“The number of things that need to go right for an outbreak to be controlled is significant — a lot of working pieces are interdependent,” said Dr Armand Sprecher of Médecins Sans Frontières at the 63rd Annual American Society of Tropical Medicine and Hygiene Conference this November in New Orleans. The health promoters and the people in the treatment centers need good information from the epidemiologists — coordination is very important to make sure that all of those things work well.”
Dr. Sprecher has worked with MSF since 1997. He has been in the field during several Ebola or related filovirus-outbreaks and has been in and out of Guinea, Sierra Leone and Liberia three times during this current Ebola outbreak.
MSF started its operations in Guinea on the 18th of March 2014 in response to a request from the ministry of health to investigate some deaths in southeastern Guinea — and found an Ebola outbreak. When the outbreak spread to other regions, MSF deployed teams in those areas to respond to it.
“Years ago, when I started doing Ebola outbreaks a ten-bed unit would be normal, a forty-bed unit would be large. Currently we have about six hundred and fifty beds in these six locations across West Africa. We have 281 staff in the field right now, we’ve sent over 700 people into the field for this outbreak, and we’re currently employing over 3,000 national staff in these locations,” he said.
MSF’s Ebola Response Framework
MSF’s framework for an Ebola outbreak response attempts to divide the world into two places – the place where the virus is managed, and the place where there should be no virus. “Step one is to try to prevent the virus from going from where it is to where it isn’t,” said Dr Sprecher.
Finding the virus has typically involved setting up aggressive contact tracing and follow-up once cases have presented for care or been identified in the community. (Laboratory support for diagnostics is also necessary to determine who has and who does not have a case of Ebola virus disease (EVD) — though MSF has not run their own PCR testing in this outbreak).
Due to aggressive contact tracing, the spread of EVD has reportedly been halted in Nigeria and Senegal but in Liberia, Sierra Leone and Guinea, “the horse is out of the barn,” said Dr. Sprecher. “There are too many cases out there and too many contacts, and the contact tracing systems are overwhelmed. So we may have to get into community surveillance.”
Effective community surveillance requires performing epidemiologic investigations and in some settings, trained teams performing active case finding literally going from door-to-door. This will require a great effort to implement throughout the three countries but a couple districts have already reported significant success with this approach, such as Keneme District in Sierra Leone. In addition, one of Dr Sprecher’s MSF colleagues, Dr Amanda Tiffany, had been scheduled to give a presentation on community surveillance at the conference (but was unable to travel to New Orleans due to Louisiana’s Ebola travel ban)
When cases of suspected EVD are identified within the community, a safe ambulance service is sent out to collect and transport the patient to the nearest Ebola Management Unit where there are also strict infection prevention and control (IPC) measures to protect unconfirmed cases as well as all healthcare workers and other staff. In addition, decontamination teams are sent to the patient’s home to render the environment safe, and where people are found dead, the teams arrange for their safe burial.
At the same time, MSF team members engage in healthcare promotion to inform people how they can prevent from getting the disease and keep their families’ safe.
“They provide a lot of psychological support. One of the hardest things we have to do is to reintegrate our survivors back into the community and that requires a lot of work to convince the communities these people are welcome back and that they are safe to touch and have back at home,” said Dr. Sprecher.
In addition, realizing that having so much malaria in the area was complicating the response, during this outbreak, Dr. Sprecher said that colleagues from MSF Paris were distributing anti-malarials to hundreds of thousands of people in Monrovia and would be distributing insecticide-treated bednets,
“The idea here is to reduce the burden of mortality and morbidity linked to malaria itself – there’s not much in the way of primary healthcare going on in Monrovia right now which is a very large city. Also, the idea is to reduce just the burden of febrile illness that can present and be mistaken for Ebola to take a bit of the burden off of the treatment units and to prevent these people from going and seeking care from the informal health sector, which we’ve seen in past outbreaks can be a risk for Ebola transmission,” said Dr. Sprecher.
Also, in September, MSF began distributing family protection kits consisting of gloves, masks, gowns, chlorine, buckets and soap to help families protect themselves in case someone fell ill in the household.
These kits are going out to patient families, to the families of healthcare workers and Ministry of Health officials, to identified high-risk groups like taxi-drivers and to high-risk areas such as West Point and Clara Town in Monrovia.
“We’ve distributed about 47,000 of the planned 70,000 kits. UNICEF is going to do some as well so we should cover much of Monrovia if all goes well,” he said.
In addition, although not a clinical research organization, he said MSF would be providing the clinical space for research that could potentially lead to therapeutics that could save patients’ lives in the next outbreak.
“All of these efforts needs to be coordinated,” he said. But coordination is difficult when operating on so many fronts and with so many players, both with local human resources in country and from external groups.
MSF has had to deal with many challenges in this outbreak including fear of EVD among the population, the stigmatization of healthcare workers and restrictions placed upon their movements.
“The biggest challenge: for the first time we’ve had healthcare workers and our staff get sick and unfortunately die – we’ve had 23 people get sick, 13 of whom have died. And that weighs very, very heavily on the teams in the field,” he said.
The high case fatality rate, particularly among some segments of the population (Dr. Sprecher noted that mortality among pregnant women is near universal and mortality has been extremely high in the under-fives) has also made the work draining.
“The older children from five to fifteen do reasonably well though — they actually do better than the adults. Which is nice except that this outbreak has produced a lot of orphans,” he said.
And Dr. Sprecher said that there are clear signs that patient’s outcomes are improving.
“We’d like to bring the care up to the standards that we have had in the past outbreaks but the sheer scale of things has kept us from doing that. But we’re taking care of them and the case fatality ratio is on the slow steady decline, and this is consistent with what we see in the past outbreaks,” he said.
Declines in Monrovia
In addition, the outbreak appears to be slowing in some areas. For instance, the Ebola Management Center in Monrovia is the largest Ebola treatment unit or management center that has ever been built — it has 250 beds — and there had been plans to add more. But Dr Sprecher said that at the moment about half of the beds were empty.
“We don’t know if that represents a true decline in transmission within Liberia,” he said, noting that there was one theory that Liberians may be avoiding the Ebola Treatment Centers because they do not want their dead being cremated.
“We’ve learned the hard way the need to bring anthropologists to figure out all of the things that we’ve done wrong and how we can correct them to better target our health promotion, and, for instance, make sure that our burial practices do not run rough-shod over people’s traditions,” he said.
Because of the focus on scaling up, it is difficult to know for certain that the teams really have a handle on what is happening in the community. Dr Sprecher said that when the mathematical modelers projected there would be hundreds of thousands of Ebola cases, resources were diverted to more Ebola Management Centers and increased bed space — neglecting some of the basics.
“We have, to a certain extent, taken our eye off the ball and are not doing a lot of the things that in the past helped us contain these outbreaks. We are still not getting the bodies taken care of in a timely fashion, we are not able to investigate the cases like we should be doing, and health promotion has been lagging behind as it usually does,” he said.
Even so, the experience in previous outbreaks gives him hope the decline may be real.
“I think these outbreaks end because at some point the population gets it, they understand what needs to happen and do what they have to do to stop disease propagation,” he concluded.
Global Health Strategies generously supported Theo Smart’s attendance at the American Society of Tropical Medicine and Hygiene Conference in New Orleans.