Ebola - the risk and action plan for Victoria

This article appeared in the February 2015 edition of vicdoc

Dr Christian McGrath from the Department of Health’s Communicable Diseases unit details information for doctors

Viral haemorrhagic fevers can be scary. And the Ebola outbreak in West Africa is scary. Since the first recognised outbreak of Ebola Virus Disease in Zaire in 1976, the infection has struck fear in communities and clinicians alike with high infectivity and high mortality rates. But before 2014, Ebola had always been limited to relatively small, self-contained outbreaks in Central Africa that were easily brought under control with the determined application of basic infection control approaches. So what has happened in the last 14 months to create the humanitarian crisis that we are now witnessing and has infected over 20,000 people and claimed almost 8,000 lives? What have we learned about Ebola and is it still as scary? And how prepared do we need to be in Victoria?

Ebola Virus Disease is caused by Ebolavirus, a member of a small group of viruses known as filoviridae. As a form of viral haemorrhagic fever, haemorrhaging is a late sign and only occurs in a small percentage of those infected. Generally the illness presents non-specifically with a flu-like illness, progressing to gastrointestinal symptoms and later complications of vascular leakage and shock. It is a difficult diagnosis to make early on out of the context of a known outbreak or exposure. Fortunately, patients with Ebola who are asymptomatic are not known to spread the infection. Indeed, it has never been an easy disease to spread - a person must make direct contact with the blood or body fluids of an infected person, which is why healthcare workers providing care to an unrecognised case are at particular risk.

The current West African Outbreak of Ebola began in December 2013 in Guinea near the border regions of Sierra Leone and Liberia in an area where Ebola had never been recognised before. There it slowly spread under the radar into the large urban populations of those three countries, striking unsuspecting healthcare workers and communities alike, aided by a strained healthcare system where gloves were a luxury and cultural practices that saw mourning community members in rituals that involve close contact with the recently deceased - when the virus is at its most concentrated in the blood and tissues of its victim.

With the death toll increasing, communities alarmed and the mounting number of cases unable to be managed in safe quarantine facilities, it became clear that a humanitarian crisis was developing. It was in August 2014 that the World Health Organization declared a Public Health Emergency of International Concern (PHEIC), an event that triggered greater activity amongst Australian public health authorities to lead the effort to improve preparedness to detect and manage one or more cases of Ebola on Australian shores.

As the West African Outbreak continued, more epidemiological evidence became available that supported ideas about the way the virus spread. Cases in the United States and Spain supported the idea that the virus was not spread in the asymptomatic stages of disease, but that the risk of spread increased as people become increasingly unwell, which was also seen to correspond with an increased viral load.

The clinical picture and care required has become clearer. Patients who were malnourished or suffered other comorbidities were at increased risk of mortality while the disease itself caused severe fluid loss and electrolyte disturbances well before any haemorrhagic complications. Supportive treatment that included fluid therapy, electrolyte management and other experimental therapies
appeared to reduce mortality.

In Victoria, the critical public health features needed to manage any infectious disease risk are as relevant as ever – surveillance and a prepared health border and health system to detect cases early on, monitoring of those at risk by public health, and control measures in the event of a case. This has resulted in the development of the Victorian Ebola Virus Disease Plan which details a co-ordinated systematic approach to how all Victorian Government bodies and health services must act together to detect and safely care for a suspected or confirmed case of Ebola. It details what a health practitioner should do, what the Department of Health will do and how the use of designated hospitals and co-ordinated arrangements involving Ambulance Victoria and specialist laboratories can safely manage a case in Victoria.

Awareness by all healthcare workers of the Ebola outbreak in Western Africa and of its clinical illness is a critical element of the Plan. Early recognition of a potential case of Ebola is vital to the control of its spread. All frontline clinicians should be aware of the Victorian case definition for Ebola Virus Disease which includes the presence of a fever in any person who has been in an Ebola affected area (currently Guinea, Liberia or Sierra Leone) in the previous 21 days.

People who arrive into Victoria from these areas are provided information about Ebola and a thermometer with instructions to monitor their temperature for 21 days. A risk assessment is carried out on every arrival and those with high risk exposures - including returning healthcare workers who have cared directly for Ebola patients - are subject to stricter monitoring. All arrivals are asked to call the Communicable Disease team if they become unwell so that we can arrange safe assessment for Ebola in a hospital environment.

Any suspected case of Ebola must be isolated and managed through the use of specific personal protective equipment to protect the healthcare worker from any contact with blood or body fluids. The Department of Health should be contacted immediately on suspicion of Ebola on 1300 651 160 (twenty-four hours a day), and a risk assessment can be carried out to determine the likelihood of Ebola and any next steps. If Ebola is a high likelihood the Department of Health will co-ordinate with Ambulance Victoria to arrange safe transport to a designated hospital. In Victoria, this is the Royal Melbourne Hospital for adults and the Royal Children’s Hospital for children. Both these hospitals have the appropriate facilities and have been practicing extensively in order to be able to safely care for a case of Ebola.

All confirmed cases of Ebola in Victoria will trigger an incident response, focused on identifying anyone who may have had close contact with a case, and overseeing monitoring of those people to identify any further cases immediately to ensure no further spread of the illness.

Cases in Western populations have led to considerable reflection and learning for countries like the United States and Australia. Plans have been updated and revised as the world adapts to an ongoing outbreak in West Africa that some health commentators predict could continue beyond 2015. But these cases have reinforced our idea that when recognised, measures can easily be put in place to control the spread of Ebola. But it must be recognised first!

With our improved knowledge of how Ebola is spread and how it causes illness, it becomes less scary. But it has highlighted our need to be prepared and to have a plan. And it has reminded us that without an appropriate coordinated public health response, even our society with its modern healthcare facilities could be at risk of an outbreak of a serious infectious disease. Frontline clinicians keep us safe by remaining vigilant for infections with the potential to cause significant illness in the community and to notify public health authorities as soon as possible to help limit the spread.

So remember, think of the possibility of Ebola in anyone with illness who has been in the affected countries in the previous 21 days. If you do have a case where you suspect Ebola, or any Group A notifiable condition, call the Communicable Diseases team anytime on 1300 651 160.

The Victorian Ebola Virus Disease Plan has a simple list of steps you can take to respond to a case and can be found here.

More information on Communicable Diseases in Victoria including instructions on how to notify can be found here.

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