The current Ebola virus disease (EVD) outbreak is the largest one recorded. It is important that school nurses are familiar with public health guidance on EVD. This article provides a clinical overview of EVD, including symptoms and transmission, as well as public health information, such as risk assessment, and the steps that school nurses must take should any potential cases be suspected in children and young people in the UK.
The current outbreak of Ebola virus disease (EVD) is documented as having started in Guinea, West Africa (World Health Organization (WHO), 2014a). The first WHO declaration of the outbreak was in March 2014, although it is suspected that the first case occurred in December 2013 (Gatherer, 2014). The outbreak is the largest EVD outbreak ever seen in the world and at the time of writing does not yet appear to be under control. It is a destructive disease overwhelming communities in the affected countries with the world's media producing a myriad of images of devastated individuals and communities. However, it is a disease that can be contained and it is possible to reduce or halt its spread when guidance is followed and effective control measures are implemented.
What is Ebola virus disease? Ebola virus disease (EVD) is a viral infection typically starting with a high fever and may lead to fatal haemorrhage or multi-organ failure. There are many symptoms that may appear during the course of EVD infection—profuse diarrhoea is a feature seen in the later stages of infection, particularly in the current outbreak. The incubation period is between 2–21 days (i.e. from the time of exposure to the onset of symptoms) (WHO, 2014a).
The infection typically starts with a fever and is often accompanied by flu-like symptoms, mimicking a number of tropical infections such as malaria. An accurate diagnosis is essential both to effectively isolate and treat someone with EVD but also to recognise and treat malaria, which may itself be rapidly fatal if not treated. There is no specific treatment for EVD and the case fatality rate in previously documented outbreaks is an average of 50% (2014a).
Small outbreaks have occurred in a number of countries in central Africa since it was first discovered in 1976; these outbreaks have varied in size but, until the current outbreak, have been relatively well controlled. The difference with the current outbreak in West Africa is not because the virus has mutated and become more pathogenic; rather it is thought to be more the lack of recognition of it as the cause of disease in the beginning, as it had rarely been seen in West African countries before. This, coupled with resource-poor health structures, allowed the virus to spread and take hold in urban communities before control measures were instigated (Centers for Disease Control and Prevention, 2014).
Epidemiology There have been a total of 15 351 cases with 5 459 recorded deaths since the beginning of the current outbreak in West Africa (WHO, 2014a). A total of 8 countries have reported cases, some of these such as England have only reported a single case in a repatriated citizen. Some countries such as Mali, Spain and the US have seen very limited transmission to health care workers but these are isolated cases. The focus of the outbreak remains in Liberia, Guinea and Sierra Leone. There have been some reports that rates of new infections appear to be stabilising in Liberia and Guinea but continuing high rates of new infections are being seen in Sierra Leone. At the time of writing there had been a total of 8 cases reported in Mali (not all linked to each other) and only time will tell if the health systems in Mali are able to contain the spread of infection and prevent the outbreak taking hold there too.
Transmission EVD is a viral disease spread by contact with infected blood or body fluids in much the same way as HIV or some hepatitis viruses (i.e. hepatitis B and C). While theoretically this should enable standard precautions of wearing basic personal protective equipment (PPE) when handling blood/body fluids to prevent spread—the symptoms of profuse diarrhoea and haemorrhage allow for a greater risk of transmission (Ftika and Maltezou, 2013). Individuals with EVD are only infectious once symptoms start, they are not infectious while incubating the infection.
There have been a number of studies and articles published demonstrating that EVD is not especially infectious compared to other well-known infections such as measles (McCandless, 2014; Science Alert, 2014). However, the rapid onset of symptoms and the mortality rate have led to a devastating toll on certain communities. This has resulted in a climate of fear of infection. It is important to remember that contacts of cases should not be excluded in any way from day-to-day activities; even if they are incubating the infection themselves they will not be infectious until symptoms appear (PHE, 2014b).
Control at macro level EVD preparedness Over the last few months there has been intense activity within the National Health Service (NHS) and Public Health England (PHE) to ensure England is prepared for a possible case of EVD. There is a high level isolation unit (HLIU) in London with highly trained and experienced staff members who have already looked after a case of EVD earlier in the year without transmission of infection to any health care workers (Royal Free London NHS Foundation Trust, 2014). In addition, other isolation facilities capable of managing suspected or confirmed cases have been identified across the country (Beckett and Monk, 2014).
PASIEKA/SCIENCE PHOTO LIBRARY There have also been a number of EVD preparedness exercises with multi-agency groups reviewing and updating plans in light of lessons learnt during the exercises, new guidance published and epidemiological information about the disease.
Guidance documents The government Advisory Committee for Dangerous Pathogens (ACDP) Viral Haemorrhagic Fever working group has produced an overarching guidance document covering all aspects of managing and controlling VHF (including EVD), which has been updated a number of times recently (ACDP, 2014). There is an accompanying algorithm for ease of reference to aid in the assessment of possible cases. PHE has produced a plethora of guidance covering a number of situations, locations and eventualities, which are also updated frequently (PHE, 2014a). This includes specific guidance for educational institutions, which will be covered in more detail later.
Screening Other control measures now in place include screening at ports of entry where returning travellers from the three affected countries in West Africa may disembark. Screening and follow up is provided mainly by PHE staff members who have training and experience in this type of work. For those who have volunteered to help control the outbreak in West Africa itself there is a monitoring framework in place for follow up on their return. These returning humanitarian workers include NHS staff, the military and other specific occupational groups such as laboratory staff who may have been exposed to the infection. The risk therefore of anyone returning from the affected areas and not being followed up through one scheme or another is very low; therefore the risk of unexpected cases occurring in settings such as schools and universities is equally extremely low.
