Ebola Outbreak: Inflight & Public Health Measures at POEs

1. Dr.Sujeet K Singh, DDG Ebola Outbreak: Inflight & Public Health Measures at POEs 29 August 2014

2. Outline • Key Facts - Ebola • Current Outbreak and Challenges -West Africa • Country situation • WHO Recommendations • MOHFW initiatives for Surveillance & Response measures at POEs • Specific issues for POEs

3. Key facts – Ebola EVD is caused by infection with a virus of the family Filoviridae, genus Ebolavirus Ebola Viral Disease (EVD), formerly known as Ebola Haemorrhagic Fever, is a severe, often fatal illness in humans, with death rates up to 90%

4. 1976 - Ebola first appeared in two simultaneous outbreaks in Sudan and DR Congo Up until December 2013 – a total of 23 outbreaks recorded: 2388 human cases and 1590 deaths Contained through isolation of affected areas Current outbreak began in Guinea in late 2013 and spread to 4 west African countries Of late another outbreak has been reported from DR Congo where there are 24 cases and 13 deaths (till 28.08.2014) – NOT related to spread from 4 west African countries History of Ebola virus outbreaks

5. How Ebola outbreaks start • Zoonotic infection, i.e. humans are infected by animals - chimpanzes, gorillas, monkeys, forest antelopes, fruit bats, porcupine – found in tropical rainforests • Fruit bats are considered likely hosts of the Ebola virus based on current evidence • There is no evidence as to how the 2014 outbreak in West Africa started

6. Transmission • Animal to Humans and then Transmission within human populations is from person-to-person • Direct contact through broken skin/ mucous membranes with blood, other bodily fluids, tissues or secretions (stool, urine, saliva, semen) of infected people. • Or contact with environments contaminated with infectious fluids such as soiled clothing, bed linen, or used needles.

8. High-risk Groups • Health care workers that care for Ebola cases who are not protected with personal protective equipment (PPE) • Family members, care-givers or others in close contact with sick Ebola patients • Mourners who have direct contact with bodies or secretions of deceased Ebola cases • For countries without Ebola cases, travellers need to be kept informed of the risks

9. Disease in humans • Incubation period (time from infection to onset of symptoms): 2 to 21 days • Patients become contagious once they begin to show symptoms. Not contagious during incubation period and are not detected by lab tests. • Symptoms of illness: • Sudden onset of fever, intense weakness, muscle pain, headache and sore throat • Followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding

10. Diagnosis and treatment • Diagnosis: Samples from patients are an extreme bio-risk and testing should be under maximum containment conditions • Treatment: Supportive care can help reduce mortality but there are no known, proven safe and efficacious treatments or antiviral drugs to treat Ebola • No licensed vaccines or drugs are currently available although some are currently in development

11. Ebola in West Africa- “Extraordinary Event” • Serious consequences of international spread, severity/fatality of illness (no vaccine or cure); intense community and health facility spread; weak health systems in affected and at-risk countries • Coordinated international response is essential to stop and reverse spread of Ebola • Declared a Public Health Emergency of International Concern (PHEIC) by DG WHO on 8 August 2014, under International Health Regulations or IHR(2005):

12. Ebola in West Africa: Health Systems preparedness is critical • Logistics: personal protective equipment and disinfectants • Trained human resources • Affected countries have limited capacity for standard containment measures, such as • Early detection and isolation of cases • Contact tracing and monitoring • Hospital procedures for infection control

13. Key Challenges:Infection Control • Even though Ebola is highly infectious, prevention is possible through application of strict infection control measures • Appropriate laboratory practices • Standard biosafety precautions • Barrier nursing procedures • Use of personal protective equipment (PPE) by healthcare workers exposed to cases • Disinfection of contaminated objects and areas • Safe burials

