatal disease in human and nonhuman primates (monkeys, gorillas, chimpanzees) caused by infection with the virus. It typically kills within a short period of time.
Ebola symptoms may appear anywhere from 2 to 21 days after exposure. Symptoms include fever, headache, joint and muscle aches, weakness, voluminous diarrhea, vomiting, stomach pain, and abnormal bleeding. Ebola is classified as a viral hemorrhagic fever (VHF) because of the fever and abnormal bleeding aspects. Among other VHFs, Ebola is feared because of the inherent high mortality rate.
Since the disease first appeared in 1976, no specific treatments have been developed for Ebola. However, supportive therapy can be provided to address the bleeding and other complications. At least two Ebola vaccines are in development, although neither has advanced to widespread clinical trials at this writing.
Four African nations are currently affected by the Ebola outbreak: Guinea, Sierra Leone, Liberia, and Nigeria. The most recent Ebola outbreak began in Guinea in March 2014, and spread to the neighboring countries of Liberia and Sierra Leone. The disease was then transmitted to Nigeria via an individual traveling to Nigeria from Liberia. More recently, Ebola cases have appeared in Mali as well.
By early November 2014, more than 5,000 people—nearly half of those known to be infected with Ebola—had died from the disease. In previous Ebola outbreaks, the mortality rate has reached 90 percent.
Risk of Ebola Infection in the US
At this writing, only two people have died of Ebola in the United States. Neither case originated here. Importantly, only healthcare personnel associated with the first victim developed subsequent Ebola infections. Otherwise, there’s been no direct transmission of Ebola in the US.
Healthcare workers or family members caring for someone with Ebola, as well as friends of infected patients, are at highest risk of contracting the disease, because they may come into contact with the blood or body fluids of an infected person.
Though the general public should be aware of the disease and its symptoms, the risk of Ebola contagion is extremely low, and it’s unlikely the disease poses a public health risk in the US. Still, state and public health officials are monitoring the situation closely with a view toward taking steps to ensure the safety of their local population.
Ebola virus is transmitted through direct contact with bodily fluids (vomit, diarrhea, urine, breast milk, sweat or semen) of an infected person. Ebola can also be transmitted through exposure to objects such as needles or bedding that have been in contact with an infected person.
People cannot contract Ebola through the air, food, or water. Even if an individual has traveled to West African countries which have sustained Ebola outbreaks, casual contact with that individual is typically not sufficient to contract Ebola. Most important to note is: individuals who don’t have symptoms are not contagious.
Spread of the virus can be prevented. Effective isolation of any suspected Ebola patient coupled with appropriate infection control measures will usually contain potential spread of the disease.
Existing regulations typically require hospitals to have isolation facilities and an infection control program. A licensed facility would be expected to follow policies and procedures necessary to ensure the health and safety of all patients. In at least one case, these policies either didn’t exist or weren’t clearly communicated. The facility failed to follow proper infection control procedures, and an Ebola infection spread from a patient to its healthcare providers.
At the ASTMH meeting I attended, scientists frequently noted that the most important component of Ebola defense involves:
- Early identification and testing of suspect cases and…
- Implementation of infection control practices to contain the disease.
To support Ebola defense measures, many Departments of Health have distributed guidance documents to healthcare providers in various states. These include information on case definition, infection control guidelines and laboratory guidance for the collection, storage, and transport of specimens to Centers for Disease Control and Prevention (CDC) for further testing.
What Your Practice Should Do to Be Prepared
1. Screen Your Patients
Patient-exposure prevention is relatively simple. It only requires screening your patient base for individuals who have traveled to West African countries where Ebola is present. Querying scheduled patients about travel to West Africa is unlikely to engender much more than annoyance. Your front office staff should put this protective measure into place immediately. If your staff does identify a patient who has recently visited one of the infected nations, the staff should suggest that the patient reschedule his or her appointment to fall outside the three-week period during which symptoms appear.
2. Set up an Isolation Area
Infection isolation is a more complicated measure and requires much preplanning. Isolation involves setting aside an infrequently used space within your office as an isolation area for any patient who presents Ebola symptoms. The isolation space should be selected with a view toward disinfection of the space following isolation of a patient. Most important, the isolation space should be known to your staff as a non-useable area once a patient has been confined there.
A Patient Might Have Ebola. What’s Should I Do?
If you suspect a patient present at your office may be infected with the Ebola virus, he or she should be immediately taken to the designated isolation area. Ideally, the period of isolation would be brief. Your staff should summon ambulance transportation for the patient if the patient cannot drive to the hospital. During the call to arrange transportation, your staff should mention that Ebola is suspected.
Once your isolation space has been occupied, you need to disinfect the area. If you and your personnel are equipped with the permeable PPE that is standard in most dental practices, disinfection poses a great hazard. Your local health department can assist you in developing disinfection protocols that will safeguard you and your staff against infection.
In the worst-case scenario, an Ebola patient is in a treatment room. At that point, the focus shifts to emergency isolation and subsequent disinfection of the treatment room. (This is likely to have substantial impact on your patient flow over a period of weeks.)
Ideally, healthcare facilities presented with a suspected Ebola case would immediately implement national guidelines on infection control to prevent possible disease transmission. In addition, the facility would alert the local health jurisdiction to the presence of the disease.
The local jurisdiction would then cooperate with state authorities to ensure that disease prevention strategies are properly implemented, assist the facility to address immediate challenges, obtain specialized laboratory testing, and identify and follow up on other community members who may have been exposed.
Exposure prevention and isolation are viable strategies that will minimize the impact of any patient with Ebola symptoms present in your office. Creating patient-isolation strategies is a burden, but something that must be undertaken to avoid a situation where subsequent infection is almost a certainty.
Ignoring Ebola won’t protect you and your team. Receiving adequate training and up-to-date information can help dentists and their staff avoid an Ebola catastrophe. While the risk of infection is slight, it’s negligible only when you and your staff are armed with proper information, training, and preparation.
Dr. Gail E. Thomas is a board-certified breast surgeon who reviews medical aspects of dental-staff training for TDA Perks Program partner Smart Training LLC. Smart Training provides an online learning management system and regulatory-compliance services to the Texas dental industry. The company offers exclusive discounts to TDA members. For more information about Smart Training’s programs, please call: 469-342-8300.