**Managing Ebola in Low-resource Settings: Experiences from Uganda**

#### Samuel Okware

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/63056

#### **Abstract**

Five outbreaks of Ebola virus disease of the Sudan Ebola virus and the Bundibugyo Ebola virus occurred in Uganda from 2000 to 2012. The attack rates and the case fatality rates were much higher for the former than the later. Fever and bleeding manifesta‐ tions associated with the clustering of cases were typical clinical features. Close contact with infected person was probably the major route of spread. Apparent asymptomat‐ ic and atypical Ebola infection was demonstrated in some close contacts, suggesting past unrecognised exposure or cross-reacting antibodies. A zoonotic connection was apparent in monkeys and asymptomatic villagers. The Ministry of Health together with its partners contained the outbreaks, sometimes with delays, but at least once prompt‐ ly. Early detection and communication yielded the best ideal outcomes. A communitybased response ensured timely case search and contact tracing for the isolation and management of patients. The syndrome-based EVD case definition and the laboratory screening tests for Ebola were used to detect cases. However, their unknown specifici‐ ty and sensitivity and their low positive predictive values were a major weakness in the screening process. Validation of the criteria and the tests at the local level was essential. There were gaps in isolation procedures as 64% of the health care workers were infected after the isolation units were established. Palliative treatment was an important part of management as it improved survival and public confidence. Therefore, survival and not just quarantine must be emphasized and be a critical component of EVD manage‐ ment. Substantial investment in human resource for health is needed to attract, reward, retain and compensate health workers. Collaboration and partnerships at national and international level is vital in building health systems for early surveillance and management of emerging infections. The Uganda experience provides opportunities for further research on some of these strategies that could improve the management and control of Ebola in low resource countries.

**Keywords:** Ebola, outbreaks, detection, management, resources

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **1. Introduction**

#### **1.1. Ebola Virus Disease (EVD)**

Five outbreaks of EVD occurred in Uganda between 2000 and 2012 [1–4]. In this paper, we describe our experience, challenges and opportunities that existed during the Ebola out‐ breaks in Uganda. The Gulu outbreak in 2000 was the largest and most complex occurrence in the midst of an insurgency and severely deteriorated social services [5]. The first reported outbreak of EVD was identified in 1976, in theDR Congo, on the border of Sudan [6]. Since then, there have been 26 outbreaks in Equatorial Africa occurring in DR Congo, Gabon, Sudan and Uganda. The majority of these outbreaks were minor. The most serious outbreak occurred in West Africa in 2014 causing some 23,000 cases and 11,000 deaths in Liberia, Guinea and Sierra Leone [7]. Of the five known species (EBOV, SUDV, RESTV, TAFV, BDBV) only three are associated with disease. The *Zaire ebolavirus* has the highest case fatality (90%) while the *Sudan ebolavirus* is medium at 50–55% [8]. The *case fatality for the Bundibugyo ebolavirus* is low at 34%. There is no known cure yet for the disease. Ebola symptoms mimic several common diseases in the tropics including malaria.

Lymphoid tissue such as the liver, spleen, and thymus are critical targets which are often severely damaged leading to liver necrosis, bleeding manifestations and shock. Organ damage leads to a series of metabolic dysfunctions which maintain blood pressure homeostasis [9, 10]. Fruit bats are potential reservoirs of the *Zaire ebolavirus* through direct contact with freshly killed bats or when ingested as food [11]. Asymptomatic infection of between 4– 15% among the pygmies in Gabon and DR Congo [12] has been demonstrated suggesting some previous exposure to Ebola or cross-reacting strains Ebola has been isolated from seminal fluids 61 days after onset of illness [13]. This may be a potential source of infection in large outbreaks in low resource settings. Direct contact with body fluids of an infected person (dead or alive) via broken skin or mucosal surfaces is probably the most important route of infection [14]. The intramuscular route is perceived to be more effective [14]. In poor healthcare settings, conta‐ minated needles and syringes are likely sources of infection. Re-use of needles, for instance, played a key role in escalating the epidemics in Sudan and DR Congo in 1976 [15].

#### **1.2. Ebola outbreaks in Uganda 2000–2012**

In 2000, some 425 cases and 224 deaths occurred in Gulu district and 31 health care workers were infected. The affected village was Rwot Obillo, 14 km north of Gulu towards the border with South Sudan. The local community was inaccessible because of on-going military operations against insurgency in the area. On the 8th of October, 2000, three student nurses died in Lacor hospital [1]. On the 12th of October the Sudan Ebola virus was confirmed among the blood samples taken. Nearly 2 million people most of whom lived in camps were at risk in the region [16]. Rural residents commuted to Gulu town for fear of Ebola and abduction from LRA rebels. Two patients in Gulu escaped to Masindi and Mbarara districts, but were followed, isolated and contained. The outbreak lasted 6 months.

Managing Ebola in Low-resource Settings: Experiences from Uganda http://dx.doi.org/10.5772/63056 5

**Figure 1.** Outbreaks of Ebola in Uganda by district, 2000–2012. Source: Adapted from Ebola outbreak reports 2000-2012; WHO Health Mapper Mapping software, version 4.2

Four more Ebola outbreaks caused by Sudan Ebola virus occurred with increasing frequency in 2011 and 2012 [3, 4]. The primary cases were from rural areas. In 2007, the Bundibugyo Ebola virus caused the second outbreak [17]. Major transmission of the early cases was associated with patient care and burial rituals [2]. The diagnosis was delayed but once detected it took just 3 weeks to contain the outbreak [18]. Serious action was launched and isolation established. Community mobilisation and action contained the outbreak. Some 116 cases and 39 deaths were confirmed, and 14 health care workers were among the victims. Unlike in the Gulu outbreak, the health care workers contracted infection before the isolation units were estab‐ lished.

#### *1.2.1. Luwero outbreaks: 2011, 2012*

**1. Introduction**

4 Ebola

**1.1. Ebola Virus Disease (EVD)**

the tropics including malaria.

**1.2. Ebola outbreaks in Uganda 2000–2012**

Five outbreaks of EVD occurred in Uganda between 2000 and 2012 [1–4]. In this paper, we describe our experience, challenges and opportunities that existed during the Ebola out‐ breaks in Uganda. The Gulu outbreak in 2000 was the largest and most complex occurrence in the midst of an insurgency and severely deteriorated social services [5]. The first reported outbreak of EVD was identified in 1976, in theDR Congo, on the border of Sudan [6]. Since then, there have been 26 outbreaks in Equatorial Africa occurring in DR Congo, Gabon, Sudan and Uganda. The majority of these outbreaks were minor. The most serious outbreak occurred in West Africa in 2014 causing some 23,000 cases and 11,000 deaths in Liberia, Guinea and Sierra Leone [7]. Of the five known species (EBOV, SUDV, RESTV, TAFV, BDBV) only three are associated with disease. The *Zaire ebolavirus* has the highest case fatality (90%) while the *Sudan ebolavirus* is medium at 50–55% [8]. The *case fatality for the Bundibugyo ebolavirus* is low at 34%. There is no known cure yet for the disease. Ebola symptoms mimic several common diseases in

Lymphoid tissue such as the liver, spleen, and thymus are critical targets which are often severely damaged leading to liver necrosis, bleeding manifestations and shock. Organ damage leads to a series of metabolic dysfunctions which maintain blood pressure homeostasis [9, 10]. Fruit bats are potential reservoirs of the *Zaire ebolavirus* through direct contact with freshly killed bats or when ingested as food [11]. Asymptomatic infection of between 4– 15% among the pygmies in Gabon and DR Congo [12] has been demonstrated suggesting some previous exposure to Ebola or cross-reacting strains Ebola has been isolated from seminal fluids 61 days after onset of illness [13]. This may be a potential source of infection in large outbreaks in low resource settings. Direct contact with body fluids of an infected person (dead or alive) via broken skin or mucosal surfaces is probably the most important route of infection [14]. The intramuscular route is perceived to be more effective [14]. In poor healthcare settings, conta‐ minated needles and syringes are likely sources of infection. Re-use of needles, for instance,

played a key role in escalating the epidemics in Sudan and DR Congo in 1976 [15].

followed, isolated and contained. The outbreak lasted 6 months.

In 2000, some 425 cases and 224 deaths occurred in Gulu district and 31 health care workers were infected. The affected village was Rwot Obillo, 14 km north of Gulu towards the border with South Sudan. The local community was inaccessible because of on-going military operations against insurgency in the area. On the 8th of October, 2000, three student nurses died in Lacor hospital [1]. On the 12th of October the Sudan Ebola virus was confirmed among the blood samples taken. Nearly 2 million people most of whom lived in camps were at risk in the region [16]. Rural residents commuted to Gulu town for fear of Ebola and abduction from LRA rebels. Two patients in Gulu escaped to Masindi and Mbarara districts, but were

More outbreaks occurred in Luwero in 2011 and 2012. Early detection was key in limiting the Luwero 2011 outbreak to a single case [3]. On the 5th of May, a 13-year-old girl was admitted to Bombo hospital with a history of fever, diarrhea and vomiting. She was isolated and her blood was investigated. She developed vaginal bleeding and deteriorated and died the following day. The Sudan Ebola subtype was detected and confirmed. The results were communicated quickly to the community on the media and by house to house messages by word of mouth. Contacts were followed up by the community. No new case was discovered or reported. This is the ideal desirable scenario for Ebola containment. In December 2012, hardly six months after the Kibaale outbreak, a second Ebola outbreak resurfaced in Luwero district [4]. The outbreak was confirmed within days and contained in 6 weeks leaving 7 cases with 4 deaths.

#### *1.2.2. Kibaale outbreak, 2012*

Earlier in July 2012, an Ebola outbreak occurred in the district of Kibaale [4]. The index case was a 16-year-old female from a remote rural community. She fell sick while preparing forest land with her husband for planting season. On admission, she complained of fever, diarrhea and vomiting. She developed a nose bleed just before she died. Nine relatives who participated at the funeral died including a mother, and several sisters who contracted the infection died. A priest who led the burial ceremony also died. One health care worker who attended to her also died. Community action followed up 408 contacts during which some 24 cases and 17 deaths were confirmed. The outbreak was contained in six weeks.

**Figure 2.** Clustering of Ebola cases by week, Bundibugyo, 2007–2008.

#### **1.3. Clinical manifestations of cases**

Cases were identified using an adapted WHO syndrome based criteria for "suspect", "prob‐ able" and "confirmed" cases. Clustering of cases (**Figure 2**) associated with sudden onset of fever particularly among health care givers is highly suspicious. The most common symptoms were fever, headache, anorexia and diarrhea. However, in a few cases (15%) no fever was observed in patients on admission. This observation and unsuspected source of infection poses [5] a potential danger to health care givers. Bleeding tendencies occurred in about 50% of the cases of SUDV, but less than 30% in the BDBGV outbreaks. The diagnosis was often compli‐ cated by the several locally endemic febrile conditions which mimicked Ebola such as malaria which accounts for up to 50% of cases at the outpatient clinics Uganda.

#### **1.4. Risk factors**

district [4]. The outbreak was confirmed within days and contained in 6 weeks leaving 7 cases

Earlier in July 2012, an Ebola outbreak occurred in the district of Kibaale [4]. The index case was a 16-year-old female from a remote rural community. She fell sick while preparing forest land with her husband for planting season. On admission, she complained of fever, diarrhea and vomiting. She developed a nose bleed just before she died. Nine relatives who participated at the funeral died including a mother, and several sisters who contracted the infection died. A priest who led the burial ceremony also died. One health care worker who attended to her also died. Community action followed up 408 contacts during which some 24 cases and 17

Cases were identified using an adapted WHO syndrome based criteria for "suspect", "prob‐ able" and "confirmed" cases. Clustering of cases (**Figure 2**) associated with sudden onset of fever particularly among health care givers is highly suspicious. The most common symptoms were fever, headache, anorexia and diarrhea. However, in a few cases (15%) no fever was observed in patients on admission. This observation and unsuspected source of infection poses [5] a potential danger to health care givers. Bleeding tendencies occurred in about 50% of the cases of SUDV, but less than 30% in the BDBGV outbreaks. The diagnosis was often compli‐

deaths were confirmed. The outbreak was contained in six weeks.

**Figure 2.** Clustering of Ebola cases by week, Bundibugyo, 2007–2008.

**1.3. Clinical manifestations of cases**

with 4 deaths.

6 Ebola

*1.2.2. Kibaale outbreak, 2012*

Some significant observations were made on risk factors. The outbreaks occurred between June and December coinciding with the rainy season, during which fields are prepared for planting. It was also a fruit season. Known primary cases occurred in the rural areas. Access to fruits partially eaten by non-human primates was common during the season and may have been a potential source of infection.

**Figure 3.** Attack rates per 10,000 inhabitants by gender and age, Gulu district, Uganda, 2000.

Age and gender were associated with infection in Gulu district. There was a 16-fold risk increase with increasing age between children and the elderly and was highest at 60–64 years age group. The attack rates among children between 5–14 years were the lowest (**Figure 3**). In Gulu district, the high risk in elderly women is associated with their role in cleansing and preparing the dead before burial [19]. In Bundibugyo too, participation in some ritual cere‐ monies was associated with a 7-fold increase in risk [2]. Contact with a known case carried between four to sevenfold increases in risk. Visiting a hospital or a hospitalized patient was associated with a ninefold increase in risk. The possibility of a zoonotic connection or cross reacting local strains was observed as some SUDV Ig G antibodies were confirmed in the monkey carcasses and a few asymptomatic local residents [1].



**Table 1.** Ebola cases by year and district, Uganda, 2000–2012

#### **2. The national response**

The national response was multisectoral and led by the President who directed all sectors to get mobilised and participate. The Ebola national task force in the Ministry of Health led the implementation of the strategic work plans. The task force reported to the Office of the Prime Minister, the leader of government business. Working groups were set up in the following areas: planning and coordination, surveillance and laboratory service, public education, case management, and logistics management (**Figure 4**).

**Figure 4.** Organization of the national response.

One national joint plan was developed to which the various collaborators subscribed both at national and international level. International support including expertise was integrated into the national plan endorsed by national and international stakeholders including bilateral development partners.

A syndrome-based case definition was adapted from the WHO1 guidelines and used for community-based active case search. A flow chart (**Figure 5**) integrated and harmonized the participation of the various actors. Community mobilization focused on public education and active case search by the community optimized through media. Full participation of church leaders, school principals and local political leadership and mobile teams was the cornerstone of community effort. Isolation and triage units were set up in district hospitals. Health care workers were recruited and paid risk allowances to boost motivation and dedication. Workers with previous experience and institutional memory were preferred and redeployed. Daily report updates and press briefings were openly communicated to the public at all levels. Similar arrangements were set up at the district, county, sub county, parish and village levels (**Figure 4**).

**Figure 5.** Flow chart for community based surveillance.

A cascade of training starting with training of trainers countrywide was carried out within days. Each village appointed a village health team led by a chairman and secretary (scout) to coordinate the implementation. At district level, a district task force coordinated the response. Incentives were paid to them for each Ebola case reported and revalidated. Burial and safe disposal of the dead was coordinated by a district burial coordinator who liaised with the hospital coordinator and the village health teams. Trained burial teams with past experience were recruited, retrained and liaised with the village scout to ensure safe and timely burials. On discharge, the patients went through a series of stringent protocols and check lists con‐ ducted by trained counsellors. Post Ebola clinics and clubs were set up for follow up of health and social outcomes.

**Year District Cases detected Deaths CFR Totala 425b 224 52.7%** 2007 Bundibugyo 116c 39 34 % 2011 Luwero 1 1 100% 2012, Jun-Aug Kibaale 24d 17 70% 2012, Nov-Dec Luwero 7 4 57%

The national response was multisectoral and led by the President who directed all sectors to get mobilised and participate. The Ebola national task force in the Ministry of Health led the implementation of the strategic work plans. The task force reported to the Office of the Prime Minister, the leader of government business. Working groups were set up in the following areas: planning and coordination, surveillance and laboratory service, public education, case

One national joint plan was developed to which the various collaborators subscribed both at national and international level. International support including expertise was integrated into the national plan endorsed by national and international stakeholders including bilateral

Source: Ebola situation analysis reports 2000-2012

**2. The national response**

8 Ebola

**Table 1.** Ebola cases by year and district, Uganda, 2000–2012

management, and logistics management (**Figure 4**).

**Figure 4.** Organization of the national response.

development partners.

<sup>1</sup> Adapted from the WHO (2003)

#### **3. Examples of best practice**

#### **3.1 Successful community action**

There were some examples when timely community action effectively stopped the spread of these Ebola outbreaks. The best examples were demonstrated in Masindi district (2000) and the Luwero district (2011). A known case escaped from Gulu hospital to her ancestral home in Masindi district because her nurse died. The patient belonged to an extended family of 73 members residing in the district. The local community imposed quarantine on the members of the extended family. Transmission was prevented beyond the extended family - of the 27 new cases in the district 25 were from the extended family and only one case came from the general population (**Figure 6**). Thus, transmission beyond the extended family of the index case was effectively prevented by early detection and action and quarantine imposed by the community [20].

**Figure 6.** Community based Ebola containment of Ebola in Masindi district, Uganda, 2000.

#### **3.2 Early detection and action**

The Luwero outbreak of 2011 demonstrated the critical role of early detection and action in containing the outbreaks [3]. The single case outbreak was contained within one week. This excellent outcome occurred when a case was promptly diagnosed and confirmed to have Ebola. She was immediately isolated and the community was mobilized to start the public response including education, active contact tracing and isolation. This is the most desirable outcome as demonstrated by the critical timelines in **Figure 7**. The need for early diagnosis and action cannot be overemphasized.

**Figure 7.** Early Ebola detection and containment, Luwero district, Uganda, 2011.

#### **4. Challenges**

**3. Examples of best practice**

**3.1 Successful community action**

community [20].