14. Risk Communication Education and communication: Raising awareness is crucial so everyone understands what Ebola is, how it is transmitted and how to protect yourself Public fears: Ebola is a disease that creates a lot of anxiety and fear. Clear, transparent and balanced messaging information can help reduce such panic. Public involvement: Getting public to take an active role in implementing preventive measures, creating awareness and participation in the management of the outbreak, can limit spread of the disease in the community

16. Affected Countries:WHO Recommendations Declare national emergency - activate national disaster management mechanisms Conduct exit screening of all persons at international airports, seaports and major land crossings Ensure Ebola cases are isolated, treated and surveillance conducted for contacts Strengthen health systems for adequate response (hospitals, labs, human resources, quality care, logistics, clinical support)

17. All CountriesWHO Recommendations • No general ban on international travel or trade • Provide relevant information to • Travelers to Ebola affected areas: with information on minimizing risks • General public: Ebola outbreak and measures to reduce risk of potential exposure • Prepare to detect, investigate and manage cases

18. Country situation • No case of EVD till date • Regular monitoring from Highest level (HFM, Sec (H), DGHS and JMG) • Surveillance both at POEs and inside country • Preparedness of Health facilities, Laboratories • Strengthening infection control practices • Training of manpower • Risk assessment • Involvement of non-govt. Health sector (IMA etc.)

19. Surveillance measures at POEs • AIM: • To mitigate the risk of EVD surveillance of travellers arriving from EVD affected countries • Enhanced Surveillance at all Designated POEs (5 International airports, 9 Ports and 1 ground crossing) • There are no Direct flights from west African countries • Screening of travellers (pax. & crew) of indirect flights from Gulf countries and Colombo at 18 international airports and Major ports as per the risk criteria

20. MOHFW initiatives • Advisories: MOCA, MEA, MHA • For travellers: families staying and travellers visiting, those returning • Airlines crew • Immigration officials • APHO/PHO/Ground crossing staff • Manpower strengthening: MOs, SN, HI • Orientation training • Health cards • Display of Health Alert • Back-up support: hospitals & Labs World Health Day 2012 – Ageing and Health

21. Screening process • Use of Health card • Categorization of travellers • Low: those who have only H/o travel to EVD affected countries • Medium: those who have H/o contact and • High risk: who have H/o travel and/ or with signs and symptoms of EVD • Low risk to be given advisory for monitoring their Health for next 30 days • Referral of travellers with medium risk to IDSP • Referral of travellers with High risk to identified quarantine/isolation facility for testing and treatment • Enlisting and referral of contacts of Medium and high risk • Special risk groups : Army, MEA feed-back, Medical staff, others

22. Logistics • Health counters to be located in pre-immigration area • Health forms distribution: by Airlines during flight • To all travellers in 11 identified airlines and • To only travellers who have visited/transited through 4 EVD affected countries • All above travellers (with Health forms ) to be FIRST examined at Health counter before immigration • Directing those with low risk to immigration directly • Note all contact details of medium risk travellers and communicate them to IDSP (SSO/DSO)

23. Responsibilities of airlines • In flight announcement as below: • “In view of the current Threat of Ebola Virus Disease (EVD): which has high mortality and is currently reported in West African Countries, travellers who have any fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, rash, bleeding should report immediately to the airlines crew and at the immigration/ medical unit on arrival. This is important for early diagnosis for prompt management and preventing spread. In case any of these symptoms develop within 30 days of arrival in the country the traveller should seek medical assistance from the designated hospitals and also inform the airport health office.” • “All travellers (passengers and crew) who have either travelled to 4 EVD affected countries or have transited through these countries during past 21 days will be required to fill Health cards and present the duly filled health cards at the Health desk prior to immigration clearance”. •  Training of crew on public health measures during the flight • All airlines should keep • First aid kits, universal precaution kits as per the ICAO guidelines and • A stock of triple layer masks (25 Nos.), disposable hand gloves (around 25) hand sanitizer and disposal bags: these are to be used for any passenger reporting with symptoms of Ebola Virus Disease (EVD) and co-passengers who are likely to have contacted the disease.