Control at micro level General principles of control Controlling the spread of any infections is important within an educational environment or any other institution setting. Standard infection prevention and control guidance will control the spread of the majority of infections, and standard precautions (where everyone is treated the same) will generally control the spread of EVD should there be an individual who is displaying symptoms of the infection. For ease of access to information on infection prevention and control in schools PHE has published specific guidance on infection control in schools and other childcare settings (PHE, 2014d).
Issues specifically for schools In relation to the risk within schools and other educational establishments it is important that while staff realise that the risk of a case is extremely low they should nevertheless be up to date with the guidance available and know what to do if a case is suspected. There are two main pieces of guidance specific for educational settings published by PHE Ebola: advice and risk assessment for educational, childcare and young persons' settings (PHE, 2014b) and Ebola: advice and risk assessment for universities and further educational establishments (PHE, 2014c). Figure 1 is a flow chart taken from the guidance demonstrating a straightforward risk assessment approach and access to further information.
(Source: Public Health England, 2014c) The key elements for all school nurses to remember are:
▪ People are not infectious until they are symptomatic (therefore there is no need for exclusion of people who have returned from affected countries) (PHE, 2014b)
▪ Standard infection prevention and control precautions will be sufficient to control the spread of infection in all but the most severe cases
▪ Guidance and help is available, and readily accessible on the internet or via the local health protection team.
Conclusions While the number of those affected is large for an outbreak of this nature, it is still a very small percentage of the total population of those countries affected. There are approximately 22 million people in Liberia, Guinea and Sierra Leone—even as many as 100 000 cases would only represent about 0.45% of the total. There are huge implications for the affected countries in terms of the collapse of health systems the impact on local economies and other devastating effects on local communities.
Although people in the UK are at low risk of Ebola (PHE, 2014b), there is a plethora of guidance available covering all aspects of health and community life. PHE, in conjunction with other experts, has published wide ranging guidance and fact sheets accessible to all on thewww.gov.uk website (enter ‘Ebola’ in the search box and select clinical guidance on the drop down list) (Beckett and Monk, 2014).
The local health protection team within PHE will be able to provide advice and support and also answer any questions in relation to the current international situation and its implications in the UK.
Further information Public Health England guidance Ebola virus disease: Clinical management and guidancehttps://www.gov.uk/government/collections/ebola-virus-disease-clinical-management-and-guidance
Ebola: Advice and risk assessment for educational, childcare and young persons' settings https://www.gov.uk/government/publications/ebola-advice-and-risk-assessment-for-educational-childcare-and-young-persons-settings
Ebola: Advice and risk assessment for universities and further educational establishmentshttps://www.gov.uk/government/publications/ebola-advice-and-risk-assessment-for-universities-and-further-educational-establishments
Guidance on infection control in schools and other childcare settingshttps://www.gov.uk/government/publications/infection-control-in-schools-poster
References Advisory Committee on Dangerous Pathogens (2014)Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence. https://www.gov.uk/government/publications/viral-haemorrhagic-fever-algorithm-and-guidance-on-management-of-patients(accessed 24 November 2014) Beckett and Monk (2014) Ebola virus disease: guidance for practice staff. Practice Nursing 25(10): 499–501 Ftika L, Maltezou HC (2013) Viral haemorrhagic Fevers in healthcare settings. Journal of Hospital Infection 83(3): 185–92 Centers for Disease Control and Prevention (2014) Ebola viral disease outbreak—West Africa, 2014. MMWR Morbidity and Mortality Weekly Rep 63(25): 548–51 Gatherer D (2014) The 2014 Ebola Virus disease outbreak in West Africa. Journal of General Virology 95: 1619–24 McCandless D (2014) Visualised: How Ebola compares to other infectious diseases. www.theguardian.com/news/datablog/ng-interactive/2014/oct/15/visualised-how-ebola-compares-to-other-infectious-diseases (accessed 24 November 2014) Public Health England (2014a) Ebola virus disease: Clinical management and guidance. https://www.gov.uk/government/collections/ebola-virus-disease-clinical-management-and-guidance (accessed 24 November 2014) Public Health England (2014b) Ebola: Advice and risk assessment for educational, childcare and young persons' settings. https://www.gov.uk/government/publications/ebola-advice-and-risk-assessment-for-educational-childcare-and-young-persons-settings (accessed 24 November 2014) Public Health England (2014c) Ebola: Advice and risk assessment for universities and further educational establishments. https://www.gov.uk/government/publications/ebola-advice-and-risk-assessment-for-universities-and-further-educational-establishments (accessed 24 November 2014) Public Health England (2014d) Guidance on infection control in schools and other childcare settings https://www.gov.uk/government/publications/infection-control-in-schools-poster (accessed 24 November 2014) Public Health England (2014e) Ebola: Environmental cleaning guidance for potential contamination (excluding healthcare settings) Royal Free London NHS Foundation Trust (2014) Ebola update: William Pooley praises care. https://www.royalfree.nhs.uk/news-media/news/ebola-update-william-pooley-praises-care/(accessed 24 November 2014) Science Alert (2014) How infectious is Ebola? www.sciencealert.com/news/20140910-26305.html (accessed 24 November 2014) World Health Organization (2014a) Ebola virus disease fact sheet. www.who.int/mediacentre/factsheets/fs103/en/ (accessed 24 November 2014) World Health Organization (2014b) Ebola response roadmap situation report update 21 November 2014. http://apps.who.int/iris/bitstream/10665/144117/1/roadmapsitrep_21Nov2014_eng.pdf (accessed 24 November 2014)