Ebola: Is Australia Prepared? An Investigation.

According to recent reports, when you walk through the streets of Freetown, Sierra Leone the fear is palpable. In the midst of the worst outbreak of Ebola in recorded history, the people are anything but free. A once vibrant, lively, colourful community is now balancing on a knife-edge. As another car pulls up to an overwhelmed treatment centre and is turned away, it is certain death for the infected passenger, barely conscious and hiccupping. There is despair and a feeling of abandonment as the Ebola crisis continues to unfold.

The number of confirmed Ebola cases have accelerated at an ever-increasing pace in recent months and the world is taking notice. Australia has responded with a number of measures to prevent and deal with cases arriving on our shores. But are these measures enough? It’s a simple question but the answer is the difference between the protection of a population, or potentially devastating consequences.

Ebola Virus Disease (Ebola) is a severe viral illness with a fatality rate of up to 90%. The World Health Organisation (WHO) advises that the virus begins with the sudden onset of a fever, muscle pain, sore throat and headache. These symptoms progress to include vomiting, diarrhoea, and in some cases internal and external bleeding.

The current devastating outbreak in West Africa is the most deadly since Ebola was first discovered in 1976 and has been traced back to a case in Guinea during December 2013. It has since spread to Sierra Leone and Liberia who continue to suffer excruciatingly at the heart of the outbreak.  Isolated cases have recently affected the US and Spain as the result of repatriated medical staff that contracted the virus working at the front line in West Africa, reminding the developed world that no one is immune from this destructive virus.

The Director-General of WHO declared the outbreak “a Public Health Emergency of International Concern” on 8 August 2014. There is no doubt that this is the case. As at 27 October, almost three months later, official figures released by WHO indicate there have been 13,703 confirmed, probable or suspected Ebola infections with 4,920 deaths. Each figure is a life that has traumatically ended early, leaving grief-stricken family members behind.

In reality these figures only reveal part of the story.  WHO has reported that many families have kept their loved ones at home due to stigma, the belief that hospitals incubate the disease, that infected loved ones will be more comfortable dying at home or simply due to treatment centres being overwhelmed. The US Centres for Disease Control (CDC) estimates that for every case reported an additional 1.5 cases are not recorded.

An even more sobering thought is the potential number of future infections if the outbreak is not brought under control. CDC estimates released in September indicate that by 20 January 2015 without “additional interventions or changes in community behaviour” there will be a total of approximately 550,000 Ebola cases in Liberia and Sierra Leone. This figure increases to 1.4 million if corrections for underreporting are made.

Around the globe World Leaders have scrambled to ensure that they are taking appropriate action to protect their citizens. Here in Australia the Australian Health Protection Principal Committee (AHPPC) has the role of responding to public health emergencies. Their most recent statement, issued on 15 August 2014 is that “Australia is well prepared to deal with Ebola“ with the Department of Health website currently informing the public that “There are no cases of EVD in Australia and the risk of an outbreak in Australia is very low.”

In efforts to protect the Australian border, the Government has advised against travel to West Africa. At this present time screening for travellers entering Australia is limited to those who have originated their travel from affected parts of West Africa. Qantas declined to comment on their procedures should a passenger develop Ebola-like symptoms on-board one of their flights.

Exit screening is in place for passengers leaving Sierra Leone, Liberia and Guinea; however, its effectiveness in preventing the spread of the virus in the age of air travel is questionable. Passengers with no symptoms are able to board international flights, but with an incubation period of up to 21 days, may develop the virus once they have reached their destination. Indeed this has been the case in the US, most recently a medical aid worker returning from Guinea to the US tested positive for Ebola in New York.

In Australia all returning medical health workers are required to undertake voluntary quarantine for up to 21 days from their last actual or potential exposure. The balance between ensuring willing medical workers are not deterred from contributing overseas and protecting the country is a difficult one to achieve.