10 Ebola

There were some examples when timely community action effectively stopped the spread of these Ebola outbreaks. The best examples were demonstrated in Masindi district (2000) and the Luwero district (2011). A known case escaped from Gulu hospital to her ancestral home in Masindi district because her nurse died. The patient belonged to an extended family of 73 members residing in the district. The local community imposed quarantine on the members of the extended family. Transmission was prevented beyond the extended family - of the 27 new cases in the district 25 were from the extended family and only one case came from the general population (**Figure 6**). Thus, transmission beyond the extended family of the index case was effectively prevented by early detection and action and quarantine imposed by the

**Figure 6.** Community based Ebola containment of Ebola in Masindi district, Uganda, 2000.

The Luwero outbreak of 2011 demonstrated the critical role of early detection and action in containing the outbreaks [3]. The single case outbreak was contained within one week. This

**3.2 Early detection and action**

#### **4.1 Delayed action**

Delays in early detection prolonged the spread of infection and late action. The respective districts experienced the following delays: in the districts of Gulu district (6 weeks delay); Bundibugyo (6 months); Kibaale (6 weeks). Most (75%) of the delays were at community level. Once the diagnosis was made, it took between 5 and 17 days to contain the outbreaks in Luwero and Kibaale respectively: only 5 days in Luwero; some 17 days in Kibaale. The corresponding figure for the Gulu epidemic was longer (91 days). It also took 41 days to contain the Bundi‐ bugyo outbreak. Thus late detection facilitated the extensive spread of the infection in both instances.


**Table 2.** Timelines from onset of illness to containment by district, Uganda, 2000–2012.


**Table 3.** Positive predictive value by case definition by district, Uganda.

#### **4.2 Validity of case definition**

**District Gulu, 2007 Bundibugyo, 2007 Kibaale, 2012 Luwero, 2012**

Date Days

since onset

19/09/2000 0 07/08/2007 0 12/6/2012 0 13/10/12 0

9/10/2000 20 27/09//2007 51 12/07/2012 30 7/11/2012 24

12/10/2000 23 29/09/2007 53 13/07/2012 31 8/11/2012 25

14/10/2000 25 28/11/2007 60 27/07/2012 45 12/11/2012 29

15/10/2000 26 29/11/2007 61 28/07/2012 46 13/11/2012 30

**117 101 63 34**

91 41 17 5

**Regarded by supervisors as non-cases**

**Positive predictive value (%)**

Last case 14/01/2001 91 08/01/2008 71 14/08/2012 63 17/11/2012 34

**Revalidated by supervisors as cases**

Gulu 1069 536 533 50.1 Bundibugyo 192 116 76 60.4 Kibaale 115 24 91 20.8 Luwero 36 7 29 19.4

Date Days

since onset Date Days

since onset

since onset

Time Date Days

Onset of strange disease in community

12 Ebola

Report to Ministry Health

Investigation: Blood sampled

Declaration national action

**Total days epidemic lasted**

From laboratory confirmation to last case

Source: Ebola situation analysis reports 2000-2012

**mobile teams**

**District Identified by**

\*. Reclassified later to 425 cases only.

**Table 2.** Timelines from onset of illness to containment by district, Uganda, 2000–2012.

**Table 3.** Positive predictive value by case definition by district, Uganda.

Blood confirmation Ebola

There were weaknesses in the application of the clinical syndrome case definition. The sensitivity and specificity of the definition were not known. The positive predictive value of the criteria used was low (Table 3). Some atypical Ebola cases presented without fever or bleeding. Fever was absent in 15% of cases while bleeding tendencies were observed only in 30-53% of admissions in Gulu. The validity of the case definition too was not known at local level. The positive predictive value of the case definition was low. Reassessment by supervisors validated less than half as true cases. Table 3 shows the low positive predictive values in the districts of Luwero (19.4%), Kibaale (20.8%), Bundibugyo (60.4%) and Gulu (50.1%).

#### **4.3 Laboratory -challenges in reliability**

Laboratory tests helped in the management of admissions and their discharge. Simple tests were used to detect and confirm Ebola: PCR, antigen detection, and immunoglobulin 1g M, and very rarely virus isolation. Surprisingly, less than 50% of the "suspected" and "probable" cases yielded positive laboratory results. Only half of the suspected and probable cases yielded positive laboratory results (Table 4). This low positive predictive value for the laboratory tests is a major weakness and delayed early diagnosis and action. The sensitivity and specificity and positive predictive values of the tests were also not known. The local validation of these tests is therefore essential. It is therefore critical to build laboratory capacity and skills at the national level to support outbreak management as well as conduct serosurveys in the popu‐ lation.


**Table 4.** Proportion of positive laboratory results of suspected Ebola cases by district, 2000–2012.

#### **5 Case management: challenges and opportunities**

#### **5.1 Infection control and barrier nursing**

Despite availability of personal protective materials, gaps remained in the practice of barrier nursing. These gaps were more pronounced among support staff especially drivers, cleaners and attendants. In Gulu, nosocomial infection persisted as 64% of the 31 health care workers got infected after the measures were put in place. Of the 6 health care workers infected in Masindi, five got infected after barrier nursing was instituted. In contrast, the infections among staff occurred before isolation units were established in Bundibugyo. Overcrowding and inadequate staff and supplies was a common feature in the isolation wards. Proper and timely use of protective materials was sometimes not followed especially when the patients were relatives. Procedures for washing and cleansing of ambulances were often taken lightly as gadgets such as cell phones were sometimes used indiscriminately. There was complacency in the general wards. A false sense of security could have been created by establishment of isolation units hence the need to train all workers in infection control. The surgical and maternity wards in particular were a major source of new inadvertent infections. Regular drills and training are essential within healthcare settings. It must also be extended to all other support staff including administrators, drivers and relatives providing bed side nursing.

#### **5.2 Human resource and financing challenges**

Caring for Ebola is a labor intensive and costly undertaking. For instance, the estimated direct costs of treating an Ebola case in the most affected countries in West Africa (Guinea, Sierra Leone and Liberia) ranged from USD 500 to 900 for those surviving and much more for the non survivors [21]. In the USA the costs of caring for one such patient was about USD 350,000 per week [22]. In Uganda, the government budget allocation for the health sector is USD 28 per capita. Therefore external support was mobilized and funds had to be diverted from the primary health care programmes in order to mount the national response. Human resources for health too are a major constraint in health delivery in Africa. Unlike developed countries, Uganda has a doctor: population ratio of 1:25,000 and the corresponding figure for nurses is 1:4000. Low salaries and lack of motivation continue to undermine performance. Poor motivation and low salaries did not attract health care workers into the isolation units leave alone the health facility. Risk allowances were introduced and this incentive provided the much needed motivation and improved performance in the isolation units. The availability of personal protective materials maintained staff confidence and commitment in the isolation wards. This demonstrated that the workers if adequately compensated can improve perform‐ ance. Thus workers when well-paid and motivated can perform beyond expectations. Com‐ pensation was provided for the health care workers who died in the line of duty, but not for the other non-medical victims. A social health insurance scheme should be considered for future outbreaks.

#### **5.3 Improving Survivalsurvival**

Differences in severity and survival were demonstrated between the two Ebola subtypes. Unlike in the Gulu outbreak, the later did not spread to other districts. The attack rates and the case fatality rates were higher in Sudan subtype (Table 5). The *c*ase fatality rate was higher (53.1%), in the Gulu outbreak compared with that in Bundibugyo (34%). The attack rates were also lower for the Bundibugyo virus than that in Gulu, p=0.001. However, the observed outcomes in severity and survival may also have been associated to differences on condition on admission, bleeding manifestation, and possible antigenic differences. It was also observed that death was more associated with bleeding tendencies and vomiting, p= < 0.001. The long term effects on survivors showed increased risk of chronic health outcomes after recovery. Of the 70 survivors followed for 2 years in Bundibugyo, 14% had blurred vision, 28% had retroorbital pain, and 23% had hearing loss. Difficulty in swallowing, muscle pain and memory loss was also reported [23]. Also, the Gulu Ebola survivors were unable to resume work one year post recovery [24].


**Table 5.** Attack rates and case fatality by district, 2000–2007.

and attendants. In Gulu, nosocomial infection persisted as 64% of the 31 health care workers got infected after the measures were put in place. Of the 6 health care workers infected in Masindi, five got infected after barrier nursing was instituted. In contrast, the infections among staff occurred before isolation units were established in Bundibugyo. Overcrowding and inadequate staff and supplies was a common feature in the isolation wards. Proper and timely use of protective materials was sometimes not followed especially when the patients were relatives. Procedures for washing and cleansing of ambulances were often taken lightly as gadgets such as cell phones were sometimes used indiscriminately. There was complacency in the general wards. A false sense of security could have been created by establishment of isolation units hence the need to train all workers in infection control. The surgical and maternity wards in particular were a major source of new inadvertent infections. Regular drills and training are essential within healthcare settings. It must also be extended to all other support staff including administrators, drivers and relatives providing bed side nursing.

Caring for Ebola is a labor intensive and costly undertaking. For instance, the estimated direct costs of treating an Ebola case in the most affected countries in West Africa (Guinea, Sierra Leone and Liberia) ranged from USD 500 to 900 for those surviving and much more for the non survivors [21]. In the USA the costs of caring for one such patient was about USD 350,000 per week [22]. In Uganda, the government budget allocation for the health sector is USD 28 per capita. Therefore external support was mobilized and funds had to be diverted from the primary health care programmes in order to mount the national response. Human resources for health too are a major constraint in health delivery in Africa. Unlike developed countries, Uganda has a doctor: population ratio of 1:25,000 and the corresponding figure for nurses is 1:4000. Low salaries and lack of motivation continue to undermine performance. Poor motivation and low salaries did not attract health care workers into the isolation units leave alone the health facility. Risk allowances were introduced and this incentive provided the much needed motivation and improved performance in the isolation units. The availability of personal protective materials maintained staff confidence and commitment in the isolation wards. This demonstrated that the workers if adequately compensated can improve perform‐ ance. Thus workers when well-paid and motivated can perform beyond expectations. Com‐ pensation was provided for the health care workers who died in the line of duty, but not for the other non-medical victims. A social health insurance scheme should be considered for

Differences in severity and survival were demonstrated between the two Ebola subtypes. Unlike in the Gulu outbreak, the later did not spread to other districts. The attack rates and the case fatality rates were higher in Sudan subtype (Table 5). The *c*ase fatality rate was higher (53.1%), in the Gulu outbreak compared with that in Bundibugyo (34%). The attack rates were also lower for the Bundibugyo virus than that in Gulu, p=0.001. However, the observed outcomes in severity and survival may also have been associated to differences on condition

**5.2 Human resource and financing challenges**

future outbreaks.

14 Ebola

**5.3 Improving Survivalsurvival**

Isolation isolated cases, provided quality care, improved survival and increased public trust. Patient survival differed from outbreak to outbreak but improved as management of palliative care was established. In Gulu, survival improved over time (**Figure 8**). Mortality declined from 100% at the onset, to just around 10% towards the end of the outbreak. Timely community detection promoted care and survival. Motivation of care givers was critical to this improved performance of health care workers. It was demonstrated that quality palliative care positively influenced survival [1]. Future interventions therefore should integrate health staff motivation in their budgets.

**Figure 8.** Case fatality rate of Ebola cases by week, Gulu district, Uganda, 2000.

#### **6. Conclusion**

Early detection and action resulted in the best outcomes for the outbreak containment. Community leadership and mobilization, including the media for action was vital in managing these Ebola outbreaks. The need to strengthen laboratory capacity for early detection of the infection cannot be overemphasized. Supportive treatment improved lives, reduced case fatality, isolated cases and indeed increased public confidence and health seeking behavior. Care and survival and not just quarantine should therefore be emphasized as a critical component of the interventions. There were serious gaps in barrier nursing as nosocomial infections continued despite institution of isolation units. Infection control strategies should be institutionalized to protect both the health workers and the support staff in the units and the general wards. There is a need to develop and implement a human resource strategy and plan that attracts rewards and retains health workers. Such plans should strengthen health care systems in order to respond effectively to future epidemics. There is a need for the international partnerships and collaboration to be strengthened so as to augment the national efforts. Such partnerships should build capacity for health systems for surveillance and care.

Surveillance of emerging infections should be strengthened by establishing networks and centers of excellence for sharing of information and monitoring emerging infections. Inven‐ tories and rapid response teams at national and international level should be shared so as to provide timely emergency stocks, expertise and technical support. The large outbreaks especially in West Africa impacted badly on social services and the economy. Early detection and action based on community effort remains the best option for low resource settings, which capacity should be integrated into primary health care and village health teams to mitigate post Ebola health outcomes.

#### **Appendices**

#### **APPENDIX 1 Adapted WHO** *Case definition of Ebola virus disease for Uganda*



#### **Author details**

**6. Conclusion**

16 Ebola

post Ebola health outcomes.

onset,

*confirmed* EHF

**Appendices**

**APPENDIX 1**

*Suspected cases*

*Probable case*

Early detection and action resulted in the best outcomes for the outbreak containment. Community leadership and mobilization, including the media for action was vital in managing these Ebola outbreaks. The need to strengthen laboratory capacity for early detection of the infection cannot be overemphasized. Supportive treatment improved lives, reduced case fatality, isolated cases and indeed increased public confidence and health seeking behavior. Care and survival and not just quarantine should therefore be emphasized as a critical component of the interventions. There were serious gaps in barrier nursing as nosocomial infections continued despite institution of isolation units. Infection control strategies should be institutionalized to protect both the health workers and the support staff in the units and the general wards. There is a need to develop and implement a human resource strategy and plan that attracts rewards and retains health workers. Such plans should strengthen health care systems in order to respond effectively to future epidemics. There is a need for the international partnerships and collaboration to be strengthened so as to augment the national efforts. Such partnerships should build capacity for health systems for surveillance and care.

Surveillance of emerging infections should be strengthened by establishing networks and centers of excellence for sharing of information and monitoring emerging infections. Inven‐ tories and rapid response teams at national and international level should be shared so as to provide timely emergency stocks, expertise and technical support. The large outbreaks especially in West Africa impacted badly on social services and the economy. Early detection and action based on community effort remains the best option for low resource settings, which capacity should be integrated into primary health care and village health teams to mitigate

> **•** Sudden onset of *fever and at least 4 of the following* symptoms in a resident of or visitor to the affected areas in the district: *vomiting, diarrhea, abdominal pain, conjunctivitis, skin rash, unexplained bleeding from any body part, muscle pain, intense fatigue, difficulty swallowing, difficulty breathing, hiccups, or headache* since suspected

> **•** OR sudden *onset of fever* in any person who had *contact* with a person with *suspected, probable, or*

**•** *Suspected* EHF in any person (dead or alive) with *at least* 3 of the following symptoms: *vomiting, diarrhoea,*

**•** OR *sudden death* in a person in the community without any other explanation.

*or unexplained bleeding from any site, conjunctivitis, or skin rash*; AND

**Adapted WHO** *Case definition of Ebola virus disease for Uganda*

#### Samuel Okware

Address all correspondence to: okwares@gmail.com

Director General, Uganda National Health Research Organisation, Entebbe, Uganda

#### **REFERENCES**


[23] Clark D.V., et al., *Long-term sequelae after Ebola virus disease in Bundibugyo, Uganda: a retrospective cohort study*. Lancet Infect Dis, 2015. 15(8): pp. 905–912.

[7] WHO, *Ebola Situation Report - 28 October 2015, in ReliefWeb*2015, WHO, Geneva.

*Sudan*. The Journal of infectious diseases, 1983. 147(2): pp. 264–267.

[10] Fieldman H., *Ebola haemorrhagic fever*. Lancet, 2011. 377: pp. 849–862.

of pathology, 2003. 163(6): pp. 2347–2370.

*cus*. BMC infectious diseases, 2009. 9: p. 159.

1983. 61(6): pp. 997–1003.

109(1): pp. 4–9.

Ministry, Health, Uganda: Kampla.

723–728.

18 Ebola

[8] McCormick J.B., et al., *Biologic differences between strains of Ebola virus from Zaire and*

[9] Geisbert T.W., et al., *Pathogenesis of Ebola hemorrhagic fever in cynomolgus macaques: evidence that dendritic cells are early and sustained targets of infection*. The American journal

[11] Leroy E.M., et al., *Human Ebola outbreak resulting from direct exposure to fruit bats in Luebo, Democratic Republic of Congo*, 2007. Vector borne and zoonotic diseases, 2009. 9(6): pp.

[12] Pourrut X., et al., *Large serological survey showing cocirculation of Ebola and Marburg viruses in Gabonese bat populations, and a high seroprevalence of both viruses in Rousettus aegyptia‐*

[13] Ksiazek T.G., et al., *Clinical virology of Ebola hemorrhagic fever (EHF): virus, virus antigen, and IgG and IgM antibody findings among EHF patients in Kikwit, Democratic Republic of the Congo, 1995*. The Journal of infectious diseases, 1999. 179 Suppl 1: pp. S177–187.

[14] Dowell S.F., et al., *Transmission of Ebola hemorrhagic fever: a study of risk factors in family members, Kikwit, Democratic Republic of the Congo, 1995. Commission de Lutte contre les Epidemies a Kikwit*. The Journal of infectious diseases, 1999. 179 Suppl 1: pp. S87–91.

[15] Baron R.C., McCormick J.B., and Zubeir O.A., *Ebola virus disease in southern Sudan: hospital dissemination and intrafamilial spread*. Bulletin of the World Health Organization,

[17] Towner J.S., et al., *Newly discovered Ebola virus associated with hemorrhagic fever outbreak*

[18] Wamala J., *Update report Ebola in Luwero Aug 2011, unpublished*, J. Wamala, Editor 2011,

[19] Lamunu M., et al., *Containing a haemorrhagic fever epidemic: the Ebola experience in Uganda (October 2000-January 2001)*. International journal of infectious diseases: IJID: official publication of the International Society for Infectious Diseases, 2004. 8(1): pp. 27–37.

[20] Borchert M., *Ebola haemorrhagic fever outbreak in Masindi District, Uganda: outbreak*

[21] Bartsch S.M., Gorham K., and Lee B.Y., *The cost of an Ebola case. Pathog Glob Health*, 2015.

[22] Szabo L., *Costs of responding toEebola adding up, in USA TODAY 2014*, USA Today: USA.

[16] UNICEF, *Humantarian action report 2007, 2007*, UNICEF Uganda: Uganda.

*in Uganda*. PLoS pathogens, 2008. 4(11): p. e1000212.

*description and lessons learned*. BMC Infect Dis, 2011 11: p. 357.

[24] Wendo C., *Caring for the survivors of Uganda's Ebola epidemic one year on*. Lancet, 2001. 358(9290): p. 1350.

