EBOLA

Can Pakistan protect its citizens from Ebola
Introduction:
The world is facing the biggest and most complex Ebola outbreak in history. On August 8, 2014, the Ebola outbreak in West Africa was declared by the World Health Organization (WHO) to be a Public Health Emergency of International Concern (PHEIC) because it was determined to be an ‘extraordinary event’ with public health risks to other countries. It is a foregone conclusion that coordinated public health actions are essential to stop and reverse the spread of Ebola.
While global efforts are being made to end the current outbreak in Africa, it is essential that Pakistan takes all possible measures to protect and prevent its citizens from this deadly infectious disease.

Pakistan needs to urgently undertake two categories of measures:
1. Measures to screen, detect and control real or suspected cases of Ebola at all entry points, i.e. airports, sea ports and land routes.
2. Measures for creating effective preparedness and response capacity of healthcare organisations to handle the identified Ebola related cases.

This proposal briefly outlines:
• Currently adopted practices and controls at the Karachi airport to screen the incoming passengers for possible exposure to Ebola. Section A.
• The proposed actions that may be taken to screen, detect and deal with arriving passengers who may be suffering or may have been exposed to Ebola. Section B.

Section A: Currently adopted practices and controls at Karachi airport.
1. PIA’s Incoming international flights do not give any Health Card or health questionnaire or declaration of health to passengers arriving at Karachi airport.
2. Passengers after arriving at Karachi airport are not given any health card or questionnaire or declaration of health document to fill.
3. Passengers arriving at Karachi airport before reaching the immigration counters have to pass close to a health desk with a caption ‘EBOLA’. However this desk serves NO purpose as it neither questions a passenger ( about health and countries visited) nor asks for filling of health card.
4. Some foreign airlines (not all) give a health card to passengers before landing at Karachi airport. However whether these cards are filled or not remains immaterial as they are NOT collected or scrutinized by the airport’s health-desk personnel, nor are any questions asked from passengers about health or countries visited in the last 21 days.
5. If an immigration officer, during the immigration process, detects a stamp of an Ebola-origin country on a passenger’s passport, he can send the passenger back to airport health officials. The chances of this event are however slim and incidental as the immigration staff is primarily focused on addressing their own immigration related actions.
6. A thermal scanner is installed close to the Health Desk. This is not an effective way to scan dozens of people walking at different distances from the scanner. In any case, one does not notice any reaction from the thermal scanner as hundreds of passengers passed in front of the scanners in hordes.
7. The airport health officials do not have a specific room and washroom facility to segregate and examine Ebola related cases, even if they ever managed to detect one.
8. The airport health officials do not have a readily available check list of what questions ought to be asked, how to classify types of Ebola cases and the type of controls required to be exercised for each category of Ebola case.

Based on the above facts, as practically witnessed and discussed with incoming passengers as well as the health staff at the airport, it may be safely assumed that Pakistan has a non-existent system for screening, detecting and control of Ebola related cases at the Karachi airport.

Section B: The proposed actions to detect and deal with Ebola related cases at airports.
1. PIA and all other international flights arriving at any airport of Pakistan be asked to give a Health Card for declaration of health to all disembarking passengers and members of crew – at least half an hour before landing. It must be mandatory for every arriving person to fill and submit this card to Health Officials at the airport of landing.
2. A proposed sample of Health Card is placed at Appendix A.
3. At each airport multiple Health Counters be organized exactly on the same pattern as the immigration counters. These could be 3 to 6 Health Counters, or more, to best suit the convenience and reduce the waiting time of passengers.
4. There must be large size information boards located well before the passengers queue up before the Health Counters. These information boards must state the following: “Those who said YES to any of the first four questions listed at Part 2 of the Health Card, Please report to Counter No.1. All other passengers please pass through Counter 2, 3, 4, 5 and 6 . Please Hand over your Health cards to the Officer on duty, before you leave the Health counter.” These boards (Urdu and English ) must be placed prominently in such a manner that they cannot escape the attention of the arriving passengers. Recorded announcements, repeating the same contents should be made every few minutes as passengers approach the Health Counters. These announcements cater to those who cannot read.
5. Passing through one or the other Health Counters must be obligatory for all passengers, before they can approach any of the immigration counters. It must be ensured that no passenger can arrive at an immigration counter, unless he has gone through the Health Desks and submitted his Health Card.
6. Health Officers must be positioned at each Health counter, who must collect the Health Cards from each passenger. The number of Health cards collected must be tallied and should be the same as the number of disembarking passengers of each flight.
7. Procedure for Health official at counters 2, 3, 4, 5, 6.
• The duty Health official wears gloves, protective goggles/glasses and N95 face mask .
• Collect the Health Card.
• Examine the Health Card carefully. If the answer to any of the first four questions at Part 2 of the Health card is YES, and the passenger has inadvertently arrived at Counter 2, 3, 4, 5, or 6, he/she may be redirected to go to Counter 1.
• Check the passport of every 4th or 5th passenger, to see if the passenger has visited any of the Ebola origin countries in the last 21 days. If yes, direct the passenger to Counter 1. (This is done to countercheck the veracity of info given on Health Cards)
• Direct any visibly sick person to counter 1.
• The immigration staff, during the immigration process, must check the passports for entry/exit stamps of Liberia, Sierra Leone, or Guinea. If so, the passenger must be redirected to Health Counter 1 (unless already cleared and declared risk-free)

