For many months now we have watched West African nations struggling with the agony of ebola haemorrhagic fever, now termed ebola virus disease (EVD). The capacity of these nations to respond to an epidemic is greatly reduced by ongoing civil war, poverty and particular cultural beliefs surrounding death. They lack the numbers of trained clinical professionals required to manage this public health crisis, and rely on teams of overseas clinicians to work collaboratively with their own. Australian nurses have bravely joined the battle-front, working in astronaut-like protective suits, gum boots and goggles, often in 45 degree heat with 95% humidity.  Nurses are only able to stay in these suits one arduous hour at a time. The ritual of their donning and removal is critically important to infection control; front-line staff have been air-lifted out as a precaution when part of the process is compromised. The appalling death rate of ebola and the consequent social and economic devastation is almost incomprehensible.  Despite the best efforts of the governments of Sierra Leone, Liberia and Guinea, between 10,000 and 12,000 people have died from this truly terrible disease.  Draconian measures are employed to staunch the flow of new cases. In Sierra Leone, for example, the entire population of six million people was recently ordered to stay at home for a period of three days in an effort to reduce infection rates.  

The Spanish Influenza of 1919 was thought to have been brought to Australia by soldiers returning from Europe after the Great War of 1914-1918. The pandemic caused the deaths of a similar number of Australians, up to 12,000 people, a hefty proportion of the then population of five to six million, already stripped of a substantial swathe of their young male population. An estimated 500 million people died world-wide,  making the Spanish Influenza one of the most lethal pandemics in history. This virulent disease was terrifying in afflicting young healthy people, the cohort perceived as having most pandemic resistance. It has been argued that the immune system of young people was the very thing that caused their vulnerability. Some researchers think a physiological process called hypercytokinemia or a “cytokine storm” (Osterholm, 2005; Harrison, 2010) occurred in these young adults: the process by which the healthy immune system over-reacts in an extreme manner, attacking host cells. 

As with the scourge of ebola, rigorous public health measures were used in Australia in 1919 to minimise infection rates: people were placed in quarantine; places of public assembly such as schools, cinemas, race tracks and libraries were closed; wearing face masks was made compulsory in some cities; the border between New South Wales and Victoria was shut.

We are extremely fortunate in Australia to be free of pandemic, but like every other nation, we need constant vigilance and have comprehensive planning in case it should occur. I worked in a national pandemic influenza exercise some years ago, Exercise Cumpston , designed to test Australian government responses to a possible H5N1 influenza pandemic. The emergency exercise was named for John Cumpston, the first Director-General of the Department of Health, a man who had an extensive career in dealing with infection control at a population level. During the “real time” exercise, hypothetical “infected patients” flew into Australia by plane from overseas. Some had influenza symptoms, but others were asymptomatic or merely mildly unwell and resumed their normal lives. They went to shopping centres, visited relatives and returned to workplaces. Over a few weeks these people developed influenza symptoms: fever, cough, headaches, chills, and myalgia. Once diagnosed and confirmed as influenza cases, nurses working in infection control began the assiduous process of contact tracing; in the first instance, the tracing of fellow passengers seated in close proximity on flights.

Contact tracing during the containment phase of a pandemic seems to require the character traits of a great detective; in the first instance, finely honed interpersonal skills: “I'm so sorry, Mrs. X, but we understand you sat next to a man on the plane who has since developed a serious influenza. You may be at risk of infection.” Clearly the rationale for delivering such disturbing news needs careful consideration. Close contacts of infected passengers, or index cases, may be defined as those sitting in the same row or in the two or three rows in front or behind them, though there is ongoing debate about whether that number should be extended to four or more (Shankar et al, 2014). “I know it's a terrible inconvenience not to be able to return to work, Mr. Y, but, hard as it is, we need you to stay home for the next few weeks.” How to tell citizens who rail at this abrogation of their civil liberties that there are penalties for breaching quarantine?

Though contemporary culture seems awash with personal identifiers - the internet, a plethora of plastic cards, the ubiquitous closed-circuit TV (CCTV) - possible case contacts may not be easy to find. It helps to have a smidgeon of obsessive-compulsive disorder (OCD) and a liberal dollop of “in-it-for-the-long-haul” dogged determination, to keep tracking exhaustively. Once identified, all contacts require clinical evaluation and follow-up, and each step in the process has to be carefully recorded.

The United States Centre for Disease Control and (CDC) Prevention is training personnel in Africa to go door to door to identify possible ebola cases. There are significant cultural barriers. The dead in some countries are traditionally washed with bare hands. People feel that if they identify their family members, they will be taken away for isolation and treatment in centers where they inevitably die, preventing their dignified burial. The proactive approach of community contact tracing, however, is prevention in practice; families are taught that if their loved ones are identified, isolated and treated before they have vomiting and diarrhea, not only are they more likely to survive, but the infection risk for the rest of the family is greatly reduced.  

The lethality of ebola is a salutary lesson to Australia about the importance of emergency planning for a pandemic in an era of global travel. Though incredibly fortunate to live in a peaceful country with greater capacity of clinical and emergency personnel for dealing with public health emergencies, we cannot afford to be complacent. If the calamitous should happen, you can be certain the sleuths of infection will be on the case.        



References:
ANAO Audit Report No.6 2007–08. Australia’s Preparedness for a Human Influenza Pandemic

Harrison, C. (2010). Sepsis: Calming the cytokine storm. Nature Reviews Drug Discovery 9(5): 360–361        

Osterholm MT (May 2005). "Preparing for the next pandemic". N. Engl. J. Med. 352 (18): 1839–42. doi:10.1056/NEJMp058068. PMID 15872196. Retrieved 2008-07-02.

Shankar et al (2014) Contact Tracing for H1N1 pdm09 Virus Infected Passengers on International Flight. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 20, No. 1, January 2014.