ddsWith Ebola rarely away from the media headlines Dr Dave Sloggett looks at just how it might manifest itself in the United Kingdom:

With Government ministers and senior health officials seemingly resigned to the first case of Ebola appearing in the United Kingdom many organisations across the emergency services sector are dusting down their plans and looking at their preparedness to deal with a confirmed case.

The threat from Ebola is very real. The latest trends suggest that it will not be very long before over 10,000 cases have been identified. Because of the difficulties of obtaining real information on the ground in the countries where Ebola has gained a foothold this figure may be a dramatic underestimate of the real scale of the problem. One fact is clear however of those that have been reported the death rate is 70%. This is a very virulent disease.

Those that survive have somehow developed natural immunities to the virus. No doubt, with time, clues that can be derived from the DNA of the survivors will help the international pharmaceutical companies develop solutions to the Ebola virus. In the meantime solutions lie in rapid identification and isolation of anyone suspected of having the virus.

Developments outside West Africa, such as in the United States, where Ebola cases have quickly been identified and contained provide some cause for hope. They show that the spread of the virus can be limited with prompt action. This bodes well for any similar potential outbreak in the United Kingdom. But is that a real assessment? Could the threat from Ebola be actually worse than imagined? What set of circumstances might create an outbreak that is very difficult and would rapidly test our resilience?

All of the focus on the issue of the domestic threat from Ebola in the United Kingdom has focused on the entry of the disease through a major airport hub, such as Gatwick or Heathrow. With screening at these airports now started some have no doubt breathed a collective sigh of relief that anyone coming into the United Kingdom with Ebola will be recognised at our borders and rapidly confined.

However this specific focus on air travel as a means of conveying Ebola into the United Kingdom misses an altogether potentially far easier way in which it could arrive; by sea. The problem lies in the routes used by economic migrants through West Africa from places like Chad and Nigeria to reach Western Europe. The international smuggling networks involved in bringing cocaine in from South America and moving economic migrants from central Africa pass through these Ebola affected areas. The possibility that a number of economic migrants might pick up Ebola on their journey through Africa to the shores of the Mediterranean Sea seems to have been ignored.

Drawbacks of the current approach
One excuse for this is the incubation period of twenty-one days. Migrant journey’s through West Africa to places of embarkation for Western Europe such as the largely unguarded Libyan coastline can take more than three weeks. But if an infected person was held in close proximity to others on the journey some may develop the disease later on, even if the original carrier subsequently dies.

Given the uncertain security situation in Libya Ebola cases may go unreported. To date as far as open sources are concerned no signature of Ebola arriving in Libya has been detected. But that does not mean it could not already be in the country. Once the migrants have arrived in Libya it’s a question of waiting for the human traffickers to provide a boat to cross into Southern Europe.

While the Italian Navy is doing its best to stem the tide of economic migrants emerging from Libya and other parts of the North African coastline it cannot guarantee to stop all of the vessels. The demand from the migrants to reach what they see as a better life in Europe is do great. Already 63,000 have arrived in Western Europe this year alone. All it takes is for one of these to be infected, spend a short time in a highly confined space on board a boat with others and the basis for a major outbreak of Ebola is suddenly at hand. Couple this with a person wanting to stay off the radar horizon of the authorities once they reached their intended destination and the situation could rapidly unfold. Anyone that hides or protects that person would then be at risk of becoming infected.

This is a very different situation to the current ‘find and treat’ people approach that is being adopted at airports. These people would arrive by subterfuge and would be difficult to locate. The first sign might be an outbreak of the disease that initially spreads quite rapidly. Those sheltering the initial source of the virus may not realise what is going on when they complain of feeling unwell. This lack of immediate referral to medical authorities could create the situation where the disease is able to gain a foothold before the necessary measures can be put in place to help contain its spread. At this point the authorities would be on the back foot in reactive mode rather than being proactive. Public confidence in the approach would then be rapidly undermined.

Irrespective of the likelihood of such a pathway occurring in dusting off their plans it would be useful for the Emergency Services not to be lulled into a false sense of security over how Ebola might manifest itself in the United Kingdom. With thinking about resilience its best to spend a little bit of time out of the box no matter how fictional the scenario might on the surface appear to be.