The devastating spread of Ebolavirus disease (EVD) in West Africa is having a widening impact globally, including on New Zealand. The risk to New Zealand from EVD is considered to be low, essentially because of our geographic isolation and no direct international passenger flights from West Africa.Regardless, past experiences with the emergence of novel viruses—such as Severe Acute Respiratory Syndrome (SARS) in 2003 followed by Avian Influenza A(H5N1) in 2004 and pandemic influenza A(H1N1) in 2009—have highlighted the benefits of advanced preparedness planning. New Zealand's Ministry of Health has led the national readiness planning, ensuring that border management measures are in place, and developing Web resources.1 Indeed, health and other sector plans are well formed, with detailed health sector planning, training and exercising in progress, which has effectively mitigated unnecessary media hype in New Zealand.Preparedness planning in the face of an emerging infectious disease has been problematic in the past largely because of the lack of scientific data. Although the current Ebola epidemic began in Guinea during December 2013, the World Health Organization (WHO) were not notified of the expanding epidemic in Guinea, West Africa, until 23 March 2014, and did not declare the epidemic to be a "public health emergency of international concern" until 8 August 2014.By September the outbreak had extended to include cases from five West African countries (Guinea, Liberia, Nigeria, Senegal, Sierra Leone) and then Mali in October. Also early in October 2014 the first transmissions of EVD outside Africa were reported in Spain and Texas, USA. With the slow realisation of the extent of the epidemic and then escalating global response, it is not surprising that the collection of scientific information from the region has been challenging.Nevertheless, the first scientific analyses of the West African Ebola epidemic are now appearing in the literature. The first comprehensive epidemiological analysis using surveillance data, along with clinical and outcome analyses carried out by the WHO Response Team and others have now been published in the New England Journal of Medicine.2,3 Clearly, the epidemic in West Africa is unprecedented in scale and is continuing to expand and without more effective control, Ebola could become endemic in the region.The EbolavirusThe Zaire ebolavirus is the virus behind the current epidemic, which is one of five species of closely related viruses that are grouped within the Ebolavirus genus. Along with Marburg virus and the distantly related Lloviu virus, the ebolaviruses make up the Filovirus family. Most of these viruses cause life-threatening viral haemorrhagic fevers (VHF) in humans.Ebolaviruses are zoonotic pathogens believed to be carried by fruit bats that are present throughout central and sub-Saharan Africa. Transmission to humans is likely to occur through direct contact with bats or with their secretions or excretions, or through the consumption of "bushmeat." Marburg virus was the first Filovirus to be discovered in 1967 when two laboratory workers in Germany handling primates, became infected.The natural reservoir of this virus has now been identified as Egyptian fruit bats, and it is strongly suspected that bats are the natural reservoir for the ebolaviruses as well.Ebolavirus diseaseEVD presents much as many other viral infections do, with nonspecific signs such as fever, fatigue and body aches. After a few days however the predominant syndrome becomes a severe gastrointestinal illness with vomiting and diarrhoea. The most extensive epidemiological data on EVD comes from the 1995 outbreak in Kikwit in the Democratic Republic of the Congo, which was associated with the same Zaire ebolavirus species.4The main risk factor identified was direct physical contact with a symptomatic person, primarily body fluids which include blood, vomit, diarrhoea, and later in the disease, sweat and saliva. Ebolavirus can survive outside the body for hours to days depending on the environmental conditions, thus transmission through contact with objects contaminated with body fluids is theoretically possible.5 Evidence suggests that virus becomes detectable by PCR 2–3 days after symptom onset, with viral loads increasing during the later stages of the illness.Two papers from the WHO Ebola Response Team and Schieffelin et al have provided data on the current West African epidemic.2,3 The WHO Team has reported on 4507 confirmed and probable EVD cases occurring up to 14 September 2014, and the clinical manifestations, the duration of illness, the case fatality rate and transmissibility were similar to those in earlier epidemics.The most common symptoms reported were