​This alert provides updated information for California healthcare providers in the evaluation and management of patients suspected of having Ebola virus disease (EVD). The Ebola outbreak in Uganda continues to be an evolving situation. As new evidence and understanding emerges, the California Department of Public Health (CDPH) continues to collaborate with federal, other State, and local health officials to assess and provide additional updates as they become available. Please refer to the CDPH and Centers for Disease Control and Prevention (CDC) Ebola webpages for the latest information. 

Summary 

• On September 20, 2022, Uganda declared an outbreak of Ebola virus disease (EVD) caused by Sudan virus (species Sudan ebolavirus). To date, there have been no cases of EVD related to this outbreak reported in the United States or any other country outside of Uganda. 
• As early EVD symptoms are non-specific, healthcare providers should ask all patients presenting with acute, possibly infectious illness, about recent travel history.  
• Individuals with EVD symptoms may seek care at outpatient clinics, urgent care clinics, or emergency departments. Healthcare providers should be prepared to immediately identify patients suspected of having EVD, isolate those patients, and inform their local health department (LHD). See the CDPH Contact Us page for CDPH immediate contact information as well. 
• It is more likely that a traveler who returned from Uganda and who developed symptoms has a more common infectious disease, such as a seasonal respiratory virus, malaria, typhoid fever, or dengue. 
• Consider telemedicine in the initial evaluation of a returned traveler from Uganda and who is experiencing infectious disease symptoms and does not need emergent in-person medical evaluation.  
• For additional information, refer to the CDC HAN-00480 issued on November 7, 2022
  

Background 

Uganda Ebola Outbreak 2022 

On September 20, 2022, the Uganda Ministry of Health declared an outbreak of Ebola virus disease (EVD) due to Sudan virus (species Sudan ebolavirus), one of four Ebola virus species that affect humans. The most current map of Ebola-affected areas in Uganda can be found within the CDC EVD Outbreak site. Since October 11, 2022, travelers arriving in the United States from Uganda are being funneled through five airports for screening. LHDs are contacting and monitoring returned travelers for 21 days after departure from Uganda. While the overall risk of EVD among travelers from Uganda is low, individuals with EVD symptoms may seek care at outpatient clinics, urgent care clinics, or emergency departments. Healthcare providers should be prepared to identify and isolate patients, and inform their LHD about patients suspected of having EVD immediately. Patients with a history of travel to Uganda and suspected to have an infectious disease who have not yet sought in-person care can be encouraged to use telehealth options for initial screening and evaluation rather than presenting directly to their provider or emergency room.

Ebola Virus Disease 

Person-to-person transmission of Sudan virus occurs through contact with any bodily fluids (e.g., blood, vomit, feces, sweat) of either a person infected with or deceased from EVD. Individuals who provide direct medical care or prepare a body for burial are at especially high risk for illness. EVD is very contagious, especially later in the disease course when a patient is exhibiting “wet” signs and symptoms and around the time of death. Sudan virus can also be transmitted through having sex with someone who recently has recovered from having EVD, and through contact with objects (e.g., needles, and medical equipment) contaminated with body fluids from a person who is sick with or has died from EVD. Infected individuals do not transmit the virus before developing symptoms. Symptoms of EVD may appear anywhere from 2 to 21 days after contact with the virus with an average of 8 to 10 days. Primary signs and symptoms of EVD often include some or several of the following: 

• Fever 
• Headache 
• Muscle and joint pain
• Weakness and fatigue
• Sore throat
• Anorexia
• Gastrointestinal symptoms including abdominal pain, diarrhea, and vomiting
• Unexplained hemorrhaging, bleeding, or bruising
• Other symptoms may include: conjunctivitis 
  • Conjunctivitis
  • diffuse maculopapular rash
  • meningoencephalitis and other neurologic symptoms o respiratory failure and hiccups (late-stage)
    

The course of EVD typically starts with non-specific “dry” symptoms (e.g., fever, aches and pains, and fatigue) typically within the first few days of illness and then progresses to “wet” symptoms (such as nausea, vomiting, severe watery diarrhea, and abdominal pain) as the person becomes sicker. Volume loss from vomiting and diarrhea may be profound. Not all EVD patients will experience fever. Severe bleeding also does not occur in every patient and usually occurs during the later stages of illness. Death often occurs in the second week of illness due to hypotension, septic shock, and multi-system organ failure. A person with EVD is most contagious at the time of death. Patients who survive usually show signs of recovery beginning in the second week of illness and show milder clinical signs and symptoms earlier in the disease course.

Recommendations for Clinicians

Clinicians should consider EVD in their differential diagnosis for any patient who has traveled to Uganda (see current outbreak areas) within the past 21 days and has signs and symptoms consistent with EVD. 

Travel History

A systematic triage and evaluation process should be implemented to assess patients for the possibility of EVD. Healthcare providers are strongly encouraged to routinely ask patients with acute and possibly infectious illness about recent international travel. While clinicians should consider EVD in the differential diagnosis of any patient who has returned from Uganda in the last 21 days, many other infectious diseases may have similar symptoms, and providers should consider other travel and non-travel related illnesses in the differential diagnosis (e.g., malaria, typhoid fever, dengue, meningococcal disease, influenza, COVID-19). For more information on malaria and undifferentiated fever in the returned traveler, see CDC’s Guidance for Malaria Diagnosis in Patients Suspected of Ebola Infection in the United States and Diagnoses for Consideration in a Returning Traveler with Fever. In the absence of concern for a suspect EVD case, prior travel to Uganda should not be a reason to defer standard laboratory testing needed for routine patient care.

