Clinical Guidance for Neonates Born to Patients with Suspected or Confirmed Ebola Disease

Key points

Neonates born to patients with suspected or confirmed Ebola disease require special care and clinical safety precautions. Neonates born to patients with confirmed Ebola disease should not breastfeed. Decisions to discharge the neonate should be made in conjunction with local public health authorities.

A baby lies in a hospital incubator. An iv is connected to the babies ankles.

Scope of guidance

All available evidence on orthoebolavirus infection in neonates and persistence in breastmilk comes from patients infected with Ebola virus (species Orthoebolavirus zairense) during pregnancy. However, CDC expects this data to be applicable to all orthoebolaviruses that cause disease in people (Ebola virus, Sudan virus, Bundibugyo virus, Taï Forest virus).

Background

Spontaneous fetal loss is high among patients who become infected during pregnancy123. Neonates born to patients with Ebola disease are often premature. They typically do not survive for more than a few weeks1456, with few published exceptions78. It's unclear whether these neonates die from in utero transmission of orthoebolavirus or from factors contributing to high infant mortality.6

The first reported survival of an infant born to a patient infected with Ebola virus occurred in 2015. A 25-year-old previously healthy woman reported onset of symptoms eight days prior to delivery. The patient was treated with favipiravir on day 5 of her illness and died on day 8 (hospital day 5) due to severe vaginal bleeding after a spontaneous vaginal delivery. The infant was treated with monoclonal antibodies (ZMapp), a buffy coat transfusion from an Ebola disease survivor, and the antiviral GS-5734. Aside from seizure-like activity, the infant had no other symptoms and was discharged home. Subsequent follow-up demonstrated normal development and growth at 12 months of life.97

In 2019, two neonates survived after being born to patients infected with Ebola virus. Both pregnant individuals died shortly after childbirth. Both the patient and neonate pairs received Ebola virus-specific monoclonal antibody treatment (Inmazeb, Ebanga)8. Inmazeb and Ebanga are now FDA-approved therapies for the treatment of Ebola virus disease due to Ebola virus in adult and pediatric patients.10

Given the risk of vertical transmission and the high mortality of neonates infected with Ebola virus (species orthoebolavirus zairense), post-delivery administration of Inmazeb or Ebanga should be strongly considered for all live-born neonates of Ebola virus-positive patients.

Clinical safety

Healthcare workers caring for a neonate born to a patient with confirmed or suspected Ebola disease should follow worker safety practices, in accordance with the principles of the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program1112. They should also follow guidance at the webpages below:

Infection Prevention and Control Recommendations for Patients in U.S. Hospitals who are Suspected or Confirmed to have Selected Viral Hemorrhagic Fevers (VHF)
Guidance for hospital staff caring for a patient who is suspected or confirmed to have viral hemorrh...
PPE: Confirmed Patients and Clinically Unstable Patients Suspected to have VHF
Guidance on PPE for management of patients confirmed or suspected with selected VHF
Interim Guidance for Environmental Infection Control in Hospitals
VHF- Guidance for Environmental Infection Control in US Hospitals. Information for healthcare. 
Handling VHF-Associated Waste
VHF Guidance for hospitals and healthcare personnel guidance on the safe handling of waste.

Anyone handling the breast milk of a confirmed or suspected Ebola disease patient should follow PPE guidance. 11 The expressed milk of a confirmed Ebola disease patient is considered Category A infectious waste and must be disposed of in accordance with CDC guidance on waste management.13

Clinical care for a neonate born to a patient with confirmed Ebola disease

A neonate delivered to a patient with confirmed Ebola disease should be considered as a suspect Ebola patient. The neonate should be immediately separated from the confirmed patient and cared for in an isolation unit for 21 days. Neonates born to patients with confirmed Ebola disease should not breastfeed1415.

If the neonate is healthy and stable, provide routine newborn care and conduct non-invasive screening tests. Decisions to delay invasive screening tests and immunizations should consider the diagnosis of the neonate, maternal conditions (such as Hepatitis B status), and family history. Delay circumcision until the end of the 21-day monitoring period and/or a negative orthoebolavirus RT-PCR result on a blood specimen.

