Fighting Ebola: What It Takes to Stop an Outbreak

May 23, 2018

Washing hands. Taking and monitoring body temperatures. Quarantine. Ring vaccination method. Outbreak investigation. Finding Patient 0. Effective public health communication campaigns. Appropriate logistics. Effective and efficient data collection system. Accurate mapping. Thousands of people. Millions of dollars. These are just some of the practical requirements that can help contain an outbreak.

Right now, there is an Ebola outbreak in the northwest region of the Democratic Republic of Congo (DRC), with 30 probable or suspected cases, 28 confirmed and 27 people dead as of May 21. From 2014-15, an Ebola outbreak occurred in Guinea, Sierra Leone, Liberia and 7 other countries, claiming more than 11,000 lives.

An experimental vaccine, rVSV-ZEBOV, was used at the end of the 2014-2015 outbreak. This week, vaccinations began in Mbandaka, the capital of Équateur Province in DRC, a city of 1.2 million people nestled where the Congo and Riku Rivers meet, where a confirmed case of Ebola was detected on May 16. Almost 10,000 doses of the vaccine will arrive in DRC over the next couple of weeks in an attempt to contain this latest outbreak using the ring vaccination method.

“I’m of course excited that we are there—and, of course, it has taken too long,” Dr. Heinz Feldmann, the designer of the vaccine manufactured by Merck, told STAT News. Targeted use of the vaccine began Monday.

The Human Side of Ending an Ebola Outbreak

What often goes overlooked is one of the most important aspects of fighting an epidemic: working with the people who are suffering from the disease and are at risk of spreading it. No matter how much science, funding or instruction is funneled into an outbreak response, the affected populations need to understand, agree, collaborate and participate in the emergency response activities.

During a public health crisis, when time is of the essence, how do you build trust in people who have been misused for centuries by former colonists, personal interest-driven personalities, donors and companies?
The answer to that lies in a sustainable effective and efficient public health communication.

“First, you have to inform the community,” Koss Mensah says. “They probably won’t believe you, but you have to try. I remember one community asked us to vaccinate one of our staff members during the Ebola vaccine trial in Guinea. We did, and then they trusted and allowed us to conduct the activity in their community.”

The answer to that lies in a sustainable effective and efficient public health communication.

“First, you have to inform the community,” Koss Mensah says. “They probably won’t believe you, but you have to try. I remember one community asked us to vaccinate one of our staff members during the Ebola vaccine trial in Guinea. We did, and then they trusted and allowed us to conduct the activity in their community.”

Koss Mensah in Conakry, Guinea, in 2014Koss Mensah in Conakry, Guinea, in 2014.

Koss is a Senior Program Specialist at ASM. He actively participated in the 2014-2015 Global Ebola Emergency Response in West Africa.

“I wasn’t scared. I knew the risk,” Koss says. “I told my relatives and friends, ‘I am trained for this. If I don’t go and help, how can I call myself a public health worker?’ I speak French. I’m from West Africa. I have to be there. I strongly believe there needs to be a way to improve health communication. Also,” he grins, “I like taking risks.”

Koss has previous public health work experience in Togo, Mali and DRC. When the United Nations sought volunteers to help stop the Ebola epidemic in West Africa, Koss joined UNMEER.

“There is serious stigma and mistrust of health care workers in some of these countries,” says Ade Olarewaju, a Program Specialist at ASM. “During the last Ebola outbreak, there were reports in the news of health care workers—including foreign medical doctors and nurses—coming under attack by locals, who falsely blamed them for bringing the disease into their communities. Explaining the science of how infection spread to the local population in remote communities during an outbreak can be challenging. They just believed ‘someone went to the community health center with mild symptoms and fell ill after the visit.’”

In the 2014 epidemic, armed men attacked a clinic in Liberia because they didn’t want an Ebola facility in their community. Some people took supplies home, thus putting their community at risk of infection. In Guinea, a taxi transporting blood samples believed to be infected by Ebola virus was robbed, and the perpetrators took away the sealed container.

There were reported cases of some communities burying their dead at night to avoid having to follow the national quarantine protocols. Caring for sick loved ones and bathing and touching the bodies of family members who have died is ingrained in many African cultures. There were also instances of underreporting cases and death numbers so that business was not affected.

Breaking through cultural beliefs remains one of the toughest agenda items.” I remember some well-known personalities avoiding disease prevention protocols during the 2014 outbreak,” Koss says. “Anyone who came into an affected locality, we had them wash their hands and take their temperature. These individuals set bad examples through their refusal to abide by the rules.”

The Clinical Side of Ending an Ebola Outbreak

Infectious disease epidemics require good scientific and medical application. You need safe, accurate labs. You need prevention and cures. You need rapid, high-tech solutions and proper diagnoses, followed by successful courses of treatment.

How do you reach this level of quality care in resource-limited countries that lack safety regulations, funding, trained health care workers and reliable infrastructures like regularly tested water and electricity? You have to train the health care staff. Building capacity includes supplies, equipment, vaccination of the staff and education.

