Ebolavirus disease (EVD) outbreaks in West Africa Important information for general practitioners 11 August 2014 Summary • • • • The largest outbreak of Ebolavirus disease (EVD)1 ever reported is continuing in Guinea, Liberia and Sierra Leone in West Africa, with probable and suspected cases also reported from Nigeria. Regular updates are available from the World Health Organization (WHO) website (http://www.who.int/csr/don/en/) As of 6 August 2014, there were 1,779 clinically-compatible cases, of which 1,134 have been laboratory confirmed, and 961 have died (case fatality rate 54%). The risk of infection is extremely low unless there has been direct exposure to the bodily fluids of an infected person (including unprotected sexual contact with confirmed cases up to seven weeks after they have recovered) or animal (alive or dead). In patients with clinically-compatible symptoms as per the Communicable Diseases Network Australia (CDNA) case definition (see section below ‘What are the symptoms and how do I manage a suspected case?’) with a history of travel or residence in affected areas (see map) in the 21 days prior to symptom onset, and contact with known confirmed or probable cases in the 21 days before illness onset, the following is recommended: 1. The patient should be placed in a single room if available and standard and transmissionbased precautions implemented (contact and droplet), including the use of personal protective equipment (PPE). The relevant state/territory public health unit/communicable diseases branch should be notified promptly of any suspected (and probable or confirmed) cases in order to discuss patient referral and coordinate management of contacts. 1 The disease has previously been called Ebola Haemorrhagic Fever, but not all cases are haemorrhagic, and the WHO has begun referring to it as EVD. 1 Map: Areas of Guinea, Liberia and Sierra Leone affected by EVD as of 7 August 2014 (from the CDC website http://www.cdc.gov/vhf/ebola/resources/distribution-map-guinea-outbreak.html, accessed 11 August 2014). What are the symptoms and how do I manage a suspected case? The likelihood that a febrile illness in a returned traveller is due to EVD is very low. However GPs should be aware of the possibility of EVD in patients who meet the suspected case definition. GPs should discuss the presentation of febrile illness in a returned traveller from an affected area with an infectious disease physician as soon as possible. The onset of symptoms is sudden and includes a flu-like illness, fever, myalgia, fatigue, and headache. The next stage may include symptoms that are gastrointestinal (vomiting, diarrhoea), neurological (headaches, confusion), vascular, cutaneous (maculopapular rash), respiratory (sore throat, cough) and can include prostration. After one week, cases may develop a septic shock-like syndrome, and progress to multi-organ failure, sometimes accompanied by profuse internal and external bleeding. The case-fatality rate (CFR) for Zaire strain of EVD cases is estimated to be between 50% and 90%, while for other species, the CFR may be lower. The suspected case definition requires clinical and epidemiological evidence: Clinical evidence A compatible clinical illness as determined by an infectious disease physician. Clinical evidence, which includes fever of greater than 38 degrees Celsius, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhoea, abdominal pain, or unexplained haemorrhage; AND Epidemiological evidence Epidemiologic risk factors within the past 21 days before the onset of symptoms, such as contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active; or direct handling of bats or primates from disease-endemic areas.* * Affected areas should currently be considered to be Guinea, Liberia, Nigeria and Sierra Leone, but travel to neighbouring countries in West Africa (Mali, Cote d’Ivoire, Guinea-Bissau, Senegal (Map)) should also be considered where there is strong clinical suspicion. Further, filoviruses are endemic in sub-Saharan Africa. It should be noted that the risk of infection is extremely low even in persons with a compatible travel history, unless there has been direct exposure to the bodily fluids of an infected person (including unprotected sexual contact with confirmed cases up to seven weeks after they have recovered) or animal (alive or dead). GPs must notify a suspected case immediately to their state/territory communicable disease branch/centre to discuss patient referral and management of contacts (see “Who do I contact if I have a suspected case?” for contact information). How do I test for EVD? • • Testing for EVD is not normally conducted in a general practice setting and patients should be notified and referred as per the previous section. If, following discussion with public health authorities and infectious disease physicians, it is decided that the patient does not require testing for EVD, the patient should be managed as per usual practice. Are health workers at risk from EVD? Caring for ill relatives is a known risk factor for infection, and healthcare workers, particularly those in resource poor settings with inadequate infection control are also at risk. What are the recommended isolation and PPE recommendations for patients in general practice? Infection control recommendations in this document for suspected cases aim to provide the highest level of protection for health care workers, given the current state of knowledge. In patients with compatible symptoms and exposure history, GPs should follow standard precautions for infection control, and to minimise the risk of spread of EVD, contact and droplet precautions (transmission based precautions) are used in addition to standard precautions. The Royal Australasian College of General practitioners (RACGP) provides infection control standards for office-based practice (http://www.racgp.org.au/yourpractice/standards/infectioncontrol/). Transmission based precautions (previously known as additional precautions) are used where patients have suspected or known infectious conditions, such as EVD: • • Contact precautions are used to prevent both direct and indirect contact transmission. Contact precautions involve the use of gloves, gowns and social distancing (i.e. move patient from general waiting area where possible). Gloves need to be worn for all manual