**Chapter 2**

## **Ebola and Health Partnerships, Action in a Time of Crisis**

Colin S Brown, Mohamed Elsherbiny, Oliver Johnson, Amardeep Kamboz, Marta Lado, Andrew Leather, Natalie Mounter, Suzanne Thomas, Dan Youkee, Naomi Walker, Waheed Awonuga, TB Kamara, Cecilia Kamara, Quaanan Kessete and Ramatu Ngauja

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/63440

#### **Abstract**

The chapter explores the role of health partnerships in delivering services throughout the West African Ebola Virus Disease epidemic, including the creation of the Ministry of Health and Sanitation, Sierra Leone, Ebola Holding Unit models, command and control structures, research into diagnostics and care pathways, and general medical care. It will highlight how this provided resilience during the Ebola response, and how this will aid health systems strengthening going forward.

**Keywords:** ebola, health partnership, impact, resilience, sustainable

### **1. Introduction to partnership working & existing health structure in Sierra Leone**

In 2014, Connaught Hospital and the King's Sierra Leone Partnership (KSLP) were at the epicentre of the Ebola Virus Disease (EVD) outbreak in West Africa and, given the unprece‐ dented nature of disease spread, had to develop new approaches to managing the clinical response. This chapter explores our model of Ebola Holding Units (EHUs) within govern‐ ment hospitals, including the role of international partnerships, how to maintain general health services during an outbreak and the importance of effective command and control. We

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

discuss how to conduct research and build longer-term capacity during a crisis. We hope the chapter will be of interest to those organisations working in EVD-prone countries, as well as those interested in broader aspects of EVD resilience and outbreak response.

#### **1.1. Connaught Hospital**

Connaught Hospital is the main adult tertiary referral and teaching hospital in Sierra Leone. Established during the colonial period and located in the downtown area of the capital city, Freetown, it has 300 medical and surgical beds and a range of specialist clinics such as for human immunodeficiency virus (HIV), tuberculosis (TB) and ophthalmology. Prior to the outbreak, the hospital was operating with limited resources for many years. As a result, patients paid fees for individual services and the infrastructure, such as sinks and taps, was degraded, with limited equipment or supplies such as gloves or cannulas. The hospital had only 10 consultants, fully specialised doctors, a small number for a facility of this size, and few ward sisters. Therefore, more junior staff would have significant clinical responsibility and only limited access to supervision.

#### **1.2. Sierra Leone context**

Connaught is part of a wider government health system with about 30 hospitals and more than 1000 primary care units across a country of six million people. Despite significant progress over the last 10 years, the health system still faced major challenges before the Ebola outbreak. A colonial legacy of few health training institutions, with the county's only medical school established in 1988, was compounded by the effects of protracted civil war (1994–2002), which saw many health workers leave the country or left unable to complete their specialist training. This all contributed to a major human resource crisis, with about 150 doctors, equal to 2 doctors per 100,000 people (compared to 280 in the UK) [1], and well below World Health Organization (WHO) minimum standards [2].

The civil war also led to significant damage to health facilities across the country and under‐ mined the capacity of key institutions that were responsible for the governance and manage‐ ment of health services, such as the Ministry of Health & Sanitation (MOHS). A small, albeit growing, economy resulted in low salaries for staff and limited resources to provide free drugs or services to patients. The country was heavily dependent on international donors to fund health services, both through the government and through non-governmental providers. Despite these challenges, the government had made a major commitment to health, symbolised by the launch of the Free Health Care initiative for under-5 year-old children and pregnant or lactating women in 2008.

Outside of the health systems, widespread extreme poverty resulted in poor housing, limited access to water and sanitation, low levels of formal employment and literacy, and a limited ability to pay for out-of-pocket fees for health services. There was also a strong culture of traditional beliefs and use of informal and unregulated health providers. These all had significant impacts on the burden of disease and the attitudes and behaviours of patients. Overall, the consequence was poor health outcomes: a life expectancy of 46 and one of highest infant mortality rates in the world (161/1000 live births) [1].

#### **1.3. Partnership working**

discuss how to conduct research and build longer-term capacity during a crisis. We hope the chapter will be of interest to those organisations working in EVD-prone countries, as well as

Connaught Hospital is the main adult tertiary referral and teaching hospital in Sierra Leone. Established during the colonial period and located in the downtown area of the capital city, Freetown, it has 300 medical and surgical beds and a range of specialist clinics such as for human immunodeficiency virus (HIV), tuberculosis (TB) and ophthalmology. Prior to the outbreak, the hospital was operating with limited resources for many years. As a result, patients paid fees for individual services and the infrastructure, such as sinks and taps, was degraded, with limited equipment or supplies such as gloves or cannulas. The hospital had only 10 consultants, fully specialised doctors, a small number for a facility of this size, and few ward sisters. Therefore, more junior staff would have significant clinical responsibility and

Connaught is part of a wider government health system with about 30 hospitals and more than 1000 primary care units across a country of six million people. Despite significant progress over the last 10 years, the health system still faced major challenges before the Ebola outbreak. A colonial legacy of few health training institutions, with the county's only medical school established in 1988, was compounded by the effects of protracted civil war (1994–2002), which saw many health workers leave the country or left unable to complete their specialist training. This all contributed to a major human resource crisis, with about 150 doctors, equal to 2 doctors per 100,000 people (compared to 280 in the UK) [1], and well below World Health Organization

The civil war also led to significant damage to health facilities across the country and under‐ mined the capacity of key institutions that were responsible for the governance and manage‐ ment of health services, such as the Ministry of Health & Sanitation (MOHS). A small, albeit growing, economy resulted in low salaries for staff and limited resources to provide free drugs or services to patients. The country was heavily dependent on international donors to fund health services, both through the government and through non-governmental providers. Despite these challenges, the government had made a major commitment to health, symbolised by the launch of the Free Health Care initiative for under-5 year-old children and pregnant or

Outside of the health systems, widespread extreme poverty resulted in poor housing, limited access to water and sanitation, low levels of formal employment and literacy, and a limited ability to pay for out-of-pocket fees for health services. There was also a strong culture of traditional beliefs and use of informal and unregulated health providers. These all had significant impacts on the burden of disease and the attitudes and behaviours of patients.

those interested in broader aspects of EVD resilience and outbreak response.

**1.1. Connaught Hospital**

22 Ebola

only limited access to supervision.

(WHO) minimum standards [2].

lactating women in 2008.

**1.2. Sierra Leone context**

In this context, Connaught Hospital invited the support of King's Health Partners (KHP) in 2012 to help strengthen the capacity of the hospital over the long term. KHP is an Academic Health Sciences Centre consisting of King's College London (KCL), in the world's top 20 university rankings, and three of the largest acute and mental health hospitals in South London. King's had over 10 years of experience of health system strengthening work in Somaliland and a strong commitment to global health.

The King's Sierra Leone Partnership was established when a small team from King's arrived at Connaught Hospital in early 2013 with the mission to help to strengthen the government health system through supporting the improvement of clinical services, training, policy and research. KSLP also partnered with the College of Medicine & Allied Health Sciences (CO‐ MAHS) and MOHS.

The King's approach was to support the hospital to implement its own improvement pro‐ gramme, rather than coming with an agenda. Early priorities included restructuring the Accident & Emergency Department, supporting an application for accreditation to provide postgraduate training in surgery, establishing a dental therapy training programme, reviewing management structures within the hospital and developing a regular teaching programme for junior doctors.

KSLP recruited a small international team on the ground including doctors, nurses, pharma‐ cists, hospital managers and others, embedded within the hospital doing a mixture of clinical and technical advisory work and teaching. This team was supported by senior specialists from the UK, who supported from a distance or visited on short trips.

The partnership was founded on the principles of mutual respect and shared learning and based on supporting the hospital's own leadership and strategy. It recognised that King's had as much or more to learn and benefit from the partnership as Sierra Leonean institutions did. Its strategy was to plan over the long term, over decades rather than months or years, and focused on the structural causes of health system challenges, such as addressing the lack of postgraduate training opportunities, rather than short term fixes, for example deploying large numbers of foreign volunteers to prop-up clinical activities. In addition, the approach was holistic, recognising that a hospital is a complex system and that to improve a particular aspect of patient care you need to address a number of interlinked components at once, which might range from developing clinical protocols to training staff, refurbishing the physical environ‐ ment, improving access to medical equipment and supplies, and overhauling the medical records and finance systems.

It was in this context, Connaught Hospital and KSLP found themselves on the frontline of the outbreak when the first EVD cases were identified in Freetown in July 2014, and had to radically restructure their work in order to mount an effective response to the epidemic whilst maintaining essential health services.

#### **2. West African EVD outbreak**

The 2014–2015 West African outbreak of Ebola Virus Disease was unprecedented in terms of longevity and magnitude. More than 11,300 people have died, with some 28,600 infected across seven countries [3]. Although the reservoir of EVD is unknown, it is thought to be a fruit bat [4,5]. One introduction from the animal reservoir to the West African population is likely responsible for all of the cases seen in the region [6]. It was apparent early in the outbreak that inadequate human resourcing and physical infrastructure delayed intervention in the face of exponential spread, with "each new suspected case bring[ing] an exponential increase in resources required for testing, isolation and contact tracing" [7].

#### **2.1. Existing models of EVD control**

There have been many models of EVD care facility established to redress this challenge, some traditionally used in combatting EVD outbreaks and others developed in response to the scale of the outbreak and adapted to local design. In Sierra Leone, there were three models of care that were utilised. Ebola Treatment Centres (ETCs) most closely represent the standard model of care. These were standalone units, often purpose-built by international agencies outwith government procurement processes and placed away from population hubs. They are often subdivided into suspect and confirmed wards for all patients presenting with illness sugges‐ tive of EVD. The UK government response in Sierra Leone included the construction of many of these ETCs, operated by a variety of Non-Governmental Organisations (NGOs) [8]. Community Care Centres (CCCs) were developed in response to uncontrolled spread of EVD, often in areas with limited access to other care facilities, and provided basic health care while suspect patients awaited their EVD test results, or for provision of early treatment of confirmed cases awaiting beds to become available at ETCs. Often built in repurposed structures or as collections of small tents, they were "small, low technology, mainly staffed by nurses and community health workers and can accommodate 8 to 10 (maximum 15) patients" [9]. Ebola Holding Units were constructed in existing healthcare facilities, either repurposing existing buildings or constructing standalone units within hospital grounds. They utilise local health care workers (HCWs), allowing for ongoing healthcare services to be safely delivered along‐ side safe isolation, testing, initial treatment and onward referral of EVD-positive patients to ETCs or ward-based or outpatient care of EVD-negative patients. They were adopted by MOHS in partnership with organisations such as KSLP, who helped establish EHUs attached to MOHS hospitals, initially at Connaught Hospital then four others. KSLP also helped other facilities prepare for EVD cases, trained local and international staff for a variety of organisa‐ tions, and supported command and control structures across the Western Area of the country (the peninsula area surrounding Freetown) to harmonise referrals and transfers between units [10].

#### **2.2. Partnership working in EVD care**

In March 2014, KSLP was invited by MOHS to contribute to the national Ebola Case Manage‐ ment Taskforce. Utilising infectious disease experience within the in-country team, we helped develop national guidelines for suspect case definition and developed safe isolation protocols for isolating and testing suspect cases across MOHS settings. KSLP staff later contributed to the WHO EVD management guidelines. The MOHS, with the support of KSLP and other international partners, started establishing EHUs at MOHS hospitals in Freetown in May 2014, before the first case of EVD in country. Initially a two-bed EHU at Connaught Hospital was opened, and as the outbreak escalated in Freetown in August 2014, KSLP and MOHS increased Connaught Hospital capacity and established four further units. We also assisted in setting up of two additional units.

The EHU model aimed to "(1) reduce cases in the local community through rapid isolation of symptomatic and suspect EVD cases to prevent onward transmission, (2) prevent nosocomial transmission through patient separation and regular decontamination of surfaces and floors, (3) improve survival of isolated patients through provision of safe EVD and non-EVD medical care, (4) maintain general healthcare through prompt diagnosis of EVD and onward transfer of patients to dedicated ETCs, alongside exclusion of EVD and triage of negative patients into outpatient or inpatient facilities for general care, allowing hospitals to remain safe and functional, even during peak EVD transmission, and (5) reducing healthcare worker infections through staff training inside the EHU and infection prevention and control strengthening on general wards, avoiding closure of facilities" [11].

Between 29th May 2014 and 19th January 2015, the five KSLP-supported MOHS EHUs (with 79 beds) had isolated a substantial proportion of the confirmed cases seen within the Western Area Urban and Rural districts (1159 of the 3097 cases). These facilities were 'front-loaded' in terms of construction of facilities, largely clustered early in the response efforts. They were cheap and quick to develop, with construction costs arriving at under \$50,000 in total with one-week start-up times. We believe this model of care, detailed in Section 3 for Connaught Hospital, has significance for future outbreak control due to the rapidity of development and resilience for hospital functioning [11].

#### **2.3. Outputs of partnership working**

**2. West African EVD outbreak**

24 Ebola

**2.1. Existing models of EVD control**

[10].

**2.2. Partnership working in EVD care**

resources required for testing, isolation and contact tracing" [7].

The 2014–2015 West African outbreak of Ebola Virus Disease was unprecedented in terms of longevity and magnitude. More than 11,300 people have died, with some 28,600 infected across seven countries [3]. Although the reservoir of EVD is unknown, it is thought to be a fruit bat [4,5]. One introduction from the animal reservoir to the West African population is likely responsible for all of the cases seen in the region [6]. It was apparent early in the outbreak that inadequate human resourcing and physical infrastructure delayed intervention in the face of exponential spread, with "each new suspected case bring[ing] an exponential increase in

There have been many models of EVD care facility established to redress this challenge, some traditionally used in combatting EVD outbreaks and others developed in response to the scale of the outbreak and adapted to local design. In Sierra Leone, there were three models of care that were utilised. Ebola Treatment Centres (ETCs) most closely represent the standard model of care. These were standalone units, often purpose-built by international agencies outwith government procurement processes and placed away from population hubs. They are often subdivided into suspect and confirmed wards for all patients presenting with illness sugges‐ tive of EVD. The UK government response in Sierra Leone included the construction of many of these ETCs, operated by a variety of Non-Governmental Organisations (NGOs) [8]. Community Care Centres (CCCs) were developed in response to uncontrolled spread of EVD, often in areas with limited access to other care facilities, and provided basic health care while suspect patients awaited their EVD test results, or for provision of early treatment of confirmed cases awaiting beds to become available at ETCs. Often built in repurposed structures or as collections of small tents, they were "small, low technology, mainly staffed by nurses and community health workers and can accommodate 8 to 10 (maximum 15) patients" [9]. Ebola Holding Units were constructed in existing healthcare facilities, either repurposing existing buildings or constructing standalone units within hospital grounds. They utilise local health care workers (HCWs), allowing for ongoing healthcare services to be safely delivered along‐ side safe isolation, testing, initial treatment and onward referral of EVD-positive patients to ETCs or ward-based or outpatient care of EVD-negative patients. They were adopted by MOHS in partnership with organisations such as KSLP, who helped establish EHUs attached to MOHS hospitals, initially at Connaught Hospital then four others. KSLP also helped other facilities prepare for EVD cases, trained local and international staff for a variety of organisa‐ tions, and supported command and control structures across the Western Area of the country (the peninsula area surrounding Freetown) to harmonise referrals and transfers between units

In March 2014, KSLP was invited by MOHS to contribute to the national Ebola Case Manage‐ ment Taskforce. Utilising infectious disease experience within the in-country team, we helped Within the EHU, Connaught Hospital and KSLP staff were able to validate a newly developed Rapid Diagnostic Test to prove its utility; assess the efficacy of the WHO suspect case defini‐ tion, and determine whether a screening algorithm could be used prospectively to identify which suspect cases had a high likelihood of being EVD-positive; identify risk factors for mortality; assess how many patients discharged with a negative EVD-diagnosis were read‐ mitted to any other facility in the Western Area, identifying the risk of potential infection within the EHU; and examine whether our environmental decontamination practices were effective (all Section 4). An ongoing programme of education focuses on delivering resilience within the hospitals for Intensive Care, Accident & Emergency and General Medicine and Surgery (Section 5), and Infection Prevention and Control (IPC) and Water and Sanitation (WASH) projects (Section 6) that will increase infrastructural resilience (Section 6). The command and control structures were developed alongside these operational research questions, which allowed for early harmonisation across the Freetown response and served as a model for national scale up to the district responses outside the Western Area (Section 7). We have also remodelled temporary EHUs into permanent infection diseases units, retaining capacity to isolate, test, and treat EVD along with other infectious outbreaks, now and in the future, and laboratory strengthening with assistance from Public Health England (PHE) will aim to provide the necessary capacity to diagnose and detect future outbreaks of cholera and other diseases that could mimic EVD. A dedicated Infectious Disease Centre for Excellence will bring together leaders for the purposes of training, education, research and capacity building. A cohort of local healthcare staff of all cadres has developed significant skills and experience that can be harnessed. These areas are expanded in the following sections.

#### **3. Operations of an Ebola Holding Unit, Connaught Hospital**

To better understand how partnership working enabled rapid instigation and scale-up of the Connaught Hospital response, the following section highlights the various aspects regarding developing the EHU facility.

