The UK Imported Fever Service (IFS) plays a key role in managing unwell travelers returning from areas affected by disease outbreaks like the 2014 Ebola outbreak. The IFS provides 24/7 clinical and infection control advice, conducts diagnostic testing for viruses like Ebola, and assists with public health responses. During the 2014 Ebola outbreak, the IFS saw a large increase in calls and conducted over 70 virus screening tests, identifying one returned healthcare worker with Ebola. The IFS acts as a national surveillance system and point of contact for virus threats imported into the UK.

1. 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

2. 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

3. 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

4. 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 ServiceImported Fever Service

5. 5 Imported Fever Service

6. 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. 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. 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 – Oct2014
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. 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 – Oct2014
Tests carried out on 40% of VHF
risk-assessed cases

10. 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

11. 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

12. 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

13. 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 ServiceImported Fever Service13

14. 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