Outbreaks of infectious disease have immense potential for loss of life and livelihood, and can lead to fear, panic and irrational, unsafe behaviour amongst the public.
For these reasons, it is essential that all countries have structures in place to prevent, detect and respond to infectious diseases that have outbreak potential. South Africa has such structures in place. The Lujo outbreak in 2008 is a good example of how healthcare services worked together to detect, identify and contain a previously unknown virus imported from Lusaka, Zambia.
In September 2008 a resident of Lusaka was transferred for intensive medical care to a private health care facility in Johannesburg with a clinical diagnosis of tick bite fever. The patient died within 48 hours without a confirmed diagnosis.
Two weeks later, the paramedic who had accompanied the patient on the mercy flight became ill and was admitted to the same hospital with symptoms of a viral haemorrhagic fever. The connection between the two patients was recognised by the attending physician. As soon as viral haemorrhagic fever was suspected, contacts of the two patients were identified, and high-level infection prevention and control measures were implemented at the hospital.
Over the next few days, three people who had been in contact with the patients and who had developed symptoms were identified, admitted, isolated and provided with supportive care. The paramedic and two of the identified contacts subsequently died. A single patient survived following intensive care and treatment with an investigational drug. No further cases were identified, most likely due to the intensive adherence to infection prevention and control practices.
On suspicion of viral haemorrhagic fever, tests were conducted at the high-level biosafety containment laboratory at the National Institute for Communicable Diseases (NICD). This is an important national resource that has provided advanced diagnostics for high-consequence pathogens since 1980s. Initial tests for all known viral haemorrhagic fevers were negative, and only subsequently, the NICD together with the USA Centres for Disease Control identified a completely new pathogen – previously unknown globally. It was named ‘Lujo’ virus for Lusaka and Johannesburg.
These events around this outbreak, and many others of lesser consequence, illustrate the fundamental principles and successful application of interventions to detect, respond to and prevent further spread of dangerous pathogens. South Africa has maintained and is expanding our capacity to respond to disease outbreaks through multisectoral, transdisciplinary structures.
Key preventive strategies for communicable disease include a robust policy framework for financing and co-ordinating communicable disease responses, access to safe water, food safety, adherence to national vaccination schedules, antimicrobial custodianship to prevent the emergence of antimicrobial resistance and implementation of adequate biosafety and biosecurity measures.
Surveillance is essential to monitor trends in disease occurrence, monitor the impact of interventions such as vaccinations and early diagnosis and treatment, and to detect cases of disease not usually present in our country. Healthcare workers, the public sector, the NICD with the National Health Laboratory Service and private laboratories co-operate to conduct surveillance for communicable diseases. Surveillance data is collected through the notifiable medical conditions (NMC) surveillance system, laboratory-based surveillance (GERMS-SA), syndromic disease surveillance and disease-specific surveillance programmes such as the ‘viral watch’ programme for influenza.
Multisectoral outbreak response teams exist at every level of government in district, provincial and national departments of health. These teams facilitate co-ordination of role-players during outbreaks and include the private sector, health promotion, communications, pharmaceutical services, disease-specific programmes, immunisation services, emergency medical services, school health programmes, police and military, disaster medicine response, civil aviation, port health and veterinary public health.
The NICD is responsible for a ‘Public Health Emergency Operations Centre’ which is activated on declaration of a national or international public health event. Trained staff ensure that all aspects of emergency response including communications, disease surveillance, laboratory services, disease control interventions, human resources, logistics and financing are effectively co-ordinated to contain disease outbreaks and prevent further cases.
Ongoing development in South Africa in the field of outbreak detection, prevention and response is anticipated as our country refines its response structures in line with the requirements of the International Health Regulations (2005).
About the Experts
Prof Lucille Blumberg is the Deputy Director of Epidemiology and the founding head of the Division of Public Health Surveillance and Response. She is currently a medical consultant to the Division for Outbreak Preparedness and Response and is a medical consultant to the Centre for Emerging, Zoonotic and Parasitic Diseases where her major focus is on malaria, rabies and zoonotic diseases. She is a member of the South African Expert Advisory Groups as well as the advisory groups to the World Health Organization.
Dr Kerrigan McCarthy is the Head of the Division of Public Health, Surveillance and Response, where her responsibilities include oversight of the Outbreak Response Unit, Notifiable Medical Conditions and GERMS-SA surveillance. She is a clinical microbiologist who graduated with MBBCh and FCPath (Micro) from the University of the Witwatersrand.