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EBOLA / VIRAL HAEMORRHAGIC FEVER IN PERSPECTIVE

http://traveldoctor.co.za/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 severeweakness in patients. This maybe 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 largeston 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-batFruit 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

    TransmissionEbola 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 AN D 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:

    • 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.)
    • 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.
    • Waterless hand cleaner can also be used.
    • Shaking hands with well persons carries a negligible risk of contracting Ebola.
    • 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 / WITHDRAWING EXPATS / STOP TRAVELLING 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.

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