EBOLA / VIRAL HAEMORRHAGIC FEVER IN PERSPECTIVE

Ebola Virus Disease

What is a viral Haemorrhagic Fever?
A group of illnesses caused by several distinct families of viruses.

  • In general, the term “viral haemorrhagic fever” is used to describe a severe multisystem syndrome.
  • Characteristically, the entire vascular system is damaged, resulting in multi-organ failure.
  • Symptoms are often accompanied by haemorrhage (bleeding).
  • Bleeding in itself is rarely life-threatening, and bleeding may be absent.
  • Whilst some types of haemorrhagic fever viruses cause relatively mild illness, many cause severe, life-threatening disease.
  • Virus survival in the ecosystem is dependent on an animal or insect host (inter alia, mosquitoes, ticks), called the natural reservoir. The viruses are geographically restricted to the areas where their host species live.
  • Humans are not the natural reservoir for any of these viruses.
  • Humans are infected when they come into contact with infected hosts. With some viruses, after the accidental transmission from the animal host, human-to-human transmission ensues.
  • Human cases or outbreaks occur sporadically and irregularly.
  • The occurrence of outbreaks is unpredictable, requiring constant vigilance in endemic areas.
  • With a few noteworthy exceptions, (E.g. Lassa Fever) there is no cure or established drug treatment for this group of diseases.
  • With the exception of Yellow Fever, another well-known Viral Haemorrhagic Fever, there is no vaccine against any of the VHF’s. (Yellow Fever affects ±230 000 people in Africa and South America every year and kills ±30 000…)
What is Ebola Virus Disease?
  • Ebola is a Viral Haemorrhagic Fever, which causes a sudden onset of fever and severe weakness in patients. This may be followed by spontaneous haemorrhaging.
  • The case fatality rate (CFR) may be as high as 90% in humans.
  • In the current outbreak the CFR is approximately 60%.
  • The virus was first diagnosed in 1976, in Sudan and The Democratic Republic of Congo (DRC)
  • Several outbreaks have been recorded since then but the 2014 outbreak is the largest on record:
  • This is not due to the fact that the virus is more virulent / aggressive but rather because of increased population mobility in an area with porous borders and difficult terrain coupled with universally poor levels of medical care and low levels of hygiene.
  • Troubled socio-political factors further impact on this outbreak.

Epidemiology

  • Fruit bats of the Pteropodidae (fruit bats or flying foxes) family are considered to be natural hosts of the Ebola Virus.
  • Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals.
  • In Africa, infection has been documented through the handling and consumption of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found dead or ill in the rainforest.
  • Ebola spreads in the human population through human-to-human transmission.
  • It is a disease of poor hygiene. Avoiding the squalor surrounding the disease, will go a long way towards protecting oneself from the disease.
  • It is NOT an air-borne disease. (Unlike influenza and SARS)
  • It is spread through direct contact with a clinically ill patient’s blood, body fluids or semen.
  • The Ebola Virus can cause severe viral haemorrhagic fever (VHF) outbreaks in humans with a case fatality rate of up to 90%.

Transmission of Ebola

Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals. It is a disease of poor hygiene spread through close contact with clinically ill patients – Ebola is not an airborne disease…

  • Burial ceremonies where mourners have direct contact with the body of the deceased person play a role in the transmission of Ebola.
  • Health Care Workers are at high risk, and must take care to use the correct infection control precautions and barrier nursing procedures.
  • Transmission via infected semen can occur up to 7 weeks after clinical recovery.

Signs and Symptoms of Ebola
Initial signs and symptoms:

  • Sudden onset of fever – just like malaria;
  • Intense weakness;
  • Muscle pain;
  • Headache;
  • Sore throat.

Followed by:

  • Vomiting;
  • Diarrhoea;
  • Rash;
  • Impaired kidney and liver function;
  • Internal and external bleeding.

Always exclude other possible causes of the signs and symptoms, such as malaria and yellow fever which is endemic in West Africa, other endemic causes of gastrointestinal disease including typhoid, shigellosis etc. Marburg Haemorrhagic Fever has caused major outbreaks in Central and West Africa in the recent past. Lassa Haemorrhagic Fever is endemic to large parts of West Africa and isolated cases occur on an on-going basis throughout the year, mostly unnoticed by the lay Press and Public…

EVD Incubation and period of Contagiousness
THE INCUBATION PERIOD FOR EVD IS 2 – 21 DAYS.

  • EVD is not transmitted from human to human during the asymptomatic incubation period.
  • The patient remains contagious as long as body fluids contain the virus.
  • The virus may remain present in semen for several weeks post-recovery from EVD.

Treatment
NO SPECIFIC TREATMENT OR VACCINE IS CURRENTLY AVAILABLE FOR EBOLA.
Preventing the Introduction and spread of Ebola

  • Awareness of the disease – brief all business staff, travellers.
  • Advise national staff / travellers to:
  • Take precautions when handling animals, especially dead wild animals.
  • Avoid the preparation and consumption of “bush meat”.
  • Avoid direct contact with ill people, and with the bodies of people who have died from Ebola or any unknown illness.
  • Do not attend hospitals that are potentially treating Ebola cases.
  • Avoid crowded areas.

