0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Viewpoint |

Ebola Virus Disease and Children What Pediatric Health Care Professionals Need to Know FREE

Georgina Peacock, MD, MPH1; Timothy M. Uyeki, MD, MPH, MPP1; Sonja A. Rasmussen, MD, MS1
[+] Author Affiliations
1Centers for Disease Control and Prevention, Atlanta, Georgia
JAMA Pediatr. 2014;168(12):1087-1088. doi:10.1001/jamapediatrics.2014.2835.
Text Size: A A A
Published online

The largest outbreak of Ebola virus disease (EVD) in history is occurring in West Africa. On August 8, 2014, the World Health Organization (WHO) declared this outbreak to be a Public Health Emergency of International Concern.1 As of October 8, 2014, 8399 EVD cases (including 416 in health care personnel) with 4033 deaths were reported, although reported cases are likely a substantial underestimate of the outbreak magnitude.2 Most EVD cases have been reported in Guinea, Liberia, and Sierra Leone, with fewer cases in Nigeria and a single case in Senegal. Although the suspected index case for this outbreak is believed to be a 2-year-old child who died in Guinea in December 2013, limited information is available on the impact of this outbreak on children.3 Cases of EVD were also identified in the Democratic Republic of the Congo, but analyses of viruses suggest that the Democratic Republic of the Congo outbreak is not linked to the wider epidemic. As of October 15, 2014, 3 EVD cases, including 2 health care personnel, had been identified in the United States and 5 EVD cases, including 4 health care personnel, were identified in West Africa and medically evacuated to the United States for further care. This situation is rapidly evolving, and new information will be posted to the Centers for Disease Control and Prevention (CDC) (http://www.cdc.gov/vhf/ebola/index.html) and WHO (http://www.who.int/mediacentre/factsheets/fs103/en/) websites as it becomes available. Our report is intended to complement information on the CDC webpages, with a focus on what pediatric health care professionals need to know.

BACKGROUND

Ebola virus disease is a rare zoonotic disease caused by infection with 1 of 5 species of Ebolavirus. Zaire ebolavirus, the species responsible for the current outbreak, was first discovered in 1976 near the Ebola River in Zaire (now the Democratic Republic of the Congo). Since then, a number of EVD outbreaks have been recognized, primarily confined to remote areas of East and Central Africa. The animal reservoir of ebolavirus is believed to be fruit bats. Zoonotic transmission can occur through direct contact with bats, primates, and duiker antelopes that have died from ebolavirus infection. Ebolavirus can spread among humans primarily through unprotected direct contact of skin (through breaks or microabrasions) or mucous membranes with blood or body fluids (eg, feces, saliva, urine, and vomit) of a person who is ill with EVD, or the corpse of a deceased patient who had EVD, or possibly with objects contaminated with the blood or body fluids of an infected person. The mean incubation period in the current outbreak is estimated at 11.4 days (typical range, 2-21 days).4,5 A person with ebolavirus infection is not contagious until symptoms are present. Currently, no specific therapeutics or vaccines are approved for EVD, and clinical management is focused on supportive care of complications (eg, hypovolemia and electrolyte abnormalities). Several investigational therapeutics are in development and some may be available for compassionate use or through enrollment in clinical trials in the future. Two investigational EVD vaccines are in Phase I trials in healthy adults.

WHAT IS KNOWN ABOUT EVD IN CHILDREN?

