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Alert to the threat of outbreaks

By Dermot - 26th May 2015

Ireland should learn from the Ebola crisis and consider setting up a permanent imported fever advice service, similar to the UK model, to deal with other emerging infectious threats like avian influenza, the Director of the Health Protection Surveillance Centre (HPSC) has suggested.

Dr Darina O’Flanagan says the Mater Hospital and the National Isolation Unit there played a very important role during the height of the Ebola crisis, with advice provided to clinicians and others in the medical profession, and she has suggested it could be beneficial if this service were to continue.

“Infectious disease consultants at the Mater were available on a 24/7 basis to provide advice to clinicians and the ambulance service in relation to possible cases that might present to their emergency departments. This is one of the areas where I think it may be useful to consider whether we should retain that on an ongoing basis into the future,” Dr O’Flanagan tells the <em><strong>Medical Independent (MI)</strong></em>.

“In the UK, they have the Imported Fever Service, which provides that expert advice to clinicians in relation to the appropriateness of tests that need to be taken or how patients should be managed. That is an area we need to look at because, of course, there are other emerging threats, such as avian influenza.

“I’d like to see the arrangement continuing whereby clinicians can seek advice from the infectious disease clinicians in the Mater in relation to management of patients who arrive from outside the country with a fever — what is called an ‘imported fever service’. This would essentially be an extension of the Mater’s role.

“At the moment, the key role for the Mater is to accept patients and manage those patients appropriately. During the Ebola crisis, they did provide an additional service giving advice to emergency departments and general practices in relation to how they should manage these cases with a fever.”


The UK’s Imported Fever Service (IFS), which was set up in 2012, is a clinical advisory and specialist diagnostic service for medical professionals managing travellers who have returned to the UK with fever.

It provides 24/7 telephone access to expert clinical and microbiological advice to support management of febrile patients, infection control and public health interventions. It also provides a 24-hour on-call molecular diagnostic service for viral haemorrhagic fevers and certain key differential diagnoses, for example malaria, dengue, and next-working-day diagnostic service for a range of other acute imported fevers.


We cannot relax and think this is over


Providing such a service on a permanent basis in Ireland could be one of the lessons learned from the Ebola crisis, Dr O’Flanagan informs <em><strong>MI</strong></em> in a wide-ranging interview about the HPSC’s work.

Its role is to improve the health of people in Ireland by providing the best possible information on disease, including infectious diseases, through surveillance and independent advice, epidemiological investigation, research and training.

“The other thing that worked well in Ireland (during the Ebola crisis) was that there was a lot of work done within the HSE in relation to developing pathways so that patients could be sent from general practice to designated hospitals and I think that work will stand to us in relation to any possible future emerging viral threats,” continues Dr O’Flanagan.

<h3>Economic climate</h3>

The Ebola crisis also highlighted the key role played by our public health service and the need to strengthen the service as the country’s economic climate improves, Dr O’Flanagan stresses. “I think as the country gets back on its feet, we need to ensure that the public health service is strengthened because it is crucially important that we have the capacity to respond to these emerging threats and to manage any outbreaks of infectious diseases.

“We need to ensure we strengthen the public health capacity, both at home and abroad. One of the most important things in relation to the Ebola outbreak was that the public health capacity in the main-affected African countries was non-existent.”

Dr O’Flanagan continues: “In recent times here at home, with the impact of cutbacks in the health services, there have been severe cuts within both the HPSC and within public health departments and I think it’s crucial that we need to learn that, with these emerging threats, we must maintain a strong public health capacity both at home and abroad. We would hope some of the cuts would be reversed.”

While Ebola was the biggest challenge the HPSC faced in the past year, its staff are always on the alert for the next emerging threat. “Before Ebola, pandemic influenza was a huge challenge and also MERS-CoV and before that, SARS. So every so often there is an emerging viral threat that will mean we have to move from the routine work we do here to an emergency phase. That is the nature of the work and during those periods, we are under huge pressure and likewise colleagues in public health departments throughout the country who work closely with us.”

She believes Ireland will inevitably face more infectious threats. “There will be more threats in the future, it’s inevitable. You only have to look at the number of infectious disease threats that have occurred over the last decade —we’ve had SARS, avian influenza, pandemic flu and now we’ve had the Ebola crisis — so we can be sure that there will be new infections causing public health concerns.”

It was never the case that Ireland was behind the curve in handling such crises, she says. “It is just that there have been cuts and we’re all suffering under the cuts. In any of these major instances, it’s a huge resources challenge to fully address that.

“We tackle them by activating our emergency team within the HPSC. That means we move people from other areas of work and bring them on to working on developing guidance and algorithms and communications in relation to Ebola. That means that the routine work obviously suffers delays and other scientific guidance that we’re working on in other areas could be delayed and put back. So it’s important that we should be able to rectify the impact of many of the cuts that have occurred.”

