A 4-year-old girl presents to the ED with a 4-day history of tactile fever, headache, malaise, joint pain, difficulty breathing, large-volume diarrhea, and nonbloody, nonbilious emesis. She lives at home with her parents and 8-year-old sister. She emigrated from Liberia 2 weeks ago. On examination, she is pale, ill-appearing, and lethargic. Her vital signs are: temperature, 40.4ºC (104.7ºF); respiratory rate, 40 breaths/min; heart rate, 185 beats/ min; blood pressure, 72/43 mm Hg; and oxygen saturation, 86% on room air. Dried blood is noted in her right nare. Her lung sounds are normal, but tachypnea with moderate retractions are present. She is tachycardic with a normal rhythm and a capillary refill of 4 seconds. Her abdomen is soft and mildly tender diffusely, but no distention or rebound is present. Her extremities are cool to the touch and mottled, but no rash is noted. She moans in response to the examination.
A 10-year-old girl presents with a 2-day history of cough, runny nose, fever to 38.6ºC (101.5ºF), body aches, abdominal pain, headache, and nonbloody, nonbilious emesis. She has not had diarrhea. Three other family members are ill with similar symptoms. Her aunt, who is staying with her, recently traveled to West Africa and returned 20 days ago. The girl’s vital signs are: temperature 38.6ºC (101.5ºF); respiratory rate, 34 breaths/min; heart rate, 127 beats/min; blood pressure, 98/69 mm Hg; and oxygen saturation, 93% on room air. She is moderately ill-appearing but alert and answering questions appropriately. Her mucous membranes are dry. She is tachycardic with normal rhythm. Her abdomen is soft and mildly tender diffusely, but no distention or rebound is present. Her lungs have bibasilar crackles, greater on the right than the left. Tachypnea is noted with mild intercostal retractions. Her capillary refill and skin examination are normal.
What is the first step in the prescreening of these patients? What precautions should healthcare workers take? What are the initial steps in assessment and resuscitation? What signs and symptoms point to multisystem involvement? What historical and physical examination clues would point to a diagnosis of Ebola virus disease? What other diagnoses should the clinician consider? What diagnostic testing should be undertaken? Which patient(s) requires quarantine? What management techniques should be initiated in the care of these patients?
On March 23, 2014, the World Health Organization (WHO) announced that an Ebola virus outbreak that started in the Republic of Guinea in December 2013 had spread to numerous West African countries.1,2 The Ebola epidemic of 2014 was the longest, largest, and most pervasive outbreak to date.3 In previous Ebola virus disease (EVD) outbreaks, children represented a small proportion of infected cases and were underrepresented in EVD studies.4,5 However, the index case for this epidemic was traced back to an 18-month-old child in Guinea.6 Early data from the 2014 EVD epidemic indicate that approximately 20% of all cases were in children aged < 16 years, with case fatality rates as high as 90% in children < 1 year old.7
EVD is an acute disease that results in high morbidity and mortality. The Ebola virus, along with the Marburg virus, belongs to the Filoviridae family.8 There are 5 distinct species of Ebola virus, each of which is named for the region where it was originally identified.9 The species are Sudan ebolavirus, Zaire ebolavirus, Taï Forest ebolavirus, Bundibugyo ebolavirus, and Reston ebolavirus.8 The filoviruses are enveloped, negative-sense single-stranded RNA viruses with a filamentous structure. The virus particles typically have a diameter of 80 nm and can be as long as 14,000 nm.10
The Ebola outbreak of 2014 had significant impact on African countries and led to a global public health emergency. The likelihood of contracting EVD in the United States is extremely low unless a person has direct contact with the blood or body fluids (eg, urine, saliva, vomit, sweat, semen, or diarrhea) of a symptomatic person with EVD.3 Case definitions for EVD have been established by the WHO. (See Table 1.) Clinicians are uniquely tasked to distinguish between EVD and common pediatric illnesses, as children with EVD may present with nonspecific signs and symptoms.
Abbreviation: EVD, Ebola virus disease.
Adapted from: World Health Organization. Case definition recommendations for Ebola or Marburg virus diseases.