#### *3.1.1. Staffing*

The first isolated patients were cared for by one of Connaught's three consultant medical physicians, junior medical staff and the senior nurse in charge of accident & Emergency. Following the consultant's sad death from EVD in June 2014, a small team of two or three international staff who had been working with KSLP before the EVD outbreak, took over care within the isolation facility. Over time the confidence of national hospital staff and volunteers grew and the team expanded to keep pace with the increase in bed numbers (see **Table 1**). As the number of Ebola cases in Freetown escalated the EHU expanded from an initial two bedded unit in late May 2014 bed capacity to nine, then a 16-bed unit with two additional child cots in August 2014. Consequently the operational aspects of running the unit also had to be scaled up.



remodelled temporary EHUs into permanent infection diseases units, retaining capacity to isolate, test, and treat EVD along with other infectious outbreaks, now and in the future, and laboratory strengthening with assistance from Public Health England (PHE) will aim to provide the necessary capacity to diagnose and detect future outbreaks of cholera and other diseases that could mimic EVD. A dedicated Infectious Disease Centre for Excellence will bring together leaders for the purposes of training, education, research and capacity building. A cohort of local healthcare staff of all cadres has developed significant skills and experience that

To better understand how partnership working enabled rapid instigation and scale-up of the Connaught Hospital response, the following section highlights the various aspects regarding

The first isolated patients were cared for by one of Connaught's three consultant medical physicians, junior medical staff and the senior nurse in charge of accident & Emergency. Following the consultant's sad death from EVD in June 2014, a small team of two or three international staff who had been working with KSLP before the EVD outbreak, took over care within the isolation facility. Over time the confidence of national hospital staff and volunteers grew and the team expanded to keep pace with the increase in bed numbers (see **Table 1**). As the number of Ebola cases in Freetown escalated the EHU expanded from an initial two bedded unit in late May 2014 bed capacity to nine, then a 16-bed unit with two additional child cots in August 2014. Consequently the operational aspects of running the unit also had to be scaled

**Staff Roles Number**

13 (national) and 8 (international)

12 (national)

4 (national)

Ensure blood sample collection by laboratory staff and check results Arrange patient transfer to ETU or discharge from EHU to hospital or home Wash bodies, collect oral swabs for testing and prepare for collection by burial

Cleaners Clean EHU and patients items to prevent cross infection between patients

Wash bodies and prepare for collection by burial team

Security staff Ensure public safety during patient admission or removal of corpses

Ensure security of patients, staff and supplies

Caregiving staff Admit patients and give personal/nursing care Administer medications

> Ensure safe disposal of waste Prepare chlorine water

Liaise with visitors and relatives

team

can be harnessed. These areas are expanded in the following sections.

developing the EHU facility.

*3.1.1. Staffing*

26 Ebola

up.

**3. Operations of an Ebola Holding Unit, Connaught Hospital**

**Table 1.** Numbers of clinical staff required for the twenty bed Ebola Holding Unit at Connaught Hospital at the height of the EVD outbreak, November 2014.

The caregiving staff, cleaners, screeners and security staff provided 24-h cover for the unit across three shifts. In order to repair and maintain the unit, some hospital maintenance staff (e.g. carpenters, electricians and plumbers) were trained in using Personal Protective Equip‐ ment (PPE) and would occasionally work in the unit under the guidance of an experienced member of staff. In addition, there was an operational team to provide support for the EHU (see **Table 2**) who were able to draw on technical advisors and an operations manager based in London for advice and assistance as required.


**Table 2.** Numbers of operational staff required to support the Ebola Holding Unit at Connaught Hospital, November 2014.

#### *3.1.2. Equipment and supplies*

With the agreement of Connaught Hospital management, a space was identified within the hospital for use as an EHU. This was prepared jointly by international volunteers and a range of hospital staff including nurses, doctors and maintenance staff. All initial equipment was purchased locally. As the outbreak continued some specific pieces of equipment which would improve safety within the EHU but were not available locally were shipped in e.g. non touch clinical waste bins. Several features made the identified space useful to create the EHU—it was adjacent to the triage area at the front of the hospital, so any patients identified at being at risk of EVD were easily transported into the unit. There were no steps, separate entrance and exits (though the latter had to be constructed) with the capacity for unidirectional flow, and was a physical building that withstood the rigors of repeated cleaning, allowed for security, and ventilation for patients. It also was self-contained from the rest of the hospital, had its own water supply, and space for dressing areas and decontamination. Construction was relatively simple and involved building temporary doors, plastic sheets between bedspaces, wooden furniture and supplies such as buckets, cabinets to store medication, and clocks.

Availability of PPE, cleaning supplies and drugs was limited at the beginning of the outbreak and a rapid donation of essential items was sent by air freight from KHP in August 2014. As more supplies became available in Central Medical Stores (CMS), the government agency responsible for distributing healthcare supplies to hospital facilities, the majority of supplies for the EHU were requested through the government supply chain. Hospital management authorised the orders which were prepared by the supplies coordinator. This approach was adopted to reduce dependence on a parallel supply chain which could distort overall data about supply requirements. Specific items continued to be shipped in either because they were considered essential but in short supply (e.g. shoe covers and long gloves) or because they were required on safety grounds (i.e. disposable masks with visor attached). Non-medical supplies for patients (e.g. soap, bedsheets, clothes and drinking water) were sourced locally and provided through another NGO who received donor funding specifically to fulfil for this function for a number of EHUs. Storage space for all the supplies was provided by the hospital management.

#### *3.1.3. Safety*

To ensure safe operation of the EHU, many aspects of care were carefully negotiated with the MOHS and hospital management. Concerns regarding overflow were managed by strictly limiting bed numbers to a capacity that was deemed safe. We never accepted more patients into the EHU than we had beds available for, however we constructed a tented area outside the hospital entrance to deal with overflow where families could bring relatives awaiting admission and were provided with IPC to care for them. Early in the Western Area outbreak, when there were no EHU beds available the Accident & Emergency department was tempo‐ rarily closed until spare beds became available to protect the general hospital wards. The whole hospital staff played a tremendous role in safely managing the wards during the outbreak, and morale was boosted for all healthcare staff who were given limited additional hazard payment for their work. Plastic sheeting was challenging—it was initially employed in the unit to provide separation between patients, however this was taken down as IPC management was easier without having to decontaminate the plastic surfaces. Security was occasionally a concern in healthcare facilities and the Royal Sierra Leone Armed Forces were stationed at the main entrance to aid with calming measures, given the high numbers of patients presenting given Connaught was one the few functioning facilities in the Western Area. Towards the end of the outbreak, from March 2015 we started testing all inpatients for HIV. All patients who tested negative for EVD and diagnosed with HIV were linked into onward services for HIV care, and all EVD-negative patients were showered and given a clean pair of clothes before leaving the unit for onward management on the medical wards. This care was enabled by a credit provided by KSLP to pay for basic medications and tests.

#### **3.2. Model of supervision**

*3.1.2. Equipment and supplies*

28 Ebola

management.

*3.1.3. Safety*

With the agreement of Connaught Hospital management, a space was identified within the hospital for use as an EHU. This was prepared jointly by international volunteers and a range of hospital staff including nurses, doctors and maintenance staff. All initial equipment was purchased locally. As the outbreak continued some specific pieces of equipment which would improve safety within the EHU but were not available locally were shipped in e.g. non touch clinical waste bins. Several features made the identified space useful to create the EHU—it was adjacent to the triage area at the front of the hospital, so any patients identified at being at risk of EVD were easily transported into the unit. There were no steps, separate entrance and exits (though the latter had to be constructed) with the capacity for unidirectional flow, and was a physical building that withstood the rigors of repeated cleaning, allowed for security, and ventilation for patients. It also was self-contained from the rest of the hospital, had its own water supply, and space for dressing areas and decontamination. Construction was relatively simple and involved building temporary doors, plastic sheets between bedspaces, wooden

furniture and supplies such as buckets, cabinets to store medication, and clocks.

Availability of PPE, cleaning supplies and drugs was limited at the beginning of the outbreak and a rapid donation of essential items was sent by air freight from KHP in August 2014. As more supplies became available in Central Medical Stores (CMS), the government agency responsible for distributing healthcare supplies to hospital facilities, the majority of supplies for the EHU were requested through the government supply chain. Hospital management authorised the orders which were prepared by the supplies coordinator. This approach was adopted to reduce dependence on a parallel supply chain which could distort overall data about supply requirements. Specific items continued to be shipped in either because they were considered essential but in short supply (e.g. shoe covers and long gloves) or because they were required on safety grounds (i.e. disposable masks with visor attached). Non-medical supplies for patients (e.g. soap, bedsheets, clothes and drinking water) were sourced locally and provided through another NGO who received donor funding specifically to fulfil for this function for a number of EHUs. Storage space for all the supplies was provided by the hospital

To ensure safe operation of the EHU, many aspects of care were carefully negotiated with the MOHS and hospital management. Concerns regarding overflow were managed by strictly limiting bed numbers to a capacity that was deemed safe. We never accepted more patients into the EHU than we had beds available for, however we constructed a tented area outside the hospital entrance to deal with overflow where families could bring relatives awaiting admission and were provided with IPC to care for them. Early in the Western Area outbreak, when there were no EHU beds available the Accident & Emergency department was tempo‐ rarily closed until spare beds became available to protect the general hospital wards. The whole hospital staff played a tremendous role in safely managing the wards during the outbreak, and morale was boosted for all healthcare staff who were given limited additional hazard payment for their work. Plastic sheeting was challenging—it was initially employed in the unit

Building on the existing model of partnership working, the ultimate aim was to build the capacity of EHU staff to run the unit independently in the future.

At the beginning of the outbreak fear of infection, lack of training and lack of resources were the main reasons for hospital staff being unwilling to work in EHUs. In order to address these issues international staff provided practical training and ongoing supervision. The role and importance of standard operating procedures was emphasised regularly to minimise HCW infection. Role modelling was an important factor in building the confidence of new staff. This helped consolidate the adoption of the correct procedures by new staff and built confidence in the safety of those procedures. For that reason international staff were recruited on the understanding that they would be expected to perform the same duties as all other staff. Development of a responsive supply chain for the unit also helped to maintain staff commit‐ ment. As the numbers and competency of the national staff increased, the numbers of inter‐ national staff decreased significantly so that by the end of the outbreak only one international clinician was on-call to assist with clinical issues. The management of supplies from CMS was handed over to the hospital pharmacy and storekeeper.

Good working relationships with the Matron and the Senior Nurse in the Emergency Depart‐ ment were critical for the recruitment, management and disciplining of EHU staff. An identified team leader for each shift strengthened communication between staff.

One challenge was the stigma experienced by those working inside the EHU from relatives and colleagues. There were reports of workers being shunned by other health workers or expelled from their houses by their families. It was important to acknowledge these difficulties with staff in the early stages of training and discuss contingency plans for dealing with these challenges.

All staff working inside the EHU were entitled to a risk allowance which was distributed by the National Ebola Response Centre (NERC). There were often problems in the access to this financial incentive, and KSLP provided a smaller performance related bonus (based on a written report of attendance, performance and safety while working) in addition to this allowance which was an effective tool for providing feedback and incentive for good per‐ formance. However at other EHUs, this was not attempted, and good mentorship and encouragement were sufficient to motivate local staff.

#### **3.3. Using the Connaught Hospital EHU as a training hub**

Training was one of the KSLP pillars of work during the outbreak. After setting up the Connaught EHU, the first in the Western Area for suspected EVD cases, KSLP developed a training method used to train more than 400 health care workers, international and national, to work in EHUs and ETCs.

#### *3.3.1. Model of training*

The training groups were structured in small groups of trainees (between 6 and 10 people per group subdivided into small teams of between 3 and 5 members). It was important to ensure that the training was practical, interactive and with opportunities for the students to engage with the live environment and implement what they had learnt in lectures with direct supervision from the trainer.

All staff working in patient areas received the three-phase training described below (see **Figure 1**). Before starting clinical work, all staff had to complete Phase 1 and Phase 2 training. See **Table 3** for an example of training timetable for Phases 1 and 2.

**Figure 1.** Three phase training model at Connaught Hospital Ebola Holding Unit.


**•** Infection prevention


**Table 3.** Example Timetable for Phases 1 and 2.

formance. However at other EHUs, this was not attempted, and good mentorship and

Training was one of the KSLP pillars of work during the outbreak. After setting up the Connaught EHU, the first in the Western Area for suspected EVD cases, KSLP developed a training method used to train more than 400 health care workers, international and national,

The training groups were structured in small groups of trainees (between 6 and 10 people per group subdivided into small teams of between 3 and 5 members). It was important to ensure that the training was practical, interactive and with opportunities for the students to engage with the live environment and implement what they had learnt in lectures with direct

All staff working in patient areas received the three-phase training described below (see **Figure 1**). Before starting clinical work, all staff had to complete Phase 1 and Phase 2 training.

encouragement were sufficient to motivate local staff.

to work in EHUs and ETCs.

supervision from the trainer.

*3.3.1. Model of training*

30 Ebola

**Day 1—Phase 1**

PM Training session 1 **•** Ebola

**•** Connaught isolation unit

**•** Infection prevention

**3.3. Using the Connaught Hospital EHU as a training hub**

See **Table 3** for an example of training timetable for Phases 1 and 2.

**Figure 1.** Three phase training model at Connaught Hospital Ebola Holding Unit.

AM General induction and orientation Conference room

Conference room followed by isolation unit

**Phase 1** consisted of generic EVD training, including basic PPE training, decontamination procedures, IPC protocols and basic knowledge and awareness of EVD. The method was based on theoretical lectures and included the principles of the construction and setting up of an isolation unit according to the WHO and Médecins Sans Frontières guidelines.

**Phase 2** focused on the application of protocols to the real life environment. Training took place within the Connaught EHU, and was provided by experienced staff who ensured adequate supervision. Throughout Phase 2, there was a gradual increase in both time spent inside the unit and procedures performed by trainees. Direct observation of procedural skills (DOPs) was used to assess competence. These practical lessons were developed inside the EHU with real patients and different scenarios to help the trainees to understand and put in practice the best clinical management with EVD patients.

**Phase 3** training was provided within their own EHU. Staff were formally revalidated in their decontamination procedures and IPC protocols on a regular basis. See **Figure 2** for an example of an assessment tool used for revalidation. All staff were retrained as new procedures or protocols were adopted. In many training sessions, direct explanations and advice in storage, supplies of consumables and PPE were also provided, based on the experiences gained at Connaught Hospital, with the aim of assisting in the setting up of new units at government facilities in the Western Area and all over the country through other partners [12].

**Phase 4**, the newest training phase, was established after Sierra Leone was declared EVD-free. It allows EVD-healthcare workers to receive updates and refreshment of previously deployed EVD training to ensure readiness when new cases arise. Currently, KSLP is developing updated training for HCWs that is focused on lessons learnt from the outbreak, mainly based


**Figure 2.** Staff PPE competency assessment tool used during phase 3 training.

in case management and care of the patients with actors and different scenarios inside the EHU, e.g. management of sepsis, and of confused and agitated patients. It also includes an update in IPC and special situations such as pregnant EVD patients. This training is also oriented to prepare trainers to deliver this material to more HCWs to ensure onward resilience. **Table 4** details an example timetable for this phase.


**Table 4.** Example timetable for Phase 4.

## **4. Prioritising research in the EVD outbreak setting: the role of health partnerships**

The scale and duration of the West African EVD outbreak provided a unique opportunity to study the clinical features and management of EVD to generate evidence for best practice. Prior to this outbreak, case management was based on expert opinion and evidence from limited case studies and small patient cohorts in Central and East Africa [13–16]. Several KSLP clinical volunteers and senior Connaught medical staff had research expertise. However, significant barriers to undertaking research existed. There was a shortage of staff to deliver basic clinical care for much of the outbreak. Upholding high standards of ethical conduct and governance was essential, but many of the clinicians (doctors and nurses) working in the EHU had not received prior training in research methodology and the necessary training and associated research governance processes required considerable time and effort to set up.

#### *4.1.1. The importance of research in an outbreak setting*

**Figure 2.** Staff PPE competency assessment tool used during phase 3 training.

32 Ebola

In this context, we focused our efforts on standardising best clinical practice and carefully recording important clinical information so that retrospective analysis could be performed. We prioritised questions that would influence patient management and interrogated our clinical dataset for the answers. In doing this, we felt we could generate evidence to improve wider practice, whilst continuing our focus on care at an individual level.

#### *4.1.2. What were the important research questions?*

Identification of suspected clinical cases for isolation and EVD testing was a critical step in EVD outbreak control. We noticed that despite applying the consensus case definition to all admissions at Connaught Hospital, several inpatients who became unwell and were later found to have EVD, did not meet the suspected case definition at presentation, and therefore potentially exposed nursing staff and other patients on general wards. Other individuals may have remained in the community, putting friends and family at risk of EVD. Effective screening of suspected cases was identified as a critical part of the patient pathway that was liable to impede EVD outbreak control.

Additionally, we struggled with lack of capacity in our facility. Despite increasing the number of Connaught EHU beds, we frequently had patients waiting outside the hospital for space to become available due to high transmission in the community. Our capacity was limited by duration of stay, proportional to the time required to obtain an EVD test result. Once a patient was admitted, a blood sample was collected for EVD testing and transported to centralised specialist laboratory for EVD polymerase chain reaction (PCR) testing. The PCR assay required technical skill and advanced laboratory equipment and turnaround time ranged from 1 to 7 days. We could not discharge or transfer patients until their results were available. It became apparent that a point-of-care test with a high sensitivity and a reasonable specificity would transform our case management, allowing us to discharge negative patients with confidence, freeing up beds for new suspected cases, and increasing our admission rate.

#### *4.1.3. Operational research around data management and EHU safety*

Clinical information was collected daily from patients admitted to the EHU using a standar‐ dised proforma, by clinicians and district surveillance officers. This included demographic data of patients including contact details and travel history, symptoms on admission, date of admission and symptom onset, source of admission, specimen collection date and time, laboratory result and patient outcome i.e. whether the patient was discharged home, trans‐ ferred to the wards, referred to an ETC or died. This information was then entered into a database in Microsoft Excel, which was used to analyse the data.

In several instances, the information gathered was used to improve the quality of care and to identify bottlenecks in the management of patients in the isolation unit. For instance, a retrospective cohort study of presenting features of EVD confirmed our suspicion that case definitions were not sensitive enough, that baseline symptoms were poor at discriminating EVD-positive cases from other illnesses, and supported the implementation of rapid diagnostic testing [17]. These findings were published open-access in July 2015. The number of hours/ days taken to send the blood sample to the laboratory and the time taken to get the results back was analysed to identify delays for targeted interventions, including reorganisation of the laboratory transport system. Delays in turnaround led to increased length of stay and delays in public health action such as contact tracing, highlighting that up-to-date real-time operational data is critical to optimise resource allocation and response [18]. When concerns about nosocomial transmission within the isolation unit were raised, we were able to demon‐ strate that this was infrequent, by examining the frequency of readmissions (amongst patients who tested negative and were discharged), which was low. We identified a maximum positive readmission rate of 3.3% [19], lower than has been previously reported [20].

These findings support the EHU model as a safe method for isolation of suspect EVD patients and their role in limiting the spread of EVD, and will be very important in the coordination and implementation of a response to any future outbreak of EVD. Further operational research was conducted within the EHU to inform decontamination practices, as evidence was lacking. We conducted an audit of decontamination procedures inside Connaught Hospital EHU, showing that prior to decontamination, Ebola virus RNA was detected by PCR within a limited area at all bedside sites tested, but not at sites distant to the bedside. Following decontamina‐ tion, few areas contained detectable Ebola virus RNA, however in areas beneath bedspaces there was evidence of transfer of Ebola virus material during cleaning. By retraining of cleaning staff (outlined in Section 3) we saw reduced evidence of environmental contamination after decontamination, highlighting that regular refresher training is essential during the course of EVD outbreaks [21].