Dr Allen Ross, a Professor of Public Health and Tropical Infectious Diseases at Griffith University has extensive experience working with poor populations in developing countries. He has recently written an article for the International Journal of Infectious Diseases that concludes that we are not ready for a global pandemic of the Ebola virus. Dr Ross highlights the inability of screening travellers at airports to contain SARS and H1N1 in the past and questions why we believe it will work in the case of Ebola.

With around 300 international flights arriving into Brisbane Airport each week, and many more across Australia, the question of airport screening is not one to be taken lightly. In September Dr Kamran Khan of St Michael's Hospital in Toronto completed a study into the potential for international dissemination of Ebola virus via commercial air travel. His team has analysed worldwide flight schedules combined with Ebola virus surveillance data. They predict that 2.8 travellers infected with Ebola virus will depart Sierra Leone, Liberia and Guinea by commercial flights every month on average, even with exit screening in place. This translates to one passenger every 11 days.

An alternative and much stronger approach - banning travel from Ebola ravaged countries in West Africa - has been deemed unnecessary by WHO. They have repeatedly recommended that there be no general ban on international travel stating that a ban could “consequently increase the uncontrolled migration of people from affected countries, raising the risk of international spread of Ebola.“ US President Barak Obama has also warned of its potential consequences as well as reminding the world of their responsibility “we can’t just cut ourselves off from West Africa.”

This week Australia has announced they have stopped processing visa applications from Ebola-affected West African countries and will cancel all temporary visas granted, causing a storm of domestic and international criticism. William Davies, a refugee from Liberia living in Australia has told the SBS that the decision is a death sentence. "It's like someone is in the house that is burning with fire and this person is trying to get out of this house and someone is shutting the door on them, it means there is no more hope.”  

Permanent visa holders still in Africa will be able to enter the country and will have to complete a mandatory 21-day quarantine period. Immigration Minister Scott Morrison described these measures as an effort to ensure the virus does not spread to Australia. The move highlights the delicate balance between human rights, politics and the view that “drastic times call for drastic measures.”

So far all suspected cases of Ebola in Australia have tested negative. But what are the protocols in place if the seemingly inevitable happens and a case is confirmed on our shores? A QLD Health spokesperson advised that Queensland has established a Communicable Disease Incident Management Team for Ebola, comprised of around 18 health experts.

All suspected cases attended by ambulance are to be taken to a designated hospital. QLD Health confirmed that the designated treatment facilities for suspected or confirmed Ebola cases in Queensland are the Royal Brisbane and Women’s Hospital, the Princess Alexandra Hospital and the Mater Children’s Hospital. Queensland-based health workers returning from West Africa will be required to go into quarantine within two hours’ drive of Brisbane so they are within reach of a designated hospital.

However, there is the potential for an infected person to present at any hospital as a walk-in patient. A Senior Nurse working in the Emergency Department at a large Brisbane Metropolitan hospital has provided an insight into the procedures in place.

Initial triage questions help the team to establish the risk of an Ebola infection, should a patient present with Ebola-like symptoms. The ensuing course of action hinges on the response to these questions; reminding us of the personal responsibility we each have in the protection of our country. Suspected Ebola patients will be placed in isolation immediately and from this moment onwards, just two senior members of staff will be permitted to enter their negative pressure room in full Personal Protective Equipment (PPE). Blood tests will establish within 6 hours whether Ebola is present.

One of the heartbreaking characteristics of this Ebola crisis is that the very people who are doing the most to combat the outbreak are also being infected with the virus, even in developed countries. When questioned about whether this fact concerns her, the source stated that she “would have no problem treating a suspected Ebola patient. I am 100% happy with procedures we have.” These procedures include a member of the Infection Control Team acting as a spotter – watching to ensure that PPE is put on correctly in right order and, equally as importantly, ensuring it is taken off safely.