Transmission of Ebolavirus to Children

Because EVD outbreaks have typically occurred in low-resource settings, detailed information about pediatric cases has not been systematically collected. Based on available data, children and adolescents often comprise a small percentage of EVD cases. For example, in an outbreak in Zaire in 1995 in which more than half of the population was younger than 18 years, only 9% of the 315 EVD cases were younger than 18 years.5 Similarly, 147 of 823 (18%) reported EVD cases reported from the current outbreak in Guinea were children,6 and 13.8% of cases from 4 affected countries were younger than 15 years.4 Investigators have suggested that the low number of pediatric EVD cases may be owing to cultural practices in which children are kept away from sick family members, resulting in reduced ebolavirus transmission.4

Manifestations of EVD in Children

A unique challenge facing pediatricians is being able to distinguish EVD signs and symptoms from features of much more common pediatric infectious diseases. Typically, children may present with nonspecific signs and symptoms of EVD similar to those in adults, which initially include fever, headache, myalgia, abdominal pain, and weakness, followed several days later by vomiting, diarrhea, and, less commonly, unexplained bleeding or bruising. However, data are very limited. This highlights the key issue of eliciting a history of exposure to Zaire ebolavirus including a travel history and especially any recent direct contact with the blood or bodily fluids of a person who was sick or died from suspected or confirmed Zaire ebolavirus infection.

In the 2000-2001 Sudanebolavirus outbreak in Uganda, all children with laboratory-confirmed EVD were febrile, while only 16% had hemorrhage.7 Respiratory (eg, cough and dyspnea) and gastrointestinal symptoms were common among children, while central nervous system signs were rare.7

The overall case-fatality proportion in the current outbreak is estimated at 70.8%, including 73.4% in children younger than 15 years, 66.1% for those aged 15 to 44 years, and 80.4% for those older than 44 years.4 However, in the Sudanebolavirus outbreak in Uganda during 2000-2001, children younger than 5 years were reported to be at increased risk for illness and death.6 The authors hypothesized that this was owing to more prolonged contact with ill caregivers (in this outbreak, young uninfected children were often admitted to EVD treatment unit isolation wards with their ill parents because of the reluctance of other adults to care for them).7

Given the impact of this EVD outbreak on the health care infrastructure in the most severely affected countries, the health of children is likely to be seriously impacted because of challenges to providing routine care (eg, immunizations and hospitalizations for common illnesses) in affected countries.

Considerations for the Pediatric Health Care Professional

Pediatric health care professionals should have a high index of suspicion for EVD if the child has compatible signs and symptoms and a history of travel from an affected country within the past 21 days. It is essential that health care professionals take a detailed travel history. Malaria, measles, typhoid fever, and other infectious diseases are also endemic in West Africa and should be included in the differential diagnosis of a febrile pediatric traveler from West Africa. Information on high- and low-risk exposures and case definitions for the United States are available at http://www.cdc.gov/vhf/ebola/hcp/case-definition.html. If EVD is suspected, appropriate infection-control precautions (eg, standard, droplet, and contact) should be implemented immediately and the state health department should be promptly notified. The CDC developed an algorithm to evaluate travelers returning from areas with cases of EVD (http://www.cdc.gov/vhf/ebola/pdf/ebola-algorithm.pdf). Laboratory specimens should be processed according to CDC guidance (http://www.cdc.gov/vhf/ebola/pdf/ebola-lab-guidance.pdf).

CONCLUSIONS

Health care professionals, including those who care for children, should be familiar with the clinical features of EVD and should inquire about recent travel to affected West African countries when assessing patients with compatible illness. Prompt implementation of recommended infection-control measures and appropriate reporting to state health departments are essential to prevent further transmission. Based on previous outbreaks and limited data from the current epidemic to date, children may be at lower risk for EVD than adults. Therefore, health care professionals should also consider other common infectious diseases prevalent in West Africa when evaluating ill children from this region, while maintaining a high level of suspicion for EVD.

ARTICLE INFORMATION

Corresponding Author: Georgina Peacock, MD, MPH, 1600 Clifton Rd, MS E-88, Centers for Disease Control and Prevention, Atlanta, GA 30333 (gpeacock@cdc.gov).

Published Online: October 17, 2014. doi:10.1001/jamapediatrics.2014.2835.