Risk Factors 

In a patient presenting with potential infectious symptoms and a history of travel to Uganda within the last 21 days, healthcare providers should evaluate whether there are any additional risk factors for EVD, especially high-risk exposures, which include: 

• Broken skin (i.e., piercing the skin), mucous membrane (e.g., eye, nose, or mouth), or skin contact with blood or body fluids of an ill or dead person with known or suspected EVD. 
• Direct physical contact (e.g., shaking hands or touching) with a person who has/had known or suspected EVD. 
• Providing health care or home care to a patient with known or suspected EVD without the use of recommended personal protective equipment (PPE). 
• Experiencing a breach in infection control precautions that results in unprotected direct contact with the broken skin, mucous membrane, or blood or body fluids of a patient or dead body with EVD.
• Living in the same household as a person with symptomatic known or suspected EVD. 
• Contact with semen from a person who has recently recovered from EVD (e.g., through oral, vaginal, or anal sex). 

Reporting & Infection Control

If a patient is a suspected EVD case based on travel history and clinical presentation, healthcare providers should immediately isolate the patient and notify their LHD and take EVD-specific infection prevention and control precautions. See the CDPH Contact Us page for CDPH immediate contact information as well. These precautions include: 

• Immediately isolating the patient in a private room with an in-room bathroom or covered bedside commode. 
• Limiting healthcare provider contact with the patient to providing essential patient care. Any persons having contact with the patient should practice appropriate precautions and use appropriate PPE as advised by CDC. Refer to the CDPH PPE for Suspected Case for further guidance.
• Minimizing procedures that could create splashes with blood and/or body fluid or increase environmental contamination with infectious material or create aerosols. The LHD, in coordination with CDPH and CDC, will provide additional consultation regarding assessment of risk, as well as guidance around PPE and infection control measures. 

The LHD, in coordination with CDPH and CDC, will provide additional consultation regarding assessment of risk, as well as guidance around PPE and infection control measures. 

Testing for Ebolavirus

Presumptive testing for EVD due to Sudan ebolavirus can be performed using the BioFireFilmArray NGDS Warrior Panel, which can also detect Zaire, Tai Forest, Bundibugyo, and Reston ebolaviruses. This test is not available at commercial or clinical laboratories. California laboratories able to perform the BioFire Warrior Panel include the following: 

• CDPH Viral and Rickettsial Disease Laboratory 
  
• Los Angeles County Public Health Laboratory 
• Santa Clara County Public Health Laboratory 
• Cedars-Sinai Medical Center, a Regional Treatment Center for Ebola 

Confirmatory testing for presumptive positive samples must be performed at the CDC. The decision to test for EVD and which laboratory will accept patient specimens for testing must be made in conjunction with the LHD, CDPH, and CDC’s Viral Special Pathogens Branch (VSPB). 

A negative RT-PCR test result from a blood specimen collected less than 3 days after symptom onset does not rule out Ebola virus infection and repeat testing may be needed. A negative RTPCR test result collected from a symptomatic patient more than 3 days after symptom onset rules out EVD. 

All personnel handling specimens from patients with suspected EVD (especially patients with travel history to Uganda 21 days before symptom onset) should adhere to recommended infection control practices to prevent infection and transmission among laboratory personnel. For further guidance, see the updated CDPH Ebola Health Professionals section related to laboratory information. 

Treatment and Vaccination 

EVD is a rare but severe and often deadly disease. The case fatality rate for patients with EVD due to Sudan ebolavirus is approximately 50%, however it may be lower with early supportive care. Mainstays of treatment include aggressive fluid resuscitation and correction of shock and electrolyte abnormalities with anti-emetic and anti-diarrheal medications as needed. No vaccines or therapeutics have been approved for prevention or treatment of EVD due to Sudan ebolavirus. The Ebola vaccine licensed in the United States (ERVEBO,® Ebola Zaire Vaccine, Live, also known as V920, rVSVΔG-ZEBOVGP or rVSV-ZEBOV) is indicated for the prevention of EVD due to Zaire ebolavirus and is not expected to protect against Sudan ebolavirus or other viruses in the Ebolavirus genus. There is still ongoing investigation and more updates will be provided as the situation continues to evolve.

Additional Information and References: 

CDPH 

• Ebola Virus Disease Information for Health Professionals 
• Local Health Department Communicable Disease Contact Information 
• Guidance on Personal Protective Equipment (PPE) to Be Used with Ebola Virus Disease (EVD)Patients
• Current Ebola Virus Disease Waste Management Interim Guidance (PDF)
  
• CAHAN: Outbreak of Ebola Virus Disease Due to Sudan Virus in Central Uganda, October 7 (PDF)
  
• Ebola Virus Disease Information and Preparedness AFL 22-24 

CDC

• HAN Archive - 00480 | Health Alert Network (HAN) (cdc.gov) 
• EVD Outbreak Uganda September 2022
• Screening Patients
• Personal Protective Equipment (PPE)
• Infection Prevention and Control Recommendations
• Guidance for Malaria Diagnosis in Patients Suspected of Ebola Infection in the United States
• Diagnoses for Consideration in a Returning Traveler with Fever
• Preparing Frontline Healthcare Facilities for Patients Under Investigation (PUIs) for Ebola VirusDisease (EVD)
• Guidance for U.S. Laboratories for Managing and Testing Routine Clinical Specimens WhenThere is a Concern about Ebola Virus Disease | For Laboratory Personnel | Ebola (Ebola VirusDisease) | CDC