This issue of Pediatric Emergency Medicine Practice focuses on the recognition, evaluation, and management of children with EVD by offering a review of the recent advances in these areas. It provides updated information and guidelines on management for clinicians who may be the first point of contact for patients. This information will allow clinicians to maintain a high index of suspicion while differentiating between common ailments and EVD. Adequate prehospital care will serve to reduce transmission to others, decrease unnecessary healthcare worker exposure, and reduce morbidity and mortality with early recognition and management.
A literature review was performed in the PubMed and Ovid MEDLINE® databases using the search terms: Ebola, Ebola virus, hemorrhagic fever, Ebola virus disease, and Ebola vaccines with limits to humans. Given the limited literature available on pediatric patients with EVD, studies involving adults were included. The search resulted in 108 articles, predominantly from the adult literature. Literature searches were also conducted using Google scholar, MDConsult, and Medscape eMedicine using the key terms: Ebola, Ebola virus, hemorrhagic fever, and Ebola virus disease. Referenced sources from these articles were also reviewed.
Unfortunately, there is scant high-grade evidence regarding EVD in children, with only 14 articles noted on MEDLINE®. A search of the Cochrane Database of Systematic Reviews resulted in 6 publications relating to Ebola virus. One publication was a technological assessment investigating the cause of current epidemics not limited to Ebola. The only review involving EVD in pediatric patients examined routes of achieving parenteral access in patients with EVD. The other 4 articles were trials looking at genomics, vaccines, and novel therapies in nonhumans. No randomized controlled trials examining the management of EVD exist, making class I evidence for management recommendations not feasible.
The WHO and the Centers for Disease Control and Prevention (CDC) both maintain robust database information on EVD and provide extensive guidelines for healthcare workers. Additional guidelines are available from the Public Health Agency of Canada (http://www.canadiancriticalcare.org/_assets/Ebola Clinical Care Guidelines_ENG.pdf)11 and the Infectious Diseases Society of America (IDSA) (http://www.idsociety.org/2014_ebola/). The IDSA primarily focuses on the adult population, but information may be extrapolated to pediatrics.12 While the American Academy of Pediatrics (AAP) website Healthy Children (www.healthychildren.org) has a patient education sheet, a further search of the AAP (http://www.aap.org/) and the Canadian Pediatric Society (http://www.cps.ca/) sites revealed no guidelines or clinical algorithms. The European Commission Public Health Task Force published guidelines in 2004, known as the Bichat Guidelines, which outline the clinical management of hemorrhagic fever viruses, especially in the context of bioterrorism.13 A recent article written by a group of critical care clinicians serves as an excellent guide for the care of children with EVD in resource-rich areas.14 Most of the literature involving humans consists of case reports and case series, with the majority being retrospective in nature and not pediatric-focused. A large body of data on the pathogenesis of Ebola virus is from laboratory experiments employ-ing nonhuman primates, mice, and guinea pigs.15,16
Following the EVD epidemic that started in Guinea, Africa in late 2013, there has been a significant increase in the literature regarding the recognition, evaluation, and management of patients with EVD. This epidemic also resulted in a greater understanding of the pathology of EVD and methods to improve survival.6 The CDC has released numerous statements since the start of the West African outbreak, including a clinical evaluation algorithm (See the Clinical Pathway For Evaluation Of Patients With Possible Ebola Virus Disease). Currently, additional algorithms are available regarding reduction of exposure to the virus and prevention of transmission, but gaps regarding practical application remain.17 It is difficult to establish large randomized studies given how rapidly patients with EVD deteriorate, the ethics associated with treatment, the scarce number of “treatments” available, and the high morbidity/mortality rate. New scientific research seeks to develop novel vaccines and treatments to eradicate Ebola.
Abbreviation: EVD, Ebola virus disease.
Adapted from: World Health Organization. Case definition recommendations for Ebola or Marburg virus diseases.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
Marlie Dulaurier, MD;Katherine Moyer, DO;Rebecca Wallihan, MD
July 2, 2016
August 2, 2019
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5 Pharmacology CME credits
Upon completion of this article, you should be able to:
Date of Original Release: July 1, 2016. Date of most recent review: June 15, 2016. Termination date: July 1, 2019.
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