Hand hygiene:

  • Shaking hands with well persons carries a negligible risk of contracting Ebola.
  • Waterless hand cleaner can also be used.
  • The token ‘anointment’ of hands with dribbles of slightly chlorinated water taking place all over West Africa currently is a waste of time and effort, leads to a false sense of security and distracts from the real issues and cause of the spread of the disease – poor health care infrastructure.
  • Wash hands properly on a regular basis with antiseptic soap under hot running water. (Both a scarce commodity in West Africa, especially in underfunded and mismanaged hospitals.)
  • ALL people with a febrile illness to call in sick and report to a health care facility immediately.
  • If the operation is in a malaria endemic area, strictly adhering to malaria prevention and taking chemoprophylaxis will decrease the likelihood of contracting malaria and thus presenting with a febrile illness that may be confused with EVD / another VHF. All of West Africa is malaria endemic and as it is currently the rainy season the risk of contracting malaria is substantially higher than the risk of contracting EVD…
  • Expatriates should obtain comprehensive cover against vaccine preventable disease to avoid falling ill with e.g. Hepatitis A / B or typhoid that may require evacuation abroad and / or cause concern regarding possible EVD.
  • Travellers and expats leaving West Africa must be advised that, should they experience a rapid onset of fever and/or extreme malaise within 2-21 days after leaving the host country, they are to:
  • Seek urgent medical care where they are.
  • Should be placed in isolation until the presence or absence of the disease has been confirmed.
  • Remind the doctor they see that they most likely have Plasmodium falciparum malaria in particular if they have NOT had any known bodily contact with a febrile patient. Malaria must be actively excluded with laboratory tests prior to attempting to seek Ebola as the cause of the illness.
  • Effective management of bio-hazardous waste through incineration. (In the unlikely event of someone collapsing ill at work and soiling clothing, carpets etc.)

Should you consider closing down business in West Africa?
IN OUR CONSIDERED OPINION, BEARING ALL THE ABOVE FACTORS IN MIND, NO.

  • The cases in Nigeria are isolated and all related to the management of the already ill patient – an American traveller from Liberia who had direct contact with his ill sister in Liberia prior to travelling to Lagos. All contacts were healthcare workers and they have been quarantined. There are no cases outside of the circle of persons that had direct contact with the patient the number of persons quarantined include well persons who have had some contact with the patients direct contacts – but are not ill themselves.
  • Patients who are clinically ill with EVD are highly unlikely to be out and about – if they are clinically well but incubating the disease they are NOT contagious.
  • Whereas there is a risk for civil unrest and therefore a theoretical security risk in the smaller affected countries, the risk of EVD causing major civil upheaval in Nigeria is extremely small.
  • The biggest risk in remaining in-country in any West African country at this point in time is falling ill or injured and having potential problems arranging a speedy evacuation by air ambulance.
  • Less serious, non-febrile illness and injuries can be evacuated by commercial airliner – and no airline flight suspensions are in force in Nigeria.
  • Whereas the CDC have raised a Level 2 travel alert for certain countries in West Africa this opinion is not shared by the WHO, who thus far (11 August 2014) have placed NO restrictions on travel to any country in West Africa.
  • Withdrawing expatriate personnel from any of the countries in West Africa sends out a very negative message to national employees. This could have long-term consequences long after the present EVD hype has become history.

In a communiqué dated 8 August 2014 the WHO:

  • “… declared the Ebola outbreak an international public health emergency (PHEIC), but is not recommending general bans on travel or trade.”
  • Emphasizes that the disease is STILL only spread through direct contact with the body fluids of clinically ill patients or persons that have died from Ebola Virus Disease.
Perspectives

YELLOW FEVER is a viral haemorrhagic fever affecting 200 000 people in Africa and South America annually. It kills 30 000 people a year – yet travellers have to be begged and regulated by law to have the safe and effective, freely available vaccine. Mosquitoes, not close contact with a patient, transmit the virus.

POLIO was declared a ‘public health emergency of international concern’ (PHEIC) in May 2014. Polio continues to maim and kill thousands of children and some adults around the world in spite of the WHO attempting to eradicate this viral disease spread in food and water and by droplets from person to person. It is vaccine preventable yet travellers have to be begged and regulated to take the vaccine. As part of the PHEIC, the WHO declared that travellers who are resident in countries that continue to have wild polio in circulation and / or are exporting polio cases, travellers from these countries MUST show proof of adequate primary vaccination AND an adult booster in the last 12 months prior to travel. Few countries and individuals pay any notice… In the horn of Africa, previously polio free, an outbreak of polio was reported in May 2013 – there were 218 cases in Somalia, Ethiopia and KENYA – yet no-one is considering deferring / cancelling travel to any of these countries for this reason. Why would travellers now avoid Kenya because of the possibility of an Ebola case arriving there? (Paris with ample connections to West Africa has at least the same risk but has not received the same “red card”)

SEASONAL INFLUENZA results in about 3 to 5 million cases of severe illness, and about 250 000 to 500 000 deaths all over the world – yet seasonal influenza vaccine uptake is, with rare exceptions in the Industrialised world, dismal – in particular in Africa.

MALARIA kills ±1 700 people A DAY – mostly in Africa. Yet travellers have to be begged to take mosquito bite precautions and effective chemoprophylaxis when travelling to high-risk malaria areas.