#### **4.2. Case study—evaluating a point-of-care rapid diagnostic test for EVD**

We conducted a study assessing the diagnostic accuracy of a new point-of-care test (RDT) against the gold-standard EVD PCR assay. The RDT test had been developed by the UK Defence Science Technology Laboratories and was delivered to us by PHE who had construct‐ ed laboratories in the Western Area. We received 300 prototypes for evaluation. The new test required only one drop of capillary blood generated from a single finger-prick (compared to several millilitres of peripheral venous blood for the standard test). The result was generated by a lateral flow device at the site of testing within 20 min. We designed a diagnostic accuracy study to evaluate the test in an operational setting. Clinical staff who provided care for patients in KSLP-supported units were trained in the study procedure and use of the new test, and tested all admissions to their isolation units with suspected EVD, following informed consent. Phlebotomists who would routinely collect venous blood from all admissions for standard EVD testing by PCR continued to do so. Therefore, all patients enrolled in the study received two tests (the new unproven RDT test) and the routine (gold standard) test. At the end of the study, we were able to compare the performance of the new test with the routine test and estimate the sensitivity, specificity, positive and negative predictive values. The study was implemented in early 2015, in four KSLP-supported clinical sites. The incidence of EVD in Freetown was rapidly decreasing during this time but despite this, the study recruited 138 participants. The test proved highly sensitive and specific and was published in an open access peer-reviewed journal, within two months of study completion [22].

#### *4.2.1. Research governance*

*4.1.2. What were the important research questions?*

impede EVD outbreak control.

34 Ebola

Identification of suspected clinical cases for isolation and EVD testing was a critical step in EVD outbreak control. We noticed that despite applying the consensus case definition to all admissions at Connaught Hospital, several inpatients who became unwell and were later found to have EVD, did not meet the suspected case definition at presentation, and therefore potentially exposed nursing staff and other patients on general wards. Other individuals may have remained in the community, putting friends and family at risk of EVD. Effective screening of suspected cases was identified as a critical part of the patient pathway that was liable to

Additionally, we struggled with lack of capacity in our facility. Despite increasing the number of Connaught EHU beds, we frequently had patients waiting outside the hospital for space to become available due to high transmission in the community. Our capacity was limited by duration of stay, proportional to the time required to obtain an EVD test result. Once a patient was admitted, a blood sample was collected for EVD testing and transported to centralised specialist laboratory for EVD polymerase chain reaction (PCR) testing. The PCR assay required technical skill and advanced laboratory equipment and turnaround time ranged from 1 to 7 days. We could not discharge or transfer patients until their results were available. It became apparent that a point-of-care test with a high sensitivity and a reasonable specificity would transform our case management, allowing us to discharge negative patients with confidence,

Clinical information was collected daily from patients admitted to the EHU using a standar‐ dised proforma, by clinicians and district surveillance officers. This included demographic data of patients including contact details and travel history, symptoms on admission, date of admission and symptom onset, source of admission, specimen collection date and time, laboratory result and patient outcome i.e. whether the patient was discharged home, trans‐ ferred to the wards, referred to an ETC or died. This information was then entered into a

In several instances, the information gathered was used to improve the quality of care and to identify bottlenecks in the management of patients in the isolation unit. For instance, a retrospective cohort study of presenting features of EVD confirmed our suspicion that case definitions were not sensitive enough, that baseline symptoms were poor at discriminating EVD-positive cases from other illnesses, and supported the implementation of rapid diagnostic testing [17]. These findings were published open-access in July 2015. The number of hours/ days taken to send the blood sample to the laboratory and the time taken to get the results back was analysed to identify delays for targeted interventions, including reorganisation of the laboratory transport system. Delays in turnaround led to increased length of stay and delays in public health action such as contact tracing, highlighting that up-to-date real-time operational data is critical to optimise resource allocation and response [18]. When concerns about nosocomial transmission within the isolation unit were raised, we were able to demon‐ strate that this was infrequent, by examining the frequency of readmissions (amongst patients

freeing up beds for new suspected cases, and increasing our admission rate.

*4.1.3. Operational research around data management and EHU safety*

database in Microsoft Excel, which was used to analyse the data.

There were ethical and governance issues to consider with the sensitive nature of the infor‐ mation that was being collected. Patients were assured of confidentiality and anonymity and permission for the research database was sought from of the Medical Superintendent of Connaught Hospital. The purpose, objectives and method of data collection were explained to all four Medical superintendents, who allowed the study to take place. The study had institutional approval at all sites and received prospective approval of the Sierra Leone Ethics and Scientific Review Committee.

#### *4.2.2. Challenges in study implementation*

A major challenge to study implementation was human resources. Few staff were willing to have direct patient contact, and these staff were overwhelmed by the demands of delivering essential clinical care under challenging circumstances. Working conditions inside the EHU were difficult, with full PPE required at all times and exemplary infection control as per the Phased Training (Section 3).

Patient notes were kept outside the unit, as records inside could not be removed. For data entry, these were inputted in batches after the patient had been discharged, which was timeconsuming given the high turnover of patients. A major challenge was forms with incomplete data, and source documents (admission logs and laboratory records) were required to fill in gaps. The RDT result was documented inside the unit and then called out to staff outside. Patient study information leaflets were kept inside the EHU, but destroyed on discharge. A fresh copy was given to patients who were discharged to take away with them. Verbal, rather than written informed consent was taken from patients. Staff documented the process by signing a log outside the EHU.

All staff working on the RDT study offered their time voluntarily, and the study received no specific funding. There were no financial incentives for staff or patients to engage with research and whilst there was enthusiasm amongst staff to be trained in research methods and to assist with the development of an RDT, this diminished once the practicalities became apparent. Taking consent and performing the test required extra time inside the EHU and some staff felt they should be financially compensated for this. Government payments for clinical work had been delayed and some staff were suffering considerable financial hardship and low morale, as described in Section 3.

The RDT study protocol required amendment to routine sample transport and processing policies and some clinical and technical staff expressed (not unfounded) concern that this would negatively impact on patient care. These concerns were addressed by the local ethical and institutional boards and the study was conducted in adherence to international standards of research practice. However, despite this there was some reluctance to support the study and instances in which this resulted in protocol interference.

#### **4.3. Lessons learned**

Recognising staff participation in clinical research was important. Certificates of achievement were produced and were popular. An experienced full time study coordinator at each study site would have been effective at encouraging staff and patient participation, and financial incentives for staff would probably have been more effective. However as with routine clinical work, leadership by example of an experienced individual was the most effective way to improve staff morale and motivation.

Communication was extremely important at all levels. Firstly, more widespread consultation with hospital, clinic and laboratory staff about research protocols prior to decisions to implement them would have been beneficial. Decisions tended to be taken at senior level without dissemination to those in key management positions on the ground and this caused misunderstandings. Training of staff in good clinical practice and research governance was vital, and as few had prior experience close supervision and re-training was necessary. Communication with patients about research was essential. We took time to do this and felt that it was effective.

With respect to the clinical database, more detailed training of the screeners on how to fill forms completely would have been beneficial and may have improved efficiency at data entry level. Automating entries into the Excel spreadsheet would have further minimised typo‐ graphical errors. Innovative technologies to improve data capture inside the unit would have helped, had they been available. Various methods were considered and some were tried e.g. the use of intercoms, photography and wireless transfer of electronic records, although none were sufficiently accessible at peak of the outbreak to make a significant impact.

One strategy to address the shortage of research staff was recruitment of medical students as volunteers, who were available as the medical school was closed. This was extremely beneficial and provided the students with experience in research methods.

Despite the demonstrated accuracy of the RDT and rapid publication, the RDT is still not widely or commercially available. Lack of financial and institutional endorsement may have delayed this, and we have learned that is not sufficient to generate evidence, we must also campaign for this work to be recognised and petition for translation into improved patient care.

As a health partnership involving KHP and Connaught staff delivering and supporting clinical care for patients with suspected EVD, we were ideally placed to address important clinical research questions. Undertaking research training addressed the partnership aim of health system strengthening. However, considerable challenges existed in terms of lack of time and human resources. We addressed this by strengthening clinical data collection, which was an essential part of routine clinical care and undertaking operational research studies that we felt would have early translational impact, as detailed above.

#### **5. General hospital functioning**

institutional approval at all sites and received prospective approval of the Sierra Leone Ethics

A major challenge to study implementation was human resources. Few staff were willing to have direct patient contact, and these staff were overwhelmed by the demands of delivering essential clinical care under challenging circumstances. Working conditions inside the EHU were difficult, with full PPE required at all times and exemplary infection control as per the

Patient notes were kept outside the unit, as records inside could not be removed. For data entry, these were inputted in batches after the patient had been discharged, which was timeconsuming given the high turnover of patients. A major challenge was forms with incomplete data, and source documents (admission logs and laboratory records) were required to fill in gaps. The RDT result was documented inside the unit and then called out to staff outside. Patient study information leaflets were kept inside the EHU, but destroyed on discharge. A fresh copy was given to patients who were discharged to take away with them. Verbal, rather than written informed consent was taken from patients. Staff documented the process by

All staff working on the RDT study offered their time voluntarily, and the study received no specific funding. There were no financial incentives for staff or patients to engage with research and whilst there was enthusiasm amongst staff to be trained in research methods and to assist with the development of an RDT, this diminished once the practicalities became apparent. Taking consent and performing the test required extra time inside the EHU and some staff felt they should be financially compensated for this. Government payments for clinical work had been delayed and some staff were suffering considerable financial hardship and low morale,

The RDT study protocol required amendment to routine sample transport and processing policies and some clinical and technical staff expressed (not unfounded) concern that this would negatively impact on patient care. These concerns were addressed by the local ethical and institutional boards and the study was conducted in adherence to international standards of research practice. However, despite this there was some reluctance to support the study and

Recognising staff participation in clinical research was important. Certificates of achievement were produced and were popular. An experienced full time study coordinator at each study site would have been effective at encouraging staff and patient participation, and financial incentives for staff would probably have been more effective. However as with routine clinical work, leadership by example of an experienced individual was the most effective way to

and Scientific Review Committee.

36 Ebola

Phased Training (Section 3).

signing a log outside the EHU.

as described in Section 3.

**4.3. Lessons learned**

improve staff morale and motivation.

instances in which this resulted in protocol interference.

*4.2.2. Challenges in study implementation*

Throughout the epidemic, and in particular following the death of one of the three consultant medical physicians at Connaught Hospital, a senior British medical physician volunteering with KSLP assisted the two remaining consultant physicians through providing consultantled ward rounds and medical student teaching. He became an integral part of the delivering clinical supervision, assisting in patient management and safety, and providing valuable ongoing training opportunities for junior medical staff [22]. This was particularly important as all school and university level education was suspended in Sierra Leone for a full year.

Internal audits of tuberculosis and HIV services showed a limited reduction in number of attendances of existing and new suspect cases, and medical inpatient numbers decreased by up to half during the early outbreak [23]. Surgical cases, sadly influenced by the death of two hospital surgical staff including the country's only trauma surgeon, dramatically dropped in August 2014, and fell to 3% of expected activity [24]. This was on a background of existing shortages in "all aspects of infrastructure, personnel, and supplies required for delivering surgical care in Sierra Leone" [25]. Despite this drop in outpatient and inpatient attendance, the hospital remained open for the duration of the outbreak, in contrast to the major referral hospitals in Guinea and Liberia, and medical wards were very busy alongside the work in the EHU. The partnership approach between COHMAS, KSLP and Connaught allowed for ongoing clinical care and training of HCWs, and all aspects of Connaught Hospital are now fully operational.

As part of reconfiguration of Accident & Emergency services KSLP assisted Connaught Hospital in establishing an effective triage system, provision of free emergency treatment and improving medical record keeping within the Emergency Department. Though Emergency department attendance was negatively correlated with the local prevalence of Ebola virus disease from June 2014-June 2015, possibly due to changes in health-seeking behaviour due to fear of EVD, it remained one of the only facilities in the country where people could access non-EVD medical care [26].

Senior infectious disease staff from KSLP were engaged in the revision of the national TB and HIV guidelines, and the TB clinic was temporarily relocated to new premises, allowing for the construction of a dedicated infectious diseases unit that can be utilised for safe isolation of patients in future highly infectious outbreaks such as cholera.

#### **6. Water, sanitation and hygiene (WASH), infection prevention & control (IPC), and general hospital functioning**

#### *6.1.1. Background to IPC in Sierra Leone*

IPC was not a known term in Sierra Leone until the recovery phase of the epidemic and there were no dedicated IPC specialists at hospital or national level. IPC was not an element of medical or nursing undergraduate training nor was there any IPC training provided by hospital facilities. Poor IPC practices within healthcare facilities have been attributed as one reason why Ebola outbreaks propagate including that seen in West Africa [27–30] and are a contributing factor in the high rate of HCW infections seen in Sierra Leone [31]. It was clear that the establishment of IPC in Sierra Leone had to be a key part of the postepidemic recovery plan that would help protect against another outbreak. Major factors affecting the proper implementation of IPC included: lack of IPC infrastructure, appropriate PPE and other essential supplies at healthcare facilities, and hand hygiene stations, and poor WASH infra‐ structure, inadequate systems for medical waste disposal, limited concepts of screening or triage, a lack of IPC knowledge among HCWs, and no IPC policies.

#### *6.1.2. IPC post-EVD epidemic*

Internal audits of tuberculosis and HIV services showed a limited reduction in number of attendances of existing and new suspect cases, and medical inpatient numbers decreased by up to half during the early outbreak [23]. Surgical cases, sadly influenced by the death of two hospital surgical staff including the country's only trauma surgeon, dramatically dropped in August 2014, and fell to 3% of expected activity [24]. This was on a background of existing shortages in "all aspects of infrastructure, personnel, and supplies required for delivering surgical care in Sierra Leone" [25]. Despite this drop in outpatient and inpatient attendance, the hospital remained open for the duration of the outbreak, in contrast to the major referral hospitals in Guinea and Liberia, and medical wards were very busy alongside the work in the EHU. The partnership approach between COHMAS, KSLP and Connaught allowed for ongoing clinical care and training of HCWs, and all aspects of Connaught Hospital are now

As part of reconfiguration of Accident & Emergency services KSLP assisted Connaught Hospital in establishing an effective triage system, provision of free emergency treatment and improving medical record keeping within the Emergency Department. Though Emergency department attendance was negatively correlated with the local prevalence of Ebola virus disease from June 2014-June 2015, possibly due to changes in health-seeking behaviour due to fear of EVD, it remained one of the only facilities in the country where people could access

Senior infectious disease staff from KSLP were engaged in the revision of the national TB and HIV guidelines, and the TB clinic was temporarily relocated to new premises, allowing for the construction of a dedicated infectious diseases unit that can be utilised for safe isolation of

**6. Water, sanitation and hygiene (WASH), infection prevention & control**

IPC was not a known term in Sierra Leone until the recovery phase of the epidemic and there were no dedicated IPC specialists at hospital or national level. IPC was not an element of medical or nursing undergraduate training nor was there any IPC training provided by hospital facilities. Poor IPC practices within healthcare facilities have been attributed as one reason why Ebola outbreaks propagate including that seen in West Africa [27–30] and are a contributing factor in the high rate of HCW infections seen in Sierra Leone [31]. It was clear that the establishment of IPC in Sierra Leone had to be a key part of the postepidemic recovery plan that would help protect against another outbreak. Major factors affecting the proper implementation of IPC included: lack of IPC infrastructure, appropriate PPE and other essential supplies at healthcare facilities, and hand hygiene stations, and poor WASH infra‐ structure, inadequate systems for medical waste disposal, limited concepts of screening or

patients in future highly infectious outbreaks such as cholera.

triage, a lack of IPC knowledge among HCWs, and no IPC policies.

**(IPC), and general hospital functioning**

*6.1.1. Background to IPC in Sierra Leone*

fully operational.

38 Ebola

non-EVD medical care [26].

In the wake of the epidemic, with funding and technical assistance from the US Centres for Disease Control and Prevention and as part of the Presidential Recovery Plan for Ebola, a large national IPC Project was started in Sierra Leone, covering all MOHS public health units and hospital facilities, titled 'IPC in Hospitals Program'. The 12-month project began in March 2015 and the first stages involved constructing an IPC infrastructure within the country, from national to facility level.

A National IPC Coordinator was appointed and the National IPC Unit was established, based at MOHS. Two national IPC policies were drawn up: one for use during an outbreak of Ebola and one for use once in non-epidemic times. Each hospital appointed a MOHS staff member as an IPC Focal Person who would be responsible for IPC within their facility. Each of these Focal Persons was supported by an NGO worker, known as an IPC Mentor. KSLP allocated IPC mentors to four different facilities in Freetown, including one to Connaught Hospital these Mentors were international clinicians with a specific background in IPC. All of the IPC Focal Persons and IPC Mentors were sent on a specialist 2-week IPC training course to give them the specialist knowledge required to induct them into their new roles.

KSLP became a member of the Ebola Response Consortium (ERC), who gathered together the majority of partners involved in the project, enabling them to guide and monitor progress as well as instigate consistency among partners in the implementation of different stages of the project.

#### **6.2. Establishing IPC at Connaught Hospital**

The IPC team at Connaught was made up of an IPC Focal Person, IPC deputy and IPC NGO Mentor. KSLP also recruited an IPC Project coordinator who oversaw the project across the four hospital sites.

The newly formed Connaught IPC Team included an IPC Focal Person and appointed IPC Deputy who had extensive clinical and leadership experience within the hospital system and good working relationships with staff and management, liaison with MOHS, and specific IPC issues within their hospital. The KSLP IPC Mentor had a specific background and extensive training in infection control and technical knowledge and practical experience to help imple‐ ment the project. Together this combination of skills and experience within the team was key to improving IPC within the hospital. We garnered support from the Medical Superintendent, Matron, and departmental managers. The IPC Focal Person always chaired and arranged these meetings, as it was essential she was recognised as the central manager for IPC at Connaught.

