News | March 7, 2001

Malaria and Ebola: Diseases without borders

Malaria and Ebola: Diseases without borders
They might seem exotic and remote, but these diseases could be closer than you think. Read on to learn how to protect your patients from them.

By Edwina A. McConnell, RN, PhD, FRCNA

Contents:
Malaria
-- Signs and symptoms
Ebola hemorrhagic fever
-- Signs and symptoms
Nursing implications

Unless you're a nurse in Africa, you don't have to worry about Ebola. And while not nearly as deadly as Ebola, malaria isn't really worth worrying about either.

Such may be the perceptions of many nurses, especially those practicing in developed countries. But if you're one of those nurses, think again.

International travel can bring the threat of infectious diseases such as these to your facility's doorstep. In February, for example, Canadian public health officials were fearful that an African woman traveling from Ethopia had arrived in the country carrying the Ebola virus. Luckily, Ebola was ultimately ruled out as a cause of her symptoms.

In this article, I'll provide questions to include in a nursing history to discover your patient's risk of infectious disease. But first, let's take a closer look at these two scourges.

Back to top

Malaria
Malaria has the dubious honor of being one of the most significant infectious diseases in the world. In 1998, malaria killed one million people, the vast majority of them in Africa.

Besides Africa, malaria is also endemic in other regions of the world, including Central America and Mexico, the Dominican Republic and Haiti, South America, some countries in the Middle East, Southern Asia, and some islands in the South Pacific. What's more, drug-resistant strains and epidemics associated with climate change exacerbate the incidence of global malaria.

In the U.S., the incidence of imported malaria began to increase in the 1970s. More than 1,000 cases per year have been documented, and an estimated 40% to 70% of cases aren't reported at all. Contributing to this increase is an increase in Americans traveling to countries where malaria is endemic and an increase in people living in endemic countries traveling to the United States.

Also increasing is the resistance of malaria parasites to available anti-malarial agents. Moreover, many cases of imported malaria result from travelers failing to follow appropriate guidelines for prevention.

Malaria is occasionally acquired in the U.S., where infected migrant workers serve as the reservoir. Cases of domestically acquired P. vivax malaria, which doesn't cause life-threatening illness, have been documented in California, Florida, Georgia, Michigan, New Jersey, New York, and Texas. (For information on the etiology of malaria and Ebola, click here.)

Signs and symptoms. The parasitic infection of erythrocytes causes malaria's initial signs and symptoms. Over several days, an initial flu-like illness, including low-grade fever, malaise, myalgias, and headache gives way to high fevers with rigors and increased weakness. However, nonspecific symptoms, such as abdominal discomfort, nausea, vomiting, diarrhea, tachycardia, tachypnea, chest discomfort, and cough can predominate.

Early signs and symptoms of all forms of malaria are the same. Therefore, until the species is identified, the causative organism is presumed to be life-threatening P. falciparum. Antibiotics are used to treat patients with malaria.

Back to top

Ebola hemorrhagic fever
Ebola hemorrhagic fever (Ebola HF) continues to strike fear in the hearts of people around the world even though it is thought native only to the African continent. First recognized in 1976 in Africa, the virus is named for a river in the Democratic Republic of the Congo (formerly Zaire). Since 1976, Ebola HF has caused several outbreaks, each of which was thought to have been caused by a single transmission from the natural reservoir to a human.

Early detection of the infection, together with isolation of patients, community education, and barrier methods such as masks, gloves and gowns, effectively halted viral spread. Ebola HF affects relatively few people when compared to major pathogens in Africa such as malaria, but the Ebola virus kills 80% to 90% of the people it infects.

Signs and symptoms. Within a few days of becoming infected with the virus, most patients become ill with flu-like symptoms. These include high fever, headache, muscle aches, stomach pain, fatigue, and diarrhea. Chest pain, shock, and death can occur within one week of infection.

Also within a few days after infection, some patients develop sore throat, hiccups, rash, red and itchy eyes, bloody vomiting, and bloody diarrhea. Blindness and bleeding occur about 10 days after the symptoms start. Contrary to some reports, internal organs don't liquefy.

Researchers don't know why some people recover from Ebola HF and others don't. What they do know, however, is that survivors have developed a significant immune response to the virus.

Diagnosis is difficult because initial symptoms are nonspecific. Laboratory tests, such as antigen-capture enzyme-linked immunosorbent assay (ELISA) testing and immunoglobulin G (IgG) ELISA are performed if the person exhibits the above-described constellation of symptoms.

Treatment is supportive, such as administering fluids and electrolytes, maintaining oxygen levels and blood pressure, and treating complicating infections.

During one virus outbreak, eight patients were given blood from individuals who had been infected with the Ebola virus and who had survived. Seven of the eight patients lived. Researchers are exploring the treatment's efficacy.

What's more, researchers continue to work on developing a vaccine strategy. Based on earlier results, human vaccination seems likely.

Back to top

Nursing implications
A high index of suspicion and a focused nursing history are critical when caring for patients with infectious diseases. Ask these questions to pinpoint your nursing history on new or imported infectious diseases. These questions pertain to patients in the U.S., but can be adapted for patients outside the U.S.

    1. Have you traveled anywhere outside the U.S. in the last 3 months?
    2. If so, where did you go and through what countries did you travel? Remember that malaria exposure depends on where a patient travels within a country. For example, travelers to the Caribbean, except Hispaniola, particularly Haiti, aren't at risk.
    3. If you're interviewing recent immigrants or visitors to America, ask them to tell you in what countries they've lived, visited, and traveled through in the last 3 months.

If you're concerned about malaria, ask patients who have traveled outside the U. S. these questions.

    1. Did you take medications to prevent malaria?
    2. If so, please tell me which medications you took and the schedule you followed. Reassure the patient that you need to know if he took all the medication as ordered. In a nonjudgmental tone, explain that it's important for you to know if he missed any doses or stopped taking the drugs at any time, which isn't uncommon.
    3. Have you ever had a malarial infection?
    4. If you're interviewing a patient who hasn't traveled outside the United States in the last 3 months and who has a persistent fever of unknown etiology, ask the patient if he lives near or works with immigrants.

As the U.S. Public Health Service says about all infectious diseases, "If it's a problem for the rest of the world, it's a problem for us."

Back to top


Edwina A. McConnell, RN, PhD, FRCNA, is an independent nurse consultant based in Gorham, ME.

References
Amundsen, S. (2001). Historical analysis of the Ebola virus: Implications for primary care nursing today. Presented at Global Health Symposium, Portland, Maine, February 2, 2001.

Burton, D.R., & Parren, P.W.H.I. (2000). "Fighting the Ebola virus." Nature, 408, 30 November, 527-528.

Compton, J. (1997). "Malaria in the emergency department." Journal of Emergency Nursing, 23, 120-123.

Dorsey, G., Gandhi, M., Oyugi, J.H., & Rosenthal, P.J. (2000). "Difficulties in the prevention, diagnosis, and treatment of imported malaria." Archives of Internal Medicine, 160, 2502-2510.

Durand, S. (2000). The globalization of infectious disease-Executive summary. Population Resource Center. Washington, D.C.

Juckett, G. (1999). "Malaria prevention in travelers." American Family Physician, 59(9), 2523-2530.

U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Infectious Diseases. Division of Viral and Rickettsial Diseases. Special Pathogens Branch. (2000). Disease Information, Viral Hemorrhagic Fevers: Fact Sheets, Ebola Hemorrhagic Fever. (http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/ebola.htm)