contact with patients, associated equipment and the immediate environment. A water impermeable apron or gown needs to be worn if clothing could be in substantial contact with the patient or their immediate environment. Droplet precautions are used to minimise transmission of droplets generated by coughing, sneezing and talking. Droplet precautions involve the use of surgical masks (worn by staff), protective eyewear (goggles or face shield) and social distancing. Patients should be asked to observe respiratory (cough) hygiene. Transmission-based precautions are further detailed in NHMRC: Australian Guidelines for the Prevention and Control of Infection in Healthcare - 2010 - External Link (particularly section B2.3). Pre-travel advice for travellers The WHO does not recommend that any travel restrictions are applied with respect to this event. GPs should emphasise the general low risk, but that travellers should avoid direct exposure to the bodily fluids of an infected person or animal (alive or dead), including unprotected sexual contact with patients up to seven weeks after they have recovered. Further information is provided by the the Department of Foreign Affairs and Trade Smartraveller Bulletin available from the DFAT website (http://smartraveller.gov.au/zw-cgi/view/TravelBulletins/Ebola) and the European Centres for Disease Control (ECDC) Ebola travel Advice, available from the ECDC website (http://www.ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f5 5ad51-4aed-4d32-b960-af70113dbb90&ID=1075). Background information Ebolaviruses EVD is caused by an Ebolavirus. Ebolaviruses are part of the family Filoviridae. Fruit bats of the Pteropodidae family are considered to be a likely natural host of the Ebolavirus, with outbreaks amongst other species such as chimpanzees, gorillas, monkeys, forest antelope from time to time. Five species of Ebolavirus have been identified, namely Zaire, Sudan, Reston, Tai Forest and Bundibugyo, from samples collected during humans and non-human primates outbreaks since the first outbreak in the Democratic Republic of the Congo. Transmission Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals (often therefore through hunting or preparation of "bushmeat"). Ebola virus then spreads through person-to-person transmission via contact with the blood, secretions, organs or other bodily fluids of infected people, and indirect contact with environments contaminated with such fluid, including in healthcare settings. The risk for infection in healthcare settings can be significantly reduced through the appropriate use of infection control precautions and adequate barrier procedures. Transmission through sexual contact may occur up to seven weeks after clinical recovery. Airborne transmission, as occurs for measles or smallpox, has never been documented. Simple physical contact with a sick person appears not to be sufficient for contracting EVD. Transmission through heavily contaminated fomites is apparently possible. Traditional burial ceremonies in affected areas of Africa are a known high risk activity for transmission. Symptoms and incubation period The onset of symptoms is sudden and includes fever, muscle aches, weakness, headache and sore throat. The next stage is characterised by vomiting, diarrhoea, rash and malfunction of liver and kidneys. Some cases present with profuse internal and external bleeding and progress to multiorgan failure. The case-fatality ratio for the Zaire strain of Ebolavirus is estimated to be between 50% and 90%. The incubation period varies from 2 to 21 days. Treatment There are no specific prophylactic (vaccine) or therapeutic (antiviral drugs) options available to treat human infections, and care is largely supportive. EVD is a quarantinable disease in Australia. Situation update See the WHO website (http://www.who.int/csr/don/en/) for the latest information Guinea As of 6 August 2014, the Ministry of Health of Guinea had reported a total of 495 clinically compatible cases, including 367 deaths (case-fatality rate, CFR 73%), of which 355 tested positive by PCR. Liberia As of 6 August 2014, the Ministry of Health and Social Welfare (MOHSW) of Liberia had reported a total of 554 clinical cases of EVD, including 294 deaths (CFR 53%) of which 148 cases tested positive by PCR. Nigeria As of 6 August 2014, the Ministry of Health in Nigeria had reported 13 clinical cases of EVD (seven probable and six suspected), including two deaths. None of the cases have been confirmed. Sierra Leone As of 6 August 2014, the Ministry of Health and Sanitation of Sierra Leone had reported a total of 717 clinically-compatible cases including 298 deaths (CFR 42%), of which 631 tested positive by PCR. Further advice Surveillance case definition for confirmed and probable cases, available from the Department of Health website (http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-surveilnndss-casedefs-cd_vhf.htm) WHO situation updates http://www.who.int/csr/disease/ebola/en/ WHO Fact Sheet on Ebolavirus disease http://www.who.int/mediacentre/factsheets/fs103/en/ WHO AFRO updates http://www.afro.who.int/en/clusters-a-programmes/dpc/epidemic-apandemic-alert-and-response/outbreak-news.html Reporting The GP must notify a suspected case immediately to their state/territory communicable disease branch/centre to discuss referral (see “Who do I contact if I have a suspected case?” for contact information). Where there is clinical need for an ambulance, this should precede contact with the state/territory communicable disease branch/centre. Advice for contacts of cases Contacts of cases should be directed to your state/territory communicable disease branch/centre for advice. Who do I contact if I have a suspected case? Contact your state/territory communicable disease branch/centre. ACT (02) 6205 2155 NSW 1300 066 055 Contact details for the public health offices in NSW Area Health Service Areas (www0.health.nsw.gov.au/publichealth/Infectious/phus.asp) NT (08) 8922 8044 Queensland 13 432 584 Contact details for the public health offices in QLD Area (www.health.qld.gov.au/cdcg/contacts.asp) SA 1300 232 272 Tasmania 1800 671 738 Victoria 1300 651 160 WA (08) 9388 4801 After hours (08) 9328 0553 Contact details for the public health offices in WA (www.public.health.wa.gov.au/3/280/2/contact_details_for_regional_population__public_he.pm)