Conflict of Interest Disclosures: None reported.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

REFERENCES

World Health Organization. WHO statement on the Meeting of the International Health Regulations Emergency Committee regarding the 2014 Ebola outbreak in West Africa. http://www.who.int/mediacentre/news/statements/2014/ebola-20140808/en/.
World Health Organization. Ebola response roadmap update: 10 October 2014. http://apps.who.int/iris/bitstream/10665/136161/1/roadmapupdate10Oct14_eng.pdf. Accessed October 10, 2014.
Baize  S, Pannetier  D, Oestereich  L,  et al.  Emergence of Zaire Ebola virus disease in Guinea. N Engl J Med. 2014;371(15):1418-1425.
PubMed   |  Link to Article
WHO Ebola Response Team.  Ebola virus disease in West Africa: the first 9 months of the epidemic and forward projections [published online September 22, 2014]. N Engl J Med. doi:10.1056/NEJMoa1411100.
Dowell  SF.  Ebola hemorrhagic fever: why were children spared? Pediatr Infect Dis J. 1996;15(3):189-191.
PubMed   |  Link to Article
United Nations International Children's Emergency Fund. UNICEF Guinea: Humanitarian Situation Report, 29 August 2014. September 5, 2014. http://reliefweb.int/report/guinea/unicef-guinea-humanitarian-situation-report-29-august-2014-0. Accessed September 11, 2014.
Mupere  E, Kaducu  OF, Yoti  Z.  Ebola haemorrhagic fever among hospitalised children and adolescents in northern Uganda: epidemiologic and clinical observations. Afr Health Sci. 2001;1(2):60-65.
PubMed

Figures

Tables

References

World Health Organization. WHO statement on the Meeting of the International Health Regulations Emergency Committee regarding the 2014 Ebola outbreak in West Africa. http://www.who.int/mediacentre/news/statements/2014/ebola-20140808/en/.
World Health Organization. Ebola response roadmap update: 10 October 2014. http://apps.who.int/iris/bitstream/10665/136161/1/roadmapupdate10Oct14_eng.pdf. Accessed October 10, 2014.
Baize  S, Pannetier  D, Oestereich  L,  et al.  Emergence of Zaire Ebola virus disease in Guinea. N Engl J Med. 2014;371(15):1418-1425.
PubMed   |  Link to Article
WHO Ebola Response Team.  Ebola virus disease in West Africa: the first 9 months of the epidemic and forward projections [published online September 22, 2014]. N Engl J Med. doi:10.1056/NEJMoa1411100.
Dowell  SF.  Ebola hemorrhagic fever: why were children spared? Pediatr Infect Dis J. 1996;15(3):189-191.
PubMed   |  Link to Article
United Nations International Children's Emergency Fund. UNICEF Guinea: Humanitarian Situation Report, 29 August 2014. September 5, 2014. http://reliefweb.int/report/guinea/unicef-guinea-humanitarian-situation-report-29-august-2014-0. Accessed September 11, 2014.
Mupere  E, Kaducu  OF, Yoti  Z.  Ebola haemorrhagic fever among hospitalised children and adolescents in northern Uganda: epidemiologic and clinical observations. Afr Health Sci. 2001;1(2):60-65.
PubMed

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment
Ebola hysteria
Posted on October 17, 2014
Michael W. Cater, MD Tustin, CA
Pediatric and Adult Medicine, Tustin, CA
Conflict of Interest: None Declared
Thank you for the valuable information. It will help all of us practicing at the primary care level to help dispel the hysteria that has developed as a result of the very few cases that have emerged in this country. I feel the media needs to be more proactive in informing the public that the risk of an epidemic developing in this country is extremely low and the risk of contracting the illness is infinitesimal. The public simple needs to be better informed. Unfortunately, the media is focusing on the actual cases rather than informing the public of the extremely minimal risk.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

25,761 Views
6 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

Care at the Close of Life: Evidence and Experience
Management of Dyspnea in Patients With Far-Advanced Lung Disease: "Once I Lose It, It's Kind of Hard to Catch It…"

Care at the Close of Life: Evidence and Experience
Dyspnea