fever (87.1%), fatigue (76.4%), loss of appetite (64.5%), vomiting (67.6%), diarrhoea (65.6%, headache (53.4%) and abdominal pain (44.3%). Haemorrhagic symptoms were rarely reported although "unexplained bleeding" was in 18% of cases. Symptom onset occurred in 95% of cases within 21 days after exposure, supporting the current advice to follow case contacts for 21 days is appropriate.In the second paper, the illness and outcome of 106 EVD patients in Sierra Leone are reviewed. The incubation period was estimated to be 6 to 12 days and the case fatality rate 74%. Clinical and laboratory features at presentation that were associated with fatal outcomes included a fever, weakness, dizziness, diarrhoea and elevated levels of blood urea nitrogen, aspartate aminotransferase and creatinine.In both studies, the majority of patients were 15–44 years of age. Patients under the age of 21 years had a lower mortality than those over 45 years, and overall the mortality rate was lower among hospitalised patients (64.3%). Laboratory data also suggested that the mortality rate was significantly higher in patients with higher Ebola viral loads (10 million copies/ml or more).It is conceivable that the overall mortality rate in EVD patients treated outside West Africa will be significantly below that reported in West Africa. The recovered healthcare workers in the USA and Spain have provided some evidence for this. As more cases emerge or are managed and recover outside of West Africa, the benefits of the intensive management of EVD and likely improved case outcome will be substantiated.Readiness planningIt is most likely that an international traveller meeting the "suspected" case definition for EVD will present in New Zealand. Although such a person could present anywhere in the country, it is logical to focus on pathways for managing the borders, primary care and secondary care and to strengthen patient isolation capability where international arrivals and case presentation are most likely to occur in Auckland, Wellington and Christchurch.Border measures involve the New Zealand Customs electronically pre-screening arriving passengers, which supplements individual passenger self-declaration of the countries visited in the past 30 days. Along with public health messaging from the New Zealand Ministry of Health, this approach relies on individual passenger responsibility rather than the more draconian approach of the Australian Government to restrict the issuing of visas to travellers from the Ebola affected West African countries.Considerable focus is being placed nationally on clinical pathways for the hospital management of "suspected" cases. Common sense is prevailing with the identification of appropriate Personal Protective Equipment (PPE) and the need for rigorous training in their appropriate use. Little focus has been placed on laboratory diagnostic support. Near patient/point of care tests are available for basic haematological and biochemical analyses and agreements are in place for Ebolavirus confirmatory testing by PCR at VIDRL in Melbourne, Australia.Patients may present early in their disease (within 3 days of symptom onset) before virus is detectable by PCR in their blood, thus requiring successive samples to be forwarded to Australia, delaying results to more than 48 hours. With malaria being the most likely differential diagnosis of febrile illness in people who have lived in West Africa, planning is in place for malaria parasite testing, a process involving either rapid tests or the preparation of smears, both processes requiring blood manipulation. It would make sense to carry out initial PCR testing for Ebolavirus by PCR under PC2+ or 3 biocontainment conditions, followed by the required confirmatory testing in Australia. The patient's blood can be inactivated prior to PCR testing which renders it non-infectious.Clearly from the WHO Ebola Response Team's report, the late recognition of the epidemic in West Africa along with inadequate control measures along with the disintegration of healthcare systems, population mobility and cultural issues, rather than a biological change in the virus have led to the epidemic's escalation. However, Ebolavirus is mainly spread through the contact with the body fluids of symptomatic patients thus transmission can be stopped by the combination of early diagnosis and appropriate patient isolation.2New Zealand has a well-informed and resourced health system, thus the early recognition of suspected EVD cases, their isolation and implementation of infection control measures, along with intensive case contact tracing and quarantine, supported by rapid diagnostic laboratory testing should minimise the risk of any secondary Ebolavirus transmission.6\r\n