24. Responsibilities of Immigration • Assign dedicated counters for immigration clearance of passengers (Category -1 Low risk). • Immigration officers should ascertain that All the travellers (as mentioned above) have been examined/cleared by the Health counter. • During immigration clearance Part A to be retained by immigration and returned to Airport Health Unit after clearance of all passengers of the flight or at the end of the day. • At all immigration counters immigration officers should screen the travel history of travellers during past 21 days and all the travellers who by chance have not been examined/cleared by Health unit then he should be directed to health counter before immigration clearance.

25. Responsibilities of Airport Management Display of Health Alert at prominent places Provide Health counters Arrange Passes for doctors and paramedics Dedicated way for suspect travellers and ambulances Arrange/facilitate aircraft disinfection, hand rub sanitizers, disposable bags for used PPEs Orientation training for airport staff and all stakeholders in facilitation meetings by APHO

26. Responsibilities of Airport Management HEALTH ALERT For Ebola Virus Disease (EVD) ALL THE TRAVELRS WHO HAVE VISITED OR TRANSITED FROM: African countries primarily west African countries which are affected with EVD like Guinea, Liberia, Sierra Leone, Senegal and Nigeria * AND ARE SUFFERING FROM: Symptoms compatible with EVD like fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, bleeding. OR HAVE BEEN IN DIRECT CONTACT WITH BLOOD OR WITH OTHER BODY FLUIDS OF A PERSON OR ANIMAL INFECTED WITH EVD SHOULD IMMEDIATELY REPORT TO HEALTH OFFICER ON ARRIVAL ADVISORY: ANY TRAVELLERS WHO AFTER VISISTING ABOVE COUNTRIES DEVELOPS ABOVE MENTIONED SYMPTOMS UPTO 30 DAYS OF ARRIVAL IN INDIA SHOULD IMMEDIATELY VISIT THE NEAREST DESIGNATED** HOSPITAL *Up dated list of affected countries can be seen from WHO website www.who.int/ ** List of designated hospitals can be seen from MOHFW website mohfw.nic.in

27. Responsibilities of APHO/Health unit • Brief AFRRO about above public health measures required for surveillance of EVD, SOPs and responsibilities of immigration staff. The immigration, airline crew and other staff should also be oriented about EVD SOPs, essential PPEs and procedure for their use and discard. • Impart orientation training to ALL immigration staff and concerned airlines staff deployed at airport. • Examine the travellers by examination of Health cards (as per the low, medium and high risk categorisation) • Aircraft disinfection after disembarkation

28. Designated Hospitals and Laboratories List hospitals has already been communicated NCDC, Delhi and NIV Pune are the designated laboratories List IDSP SSOs and DSOs has also been communicated to all APHOs/PHOs Letters have been written by Secretary (Health) to Secretaries of MHA, MEA and MOCA By Joint secretary (MOHFW) all Principle Health Secretaries of States for manpower, logistics and PPEs

29. Ebola - WHO Website • Technical information • Infection control • Social mobilization • Epidemiology • Preparedness and response • Patient care • Meeting reports • Disease Outbreak News • Updated guidance and tools http://www.who.int/csr/disease/ebola/en/

30. Special Issues- changing scnerios • Intense spread: In the 2014 Ebola outbreak, almost all of the cases of EVD are a result of human-to-human transmission with high rate of infection among Health care workers • Disease has spread to USA and Spain. Spread in Senegal has been contained • 47% of those sickened by Ebola have survived • Early reporting/detection gives better prognosis

31. Issues – contd. The risk of transmission during air travel is low. Ebola is not airborne (i.e. not spread by breathing air) Transmission of Ebola requires direct contact with EVD cases or blood, secretions, organs or other body fluids of infected people (living or dead persons) which are all unlikely exposures for the average traveler. Aircraft disinfection is critical

32. Contd. 3) A person who is infected is only able to spread the virus to others after the infected person starts having symptoms WHO believes that countries with health systems that are prepared to respond can quickly contain any imported cases

33. Thank you…