The capacity of public health systems internationally to deal with such crises also needed to be strengthened, she stresses. “What worked well in Ireland was that there was an extremely good working relationship with the Department of Foreign Affairs, the Department of Transport, the Department of the Environment, and that was facilitated by the Department of Health. This was replicated at a local level by the departments of public health working with their local agencies and the ports and so on by providing information in relation to people who may be coming in from the affected countries, so that worked well.

“However, I think that internationally, it is really important that the public health systems in these countries are strengthened.”

<h3>Community engagement</h3>

Another important issue that should be addressed, she says, is the need to improve the way in which agencies communicate with affected countries when diseases like Ebola strike so that they quickly win the trust of local communities.

“A real problem that allowed this outbreak to get out of control in the affected countries was that those countries didn’t often trust their own authorities.

Trust was a major issue — and while they didn’t trust their own authorities, they even less trusted people in white suits who came to help. Community engagement is really important in these areas. Belatedly, people have brought in anthropologists and other social mobilisers to get that message across and I think that’s really important.

“We have to ensure when we’re working in these areas that we manage to engage with the community. It’s easier for developed countries because we work closely with journalists and with television and radio to get our message across but that’s not the case in many of these countries. So it’s really important to engage with the local community — that’s how they managed to improve the situation in Liberia.

“The difficulty in many of these areas is that they are used to looking after their own families in their own areas because of the lack of medical services, so you can understand why people would be reluctant to let a family member go into Ebola treatment centres. It is a major communications issue and getting the trust of the people is the best way to work.”


It’s easier for developed countries because we work closely with journalists and with television and radio to get our message across


Dr O’Flanagan explains to <em><strong>MI </strong></em>how the HPSC goes about implementing its work of protection and surveillance through close links with national and international agencies.

“The HPSC gets information about disease, both national and international, on an ongoing basis. Nationally, we get data routinely on infectious disease notification from microbiologists with lab data and also from clinicians. We also have a number of personnel systems where we gather data from general practice, from ICU in relation to flu and severe flu infections but we also collaborate in a number of international surveillance projects.

“We are the international health regulations focal point with the World Health Organisation. So we regularly get alerts coming from the WHO in relation to international outbreaks. Normally, what we do with those is to communicate them to clinicians immediately when we get them. We have an alerts system to alert people on the same day or, if it is not immediately urgent, we alert people within the next working day.

“So we have a system that’s already in place. It is not only in relation to the international heath regulations — there’s also a system called the EWRS, which is the Early Warning and Response System, which is run by the European Centre for Disease Prevention and Control in Stockholm on behalf of the European Commission. All EU member states participate in this early warning and response system.

“If there’s a serious outbreak within Europe, there is an obligation on EU states to inform each other of such a serious threat and there has been a recent cross-border directive, which is now in operation across Europe, which outlines those obligations and the HPSC is the focal point for the early warning and response system here in relation to communicable diseases.”

<h3>Ebola crisis</h3>

Dr O’Flanagan outlines how the HPSC mobilised when the seriousness of the latest Ebola outbreak became clear last year. “Last March, immediately we were informed of the Ebola outbreak, we informed our clinicians. We also have a scientific advisory committee that develops guidance and we had previously prepared guidance on viral haemorrhagic fevers. It was initially developed in 2002 and then it was updated in 2012 to take account of the new health regulations and also the fact that the Mater had established the isolation unit.

“So we were in a relatively fortunate position in that there was already extensive guidance on how cases would be managed in Ireland and there was guidance in relation to public health management and in relation to transfer by ambulance of any possible suspect cases. So that was all relatively well prepared.”

But, given that this was the worst Ebola outbreak since the recognition of the first one back in 1976, how well did the HPSC system respond?

“As this Ebola outbreak became more serious and it was clear that there were extreme difficulties in controlling it, we would have sent out more guidance to our clinicians,” says Dr O’Flanagan. “These are sent by email but it depends on the seriousness of the threat. If it is within the normal working hours and normal working day, they are sent by email. But if it is something we’re very concerned about and it occurs over the weekend, we have a system in place with our colleagues working in departments of public health, which is 24/7.

“So if we’re very concerned, we would discuss it with our partners in public health departments throughout the country and ask them to make sure the hospitals or GPs or whoever we thought was at risk was aware of an emerging problem.”

Nevertheless, grabbing people’s attention and getting them to sit up and take notice about an issue before it hits closer to home can be a challenge in healthcare, as in any field. “It’s human nature that people only become concerned about something when they think it’s going to affect themselves and so quite often when we might let clinicians know about things that are going on in other parts of the world, they may think that it’s not going to directly affect them.”