With over 800 workers at the hospital and a physically large facility, the IPC team established a system of IPC link persons in each clinical department, as recommended by the KSLP IPC Mentor. These were mostly nurses selected by their managers to be advocates for IPC on the wards and other clinical areas, attend regular IPC meetings and to monitor and report relevant problems to the IPC team. A Patient Safety Committee was established, comprising of heads of departments that were relevant to IPC practice and implementation, such as the environ‐ mental services department, supplies manager, Matron, Medical Superintendent, senior ward managers, and representatives from high risk areas such as the laboratory, theatres and the Infectious Diseases Unit. The IPC Focal person always chaired the meetings and guided the agenda as it was essential to establish her as the key person for IPC across the hospital.

There were several key areas that the team worked on to improve IPC within the hospital, detailed below with examples of how we used partnership working to improve the IPC system at the facility.

#### *6.2.1. Supplies*

The IPC project highlighted a long-standing national problem of lack of essential supplies and an inadequate national supplies system. Vital items such as examination gloves, bin bags, sharps containers, liquid hand soap and hand sanitiser had always been in short supply or not supplied before or during the outbreak.

The first stage of the IPC in Hospitals Program trained all staff in key IPC elements including hand washing, how and when to use and dispose of PPE, waste segregation and sharps disposal. The Connaught IPC team were aware that the theoretical training would be less effective if staff were not able to fully employ what they had learnt due to lack of supplies in clinical areas. The IPC Team therefore decided to withhold training until they first established the appropriate facilities and supplies to aid implementation of IPC practices.

The hospital staff had long been used to poor access to essential supplies and the KSLP IPC Mentor and IPC Focal Person determined the best way to improve the internal supply chain. The IPC Team used KSLP connections to liaise with and highlight supply problems to the CMS, and linked with other NGOs to see how they tackled supply issues. The IPC Focal Person and deputy used their own status and networks within MOHS to try to address existing problems.

It was vital to establish long-term sustainability within systems and also to ensure that safe practices were maintained, particularly during the tail of the EVD epidemic: this often presented a challenge with supplies. When essential supplies were not received through national procurement, KSLP resolved to provide supplies in the interim, but worked with hospital management to establish a plan of providing supplies in the long term. This strategy was effective and within two months the hospital was procuring essential IPC supplies independently. The improvements seen were due to the efforts of the management and IPC Focal Person, with encouragement and support from KSLP, to redress the problems surround‐ ing long-term provision of supplies.

#### *6.2.2. Training*

Under guidance from the IPC in Hospitals Program, the Connaught IPC team set about training every HCW in relevant IPC aspects. Although HCWs in Sierra Leone had training during the outbreak, this was always focused on EVD and PPE, and not on more general aspects. Therefore, this was the first universal training of its kind in Sierra Leone and plans to involve all HCWs across the country were produced.

At Connaught, as with most institutions in the country, there is difficulty accessing lists of all relevant department employees, however after advertising the training the IPC Focal Person was able to organise attendees into the appropriate sessions. The team established two separate curricula for clinical and non-clinical staff. The IPC Focal Person and deputy highlighted specific IPC problems that clinical staff encountered and targeted the training around this, with the IPC Mentor giving guidance on specific technical areas. The non-clinical staff training presented a challenge as most participants were illiterate so the IPC team adapted training materials and used non-written assessment during the course. All team members were keen on pre- and postcourse testing for participants: the IPC Focal Person was clear that without assessment many would not study and attend all aspects of the course. The KSLP IPC mentor was aware of the valuable data that could be gathered from this training, and helped design appropriate tests, with the IPC Focal Person advising on what language was appropriate to use, the academic level of the participants and the types of questions that trainees would understand. The test was used to determine if participants should pass the training course and we shared resulting data with the hospital Monitoring and Evaluation department, the ERC, and relevant donors to help them understand IPC knowledge within the facility and the effectiveness of the training program.

#### **6.3. WASH**

managers, and representatives from high risk areas such as the laboratory, theatres and the Infectious Diseases Unit. The IPC Focal person always chaired the meetings and guided the agenda as it was essential to establish her as the key person for IPC across the hospital.

There were several key areas that the team worked on to improve IPC within the hospital, detailed below with examples of how we used partnership working to improve the IPC system

The IPC project highlighted a long-standing national problem of lack of essential supplies and an inadequate national supplies system. Vital items such as examination gloves, bin bags, sharps containers, liquid hand soap and hand sanitiser had always been in short supply or not

The first stage of the IPC in Hospitals Program trained all staff in key IPC elements including hand washing, how and when to use and dispose of PPE, waste segregation and sharps disposal. The Connaught IPC team were aware that the theoretical training would be less effective if staff were not able to fully employ what they had learnt due to lack of supplies in clinical areas. The IPC Team therefore decided to withhold training until they first established

The hospital staff had long been used to poor access to essential supplies and the KSLP IPC Mentor and IPC Focal Person determined the best way to improve the internal supply chain. The IPC Team used KSLP connections to liaise with and highlight supply problems to the CMS, and linked with other NGOs to see how they tackled supply issues. The IPC Focal Person and deputy used their own status and networks within MOHS to try to address existing problems.

It was vital to establish long-term sustainability within systems and also to ensure that safe practices were maintained, particularly during the tail of the EVD epidemic: this often presented a challenge with supplies. When essential supplies were not received through national procurement, KSLP resolved to provide supplies in the interim, but worked with hospital management to establish a plan of providing supplies in the long term. This strategy was effective and within two months the hospital was procuring essential IPC supplies independently. The improvements seen were due to the efforts of the management and IPC Focal Person, with encouragement and support from KSLP, to redress the problems surround‐

Under guidance from the IPC in Hospitals Program, the Connaught IPC team set about training every HCW in relevant IPC aspects. Although HCWs in Sierra Leone had training during the outbreak, this was always focused on EVD and PPE, and not on more general aspects. Therefore, this was the first universal training of its kind in Sierra Leone and plans to involve

the appropriate facilities and supplies to aid implementation of IPC practices.

at the facility.

40 Ebola

*6.2.1. Supplies*

supplied before or during the outbreak.

ing long-term provision of supplies.

all HCWs across the country were produced.

*6.2.2. Training*

As with many hospitals in Sierra Leone, there were occasional shortages of running water, and a lack of working sinks and taps, flushing toilets and functioning showers within Connaught, and it was clear that improved WASH infrastructure would have a direct impact on IPC practices within the hospital. It made IPC more implementable, and the sense of improvement and investment in hospital infrastructure raised HCW morale that subsequently increased enthusiasm for the project and improved IPC practice. With the involvement of the hospital management and the IPC team, we engaged an external contractor to work on WASH infrastructure and this was monitored and evaluated by KSLP, the ERC, MOHS and the President's office with regular updates given to Connaught senior management. In order to ensure longevity, new fixtures and fittings were procured internationally. The IPC team was keen to ensure that the fixtures would be properly maintained as they could not be easily replaced. KSLP management and the IPC team liaised with Connaught management and together we gave responsibility to the heads of each clinical department for the new fixtures and fittings in their area and ensured that they worked with the IPC team and regularly monitored WASH facilities. This provided a sense of responsibility and ownership from the clinical areas to ensure fittings were properly cared for. Successes outside of WASH included the construction of a building housing a new oxygen plant within Connaught Hospital.

#### **6.4. Ward assessments**

It was clear to the IPC Mentor and IPC Coordinator that there would need to be documented evidence of positive behaviour change and improved practice to submit to donors, the MOHS and the President's Office. The local IPC staff were not familiar with the concept of observa‐ tional audits, assessing routine practice and data reporting but were quick to grasp the concept when it became clear how useful it would be to project implementation. The IPC Mentor designed an initial ward assessment and audit tool and the local IPC staff were able to give input into what were the specific ward problems and how they should be monitored. The ERC were keen to develop national ward monitoring, and Connaught's assessment tool was used as the basis of the national tool given its success. Local members of the IPC team harnessed a competitive nature among staff through weekly and monthly IPC competitions based on the results of the ward assessments, with initial prizes and scores displayed in public areas around Connaught. This remains one of the most effective ways of improving IPC practice in the hospital, though early prizes were discontinued as it was felt this was not sustainable or desirable.

#### **6.5. Ongoing IPC at Connaught**

The focus on sustainability, partnership and knowledge-sharing meant that before the end of the project, the team established an ongoing IPC system within the hospital involving regular training, link nurse meetings, sustainable supply chains and regular ward monitoring with a focus on constant improvement and evidence based practice. With this in place, Connaught, as the main tertiary hospital in the country, can further develop to become a model for the IPC in Hospitals program and for other institutions hoping to improve their own IPC practice and systems.

#### **7. Command centre**

In September 2014, KSLP assisted the District Health Management Team (DHMT) for the Western Area in building a Command Centre, as a result of an emerging need to integrate a growing number of KSLP (and other) EHUs within the wider Ebola response, and to create robust systems to direct the flow of cases from the community to EHUs, and from EHUs to ETCs. Before this time, there was a major perceived risk of EHUs overflowing (with concom‐ itant risks to the safety of health care workers and patients), little was known of the number of suspect and probable cases within the Western Area, and there was no co-ordinated system for the transfer of suspect and positive EVD cases. With the support of KSLP, the Command Centre:


#### *7.1.1. Systems*

when it became clear how useful it would be to project implementation. The IPC Mentor designed an initial ward assessment and audit tool and the local IPC staff were able to give input into what were the specific ward problems and how they should be monitored. The ERC were keen to develop national ward monitoring, and Connaught's assessment tool was used as the basis of the national tool given its success. Local members of the IPC team harnessed a competitive nature among staff through weekly and monthly IPC competitions based on the results of the ward assessments, with initial prizes and scores displayed in public areas around Connaught. This remains one of the most effective ways of improving IPC practice in the hospital, though early prizes were discontinued as it was felt this was not sustainable or

The focus on sustainability, partnership and knowledge-sharing meant that before the end of the project, the team established an ongoing IPC system within the hospital involving regular training, link nurse meetings, sustainable supply chains and regular ward monitoring with a focus on constant improvement and evidence based practice. With this in place, Connaught, as the main tertiary hospital in the country, can further develop to become a model for the IPC in Hospitals program and for other institutions hoping to improve their own IPC practice and

In September 2014, KSLP assisted the District Health Management Team (DHMT) for the Western Area in building a Command Centre, as a result of an emerging need to integrate a growing number of KSLP (and other) EHUs within the wider Ebola response, and to create robust systems to direct the flow of cases from the community to EHUs, and from EHUs to ETCs. Before this time, there was a major perceived risk of EHUs overflowing (with concom‐ itant risks to the safety of health care workers and patients), little was known of the number of suspect and probable cases within the Western Area, and there was no co-ordinated system for the transfer of suspect and positive EVD cases. With the support of KSLP, the Command

**•** Created a system of real-time case-identification and reporting of suspect cases by ensuring that alerts from the national alerts hotline were conveyed to a Disease Surveillance Officer (DSO) as soon as received (within daylight hours), and that DSOs alerted the Command

**•** Tracked in real time the number of beds available in EHUs to ensure that cases were distributed according to space and facilities did not incur the risk of overflow, and to ensure

**•** Created a system of ambulance co-ordination to enable the transfer of suspect EVD cases from the community into EHUs, from EHUs already at capacity into other EHUs, and EVD-

Centre as soon as a suspect met the case definition

that every available bed was filled

positive patients to ETCs

desirable.

42 Ebola

systems.

Centre:

**7. Command centre**

**6.5. Ongoing IPC at Connaught**

All systems were either paper based, using simple spreadsheets or using whiteboards, and most operations were carried out by phone and SMS—systems that could be easily be understood and learnt.

In the absence of technological resources, large whiteboards were set out around the Command Centre to enable to whole team to track operations. These detailed the following:


#### *7.1.2. Early operations*

The early stages of set-up of the Command Centre at the DHMT, and particularly the presence of an international NGO embedded within in a government organisation, required a great deal of sensitivity to the enormous pressure the DHMT was under to respond to the rapidly growing numbers of cases in the Western Area. One of the key aims of the Command Centre was to create an objective referral system that regulated strictly prevented the overflow of the already severely limited capacity of existing EHUs and ETCs. Severe shortages of beds, ambulances, training and other resources meant that a majority of EVD-suspect cases could not be moved from their homes within 24 h. The first weeks of Command Centre operations drew attention to acute gaps in the response and the need for a rapid scale up of resources, capacity and services, such as co-ordinated ambulance, laboratory and burial services; the need for specific EVD-related services for special populations (pregnant women, neo-nates and children, those with mental health needs); better co-ordination between pillars and partners on district and national levels; better allocation and prioritisation of resources and the formation of consistent strategic policy.

Whilst data generated by the Command Centre called immediate attention to both the severity of the outbreak in the Western Area and the acute lack of resources available to mount a robust response, it was also perceived to reflect adversely on the DHMT's management of the response. KSLP remained aware of the DHMT's concerns, and tried to ensure that its rela‐ tionship with the DHMT was both supporting and supportive, both operationally and in public. However, such issues highlighted how essential it was to ensure that the Command Centre was represented by a trusted figurehead with thorough knowledge of national context and good relationships with local and national government bodies, who could actively promote Command Centre operations but also resolve sensitive issues diplomatically. In the absence of such a figure during the early response period, KSLP, as the external partner helping build the Command Centre systems was continually at risk of being perceived as an under‐ mining force.

#### *7.1.3. Evolution*

As a result of reporting from the Command Centre, in November 2014, with support from the Government of Sierra Leone and international donors, a NERC was built to ensure coordination and implementation of strategy and resources at national scale, to oversee Ebola Response Centres in each District (DERC). A DERC comprised of surveillance, case manage‐ ment, burial, quarantine, laboratory sample co-ordination and protection cells. The DERC model, which began in the Western Area and which evolved directly from operations at the DHMT Command Centre, was implemented across the country, with adaptations in line with the needs and requirements of each district.

Having assisted with the migration of the DHMT Command Centre and its functions into this new structure, KSLPs work within the DERC in the Western Area continued to focus primarily on the 'Live Case Management' cell, with a rapidly expanded team of national volunteers, who were by this time well-trained in the core processes outlined above.

#### **7.2. Staffing**

Staffing of the Live Case Management Cell were divided into five 'teams' in a flat structure under a co-ordinator who was ultimately responsible for overseeing day-to-day operations of the cell:.

Chief functions of each team were as follows:


#### **7.3. Case prioritisation**

on district and national levels; better allocation and prioritisation of resources and the

Whilst data generated by the Command Centre called immediate attention to both the severity of the outbreak in the Western Area and the acute lack of resources available to mount a robust response, it was also perceived to reflect adversely on the DHMT's management of the response. KSLP remained aware of the DHMT's concerns, and tried to ensure that its rela‐ tionship with the DHMT was both supporting and supportive, both operationally and in public. However, such issues highlighted how essential it was to ensure that the Command Centre was represented by a trusted figurehead with thorough knowledge of national context and good relationships with local and national government bodies, who could actively promote Command Centre operations but also resolve sensitive issues diplomatically. In the absence of such a figure during the early response period, KSLP, as the external partner helping build the Command Centre systems was continually at risk of being perceived as an under‐

As a result of reporting from the Command Centre, in November 2014, with support from the Government of Sierra Leone and international donors, a NERC was built to ensure coordination and implementation of strategy and resources at national scale, to oversee Ebola Response Centres in each District (DERC). A DERC comprised of surveillance, case manage‐ ment, burial, quarantine, laboratory sample co-ordination and protection cells. The DERC model, which began in the Western Area and which evolved directly from operations at the DHMT Command Centre, was implemented across the country, with adaptations in line with

Having assisted with the migration of the DHMT Command Centre and its functions into this new structure, KSLPs work within the DERC in the Western Area continued to focus primarily on the 'Live Case Management' cell, with a rapidly expanded team of national volunteers, who

Staffing of the Live Case Management Cell were divided into five 'teams' in a flat structure under a co-ordinator who was ultimately responsible for overseeing day-to-day operations of

**•** Case management: focal point for all EHUs and ETCs; determine bed occupancy and availability for transfers and track on whiteboards; communication of lab results, determine the movement of suspect and positive EVD cases, track and record details of patients across

**•** Fleet management: Manage the maintenance, fuelling and supply of ambulances, ambu‐

were by this time well-trained in the core processes outlined above.

formation of consistent strategic policy.

the needs and requirements of each district.

Chief functions of each team were as follows:

all units and their outcomes

lance staff rotas

mining force.

44 Ebola

*7.1.3. Evolution*

**7.2. Staffing**

the cell:.

Still with an acute shortage of beds, KSLP introduced an accessible, public health-based scoring system to prioritise collection of suspect EVD cases based on their clinical state, whether they were from a home that was already quarantined, the number of people residing in the household, and their vulnerability, e.g. children under 15 who were alone, cases in public places, cases with known or perceived mental health issues.

#### **7.4. Co-ordination**

A rapid scale up of EHUs and ETCs across the Western Area began in November 2014. The Live Case Management cell, with KSLP support, became the focal point for co-ordinating and monitoring the safe opening of these facilities, ensuring each facility fully integrated with DERC systems and processes. This rapid expansion also signalled a greater need for coordination between EHUs and ETCs, which led to the introduction of weekly meetings, led by KSLP. These meetings became a valuable forum for updating partners on the wider picture of the response, assessing outbreak trends, for discussing daily clinical challenges, and for providing a vital feedback loop for the Live Case Management Cells on their operations. With King's support, a 'scorecard' system based on the throughput of patients through facilities, was produced and presented to all facility representatives at these meetings, which incenti‐ vised lower performing facilities to quickly resolve bottlenecks that hindered optimal through‐ put.

#### **7.5. Reporting**

KSLP's more targeted support to the Live Case Management Cell included developing existing capacity within the data team to generate sophisticated reports from their main database (a simple but extensive spreadsheet). As a result of KSLP's assistance in this area, by January 2015 the data team within the Cell were able to:

**•** Generate daily reports with Key Performance Indicators (KPIs) such as percentage occu‐ pancy of holding and treatment beds, the percentage of suspect EVD cases attended to within a 24-h period, and the inflow and outflow of cases through EHUs and into ETCs. Such KPIs facilitated tailored decision making at strategic levels of the response, for example EHU and ETC expansion was planned according to need, and additional resources were allocated as needed to ensure that suspect EVD cases were responded to within a 24-h period.


