Guidance

Public health message to all NHS service providers regarding Ebola virus outbreak in Uganda (Sudan ebolavirus)

Updated 6 October 2022

Actions for the NHS

1. Providers to ensure that relevant clinical services – particularly primary care, urgent care and emergency departments – are aware of the information in this public health message and that Ebola virus disease (EVD) is considered in the differential of any patient with relevant symptoms returning from the areas affected by the outbreak. The great majority of patients with fever from Uganda will have other, treatable, causes such as malaria and these need to be considered in parallel.

2. Providers to ensure that they have adequate stocks of appropriate personal protective equipment (PPE) and relevant staff are trained in its use for the assessment and treatment of patients presenting with possible EVD.

3. Providers to ensure there is a clinical pathway for isolation and management of suspected EVD cases within their setting. This should include isolation of the patient, liaison with local infection prevention and control (IPC) teams, and arrangements for discussion of the case with local infectious disease, microbiology and/or virology consultants if a diagnosis of EVD is being considered so that appropriate clinical management, including testing and infection control measures, can be implemented.

4. Providers to note the information below for the clinical assessment and testing of patients with potential EVD.

Background information

On 20 September 2022, health authorities in Uganda declared an outbreak of EVD following confirmation of a case, infected with the Sudan ebolavirus (SUDV), in Mubende District, Central Region, Uganda.

As of 2 October 2022, 43 confirmed cases (9 deaths) and 20 probable cases (all deceased) have been reported from 5 districts of Uganda: Mubende and Kassanda districts in Central Region, and Bunyangabu, Kagadi and Kyegegwa districts in Western Region, Uganda.

SUDV is an Ebola virus, a member of the filovirus family, and is part of a wider group of diseases known collectively as viral haemorrhagic fevers (VHFs). Six species of Ebola virus have been identified, of which 4 are known to cause disease in humans. SUDV outbreaks have occurred sporadically in Uganda and South Sudan, with the most recent previous outbreak reported in Uganda in 2011.

EVD presents with a wide range of symptoms, with an incubation period of between 2 to 21 days post-exposure (average 4 to 10 days). The onset of symptoms can be sudden, with fever, malaise, myalgia, and headaches. These symptoms may progress to include rash, nausea, vomiting, diarrhoea and abdominal pain. Internal and/or external bleeding may occur but will not be present in all cases, nor early in illness, and this should not be used as the sole indicator for suspicion of EVD.

There is no definitive treatment regimen for EVD, and clinical interventions are mainly supportive. The illness has a case fatality rate of between 40% to 90% (depending on the virus species) with SUDV having a case fatality rate of approximately 50% seen in previous outbreaks.

There are currently no licensed vaccines for use against SUDV and the current evidence suggests that vaccines against other EVD strains do not provide cross-protection for SUDV. Several trials for SUDV-specific vaccines are ongoing and being led by the World Health Organization (WHO) R&D Blueprint group.

Ebola virus is transmitted from person to person through direct contact with blood, secretions, or other bodily fluids of an infected person. There is no evidence for an airborne route of transmission – transmission via large saliva droplets may be possible but this is an unlikely route of spread.

It is important that appropriate PPE and barrier treatment methods are utilised by all healthcare professionals involved in the treatment and management of potential EVD patients (including the deceased) to prevent transmission.

Transmission via environmental contamination is possible so healthcare settings where EVD patients have been treated should be deep cleaned and waste be managed according to national guidelines.

Clinical assessment and diagnosis

The Advisory Committee on Dangerous Pathogens (ACDP) have produced an algorithm that should be used for the assessment of any suspected EVD case.

In summary, any febrile patient is eligible for testing if they have become unwell within 21 days of leaving an endemic country and they have visited an area with a current VHF outbreak. During the current outbreak this applies to any patient with a fever who has left Uganda within the past 21 days.

The UK Health Security Agency (UKHSA) Ebola resource collection will be kept up to date with information on affected areas for the duration of the outbreak to assist NHS clinicians in diagnosis.

Suspected EVD cases should be discussed with the local infection consultant (microbiology, virology, or infectious diseases) who can access pathways for VHF testing via the UKHSA Imported Fever Service. Where there is no local infection consultant available, the UKHSA Imported Fever Service may be contacted directly by the treating clinician.

Infection prevention and control

Infection prevention and control measures during assessment and testing are described in the ACDP guidance. Any patient that tests positive will be transferred to a High Level Isolation Unit.

During the period of assessment in secondary care, all suspected cases should be isolated in a side room immediately with dedicated en-suite or commode. The number of staff contacts should be restricted.

The appropriate PPE is double gloves, fluid repellent disposable gown (or coveralls), full length plastic apron, head cover, fluid repellent footwear, full face shield or goggles, and fluid repellent FFP3 respirator. Safe waste management and decontamination are also required. Full details on PPE and all IPC procedures are provided in the ACDP guidance.

If the patient presents to primary care and initial clinical assessment using the flowchart in the ACDP guidance indicates EVD, they should be isolated immediately in an empty room. The case should be urgently discussed with the local acute infectious disease unit and, if EVD is still suspected, specialist ambulance transfer should be arranged to a dedicated inpatient facility for detailed clinical assessment and treatment.

Healthcare providers should ensure staff have access to and are trained in the donning and doffing of appropriate PPE for managing a suspected case.

Dr Thomas Waite
Deputy Chief Medical Officer, DHSC

Prof Susan Hopkins
Chief Medical Advisor, UKHSA

Prof Stephen Powis
National Medical Director
NHSE