ASM collaborates with the U.S. Centers for Disease Control and Prevention in multiple countries to create national surveillance systems to combat outbreaks. Together, we deliver mentorship and training to laboratory professionals, which helps them build capacity to diagnose infectious diseases, especially HIV/AIDS and sexually transmitted and opportunistic infections in the HIV-affected population. ASM also supports implementation of national biosafety and biosecurity programs through training and procurement. This is crucial, because health care workers are front-line providers/ responders during outbreak, they are the most vulnerable. Once trained, laboratory staff in turn pass down their knowledge and techniques of safe lab practices and accurate, improved diagnostics to other lab technicians.

Ade1Ade Olarewaju in DRC in 2018.

Ade previously specialized in food safety in Nigeria and England, and worked on HIV community awareness and infection control training programs in Nigeria before joining ASM. She currently supports the ASM President's Emergency Plan For AIDS Relief (PEPFAR) early infant diagnosis/viral load scale-up plan in DRC.

“ASM does a lot of capacity-building work for lab techs and professionals,” Ade says. “We deliver targeted technical and quality-focused training and mentorship to local laboratory professionals and staff of selected national reference laboratories to build capacity to test and diagnose. Our expert consultants use the ASM training packages that include the ASM Microbiology Mentorship Package and other ISO-approved training materials for on-site mentoring activities and remote follow-up to ensure that action plans developed during the visits are completed. We conduct trainings to improve routines and  quality testing practices in the lab.”
Health care workers are taught infection prevention measures, so that they do not infect themselves while working with pathogens in the lab.

“We ensure that they learn the importance of using personal protective equipment, and we procure essential supplies and equipment to support these labs. Training is across the board for any outbreak—Ebola, tuberculosis, malaria, and syphilis. Our trainings are not pathogen-specific,” Ade adds.

The Reality of Combating an Ebola Outbreak

What’s a day in the life of an Ebola fighter like? 

When Koss got to Guinea, the Ebola epidemic was widespread. Hotels and restaurants were closed. Many businesses and public transport were shut down.

Fighting an Ebola outbreak is a race against time, since the virus has a 2- to 21-day (0-3 week) incubation window and up to a 90% fatality rate. When you find patient 0, you can define the starting point of  the epidemic. “We were chasing the disease,” Koss says. “Outbreak investigations work both ways. A team starts working backward to find the source, and we have another team working forward to stop it.”

Koss2Koss Mensah (R) and his former colleague Yagoub Maragan at the UNMEER HQ in Accra, Ghana, in 2015.

“You wake up in the morning, have coordination meetings with all the agencies and implementing partners on the ground and discuss the plan for the day,” he remembers. “Your action plan could include sending a Red Cross team to conduct safe burials of dead people. You would need security to keep the families from touching the bodies of their loved ones. You deploy contact tracing and public health communication teams to talk with people in the affected communities. Then you come back in the evening and report back. When an implementation partner needs anything, you have to find a way to provide, from food and medical supplies to airlifts.”

Circling back to the capacity of these countries, Ade focuses on the health care workers.

“When there is a reported outbreak, I’m worrying about that health care worker who just went in to work one day, and then received a blood sample or a patient who turned out to be Ebola virus positive,” says Ade. “I’m thinking, ‘Was the specimen collected safely? Did the health workers have and use their personal protective equipment? Are they trained to deal with situations like this? It’s painful, because too often the answer is no.”

“How many health care workers have paid the price with their lives?” Ade asks. “So many health care workers died last time. In Nigeria, a lead consultant and endocrinologist who contracted the Ebola virus from the first recorded Ebola patient in the country, died in the process. She is one of the numerous health care workers that died during the 2014- 2015 outbreak. Her foresight and knowledge of the disease helped stem the outbreak in Nigeria. This is one of the numerous, fearless health care workers; her action saved thousands of people.”

Finding Solutions to Stop a Spreading Disease

Having an effective response is key. That many-faceted response takes health education, training and procurement of equipment and supplies. It means being ready. 

Community outreach. Rapid response. The latest in medical treatment and scientific application poised to be applied in environments that can handle them.

“Can we improve preparedness for the next disease outbreak coming?  Can we improve disease surveillance to stop the spread of infectious diseases?,” Ade asks. “Sure we can, with continued appropriate support. This could be stopped now.”

The trusted partnership between communities, governments, community mobilizers, local leaders, public health institutions and local and international agencies to ensure effective, efficient and well-coordinated interventions is the ultimate solution for ending an epidemic.
“There will always be outbreaks,” Koss says. “How we are prepared for it and our response strategy will make all the difference.”

Read ASM’s 2018 Global Impact Report and keep up with our exhibit Outbreak, which launches at the Smithsonian next year in Washington, D.C.

Koss Mensah was born in Togo and majored in Statistics at the University of Ghana, Legon, and then earned his M.P.H. at George Mason University in Fairfax, Va., U.S.

Ade Olarewaju was born in Nigeria and earned her B.Sc. in Microbiology from the Federal University of Agriculture Abeokuta (UNAAB) in Nigeria. She earned her M.Sc. in Environmental Health from the University of the West of England in Bristol-UK.

Author: Courtney Reyers

Courtney Reyers
Courtney Reyers is the Senior Manager of Digital Strategy at ASM. She presented on ASM's taxonomy build at ASAE's Tech Conference as well as CESSE Pasadena in 2018.