**Figure 3.** Live case management operational flow.

#### *7.5.1. SMS Platform*

Such KPIs facilitated tailored decision making at strategic levels of the response, for example EHU and ETC expansion was planned according to need, and additional resources were allocated as needed to ensure that suspect EVD cases were responded to within a 24-h

**•** Develop metrics to assess case flow from the time of identification of a suspect case by a DSO, through to discharge (if EVD-negative) or to ETC (if EVD-positive). These metrics were crucial in assessing the throughput of cases through facilities, identifying bottlenecks in the system, and enabling facilities to assess and optimise their own performance (see **Figure 3**). The optimal throughput target was for a suspect EVD case to be tested and either

**•** Collect and aggregate simple clinical data such as fatality rates and rates of discharge across

**•** Assess and aggregate the number of EVD suspect cases admitted to EHUs via notification to the national hotline, and the number of EVD suspect cases arriving at EHUs of their own volition, thereby helping policy makers assess and monitor the use and effectiveness of the

**•** Maintain a database of all suspect EVD cases in the Western Area and their paths to testing and treatment, eventually enabling status updates to be given to families as required.

discharged or transferred to an ETC within 24 h of admission.

EHU and ETCs for use by EHUs, ETCs and epidemiological partners.

period.

46 Ebola

national hotline.

**Figure 3.** Live case management operational flow.

KSLP supported an SMS platform to relay laboratory results to EHUs as close as possible to the publication of results. This was crucial in a low-resource setting with limited internet and data sharing capabilities, and the system was later adopted by laboratories in the Western Area. Relaying results via SMS from source sought to minimise errors in communication and create accountability for the reporting of results by creating a record of time between the receipt of results by the Live Case Management Command Cell and the time results were relayed by SMS.

#### **7.6. Lasting capacity**

By the time KSLP phased out its support of the Western Area DERC in March 2015, a team of twenty national volunteers were able to confidently manage the Live Case Management Cell, and continued to utilise the systems KSLP helped to put in place to manage case flow. A number of national staff were seconded during later periods of the outbreak to support and mentor teams in other districts of Sierra Leone.

#### **8. Legacy of EVD partnership working**

Moving forward, KSLP has ongoing partnership and collaboration with the national secretary of HIV and TB, providing technical support for training, elaboration and implementation of treatment and management guidelines. Together we have established the first infectious diseases unit in the country at the main referral hospital, and will work with the medical school to undertake teaching of medical students in infectious diseases.

KSLP will assist Connaught in creating a Centre of Excellence in Infectious diseases to be a hub for care, education and research of infectious diseases. The main aims are to build individual, institution and national clinical research capacity in infectious disease response, with a focus on three work streams:


There is also very limited information available on antimicrobial resistance across the region, and KSLP aims to work with Connaught and partners in developing protocols for clinical management of patients based on a variety of syndromic management. The new ID unit will have an electronic patient record established in order to track demographics and clinical syndromes of patients. Other areas of clinical activity will include the ongoing care of those suffering sequelae of EVD infection, as ongoing IPC and WASH developments continue. KSLP and Connaught are also working with MOHS to initiate free tertiary care for adult Ebola survivors at the hospital.

These outcomes described were delivered through a partnership model. In this chapter we have revisited the various stages of the EVD outbreak, from early triage and case definitions, through ramping up isolation and treatment capacity, to how best to retain and develop resilience in health systems, alongside research efforts and outbreak control principles. We hope we have highlighted how an embedded organisation working in close collaboration with senior leaders in an MOHS hospital and other partners can assist in developing institutional and national response.

#### **Glossary**


#### **Author details**

and Connaught are also working with MOHS to initiate free tertiary care for adult Ebola

These outcomes described were delivered through a partnership model. In this chapter we have revisited the various stages of the EVD outbreak, from early triage and case definitions, through ramping up isolation and treatment capacity, to how best to retain and develop resilience in health systems, alongside research efforts and outbreak control principles. We hope we have highlighted how an embedded organisation working in close collaboration with senior leaders in an MOHS hospital and other partners can assist in developing institutional

Central Medical Stores CMS College of Medicine & Allied Health Sciences COMAHS Community Care Centre CCC District Ebola Response Centre DERC District Health Management Team DHMT Disease Surveillance Officer DSO Ebola Holding Unit EHU Ebola Response Consortium ERC Ebola Treatment Centre ETC Ebola Virus Disease EVD Health Care Worker HCW Human Immunodeficiency Virus HIV Infection Prevention and Control IPC Key Performance Indicators KPI King's Health Partners KHP King's Sierra Leone Partnership KSLP National Ebola Response Centre NERC Non-Governmental Organisations NGOs Personal Protective Equipment PPE Polymerase chain reaction PCR Public Health England PHE Rapid Diagnostic Test RDT Tuberculosis TB Ministry of Health & Sanitation MOHS Water, sanitation & hygiene WASH

survivors at the hospital.

and national response.

**Glossary**

48 Ebola

King's Sierra Leone Partnership:

Colin S Brown1,2\*, Mohamed Elsherbiny1 , Oliver Johnson1 , Amardeep Kamboz1 , Marta Lado1 , Andrew Leather1 , Natalie Mounter1 , Suzanne Thomas1 , Dan Youkee1 , Naomi Walker1,3

Ministry of Health & Sanitation and Connaught Hospital:

Waheed Awonuga4 , TB Kamara4,5, Cecilia Kamara5 , Quaanan Kessete4 , Ramatu Ngauja5

1 King's Sierra Leone Partnership, King's Centre for Global Health, King's College London, and King's Health Partners, London, United Kingdom

2 Hospital for Tropical Diseases, University College London Hospital, London, United Kingdom

3 Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom

4 College of Medicine and Allied Health Sciences, Freetown, Sierra Leone

5 Ministry of Health and Sanitation, Sierra Leone

\*Address all correspondence to: colin.1.brown@kcl.ac.uk

#### **References**


five Ebola Holding Units in Western Area, Sierra Leone. Tropical Medicine & Interna‐ tional Health, March 2016, accepted pending minor revisions.


[7] Brown CS, Cropley I. Ebola virus disease: where are we now and where do we go.

[8] UK Government Press Release. First British Ebola treatment facility opens in Sierra

[9] Olu O, Cormican M, Kamara KB, Butt W. Community Care Centre (CCC) as adjunct in the management of Ebola Virus Disease (EVD) cases during outbreaks: experience from

[10] Brown CS, Arkell P, Rokadiya S. Ebola virus disease – the 'Black Swan' in West Africa.

[11] Johnson O, Youkee D, Brown CS, et al. Ebola Holding Units at Government Hospitals in Sierra Leone: evidence for a flexible and effective model for safe isolation, early treatment initiation, hospital safety, and health system functioning. BMJ Global Health,

[12] King's Sierra Leone Partnership. A Guide for the Establishment & Supervision of Ebola

[13] Boumandouki P, Formenty P, Epelboin A, et al. Clinical management of patients and deceased during the Ebola outbreak from October to December 2003 in Republic of Congo. Bulletin De La Societe De Pathologie Exotique 2005;98(3):218–23 [in French].

[14] Roddy P, Howard N, Van Kerkhove MD, et al. Clinical manifestations and case management of Ebola haemorrhagic fever caused by a newly identified virus strain,

[15] Guimard Y, Bwaka MA, Colebunders R, et al. Organization of patient care during the Ebola hemorrhagic fever epidemic in Kikwit, Democratic Republic of the Congo, 1995.

[16] Nkoghe D, Kone ML, Yada A, Leroy E. A limited outbreak of Ebola haemorrhagic fever in Etoumbi, Republic of Congo, 2005. Transactions of the Royal Society of Tropical

[17] Lado M, Walker NF, Baker P, et al. Clinical features of patients isolated for suspected Ebola virus disease at Connaught Hospital, Freetown, Sierra Leone: a retrospective

[18] Brown CS, Kessete Q, Baker P, et al. Bottlenecks in health systems functioning for control of Ebola Virus Disease in Connaught Hospital, Freetown, Sierra Leone. Poster Presentation P0092, European Conference on Clinical Microbiology and Infectious

[19] Arkel P, Youkee D, Brown CS, et al. Quantifying the risk of nosocomial infection within Ebola Holding Units: a retrospective cohort study of negative patients discharged from

Bundibugyo, Uganda, 2007–2008. PLoS One 2012;7(12):e52986.

Journal of Infectious Diseases 1999;179 Suppl 1:S268–73.

Medicine and Hygiene 2011;105(8):466–72.

cohort study. Lancet ID 2015;15(9):1024–33.

Diseases, Amsterdam, 2016.

Sierra Leone. Pan African Medical Journal 2015;22:Suppl 1–14.

Postgrad Med J 2014;90:610–12.

50 Ebola

Leone. London: Gov. UK, 2014.

Tropical Doctor 2015;45(1):2–5.

Holding Units. Freetown: KSLP, 2014.

accepted for publication


#### **Chapter 3**

## **Ebola Preparedness and Risk in Latin America**

Alfonso J. Rodriguez‐Morales, Jaime Andrés Cardona‐Ospina, Sivia Fernanda‐Urbano, Katherinn Melissa Nasner‐Posso, Stefania Cruz‐Calderón, Carlos E. Calvache‐Benavides, Yudy Lorena Delgado‐Pascuaza, Juan Camilo Castillo, Maria Yamile Alvarez‐Ríos, Hamilton A. Marín‐Rincón, Liceth Urrutia and Alberto Paniz‐Mondolfi

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62945

#### **Abstract**

Until today, February 22, 2016, no confirmed Ebola cases have been diagnosed in Americas (except USA, four cases with one death). Confusion, lack of knowledge, and fear have led to quickly misclassify cases as suspected, when in fact most of them are false alarms. Nevertheless, European governments summoned to mobilize resources to attend the Ebola outbreak in West Africa. And also Latin American governments should contrib‐ ute to halt this humanitarian crisis and to be prepared for the potential arrival of this deadly virus in the Caribbean, Central, and South American mainland. In this chapter, we described the experience of preparedness as well as risk assessment done in Latin America regarding the threat of Ebola for the region.

**Keywords:** Ebola, preparedness, risk assessment, travel medicine, Latin America

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **1. Introduction**

Ebola virus (EBOV) was the second genus of the Filoviridae family to be discovered. This negative‐sense, single‐stranded RNA virus was first identified in 1976 following two simulta‐ neous outbreaks in Zaïre (now known as the Democratic Republic of Congo) and Sudan [1–4]. Since then, at least 25 subsequent outbreaks, including the ongoing outbreak in West Africa, have occurred and various EBOV species have been identified with genetic and virulence variability and still unknown pathogenesis. Before 2014, none of those epidemics implied imported cases outside Africa, with its multiple implications [1–9].

Nowadays, the ongoing outbreak (almost finished) in West Africa has been the largest reported in history, and from a global health perspective, it showed again how poverty, cultural practices, and weak and unprepared health systems could interact exacerbating infectious disease spread, limiting its control and mitigation, and the importance of travel in a globalized world, since this was the first outbreak in which EBOV cases and transmission were reported outside of Africa [5, 6, 8].

This outbreak has challenged global capability of response of world policymakers to organize and implement resources in an impoverished and previous overlooked area, it taught the implication of reactive rather than proactive health systems organization, and in a setting of unpreparedness and lack of knowledge, social media played an important role in spreading unfounded fear through false alarms [5, 6, 8].

Until today, February 14, 2016, a total of 28,639 cases and 11,316 deaths (case fatality rate [CFR %] of 39.5%) were reported according to the World Health Organization (WHO) report of February 17, 2016 [10]. The majority of these cases and deaths occurred between August and December 2014, after which case incidence declined apparently associated with scale‐up of treatment, isolation, and safe burial.

In the last 21 days, zero cases were reported in the implicated countries (Guinea, Liberia, and Sierra Leone) and on November 7, 2015, December 29, 2015, and January 14, 2016, the WHO declared that human‐to‐human transmission of Ebola virus has ended in Guinea, Sierra Leone, and Liberia, respectively, if no further cases appear, entering in a period of heightened surveillance, putting these countries in the way on recovery, and giving the chance of getting essential health services backup and to address weaknesses to rebuild a resilient health system [10].

Likewise, there were a total of seven cases reported outside of African continent with one death at USA [10]. Countries involving imported cases outside Africa have been Italy, Spain, United Kingdom, and USA (each one with one case, except USA with four cases) [11] (**Figure 1**), without truly suspected cases in Latin America and the Caribbean (LAC) [6–13].

Nevertheless, European governments summoned to mobilize resources to attend the Ebola outbreak in West Africa during the peak of the epidemics [14–16]. But also LAC governments have been called to contribute to halt this humanitarian crisis and to be prepared for the potential arrival of this deadly virus in the Caribbean, Central, and South American mainland, particularly during the peak of the epidemics in Africa. In this chapter, we described the experience of risk assessment as well as preparedness done in Latin America regarding the threat of Ebola for the region.

**Figure 1.** Confirmed, probable, and suspected EVD cases worldwide. From: WHO Ebola Situation Report – February 17, 2016.

#### **2. Risk assessment**

**1. Introduction**

54 Ebola

outside of Africa [5, 6, 8].

unfounded fear through false alarms [5, 6, 8].

treatment, isolation, and safe burial.

[10].

Ebola virus (EBOV) was the second genus of the Filoviridae family to be discovered. This negative‐sense, single‐stranded RNA virus was first identified in 1976 following two simulta‐ neous outbreaks in Zaïre (now known as the Democratic Republic of Congo) and Sudan [1–4]. Since then, at least 25 subsequent outbreaks, including the ongoing outbreak in West Africa, have occurred and various EBOV species have been identified with genetic and virulence variability and still unknown pathogenesis. Before 2014, none of those epidemics implied

Nowadays, the ongoing outbreak (almost finished) in West Africa has been the largest reported in history, and from a global health perspective, it showed again how poverty, cultural practices, and weak and unprepared health systems could interact exacerbating infectious disease spread, limiting its control and mitigation, and the importance of travel in a globalized world, since this was the first outbreak in which EBOV cases and transmission were reported

This outbreak has challenged global capability of response of world policymakers to organize and implement resources in an impoverished and previous overlooked area, it taught the implication of reactive rather than proactive health systems organization, and in a setting of unpreparedness and lack of knowledge, social media played an important role in spreading

Until today, February 14, 2016, a total of 28,639 cases and 11,316 deaths (case fatality rate [CFR %] of 39.5%) were reported according to the World Health Organization (WHO) report of February 17, 2016 [10]. The majority of these cases and deaths occurred between August and December 2014, after which case incidence declined apparently associated with scale‐up of

In the last 21 days, zero cases were reported in the implicated countries (Guinea, Liberia, and Sierra Leone) and on November 7, 2015, December 29, 2015, and January 14, 2016, the WHO declared that human‐to‐human transmission of Ebola virus has ended in Guinea, Sierra Leone, and Liberia, respectively, if no further cases appear, entering in a period of heightened surveillance, putting these countries in the way on recovery, and giving the chance of getting essential health services backup and to address weaknesses to rebuild a resilient health system

Likewise, there were a total of seven cases reported outside of African continent with one death at USA [10]. Countries involving imported cases outside Africa have been Italy, Spain, United Kingdom, and USA (each one with one case, except USA with four cases) [11] (**Figure 1**),

Nevertheless, European governments summoned to mobilize resources to attend the Ebola outbreak in West Africa during the peak of the epidemics [14–16]. But also LAC governments have been called to contribute to halt this humanitarian crisis and to be prepared for the potential arrival of this deadly virus in the Caribbean, Central, and South American mainland,

without truly suspected cases in Latin America and the Caribbean (LAC) [6–13].

imported cases outside Africa, with its multiple implications [1–9].

Some studies have provided perspectives on the potential for Ebola virus disease (EVD) to spread across international borders via commercial air travel [17–20]. However, they have only focused on top international destinations in Africa, Europe, Asia, and North America. Recently, we have assessed this for Latin American countries.

During the peak of the epidemics, we gathered epidemiological data from the Ebola response roadmap situation report of the World Health Organization (WHO) (for October 29, 2014) [20]. We included Sierra Leone, Guinea, and Liberia as officially affected regions by the EVD epidemics. Because data concerning commercial air travel out of Guinea, Liberia, and Sierra Leone to LAC countries were unavailable, we used population migration data from the United Nations' international migrant stock by destination and origin database (estimates of the international migrant stock exodus for the midpoint [1 July] of each year: 1990, 2000, 2010, and 2013). We assessed the number of people migrating from Guinea, Liberia, and Sierra Leone to LAC countries in years 2000, 2010, and 2013. We also included within those numbers all potential returns of previously deployed persons from LAC countries to affected West African nations. We took the maximum number of migrating people from West African countries to LAC during those three years, as the potential number of people migrating in 2014, followed by an estimation on the prevalence of EBV in source countries (cases/100,000 pop and %), based on WHO reports and official population estimates, gathered from the World Bank registry data. We assumed a random distribution of prevalence among population as equal for migrating people in order to calculate the number of potential persons migrating with EBV to CSA countries [8].

Up to October 29, 2014, WHO reported 13,676 cases of EBV, with 6535 cases from Liberia, Sierra Leone (5235), and Guinea (1906). During the last 21 days, 1433 active cases were reported in Sierra Leone, 867 in Liberia, and 666 in Guinea, revealing prevalence rates for this period of 23.52 cases/100,000 pop (0.0235%), 20.19 cases/100,000 pop (0.0202%), and 5.67 cases/100,000 pop (0.0057%), respectively [8, 20].

Based on those prevalence rates and assuming migration numbers would be similar for 2014, we estimated the potential number of people with EVD relying on each country's individual prevalence, which resulted in a probability of less than 1 possible EVD case potentially arriving to LAC countries. Assuming the same prevalence of active cases, migration should increase up to 4255 persons/year from Sierra Leone, 4950 from Liberia, and 17,544 from Guinea, to reach at least 1 case in some Latin American countries [8].

Previous reports estimated that one infected international air traveler would leave Guinea every 2.7 months, Liberia every 0.2 months, and Sierra Leone every 0.6 months [17–20]. However, such numbers may represent an underestimate of the real situation if we take into consideration the fact of potential cases originating from the shipping sector and spreading through maritime transport. In addition, connection flights (e.g. Bogota, Colombia to Monro‐ via, and Liberia with connections at New York, USA, and Casablanca, Morocco) may increase the odds of affected passengers to reach Latin America from these countries by connecting through such alternate bridging destinations [8].

