Ten Key “Facts” About Ebola: True or False?

November 7, 2014

Ten Key “Facts” About Ebola: True or False?

  1. Kristi L. Koenig, MD, FACEP, FIFEM

Our public health preparedness expert cuts through the misinformation.

  1. Kristi L. Koenig, MD, FACEP, FIFEM

1. Restricting travel from Ebola-outbreak countries to the United States is the best way to prevent the spread of Ebola to our shores.


There is no evidence that restricting travel will prevent spread of Ebola to the U.S. Exposed and infected persons might reach our country undetected and thereby escape essential public health monitoring, which could worsen transmission risk. The key to controlling this epidemic is to stop Ebola at its source in West Africa.

2. Ebola is not contagious until a person is symptomatic; the average incubation period for Ebola is 8 to 10 days.


Symptoms may be very subtle in the early stages of disease when viral loads are low. While nearly all patients will become symptomatic from 2 to 21 days after exposure to Ebola, the average time from exposure to symptoms is 8 to 10 days. Ebola is not contagious prior to symptom onset.

3. A patient presenting with symptoms of Ebola and travel to Liberia within the past 21 days can be safely removed from isolation after a negative serum test.


Many hospitals send serum samples to regional laboratories for testing. Results must be confirmed by the CDC. An initially negative reverse transcription polymerase chain reaction (RT-PCR) test result for Ebola virus does not rule out Ebola virus infection. If an initial test is negative in a person under investigation for Ebola, repeat testing is indicated in 72 hours.

4. Quarantine is an essential public health measure to control the spread of Ebola.


Quarantine is a strategy to prevent spread of diseases that may be transmissible prior to the onset of symptoms. Ebola is not transmissible before a person is symptomatic, so there is no scientific basis for restricting the movement of healthy, asymptomatic people who may have been exposed. Immediate isolation is indicated once symptoms develop.

5. Ebola is a highly contagious disease and can be spread via airborne transmission.


Ebola is not easily spread; for example, it does not spread by casual contact — no household contacts of the first Ebola patient in Texas contracted the disease — and there is no evidence for airborne transmission of Ebola. While some experts have suggested that Ebola could mutate to become airborne, scientific consensus is that this would be extremely unlikely. Ebola is spread via contact with blood and other bodily fluids, including saliva, mucous, vomit, feces, sweat, tears, breast milk, urine, and semen, and is highly infectious if the patient is critically ill with a high viral load. This is the rationale for the high degree of precaution, including monitored donning and doffing of personal protective equipment (PPE), when caring for such a patient.

6. A patient presenting with fever and travel to West Africa within the past 21 days is more likely to have malaria than Ebola.


In travelers from sub-Saharan Africa, diseases with short incubation periods, such as malaria and typhoid fever, also present with fever and must be considered in the differential diagnosis of Ebola. Malaria is much more common than Ebola. However, a positive malaria test does not rule out Ebola, as malaria is extremely prevalent in this population and the diseases could coexist.

7. The single most important step in Ebola preparedness is early screening for Ebola.


Many patients will present with nonspecific flu-like symptoms who are not at risk for Ebola. The most important first step is to identify patients with epidemiological risk factors (travel to an Ebola outbreak region or direct contact with a known Ebola patient within the prior 21 days). For patients without these risk factors, triage can proceed as usual. For those with risk factors and symptoms, immediate isolation and donning of PPE is indicated before any further contact or evaluation. Initial signs and symptoms of Ebola can be nonspecific and may include fever, myalgia, and malaise. Gastrointestinal symptoms develop later and manifest as severe watery diarrhea, nausea, vomiting, and abdominal pain. Up to 18% of patients in the current outbreak have developed hemorrhage, most often blood in the stool. Patients may develop a diffuse erythematous maculopapular rash that can desquamate. Multiorgan failure and septic shock can ensue. Patients who survive can have a prolonged convalescence.

The algorithm Identify-Isolate-Inform is useful to remember preparedness priorities that include prompt notification to hospital infection control and public health authorities for suspected Ebola cases.

8. Ebola patients may present with profound hypovolemia and arrhythmias secondary to hypokalemia.


Ebola patients are subject to large volume loss due to copious watery (and sometime bloody) diarrhea (such as that seen with cholera) and profuse vomiting. Profound dehydration and hypokalemia can result. Life-threatening arrhythmias due to electrolyte abnormalities have been reported.

9. Cardiopulmonary resuscitation is indicated for Ebola patients in cardiac arrest.


Prevailing expert opinion is that if a patient has loss of cardiac output due to multisystem organ failure from septic shock in the setting of Ebola, resuscitative efforts would be futile and also extremely risky for the clinicians performing the procedures. Some Ebola centers have requested that patients sign a do-not-resuscitate (DNR) order. The efficacy of other invasive procedures such as intubation and dialysis are still being debated, with anecdotal reports arising in the Western world of good outcomes after their application.

10. Doffing of personal protective equipment (PPE) is more difficult than donning.


A buddy system involving a safety officer with a checklist is recommended for both donning and doffing of PPE. Clinicians must be sure that none of their skin is exposed. Doffing is more difficult than donning because the PPE may be contaminated with blood and bodily fluids from the Ebola patient at that point, and even a small exposure can lead to transmission of the disease. There is no room for error when removing PPE.

Dr. Koenig is the Director of the Center for Disaster Medical Sciences at the University of California at Irvine and a member of the American College of Emergency Physicians Ebola Expert Task Force. She also serves on the State of California EMS Commission and as guest editor for the Disaster Medicine and Public Health Preparedness journal's special edition on Ebola.

Editor Disclosures at Time of Publication

  • Disclosures for Kristi L. Koenig, MD, FACEP, FIFEM at time of publication Editorial boards Koenig & Schultz's Disaster Medicine: Comprehensive Principles and Practices

Reader Comments (3)

JAMES SPALL Other Healthcare Professional, Family Medicine/General Practice, Corrections

Thank you for the info, which I need to respond to on a daily basis.

Bruce Schreider M.D., Ph.D Physician, Anesthesiology

For me the question of I forced isolation/quarantine is not about science but human nature. As frightening as the disease is, many persons having the first symptoms may well convince themselves that they only have a cold. We have already seen two physicians who knew better than the experts. What about the history of mankind makes you believe that self monitored patients will report symptoms in a timely manner?

Mary Szabo MD Physician, Family Medicine/General Practice, Calgary Canada

Very informative! I agree doffing of PPE is more difficult than donning. Both are important and the military provide excellent practice and instruction for such procedure. It would be valuable if they can provide frontline medical personnel with some hands on instruction and practice.

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