South Africa’s experiences with Ebola.

The outbreak of Ebola virus disease (EVD) in West Africa has been raging for nearly a year. On 15 November 2014, a total of 15 113 suspected and confirmed cases of EVD, culminating in more than 5 000 deaths, has been reported (1). In recent months, nations worldwide have been bolstering their capacity to detect and manage EVD. Although the outbreak remains largely confined to Guinea, Liberia and Sierra Leone, the exportation of EVD to Nigeria in July 2014 has fuelled international fears of further spread beyond the affected countries in West Africa. In retrospect, with the outbreak nearing the one-year time mark, only five cases of EVD have been introduced to countries outside Guinea, Liberia and Sierra Leone (Nigeria, Senegal, Mali, USA) of which four resulted in transmission to secondary cases (in Mali, Senegal, USA, Nigeria) (1).

How does South Africa (SA) measure up to the challenge of responding to imported cases? A review of SA’s track record in dealing with imported cases of haemorrhagic fever and rapid containment of these infections may provide some degree of reassurance. SA’s capacity to deal with haemorrhagic fever cases has developed against the backdrop of endemic Crimean-Congo haemorrhagic fever (CCHF). Since it was originally diagnosed in SA in 1981, nearly 200 cases have been recognised and managed at various hospitals and confirmed by specialised laboratory testing at the National Institute for Communicable Diseases (NICD)  (2). Each of these cases has involved isolation management and intensive case tracing and monitoring. Apart from two small nosocomial outbreaks and one secondary case of CCHF in a laboratory worker, cases have not resulted in secondary spread (3,4). The most important factor is early recognition of potential cases and especially protection of front-line health workers, who are the most vulnerable. A person is only suspected to have Ebola if they have the following (5):

  1. Acute onset of fever (≥38°C)
  2. Severe headache, muscle pain, vomiting, diarrhoea, abdominal pain, or unexplained bleeding.
    AND
  3. Visited or been resident in Guinea, Liberia, Sierra Leone, or another country reporting imported cases with local transmission, in the 21 days prior to onset of illness.
    AND
  4. Had direct contact or cared for suspected/confirmed EVD cases in the 21 days prior to onset of illness, or been hospitalised in Guinea, Liberia, Sierra Leone, or another country reporting imported cases with local transmission.
    OR
  5. Has unexplained multisystem illness that is malaria negative.

The NICD has the only biosafety level 4 laboratory in Africa, a facility with established experience in dealing with haemorrhagic fever viruses (2-4). As of 12 November  2014, 24 cases have been tested for EVD, in infectious travellers; 18 in South Africa and 6 in other SADC countries (3 in Namibia, 2 in Zimbabwe and 1 in Angola). All cases  tested  negative for Ebola virus (PCR and serology). The primary differential diagnosis has been malaria (n=5); non-infectious etiology (n=7); bacterial sepsis (n=2) (NICD data).

In an interconnected world, while any country runs the risk of importation of EVD, the risk of a community outbreak will be low if the index case is recognised early and appropriate infection prevention and control measures are applied. SA is well prepared for the possibility of imported EVD, including traveller health screening at entry points and training of air, sea and land port health staff. There are 11 designated public sector health facilities (at least one in each province), with staff trained and provided with personal protective equipment. The Public health response to the Ebola outbreak must be used to strengthen surveillance and the response to other communicable disease threats.

This article is an extracted from the South Africa medical journal editorial published in November 2014 by Dr Jacqueline Weyer, Centre for Emerging and Zoonotic Diseases, National Institute for Communicable Disease, National Health Laboratory Service, and Prof Lucille Blumberg, Division for Surveillance and Outbreak Response, National Institute for Communicable Diseases, National Health Laboratory Service.

For more information and updates visit the NICD website

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