The devastating spread of Ebolavirus disease (EVD) in West Africa is having a widening impact globally, including on New Zealand. The risk to New Zealand from EVD is considered to be low, essentially because of our geographic isolation and no direct international passenger flights from West Africa.Regardless, past experiences with the emergence of novel viruses—such as Severe Acute Respiratory Syndrome (SARS) in 2003 followed by Avian Influenza A(H5N1) in 2004 and pandemic influenza A(H1N1) in 2009—have highlighted the benefits of advanced preparedness planning. New Zealand's Ministry of Health has led the national readiness planning, ensuring that border management measures are in place, and developing Web resources.1 Indeed, health and other sector plans are well formed, with detailed health sector planning, training and exercising in progress, which has effectively mitigated unnecessary media hype in New Zealand.Preparedness planning in the face of an emerging infectious disease has been problematic in the past largely because of the lack of scientific data. Although the current Ebola epidemic began in Guinea during December 2013, the World Health Organization (WHO) were not notified of the expanding epidemic in Guinea, West Africa, until 23 March 2014, and did not declare the epidemic to be a "public health emergency of international concern" until 8 August 2014.By September the outbreak had extended to include cases from five West African countries (Guinea, Liberia, Nigeria, Senegal, Sierra Leone) and then Mali in October. Also early in October 2014 the first transmissions of EVD outside Africa were reported in Spain and Texas, USA. With the slow realisation of the extent of the epidemic and then escalating global response, it is not surprising that the collection of scientific information from the region has been challenging.Nevertheless, the first scientific analyses of the West African Ebola epidemic are now appearing in the literature. The first comprehensive epidemiological analysis using surveillance data, along with clinical and outcome analyses carried out by the WHO Response Team and others have now been published in the New England Journal of Medicine.2,3 Clearly, the epidemic in West Africa is unprecedented in scale and is continuing to expand and without more effective control, Ebola could become endemic in the region.The EbolavirusThe Zaire ebolavirus is the virus behind the current epidemic, which is one of five species of closely related viruses that are grouped within the Ebolavirus genus. Along with Marburg virus and the distantly related Lloviu virus, the ebolaviruses make up the Filovirus family. Most of these viruses cause life-threatening viral haemorrhagic fevers (VHF) in humans.Ebolaviruses are zoonotic pathogens believed to be carried by fruit bats that are present throughout central and sub-Saharan Africa. Transmission to humans is likely to occur through direct contact with bats or with their secretions or excretions, or through the consumption of "bushmeat." Marburg virus was the first Filovirus to be discovered in 1967 when two laboratory workers in Germany handling primates, became infected.The natural reservoir of this virus has now been identified as Egyptian fruit bats, and it is strongly suspected that bats are the natural reservoir for the ebolaviruses as well.Ebolavirus diseaseEVD presents much as many other viral infections do, with nonspecific signs such as fever, fatigue and body aches. After a few days however the predominant syndrome becomes a severe gastrointestinal illness with vomiting and diarrhoea. The most extensive epidemiological data on EVD comes from the 1995 outbreak in Kikwit in the Democratic Republic of the Congo, which was associated with the same Zaire ebolavirus species.4The main risk factor identified was direct physical contact with a symptomatic person, primarily body fluids which include blood, vomit, diarrhoea, and later in the disease, sweat and saliva. Ebolavirus can survive outside the body for hours to days depending on the environmental conditions, thus transmission through contact with objects contaminated with body fluids is theoretically possible.5 Evidence suggests that virus becomes detectable by PCR 2–3 days after symptom onset, with viral loads increasing during the later stages of the illness.Two papers from the WHO Ebola Response Team and Schieffelin et al have provided data on the current West African epidemic.2,3 The WHO Team has reported on 4507 confirmed and probable EVD cases occurring up to 14 September 2014, and the clinical manifestations, the duration of illness, the case fatality rate and transmissibility were similar to those in earlier epidemics.The most common symptoms reported were