Ebola or MERs-CoV: Do we panic with these emerging new or old infectious diseases?

[hr]Internationally, we are seeing the emergence of new and old infectious diseases. Marija Juraja asks: Is there a risk, with the penchant for travels, that these infectious diseases could land on our doorstep?[hr]
Two have recently been escalated in the media. They are predominantly the Middle East - Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and West Africa - Ebola (Viral Haemorrhagic Fever).  The potential for someone presenting to a hospital or doctor’s office, is possible in any part of Australia, especially with direct flights between capital cities and the Middle East and Africa, including Dubai, Harare and Johannesburg. It is important that we remember that the risk to Australia and its citizens is present but that risk is still low.
MERS-CoV is caused by a new virus that can cause a rapid onset of severe respiratory disease. Most severe cases have occurred in people with additional underlying conditions (co-morbidities such as heart disease, diabetes, renal disease, respiratory disease, etc) that may make them more likely to get respiratory infections. To date all the cases have lived or travelled to the Middle East (primarily Jordan, the Kingdom of Saudi Arabia, Qatar, Kuwait, Oman, the United Arab Emirates,  Yemen and Lebanon) or have had close contact with people who had contracted the infection in the Middle East. [1]
On July 3, 2014 the World Health Organisation updated its interim case definitions for MERS-CoV.

1. A person with a febrile acute respiratory illness with clinical, radiological, or histopathological evidence of pulmonary parenchymal disease (e.g. pneumonia or Acute Respiratory Distress Syndrome) AND testing for MERS-CoV unavailable or negative on a single inadequate specimen AND there is a direct epidemiological link with a confirmed MERs-CoV case


2. As above AND residency or recent travel to the Middle East where MERs-CoV is circulating in the 14 days before onset of illness


3. A person with a febrile acute respiratory illness of any severity, AND an inconclusive MERS-CoV laboratory test (that is, a positive screening test without confirmation) AND a direct epidemiological link with a confirmed MERS- CoV case[2]

Acute respiratory illness is characterised by fever (temperature >38°C), cough, shortness of breath, breathing difficulties and fatigue with onset of symptoms within 14 days of exposure or contact.
Viral haemorrhagic fevers (VHFs) are a group of diseases described in humans in the last 20 years. Several distinct viruses are endemic in specific geographic regions - primarily in Africa (i.e. Ebola, Marburg).  VHFs are internationally quarantinable diseases.  Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a severe, often fatal disease in humans. Ebola first appeared in 1976 with two concurrent outbreaks in Nzara, Sudan and in Yambuku, Democratic Republic of Congo. [2] The genus Ebolavirus is one of three members of the Filoviridea family (filovirus), along with the genus Marburgvirus and genus Cuevavirus.[3] In previous Ebola outbreaks, between 50% and 60% of infected people survived, and these survivors may be protected against further infection. Médecins Sans Frontières (MSF) has reported that the mortality of patients in their Guinea treatment centres is as low as 25%, compared to 56% for the outbreak as a whole.[4]
The current Ebola outbreak is centred on three countries in West Africa: Liberia, Guinea and Sierra Leone although there is still the potential for further spread to neighbouring African countries. Symptoms include: fever, headache, joint and muscle aches, weakness, diarrhoea, vomiting, stomach pain, lack of appetite, and abnormal bleeding. Symptoms can appear anywhere from 2 to 21 days after exposure to the virus though 8-10 days is most common.
Infections, especially a febrile illness are under-recognised as a travel risk, despite being one of the leading causes of hospital visits for returned travellers. An estimated 15%–37% of short-term travellers experience a health problem in relation to overseas travel, and a febrile illness occurs in up to 11% of returned travellers. [5]  So what do Infection Control Professionals (ICPs) need to do to ensure their organisations are prepared for a possible or confirmed case?
Firstly, and most importantly, it is important as ICPs that we work closely with Infectious Diseases doctors/ microbiologists, laboratory staff, public health departments and our own healthcare staff to ensure we are vigilant and prepared, especially as these patients often are quite sick and may require intensive care treatment.
There are several key strategies all healthcare facilities should have in place:

• a plan or procedure to manage these patients regardless of where they present. They could be in an emergency department at a large metropolitan hospital or the local country general practice


• staff have received education on the plan


• staff ask about travel history when patients present to the emergency department triage staff or a local general practice reception desk


• correct personal protective equipment and an appropriate room to isolate patients


• a procedure in place to transfer the patient to an approved VHF facility if required as per your jurisdictional policy


• a fact sheet or can access one


• What about the patient? Do staff know where to direct patients to get more information or be able to provide some general information on protecting themselves when travelling?