<h3>Personal protective equipment</h3>

“It was really only in August (2014) that the WHO declared this to be a public health emergency and that was quickly followed by transmission in the United States and transmission in Spain to healthcare workers. A lot of healthcare workers then became very concerned that this might well arrive at their own doorstep and cause problems. I can understand why that happened.

“I think that is inevitable no matter what the warning — whether it’s to the general public or whether it’s to clinicians or whomever — people’s antennae are obviously heightened when they think they may be at risk themselves. That’s human nature. That explains why there was a marked increase in concern expressed by healthcare workers back in August and September. There was obviously concern then about personal protective equipment (PPE) and what was available, particularly in relation to the fact that there was obviously transmission in Spain and the US, despite people wearing what was thought at the time to be adequate PPE.”

These concerns prompted a number of countries to look at their personal protective equipment to see whether changes were needed. “That was also done in Ireland,” Dr O’Flanagan explains, and adjustments were made.

“It’s important to say that in the Ebola cases in Spain and the United States, that these were transmissions that happened in intensive care units where people were dying.

“When Ebola presents in the early stages, people have fever and flu-like illness and it is only if the disease progresses that they develop severe vomiting, diarrhoea and maybe bleeding. It is only in the final stages that it’s at its most dangerous in terms of transmission and it was in these final stages that the transmission occurred in Spain and the US.

“What was clear then was that we needed to do different levels of PPE — one level when people might present at the early stages, and then a different level of PPE for people who are managing, on an ongoing basis, the care of people with Ebola. So huge work was done on the development of some of the guidelines in relation to personal protective equipment, both for those who might present at the initial stages and those at the later stages.”

Concerns were also heightened in Ireland when the disease hit Nigeria because of our level of traffic with that country. “Prior to that, the main countries affected were Guinea, Sierra Leone and Liberia and there is not much traffic to Ireland from those countries but when Nigeria became involved, then there was an increase in the numbers presenting to emergency departments and general practice with fevers who had recently been to Nigeria. The issue with people from Nigeria was that the risk was low because these people would not have been in contact with anybody [with Ebola]. We had no people coming from Nigeria who had high-risk exposure.”

But Dr O’Flanagan warns that the current Ebola crisis isn’t over yet. “This means that anybody who arrives in this country will be transferred immediately to the Mater [National Isolation Unit], even if they are a high-risk suspect case. The issue is that the risk of someone having Ebola is very much related to whether they were in direct contact with somebody who had Ebola.

“There have been great reductions in Ebola in Liberia and Sierra Leone. But at the same time, there is transmission still ongoing in Sierra Leone and Guinea. We cannot relax and think this is over. The evidence now is that people can be infectious through sexual contact and the WHO has advised people to abstain from sex for three months post-recovery and then to make sure they use condoms.

“There’s always the possibility, therefore, that small outbreaks could begin to be seen again. So, all in all, this current episode is not over yet.”

Dr O’Flanagan adds: “Internationally, one of the problems was the trial of therapies and vaccinations started too late. For a number of logistical reasons, it was very difficult to get those trials up and running so I think internationally, we have to work harder at removing obstacles to doing trials of therapies and vaccines in the field at an earlier stage.”

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<h3>‘The world needs a global warning and response system for future health threats’</h3>

The tragic Ebola epidemic in Guinea, Sierra Leone and Liberia should serve “as a wake-up call,” according to Dr Nicole Lurie, Assistant Secretary for Preparedness and Response at the US Department of Health and Human Services.

Dr Lurie, in a recent podcast with the New England Journal of Medicine, said there is a significant chance that an epidemic of “a substantially more infectious disease will occur sometime in the next 20 years”.

She said that, as the Ebola epidemic fades from the world’s attention, “we risk missing the opportunity to learn from it”.

According to Dr Lurie, the world does not fund any organisation to manage the broad set of co-ordinated activities required in an epidemic. “Few countries have met their commitments under the International Health Regulations, which were adopted by the United Nations after the 2002-2003 outbreak of the severe acute respiratory syndrome (SARS) and were intended to improve the world’s ability to prevent and contain outbreaks.

“The world needs a global warning and response system for outbreaks. Though the World Health Organisation has a Global Outbreak Alert and Response Network, it is severely understaffed and underfunded.”

She said there is also a critical need to reinforce basic public health systems, including primary healthcare facilities, laboratories, surveillance systems and critical care facilities.

In addition, there is no systematic disease surveillance process in place today in most poor countries, “which is where a naturally-occurring epidemic seems most likely to break out”.

In the podcast, Dr Lurie also said rules should be developed to expedite drug approvals in future epidemics and establish clear guidelines for approving studies and treatments, including experimental ones. A global epidemic drug approval process could avert long delays by indemnifying companies working on new approaches, she said.



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