Ensure that the patient was screened for other causes of tropical febrile illnesses that could contribute to increased morbidity in the neonate, especially malaria. If the neonate becomes febrile during hospitalization, local causes of fever, including hospital-acquired bacterial infections and viral illnesses other than Ebola disease, should also be considered.

In accordance with CDC guidance on Infection Prevention and Control Recommendations for Patients in U.S. Hospitals who are Suspected or Confirmed to have Selected Viral Hemorrhagic Fevers, visitors should not be allowed for a neonate born to a patient with confirmed Ebola disease until the neonate is beyond the 21-day monitoring period and determined to be uninfected. Visual observation through a window or use of videoconference technology can be used instead of in-person visitation.

Clinical care for a neonate born to a patient with suspected Ebola disease

A neonate born to a patient with suspected Ebola disease should be considered a suspect Ebola patient until the status of the patient who delivered is determined. The neonate should be immediately separated from the suspect patient and cared for in an isolation unit for 21 days. A patient being evaluated for Ebola disease should not breastfeed until the status of their illness is resolved.

If the patient is negative for Ebola disease, remove the neonate from isolation and provide care using standard hospital protocol.

If the patient is confirmed to have Ebola disease, follow the Clinical Care for a Neonate Born to a Patient with Confirmed Ebola Disease guidance above.

If the patient later develops signs and symptoms consistent with Ebola disease during the 21-day monitoring period, follow the above Clinical Care for a Neonate Born to a Patient with Confirmed Ebola Disease until an orthoebolavirus infection in the neonate is ruled out.11 If the patient tests positive, the 21-day monitoring period for the neonate resets to the date of last contact with the patient.

Visitors should not be allowed for a neonate born to a person under evaluation for orthoebolavirus infection until the person's infection status is resolved. Visual observation through a window or use of videoconference technology can be used instead of in-person visitation.

Clinical care for a neonate born to an asymptomatic person with exposure to an orthoebolavirus

Monitor neonates born to an asymptomatic person who had potential orthoebolavirus exposure while pregnant. The neonate can remain in the same room as the potentially exposed person, unless either becomes symptomatic. If either develop symptoms, they should be separated.

Monitor the neonate with twice-daily rectal temperatures and assess for signs of infection and other changes in behavior (e.g., not feeding well, excessive sleepiness, uncontrollable crying). This monitoring period should continue for 21 days after the asymptomatic person's last known exposure to an orthoebolavirus.

If the neonate appears healthy and stable after delivery, provide routine newborn care and conduct non-invasive screening tests. Conduct invasive screening tests and immunizations as long as the patient and neonate remain asymptomatic. Delay circumcision until the end of the 21-day monitoring period.

A neonate born to an asymptomatic person with an orthoebolavirus exposure should be allowed visitors in accordance with standard hospital protocol.

Special considerations for breastfeeding

Orthoebolaviruses have been shown to be present in breast milk. Neonates born to patients with confirmed Ebola disease should not breastfeed.1415 Where available, testing breastmilk can help guide decisions about when breastfeeding can safely begin.

A patient being evaluated for Ebola disease should not breastfeed until the status of their illness is resolved.16 To establish and maintain breast milk production, the patient may express breast milk. If pumping, the patient should use a single-use disposable pump start kit. This breast pump should remain in the patient's room and must not be used by any other patient.

If the patient is negative for Ebola disease, they can begin breastfeeding the neonate from the breast.

If the patient is confirmed to have Ebola disease, follow the Clinical care for a Neonate Born to a Patient with Confirmed Ebola Disease guidance above.

Donor breast milk or Ready to Use Infant Formula (RUIF), if available, may be an acceptable substitute.

Special considerations for discharge

Decisions to discharge the neonate should be made in conjunction with local public health authorities. Discharge may only happen after a 21-day monitoring period with no signs of infection and a negative orthoebolavirus RT-PCR result of a blood specimen.

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Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
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