The Australasian College for Infection Prevention and Control (ACIPC) has recently developed a mini website for consumers on Infection Prevention strategies to help them prevent infections in the home, when staying or visiting a healthcare facility, and when travelling. [5] For healthcare facility staff, ACIPC has developed resources for Ebola and MERS-CoV, such as a procedure/management plan that covers infection prevention and control strategies, and a consumer information sheet, including links to other relevant website resources. These can be used by ICPs and adapted to suit their facilities.[7]
As Allen Cheng, Associate Professor of Infectious Diseases Epidemiology and Deputy Head of Infection Prevention and Healthcare Epidemiology at Alfred Health stated in a recent article in The Conversation, we need to stay vigilant. [8]  We also need to consider the risks and currently our risk is still low, but the risk where these outbreaks are currently occurring for Ebola is high. Many of the staff are working in low socio-economic areas, reliant on staff who know these areas, with strong support from voluntary organisations such as medical aid organisation, Médecins Sans Frontières (MSF), World Health Organisation (WHO), Global Outbreak Alert and Response Network (GOARN), etc. Their work environments are much tougher, their resources not as easily accessible as ours and they are working long hours, to ensure the safety and welfare of the people they are caring and protecting. We should never forget what we take for granted - healthcare is important  and health service staff from the cleaner, nurse and medical officer are all important in achieving the goal - safe healthcare and preventing the spread of further infections like Ebola and MERS-CoV.
Is there a risk? Yes, but the risk is low in comparison to our international colleagues working in the settings currently affected. We should be mindful and vigilant of where we travel, the potential risk of acquiring an infection, and the potential risk we pose to others.

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 About the Author

Marija Juraja RN, Grad Cert IC, CICP, is the immediate Past President of ACIPC and holds state and national appointments including past appointment to the Healthcare Associated Infection’s Implementation Advisory Committee at the Australian Commission on Safety & Quality in Health Care. She currently sits on the National Coalition of National Nursing Organizations’ council board. She is a committee member of the Joanna Briggs Institute (JBI) Infection Control Node Expert Reference Group.
Marija is the Clinical Service Coordinator for Infection Prevention and Control at The Queen Elizabeth Hospital in South Australia. She holds an adjunct teaching position at The University of South Australia. She has published and co-authored several articles and guidelines and presented at both national and international conferences.

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About ACIPC

The College is the peak body for Infection Prevention and Control professionals in the Australasian region. The College commenced in January 2012 and brings together the various State and Territory infection control associations formerly in AICA (The Australian Infection Control Association) to support and encourage collaboration across Australasia, using a corporate model.
 

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1. World Health Organisation (WHO). Global Alert and Response (GAR). Coronavirus infections. Accessed 6/8/2014 http://www.who.int/csr/ disease/coronavirus_infections/en/


2. World Health Organization (WHO). Revised interim case definition for reporting WHO-Middle Eastern respiratory syndrome coronavirus (MERS- CoV) http://www.who.int/csr/disease/coronavirus_ infections/case_definition/en/


3. World Health Organization (WHO). Ebola haemorrhagic fever in Zaire, 1976 . Report of an International Convention. Bulletin of the World Health Organization. 1978;56(2):271-293.


4. World Health Organization (WHO). Ebola virus Disease. Fact Sheet N103. Updated April 2014. http:// www.who.int/mediacentre/factsheets/fs103/en/


5. Australasian College for Infection Prevention and Control (ACIPC) Mini Website Consumer Information. http://interactivejam.com.au/ACIPC- Consumer-minisite-v2/


6. O’Brien, Daniel. et al. Fever in Returned Travelers:Reveiw of Hospital Admissions for a 3-Year Period. Clinical Infectious Diseases 2001; 33:603–9


7. Australasian College for Infection Prevention and Control (ACIPC) Position Statements
   http://www.acipc.org.au/knowledge/position- statements


8. Cheng, A. Ebola Outbreak is cause for concern but there’s hope yet. 1 August 2014 [Accessed on line 6/8/2014] http://monash.edu/news/show/ebola- outbreak-is-cause-for-concern-but-theres-hope-yet