The Ebola outbreak continues in West Africa, currently affecting areas of Sierra Leone, Mali and Guinea. (Please note that on 9th May, the WHO announced that Liberia was removed from the list of affected countries in West Africa). As knowledge is gleaned from managing cases, the advice on managing patients suspected to have this condition is evolving, e.g. the recently launched WHO statement on the sexual transmission of Ebola virus disease. There is a small risk of a case arriving into Ireland, and therefore it is important to be aware of the latest information should a potential case present to you.

A "talk, don't touch" approach is recommended. While information on PPE use is provided, avoiding contact is preferable. Patients in early symptomatic stages pose a low infection risk, though this changes greatly as the disease advances. (For more details, see Management of Suspected EVD Patients in a Primary Care Setting).

The GP's role is fundamentally to identify a possible case, based on the history, and arrange transfer for hospital assessment. The emphasis is on minimising contact and exposure, and avoiding unnecessary risk. Once you establish that the patient has a fever or history of fever and travelled to the affected countries within 21 days of onset, the patient can be referred for further assessment in hospital, without undertaking a clinical examination.

The Health Protection and Surveillance Centre (www.hpsc.ie) hosts the most up to date news and documentation and can be accessed here. 

There are 5 key documents:

1. Ebola Virus Disease (EVD) Risk Assessment for use in General Practice

This is an algorithm showing the steps to be taken when a suspected EVD patient telephones or presents in person at a GP's surgery.

2. GP EVD Referral Pathway

This document is a list of the contact details and local procedures in each of the designated hospitals for referral of suspected EVD patients. It is essential that the hospital is contacted before a patient is referred. Please note that where the ambulance service is involved they will carry out their own risk assessment which includes liaising with the National Isolation Unit in the Mater Hospital before they transport the patient. The GP should alert Public Health at the earliest opportunity.

3. Guidelines by the HPSC on PPE to to used in suspected or confirmed ebola virus disease (EVD) scenarios (published in April 2015)

Click here for the document.

Click here for videos of the HSPC Ebola Virus Disease PPE Training Day

4. Management of Suspected EVD Patients in a Primary Care Setting

This is a reference document on the management of EVD in a primary care setting. It contains useful information on infection risk and control measures.

5. Infection Prevention & Control and Waste Disposal in Non-Hospital Settings

 This document outlines the approach to decontamination and waste management relating to EVD in non-hospital settings, including primary care. Local public health should be contacted as soon as possible to advise on decontamination, a follow-up of the case and contacts and other support. A room used by a suspected case, and associated waste, should be quarantined until the hospital assessment has been completed; this will cause disruption but may be avoided by having procedures in place to identify cases before they arrive at or enter the surgery. In a proven case, professional decontamination will be provided by the HSE.

Preparation checklist

• Have alert posters at the entrance and in waiting areas.
• Make all staff aware of the importance of ascertaining travel history in cases of febrile illness.
• Make staff aware of actions to take once a case has been identified.
• Print off and be familiar with the Ebola Virus Disease (EVD) Risk Assessment for use in General Practice and your local hospital referral procedure and contacts.
• If you have not received PPE packs they can be ordered by emailing ppepack@hse.ie.
• Check your PPE supplies are available and intact in case they are required. Refer to guidance on donning and doffing, but remember that maintaining a personal protective distance is advised.
• Ensure that your procedures for clinical waste are adequate.

If you do have to deal with a case, remember:

• Maintaining a personal protective distance and scrupulous hand disinfection are essential.
• Avoid unnecessary contact or examination. Use PPE if contact is unavoidable.
• Refer to the latest algorithm and supporting documentation on the HPSC website.
• Contact public health at an early stage for support
• Use the local hospital contact pathway
• Ambulance service will perform their own assessment before transfer
• Public health will liaise about the outcome of the assessment and infection control measures
• Pre-symptomatic cases are not infectious

Information for patients

Patients may be concerned due to recent media coverage and you might want to consider displaying an information poster at reception if you consider this of particular relevance in your practice.

Click here for an infection risk poster.

The HSPC also produce posters in several languages.

If you are receiving requests for information from patients there are fact sheets available here for the general public which you could print off for waiting rooms.

Travel advice is also available here. 

Further information 

• If you are interested in further information, an overview of Ebola, specifically for health care workers, can be found on YouTube.
• BMJ
  BMJ has opened up access to a number of resources free of charge to support healthcare workers who would like more information on Ebola. 
  Click here for details.
• RCGP
  The RCGP have produced a useful series of cue cards with step by step instructions for individual staff members including doctor, receptionist, practice manager and clinical team members. 
  Click here for details.
• Infection Risk Poster 

Other emerging viral threats

It is also opportune to remind you of other emerging viral threats, specifically Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV ) and Avian Influenza A (H7N9).

MERS-CoV commonly presents as acute, respiratory illness with fever, cough, shortness of breath and breathing difficulties within 14 days of returning from the Middle East. Most patients have had pneumonia. Many have also had gastrointestinal symptoms, including diarrhoea. Some patients have had kidney failure. Approximately one-third of people infected with MERS-CoV have died. Approximately 20% of cases occurred in healthcare workers.

There have also been sporadic cases of Avian Influenza A (H7N9) in China with a small number in returning international travellers, but no sustained person to person spread to date.

Click here for further information on the HPSC website on emerging viral threats.