Page 127 - Journal of Special Operations Medicine - Winter 2014

thrombocytopenia, followed by hematocrit elevation and symptoms such as severe headache, muscle pain,
(greater than 20%), leukopenia, and elevated transami- vomiting, diarrhea, abdominal pain, or unexplained
nase levels. The tourniquet test may also aid in deter- hemorrhage; and (2) epidemiologic risk factors in the
mining hemorrhagic tendency and diagnosing dengue 3 weeks before the onset of symptoms, such as contact
infection. This is performed by application of a blood with body fluids of a patient known to have or suspected
pressure cuff inflated to the midpoint between systolic to have EVD, travel to an area where EVD transmission
and diastolic blood pressures for 5 minutes. More than is active, or direct handling of bats, rodents, or primates
20 petechiae per square inch is considered positive. from disease-endemic areas. 14
Treatment includes acetaminophen for pain and fever,
maintenance of hydration, and evacuation to a higher There is no known vaccine or cure for Ebola. EVD di-
echelon of care. Aspirin or NSAIDs should be avoided agnosis may be made through blood samples sent to
due to the risk of bleeding. 12 approved EVD testing centers, which is an evolving sys-
tem at this point in the current outbreak as part of the
Ebola US Department of Defense response plan. Laboratory
The 2014 Ebola outbreak in West Africa is an ongoing PCR confirmation of suspected EVD requires a 2mL
public health disaster that has involved Guinea, Liberia, to 4mL blood sample in an ethylenediaminetetraacetic
Sierra Leone, Nigeria, and Senegal at the time this ar- acid (EDTA) purple- or red-top tube kept cold during
ticle was submitted for publication. It is critical for SOF transport, preferably in an International Air Transport
providers on the continent to be familiar with the trans- Association specimen transportation box. The standard
mission and presentation of Ebola virus disease (EVD) of care remains in limited supportive therapy that con-
to protect their units on the ground from this disease, as sists of balancing the patient’s fluids and electrolytes,
well as to intelligently educate their commanders as to maintaining their oxygen status and blood pressure, and
the impact this outbreak may have on operations. For treating them for any complicated infections. Malaria di-
example, the present outbreak has modified evacuation agnostics should be a part of the initial testing because it
plans where certain countries have closed their borders is a common cause of febrile illness with similar present-
to airflow. ing signs and symptoms in persons with travel history
to the affected countries. If treating a suspected Ebola-
The earlier the disease can be identified, the greater is infected patient, the SOF medic must use the proper
the chance for survival. Historically, Ebola outbreaks personal protective equipment such as eyewear/goggles,
have had fatality rates as high as 90%. The fatality rate facemask, gloves, and gown to reduce exposure as well as
for the current outbreak in West Africa is approximately to maintain strict isolation precautions of any suspected
50%. Signs and symptoms of EVD include, but are not patients to prevent spread to others on the team. 13,14
13
limited to, fever between 103°F and 105°F, intense weak-
ness, sore throat, headache, profuse vomiting, and diar- Human Immunodeficiency Virus
rhea. Severe symptoms include bleeding from nasal and The human immunodeficiency virus (HIV) attacks and
oral cavities, hemorrhagic skin blisters, and renal fail- destroys CD4 cells of the immune system, resulting in
ure leading to multisystem organ failure. The incubation decreased ability to fight infections and certain cancers.
period of Ebola is between 2 and 21 days. Infected pa- HIV is spread through the blood, semen, vaginal flu-
tients usually begin to show signs and symptoms around ids, or breast milk, and is most commonly transmitted
8 to 10 days. Only infected patients showing signs and through oral, vaginal, and anal sex and sharing needles
symptoms are infectious to others. Ebola virus is not with a person infected with HIV. The HIV prevalence
15
spread by casual contact. It is transmitted by direct con- rate of female sex workers in Africa varies by region,
tact of secretions such as vomit, diarrhea, and blood of but is as high as 30% to 51% in countries with average
an infected person, but also through exposure to saliva, or high HIV rates in the general population. 16
sweat, tears, or objects that have been contaminated
with infected secretions. Contact with eyes, nose, mouth, The principal HIV concern for SOF forces deployed to
or nonintact skin surface increases the risk of transmis- Africa, though, is from the accidental exposure to HIV-
sion. Ebola cannot be contracted through food, air, or contaminated blood or body fluids. This is important
13
water, although preparation or consumption of fruit bats especially for SOF medical personnel, since the preva-
has been implicated in the spread of EVD. lence of HIV-positive local nationals can be as high as
25% in some regions on the continent. Therefore,
16
How to recognize and handle a suspected case of EVD the safest practice for the prevention of HIV in the de-
is a critical skill for SOF providers in Africa now. A ployed setting is to assume an African patient is HIV
suspected Ebola case is a person who has both consis- positive until proven otherwise. In prospective studies
tent symptoms and risk factors as follows: (1) clinical of healthcare workers, the average risk for HIV trans-
criteria, which include temperature higher than 101.5°F mission after a percutaneous exposure to HIV-infected

Clinical Considerations in African Operations 117