In the time of a potential crisis, communication between the public and government is key to maintain trust. The Nurse confirmed that if a case of Ebola is detected in Australia it is likely to be become public knowledge very quickly “everyone knows you can’t keep anything quiet in a hospital.”

Another key aspect of communication is informing the public about the ways in which Ebola can be transmitted. The potential saving grace of the virus is that, unlike viruses such as the Influenza and Measles that are airborne, Ebola is only infectious once symptoms appear and through contact with bodily fluids. It therefore spreads much more slowly, taking 66 days to infect 100 people, compared to Influenza that takes just 14 days as illustrated in a simulation by The Washington Post. However, the critical difference is the fatality rate, estimated to be up to 70% in the current Ebola outbreak.

Dr Allen Ross believes that the effectiveness of Australia’s response to the threat of Ebola will be determined in how it deals with the first few isolated cases, and its ability to contain these will establish whether an outbreak can occur here. If cases are not contained, the number of available isolation units is likely to serve as a limitation, as is the ability to contact trace an increasing number of people.

The jury is out on whether the measures taken by Australia to avoid an outbreak will be effective. The true capacity of our health system to deal with this threat is unlikely to be known unless it is put to the test.

However, the global community seems to be in agreement that in order to overcome Ebola we need to deal with the source of the outbreak in West Africa. UN Secretary-General Ban Ki-moon has declared, "This is more than an African crisis. It has become a global crisis which requires a global response, a massive global response." Efforts up to now have been inadequate to contain the virus with the president of the World Bank, Jim Kim, highlighting that the international community had “failed miserably.”

A person in the position of authority does not make such statements lightly. They should be given notice warns Brian Owler, the President of the Australian Medical Association (AMA), as public health officials are “trained to be conservative and moderate in language” when talking about such epidemics. Owler likens the Ebola outbreak to previous African crises such as the Rwandan genocide in the inability of Western nations to act as “a humanitarian disaster of similar proportions is unfolding” and questions whether we have “learnt from history, or whether we continue to accept massive loss of life in Africa as a regular phenomenon.”

Tulip Mazumdah has visited West Africa on three occasions, reporting for the BBC as their Global Health Correspondent. She has witnessed the situation on the ground first hand. She describes the sense of helplessness experienced by the people. “In these countries the health systems are weak and they can’t cope with it alone. A strong health system would be overwhelmed.”

The United Nations Mission for Ebola Emergency Response (UNMEER) was established on 19 September, in an effort to develop a much-needed coordinated international response. They have established a 70-70-60 target, with the goal of isolating and treating 70 per cent of suspected Ebola cases and safely burying 70 per cent of the dead within the 60 days to 1 December 2014. As this date draws closer the next few weeks are critical.

There has been sustained criticism of the support provided by Australia to West Africa. Despite petitioning by the AMA, Australia is yet to send medical personnel to assist, choosing instead to provide funds to support others existing efforts. However, the upcoming G20 Summit in Brisbane gives Australia the opportunity to take a leading role and facilitate a unified response.

Giving Ebola a low priority has clear risks. “When a deadly and dreaded virus hits the destitute and spirals out of control, the whole world is put at risk” WHO Director-General, Dr Margaret Chan reflects on the Ebola crisis 6 months in.

Dr Allen Ross stresses the importance of treating the Ebola virus with respect “we need to have a healthy fear. This is something very dangerous,” he warns, “the capacity of developed nations to contain a possible outbreak of the Ebola virus on their own soils should not be taken for granted.”

Many thousands of kilometers away in Sierra Leone, locals are trying to deal with the outbreak, but are painfully aware that they are not equipped to do it on their own and desperately need help. There is no light at the end of the tunnel for them at the moment. Will the world’s actions be adequate and provide this light? Despite the efforts of many, the effectiveness of the response up to now proves that there are no guarantees.

Published on the 'Africa: The Real Picture' blog in October 2014 https://africatherealpicture.wordpress.com/2014/10/31/ebola-is-australia-prepared-an-investigation/