fever (87.1%), fatigue (76.4%), loss of appetite (64.5%), vomiting (67.6%), diarrhoea (65.6%, headache (53.4%) and abdominal pain (44.3%). Haemorrhagic symptoms were rarely reported although "unexplained bleeding" was in 18% of cases. Symptom onset occurred in 95% of cases within 21 days after exposure, supporting the current advice to follow case contacts for 21 days is appropriate.In the second paper, the illness and outcome of 106 EVD patients in Sierra Leone are reviewed. The incubation period was estimated to be 6 to 12 days and the case fatality rate 74%. Clinical and laboratory features at presentation that were associated with fatal outcomes included a fever, weakness, dizziness, diarrhoea and elevated levels of blood urea nitrogen, aspartate aminotransferase and creatinine.In both studies, the majority of patients were 15–44 years of age. Patients under the age of 21 years had a lower mortality than those over 45 years, and overall the mortality rate was lower among hospitalised patients (64.3%). Laboratory data also suggested that the mortality rate was significantly higher in patients with higher Ebola viral loads (10 million copies/ml or more).It is conceivable that the overall mortality rate in EVD patients treated outside West Africa will be significantly below that reported in West Africa. The recovered healthcare workers in the USA and Spain have provided some evidence for this. As more cases emerge or are managed and recover outside of West Africa, the benefits of the intensive management of EVD and likely improved case outcome will be substantiated.Readiness planningIt is most likely that an international traveller meeting the "suspected" case definition for EVD will present in New Zealand. Although such a person could present anywhere in the country, it is logical to focus on pathways for managing the borders, primary care and secondary care and to strengthen patient isolation capability where international arrivals and case presentation are most likely to occur in Auckland, Wellington and Christchurch.Border measures involve the New Zealand Customs electronically pre-screening arriving passengers, which supplements individual passenger self-declaration of the countries visited in the past 30 days. Along with public health messaging from the New Zealand Ministry of Health, this approach relies on individual passenger responsibility rather than the more draconian approach of the Australian Government to restrict the issuing of visas to travellers from the Ebola affected West African countries.Considerable focus is being placed nationally on clinical pathways for the hospital management of "suspected" cases. Common sense is prevailing with the identification of appropriate Personal Protective Equipment (PPE) and the need for rigorous training in their appropriate use. Little focus has been placed on laboratory diagnostic support. Near patient/point of care tests are available for basic haematological and biochemical analyses and agreements are in place for Ebolavirus confirmatory testing by PCR at VIDRL in Melbourne, Australia.Patients may present early in their disease (within 3 days of symptom onset) before virus is detectable by PCR in their blood, thus requiring successive samples to be forwarded to Australia, delaying results to more than 48 hours. With malaria being the most likely differential diagnosis of febrile illness in people who have lived in West Africa, planning is in place for malaria parasite testing, a process involving either rapid tests or the preparation of smears, both processes requiring blood manipulation. It would make sense to carry out initial PCR testing for Ebolavirus by PCR under PC2+ or 3 biocontainment conditions, followed by the required confirmatory testing in Australia. The patient's blood can be inactivated prior to PCR testing which renders it non-infectious.Clearly from the WHO Ebola Response Team's report, the late recognition of the epidemic in West Africa along with inadequate control measures along with the disintegration of healthcare systems, population mobility and cultural issues, rather than a biological change in the virus have led to the epidemic's escalation. However, Ebolavirus is mainly spread through the contact with the body fluids of symptomatic patients thus transmission can be stopped by the combination of early diagnosis and appropriate patient isolation.2New Zealand has a well-informed and resourced health system, thus the early recognition of suspected EVD cases, their isolation and implementation of infection control measures, along with intensive case contact tracing and quarantine, supported by rapid diagnostic laboratory testing should minimise the risk of any secondary Ebolavirus transmission.6\r\n