8. Screening Procedure for Health Officials at Health Counter 1.
• The duty Health official wears gloves, protective goggles/glasses and N95 face mask .
• Examine the Health card.
• Identify dates when he visited Guinea, Liberia or Sierra Leone
• Initial questions on contact with people who suffered or were suffering from Ebola or handled an Ebola related death body.
• Take the passenger to a segregated Health Care room at the airport.
• Use full PPE. (Advice on PPEs may be obtained from Executive Director Jinnah Post graduate Medical Centre). A number of such PPEs must be available at all times at each airport.
• Examine the patient.
• Ask detailed questions based on guidelines given at Appendix B.
• Categorize the passenger, based on Degree of Exposure into Risk Levels – High Risk, Some Risk, Low Risk or No Risk category, using information given at Appendix B
• People showing any of Ebola symptoms and categorized as either High, Some, or Low Risk categories, MUST have a medical examination to make sure they don’t have Ebola. They will remain isolated in a hospital until doctors are certain that Ebola is not a concern.
• Symptoms of Ebola are: Fever, severe headache, fatigue, muscle pain, vomiting, diarrhea, stomach pain, unexplained bruising or bleeding.
• People who do not show Ebola symptoms, but fall in High, Some or Low Risk category must be dealt with as described at Appendix C. The arrangement for Direct Monitoring or Active Monitoring or Travel restrictions must be fully explained and agreed before the passenger is allowed to leave. Such a passenger must be given a copy of Appendix C, and also made to sign for compliance of the prescribed instructions.
• Definitions of Isolation, Active monitoring, Direct Monitoring, or Travel Restrictions are also given at Appendix C.
• Guidelines for precautions to be taken by healthcare professionals are given at Appendix D. A copy of these guidelines may also be given to all outgoing passengers as a precautionary measure.
9. Health Screening and Examining facilities at all airports must be upgraded to consist of at least the following:
• One office with necessary storage
• One completely isolated examination room with an attached wash room.
• One ambulance positioned as close to the isolated room as possible, to take an Ebola patient to hospital.
• Adequate Personal Protective Equipment. Necessary ((Advice on PPEs may be obtained from Executive Director Jinnah Post graduate Medical Centre.)
• Necessary equipment for medical examination.

10. Arrangements with Hospitals: The Airport Health Authorities must have a standing arrangement with at least one hospital in the city, where people showing any of Ebola symptoms can be sent and they will remain isolated until doctors and are certain that Ebola is not a concern. Similar arrangements may be made in other cities where passengers arrive from other countries.

11. Internal and External Audit: No system is sustainable unless some internal and external audit / monitoring processes are built in. It is proposed that the implementation of above described processes be audited internally at least once a week and externally at least once a fortnight. The proposed actions listed in this report (Section B) be used as a check-list for audit. The audit reports must be sent to the senior most health officials at the Airport, CAA and the ministry dealing with National Health Services.

12. A body consisting of a doctor from Jinnah Post graduate Medical Centre, a doctor from Airport Health Department and two independent citizens be instituted to oversee and audit the proposal (Section B) described in this report. Similar arrangement be made for other cities where passengers arrive from other countries.

Naeem Sadiq