The UK Imported Fever Service: Role in the management of unwell travellers returning

from areas affected by the 2014 Ebola outbreak

ESCAIDE 2014

Amanda Semper, Caoimhe Nic Fhogartaigh, Andrew Simpson,

Emma Aarons, Jane Osborne, Peter Chiodini, Nicholas Beeching

and Tim Brooks

Overview

Aims of the service

How the IFS works

IFS role in 2014 ebola outbreak

• Advice

• VHF risk assessments

• Specialist testing

• ‘Surveillance’

• Public health response

2 Imported Fever Service

Imported Fever Service: Aims

• National specialist diagnostic and clinical advice service

for undiagnosed acute imported fevers

• Serves hospital-based ID and microbiology specialists

• Led by PHE Rare and Imported Pathogens Laboratory

(RIPL) in collaboration with two NHS specialist centres

• HTD / LSHTM

• TIDU / LSTM

• In operation since June 2012

3 Imported Fever Service

What the IFS offers 1. Clinical & infection control advice

• Single point of contact nationwide, 24/7: 08447 788 990

• VHF-risk assessment & differential diagnoses

• Treatment, infection control and decontamination advice

2. Diagnostic service (at RIPL)

• On-call PCR tests for VHFs & malaria (± common “exotics”)

• Next working day tests for comprehensive range of “exotic” pathogens

• Geographical panels

• Rapid turnaround

3. Support for Public Health responses

Imported Fever Service Imported Fever Service

5 Imported Fever Service

6 Imported Fever Service

0

20

40

60

80

100

120

27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44

01/07-06/07

07/07-13/07

14/07-20/07

21/07-27/07

28/07-03/18

04/08-10/08

11/08-17/08

18/08-24/08

25/08-31/08

01/09-07/09

08/09-14/09

15/09-21/09

22/09-28/09

29/09-05/10

06/10-12/10

13/10-19/10

20/10-26/10

27/10-02/11

Weekly volume of calls received by IFS (July – Oct 2014)

IFS calls

7 Imported Fever Service

0

20

40

60

80

100

120

27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44

01/07-06/07

07/07-13/07

14/07-20/07

21/07-27/07

28/07-03/18

04/08-10/08

11/08-17/08

18/08-24/08

25/08-31/08

01/09-07/09

08/09-14/09

15/09-21/09

22/09-28/09

29/09-05/10

06/10-12/10

13/10-19/10

20/10-26/10

27/10-02/11

Weekly volume of calls received by IFS (July – Oct 2014)

IFS calls Relative frequency of UK Ebola-related Google searches

7 Aug 14 WHO: Ebola outbreak is

PHEIC

11 Oct 14 Ebola response

exercise in England

14 Oct 14 Screening starts at

Heathrow

8 Imported Fever Service

Week beginning

Calls VHF RAs

14-Jul-14 20 3

21-Jul-14 15 2

28-Jul-14 56 13

04-Aug-14 85 18

11-Aug-14 69 14

18-Aug-14 60 13

25-Aug-14 46 9

01-Sep-14 43 17

08-Sep-14 36 17

15-Sep-14 42 11

22-Sep-14 23 4

29-Sep-14 40 8

06-Oct-14 90 13

13-Oct-14 106 13

20-Oct-14 69 10

27-Oct-14 54 7

Total 854 172

VHF risk assessments & advice July – Oct 2014

20% of calls:

• credible (or inadequate) ‘W Africa’ travel history

and/or exposure

• VHF risk assessment carried out

Remaining calls:

1. Routine IFS business: unwell travellers returning

from other global destinations; advice and / or

diagnostic tests required

2. Majority of callers were healthcare professionals

seeking advice about setting up their local

procedures

3. Few calls from members of public seeking

reassurance

9 Imported Fever Service

Week beginning

Calls VHF RAs VHF tests Not tested

14-Jul-14 20 3 2 1

21-Jul-14 15 2 1 1

28-Jul-14 56 13 5 8

04-Aug-14 85 18 5 13

11-Aug-14 69 14 8 6

18-Aug-14 60 13 4 9

25-Aug-14 46 9 5 4

01-Sep-14 43 17 6 11

08-Sep-14 36 17 8 9

15-Sep-14 42 11 3 8

22-Sep-14 23 4 0 4

29-Sep-14 40 8 4 4

06-Oct-14 90 13 7 6

13-Oct-14 106 13 4 9

20-Oct-14 69 10 5 5

27-Oct-14 54 7 4 3

Total 854 172 71 101

Outcomes from VHF risk assessments July – Oct 2014

Tests carried out on 40% of VHF

risk-assessed cases

Positive diagnoses by IFS

10 Imported Fever Service

VHF panel

Malaria

CCHF

Lassa

Marburg

Ebola

Generic filovirus

Additional tests for

West Africa

Dengue

Chikungunya

Rift Valley fever

Rickettsias

Leptospirosis

No.

tests Malaria Lepto Ebola

Jul 2014 9 2 - -

Aug 2014 24 6 1 1*

Sep 2014 18 6 - -

Oct 2014 23 7 - -

*Repatriated health care worker from Sierra Leone

with known EVD

Outcomes: Patient care

11 Imported Fever Service

Advice (24/7):

appropriate patient management

Timely negative VHF diagnosis (24/7):

de-escalation of infection control

appropriate patient management

Positive non-VHF diagnosis:

Implementation of appropriate treatment /

patient management

Outcomes: Public Health ‘Surveillance’

IFS is single national contact point for VHF / ebola advice and testing

‘Coverage’ means IFS provides ‘sentinel’ function for VHF/ ebola (& other

non-endemic diseases) imported into England /UK

Public health response

Liaison with regional and national health protection bodies

Advice on infection control and decontamination

Follow-up diagnostic tests of any positive VHF cases

Testing contacts if required

12 Imported Fever Service

Conclusions

• In routine use the IFS improves the capability to diagnose

and manage fever in returned travellers in a clinically

relevant timeframe

• The IFS has been in use for > 2 yrs and is embedded in

national protocols

• In the 2014 ebola outbreak the IFS provides a single

national contact point for advice, VHF risk assessment and

diagnostic tests and is a key player in the public health

response to the threat posed by imported ebola virus disease

Imported Fever Service Imported Fever Service 13

The IFS team

14 Imported Fever Service

PHE (Porton) IFS StR trainees Liverpool NHS

Tim Brooks Katherine Russell Nick Beeching

Amanda Semper Cathy Roberts David Lalloo

Andrew Simpson Behzad Nadjm

Emma Aarons Jon Lambourne

Malur Sudhanva Alex Aiken

Matthew Dryden Pasco Hearn

Jane Osborne Caoimhe Nic Fhogartaigh

All RIPL lab staff Alastair McGregor

All on-call staff UCLH NHS

All administrative staff Peter Chiodini

Phil Gothard

PHE (Manchester) Mike Brown

Ken Mutton Consultant team

Ed Kaczmarski StR tropical on-call team

Imported Fever Service amanda.semper@phe.gov.uk