Based on the aforementioned facts, the possibility of EVD spreading to Latin America raises concerns in regard to the capacity of healthcare institutions and laboratories in the region to provide adequate facilities, competently trained healthcare staff, acceptable infection control measures and equipment, supplies, protocols and resources to provide effective disease management, diagnosis, and overall containment strategies [6, 8]. Previously, WHO published the public health actions for early detection and prevention of transmission of Ebola and Marburg viruses. Even in a low‐risk setting, there are significant concerns over whether Latin American countries are ready to face EVD within their vulnerable healthcare systems [6, 8]. Fortunately, after the epidemics in Africa, none confirmed cases nor real suspected cases arrived to Latin America, although most countries in the region, particularly Brazil and Colombia, were prepared for the arrival, developed national guidelines for preparedness, and managed some false alarms properly, in most of the cases.

#### **3. Preparedness**

Leone to LAC countries were unavailable, we used population migration data from the United Nations' international migrant stock by destination and origin database (estimates of the international migrant stock exodus for the midpoint [1 July] of each year: 1990, 2000, 2010, and 2013). We assessed the number of people migrating from Guinea, Liberia, and Sierra Leone to LAC countries in years 2000, 2010, and 2013. We also included within those numbers all potential returns of previously deployed persons from LAC countries to affected West African nations. We took the maximum number of migrating people from West African countries to LAC during those three years, as the potential number of people migrating in 2014, followed by an estimation on the prevalence of EBV in source countries (cases/100,000 pop and %), based on WHO reports and official population estimates, gathered from the World Bank registry data. We assumed a random distribution of prevalence among population as equal for migrating people in order to calculate the number of potential persons migrating with EBV to

Up to October 29, 2014, WHO reported 13,676 cases of EBV, with 6535 cases from Liberia, Sierra Leone (5235), and Guinea (1906). During the last 21 days, 1433 active cases were reported in Sierra Leone, 867 in Liberia, and 666 in Guinea, revealing prevalence rates for this period of 23.52 cases/100,000 pop (0.0235%), 20.19 cases/100,000 pop (0.0202%), and 5.67 cases/100,000

Based on those prevalence rates and assuming migration numbers would be similar for 2014, we estimated the potential number of people with EVD relying on each country's individual prevalence, which resulted in a probability of less than 1 possible EVD case potentially arriving to LAC countries. Assuming the same prevalence of active cases, migration should increase up to 4255 persons/year from Sierra Leone, 4950 from Liberia, and 17,544 from Guinea, to reach

Previous reports estimated that one infected international air traveler would leave Guinea every 2.7 months, Liberia every 0.2 months, and Sierra Leone every 0.6 months [17–20]. However, such numbers may represent an underestimate of the real situation if we take into consideration the fact of potential cases originating from the shipping sector and spreading through maritime transport. In addition, connection flights (e.g. Bogota, Colombia to Monro‐ via, and Liberia with connections at New York, USA, and Casablanca, Morocco) may increase the odds of affected passengers to reach Latin America from these countries by connecting

Based on the aforementioned facts, the possibility of EVD spreading to Latin America raises concerns in regard to the capacity of healthcare institutions and laboratories in the region to provide adequate facilities, competently trained healthcare staff, acceptable infection control measures and equipment, supplies, protocols and resources to provide effective disease management, diagnosis, and overall containment strategies [6, 8]. Previously, WHO published the public health actions for early detection and prevention of transmission of Ebola and Marburg viruses. Even in a low‐risk setting, there are significant concerns over whether Latin American countries are ready to face EVD within their vulnerable healthcare systems [6, 8]. Fortunately, after the epidemics in Africa, none confirmed cases nor real suspected cases arrived to Latin America, although most countries in the region, particularly Brazil and

CSA countries [8].

56 Ebola

pop (0.0057%), respectively [8, 20].

at least 1 case in some Latin American countries [8].

through such alternate bridging destinations [8].

We acknowledged a huge need for field‐based laboratories, epidemiological and microbio‐ logical surveillance resources, diagnostic equipment, and mobile communications software as well as other technological assets. As revealed by the ongoing chikungunya and Zika epidem‐ ics [21–25], LAC is particularly vulnerable to infectious disease spreading given that there is a lack of appropriate healthcare infrastructure to tackle a challenge of such dimensions, particularly from airborne (e.g. Influenza H1N1 in 2009) and vector‐borne diseases [22, 26]. However, regarding the collaboration to intervene the crisis, it is important to highlight that the Cuban government sent a team of 165 highly trained healthcare professionals to assist and mitigate the epidemic, being, so far, the largest medical team that any single foreign country sent out to the field, from LAC to Africa [6, 8].

Besides that, the Pan American Health Organization (PAHO) [15], along with the WHO, have recommended nations to implement measures based on surveillance [20], laboratory diagno‐ sis, case management, infection prevention and control, clinical management and awareness and communication. This in order to be prepared and to have an appropriate response to the hypothetical arrival of EVD to LAC, which as has been mentioned, was expected to be low to very low [6, 8]. Although early detection, tracing, and isolation of truly suspected cases and contacts would limit the risk of disease spread, the proper laboratory assessment and sample management will be restricted given the lack of trained health personnel, protective equip‐ ment, and adequate transport particularly in some highly densely populated areas, where poverty and deficient basic services constitute a melting point for the development of potential outbreaks. Health personnel must be capable to manage risk group 4 pathogen, as EBOV, and must account with protective equipment like non‐sterile gloves, masks, goggles preferably with an anti‐fog visor and apron or waterproof apron, disposable if possible [6, 8, 16, 18]. Additionally, staff in charge of handling and transporting the samples must account with a certification by the International Air Transport Association for shipping and handling Category A infectious substance in order to send samples to the only two laboratories in the region that can receive them: the National Center for Emerging Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC) and Zoonotic Diseases and Special Pathogens, National Microbiology Laboratory, Infectious Disease and Emergency Preparedness Branch Public Health Agency of Canada. Furthermore, as opposed to Europe, where BSL‐4 (BSL‐4) laboratories network already exists, LAC still requires a significant increase in technical partnership as well as other resource capabilities, BSL‐4 in LAC are scarce what has limited the work with other important BSL‐4 required viral pathogens endemic to the region, such as hantaviruses in the past and in the middle of current of cases of this zoonotic viruses in Chile and other countries in the region [6, 8, 16, 18].

On the other hand, if EBOV arrives to LAC, it would pose an immense diagnostic challenge in a region where endemic viral hemorrhagic fevers exhibit remarkable similar clinical findings. Distinguishing cases of Guanarito (Venezuela), Machupo (Bolivia), Junín (Argenti‐ na), and Sabiá (Brazil) viruses from Ebola, as well as from other highly prevalent infections such as yellow fever, dengue with hemorrhagic manifestations, leptospirosis, and typhoid fever, among others, will constitute an ever‐increasing challenge. Point‐of‐care testing using a biothreat panel like the BioFire diagnostics BioSurveillance system would be useful for screening highly suspicious cases, while at the same time, providing an automated sample‐to‐ answer diagnostic platform in areas with lack of healthcare trained personnel, even though rapid diagnostic test use is discouraged given its low specificity. We still do not know how such tests would perform in a non‐prevalent Ebola region, and at the same time, it could be cost prohibitive for many governments in the hemisphere [6, 8, 16, 18].

Otherwise, the clinical management of those suspected and confirmed cases should be at designated hospitals that must comply with contact isolation conditions, ideally individually and not by cohorts of suspected or confirmed cases, appropriate provisions of personal protective equipment, and health services with personnel trained in infection prevention and control [6, 8, 16, 18]. These characteristics probably are lacking even in some intermediate cities of LAC forcing to translate patients to places where these are attained and making to consider that transport of those patients needs special protective measures too. Even more, healthcare institutions should start joining efforts to design preparedness and response programs in order to revamp or build up de novo infrastructure to properly address suspicious cases and prepare healthcare professionals for caring of confirmed Ebola‐infected patients. It is also important to coordinate this LAC response to Ebola with the guidance of the regional multilateral health organisms: The PAHO should lead this process; and the recently created South American Institute of Government in Health (www.isags‐unasur.org) and the South American National Institutes of Health Network could demonstrate their ability to recruit and materialize resources for global health [6, 8, 16, 18].

The call for attention that was the EBOV outbreak highlighted the importance of proactive organization of health systems particularly in those settings in which poverty, social inequal‐ ity, and lack of basic healthcare services and facilities could limit action when an infectious disease has established [6, 8, 16, 18]. Many countries in LAC have proved its restraints in infectious disease control, as recently reported for malaria, dengue, chikungunya, and Zika in Venezuela, and its social and economic context can act as boosters for infection spread [22, 26]. As taught, the entire world needs to turn out its look and watch for those impoverished areas before crisis, searching to close gaps in order to reach fairer societies.

Latin America is endemic for many febrile infectious diseases conditions; then, signs and symptoms of EVD may overlap with other acute viral hemorrhagic fevers like dengue, chikungunya, and now Zika posing a challenge at the time of diagnosis [9]. Despite the low‐ risk for a local outbreak in LAC, the possibility of an imported case always remains latent [6, 8]. Thus, in light of such hypothetical epidemiological scenario, we also considered that assessing knowledge and perceptions among healthcare students and workers about the epidemiology, transmission, and clinical manifestations of Ebola in a country like Colombia is of utmost importance; particularly, taking into account that before the 2014–2015 epidemic, no information concerning EVD was available in Colombia's public health surveillance program [9]. Then, an observational, descriptive, cross‐sectional study was conducted among 107 healthcare workers attending the symposium "What we should know about Ebola?" (organized by the Coffee Triangle regional chapter of the Colombian Association of Infectious Diseases and the Universidad Tecnológica de Pereira) held in October (2014) in one city of Colombia: Pereira, Risaralda [9]. Attendees who agreed to be part of the research (convenience sample) filled out a basic knowledge questionnaire, which included aspects on the epidemi‐ ology, symptoms, and prevention of the disease (five questions). Questionnaires were completed before and after the event. Statistical analysis was performed using the SPSS statistical package, version 19.0. A chi‐square test (*p* < 0.05) was run to assess the significance and compare observed frequencies of correct answers before and after the symposium. The results obtained for each individual question revealed an increasing statistical significance when comparing presurvey to postsurvey answers (*p* < 0.05), highlighting the pivotal role of disease prevention, surveillance, preparedness, and response informational resources [9].

As healthcare workers, it is essential to rely on complete and updated information about emergent diseases such as EVD, a disease which has recently been cataloged by WHO as an international public health emergency. Unfortunately, to date, many aspects on the basic ecology, transmission, and pathogenesis of the disease remain unclear. The possibility that different species of bats and primates endemic to the New World could serve as hosts for the virus remains a lurking possibility, as well as a threat to the possible arrival of this disease to the Americas [9].

A lack of experience on how to recognize its signs and symptoms as well as how to approach and manage outbreaks still remains a challenge in most affected countries and a most inherent peril to unaffected regions. All in all, it is imperative to call for awareness and prepare to handle and recognize this disease, for which world class organizations like the CDC and WHO have already issued the necessary guidelines on how to prevent possible epidemics through early recognition of cases, as well as how to achieve prompt institution of containment measures [9].

Due to a lack of efficient healthcare policies and systems, Latin American countries are particularly vulnerable to infectious diseases, as it has been shown with other endemic infectious maladies such as chikungunya, Zika, and malaria [22–26]. In view of this, besides preparing for preventive and interventional actions, educational resources should also aim to battle the negative impact of misinformation and fear, which may lead to jitters as a conse‐ quence of false alarm cases which occurred in fact in LAC in the middle of the epidemics of EVD in Africa [6–9].

Informational and educational tools play on improving knowledge about clinical manifesta‐ tions and disease management among caregivers residing in non‐affected areas, as well as how to respond if challenged to face such an unlikely event, in this case, in LAC [9].

#### **4. False alarms**

findings. Distinguishing cases of Guanarito (Venezuela), Machupo (Bolivia), Junín (Argenti‐ na), and Sabiá (Brazil) viruses from Ebola, as well as from other highly prevalent infections such as yellow fever, dengue with hemorrhagic manifestations, leptospirosis, and typhoid fever, among others, will constitute an ever‐increasing challenge. Point‐of‐care testing using a biothreat panel like the BioFire diagnostics BioSurveillance system would be useful for screening highly suspicious cases, while at the same time, providing an automated sample‐to‐ answer diagnostic platform in areas with lack of healthcare trained personnel, even though rapid diagnostic test use is discouraged given its low specificity. We still do not know how such tests would perform in a non‐prevalent Ebola region, and at the same time, it could be

Otherwise, the clinical management of those suspected and confirmed cases should be at designated hospitals that must comply with contact isolation conditions, ideally individually and not by cohorts of suspected or confirmed cases, appropriate provisions of personal protective equipment, and health services with personnel trained in infection prevention and control [6, 8, 16, 18]. These characteristics probably are lacking even in some intermediate cities of LAC forcing to translate patients to places where these are attained and making to consider that transport of those patients needs special protective measures too. Even more, healthcare institutions should start joining efforts to design preparedness and response programs in order to revamp or build up de novo infrastructure to properly address suspicious cases and prepare healthcare professionals for caring of confirmed Ebola‐infected patients. It is also important to coordinate this LAC response to Ebola with the guidance of the regional multilateral health organisms: The PAHO should lead this process; and the recently created South American Institute of Government in Health (www.isags‐unasur.org) and the South American National Institutes of Health Network could demonstrate their ability to recruit and materialize

The call for attention that was the EBOV outbreak highlighted the importance of proactive organization of health systems particularly in those settings in which poverty, social inequal‐ ity, and lack of basic healthcare services and facilities could limit action when an infectious disease has established [6, 8, 16, 18]. Many countries in LAC have proved its restraints in infectious disease control, as recently reported for malaria, dengue, chikungunya, and Zika in Venezuela, and its social and economic context can act as boosters for infection spread [22, 26]. As taught, the entire world needs to turn out its look and watch for those impoverished

Latin America is endemic for many febrile infectious diseases conditions; then, signs and symptoms of EVD may overlap with other acute viral hemorrhagic fevers like dengue, chikungunya, and now Zika posing a challenge at the time of diagnosis [9]. Despite the low‐ risk for a local outbreak in LAC, the possibility of an imported case always remains latent [6, 8]. Thus, in light of such hypothetical epidemiological scenario, we also considered that assessing knowledge and perceptions among healthcare students and workers about the epidemiology, transmission, and clinical manifestations of Ebola in a country like Colombia is of utmost importance; particularly, taking into account that before the 2014–2015 epidemic, no information concerning EVD was available in Colombia's public health surveillance

areas before crisis, searching to close gaps in order to reach fairer societies.

cost prohibitive for many governments in the hemisphere [6, 8, 16, 18].

resources for global health [6, 8, 16, 18].

58 Ebola

During the epidemics of Ebola in Africa and the arrival of imported cases to Europe and North America, fear and alert were combined in LAC regarding the potential arrival of suspected cases of EVD in this region [6–9]. As consequence of that, confusion, lack of knowledge, and fear led to quickly misclassify cases as suspected, when in fact most of them are false alarms. Latin America was challenged with false alarms of "suspected" cases of EVD that not met the criteria to be classified as real suspected cases.

Our group assessed false alarms and suspected cases in the Americas of EVD, based on online available information on such cases. Analyzing online news information sources, data on suspected cases were collected and the WHO Ebola fever suspected case definition reviewed in order to classify them as suspected or false alarms.

Until April 1, 2015, 67 reports, containing 232 suspected or false alarm cases, were retrieved from the Web in 25 American countries. From them, 79.1% corresponded to false alarms and 20.9% suspected cases (WHO complied definition). From false alarms, only 18.9% came from Sierra Leone (13%), Liberia (4%), or Guinea (2%), but none of them presented symptoms during last 21 days (**Figure 2**). Although those cases not met the definitions, were considered sus‐ pected cases and then reported as that. From real suspected cases (14), all came from Ebola endemic places (28.6% Nigeria, 21.4% Guinea, 7.1% Liberia, 7.1% Sierra Leona), all of them with symptoms (mostly fever) during the last 21 days (**Figure 3**).

**Figure 2.** Geographical origin of the false alarm cases.

**Figure 3.** Geographical origin of the suspected cases (met WHO definition of suspected case).

cases of EVD in this region [6–9]. As consequence of that, confusion, lack of knowledge, and fear led to quickly misclassify cases as suspected, when in fact most of them are false alarms. Latin America was challenged with false alarms of "suspected" cases of EVD that not met the

Our group assessed false alarms and suspected cases in the Americas of EVD, based on online available information on such cases. Analyzing online news information sources, data on suspected cases were collected and the WHO Ebola fever suspected case definition reviewed

Until April 1, 2015, 67 reports, containing 232 suspected or false alarm cases, were retrieved from the Web in 25 American countries. From them, 79.1% corresponded to false alarms and 20.9% suspected cases (WHO complied definition). From false alarms, only 18.9% came from Sierra Leone (13%), Liberia (4%), or Guinea (2%), but none of them presented symptoms during last 21 days (**Figure 2**). Although those cases not met the definitions, were considered sus‐ pected cases and then reported as that. From real suspected cases (14), all came from Ebola endemic places (28.6% Nigeria, 21.4% Guinea, 7.1% Liberia, 7.1% Sierra Leona), all of them

criteria to be classified as real suspected cases.

60 Ebola

**Figure 2.** Geographical origin of the false alarm cases.

in order to classify them as suspected or false alarms.

with symptoms (mostly fever) during the last 21 days (**Figure 3**).

**Figure 4.** Countries receiving false alarms and suspected cases.

With regard to the countries receiving these cases (suspected and false alarms), most corre‐ sponded to Trinidad and Tobago (11.9%), followed by Saint Vincent and the Grenadines (10.4%), USA (9.0%), Argentina (7.5%), Canada (7.5%), Chile (7.5%), Colombia (7.5%), and Mexico (6.0%) (**Figure 4**). These findings were consistent with the risk assessment previously performed based on the migration and travel patterns from EVD risk countries from Africa to potential countries in LAC region, as described.

Although the possibility of Ebola spreading to Latin America always has been low, as previous models have shown, concerns in regard to the capacity of healthcare institutions and labora‐ tories in the region are real. Even more, healthcare workers in the region are not prepared at all. Then, actions include reinforcement of infection control actions in healthcare settings and access to high‐quality diagnosis testing, among others, should be enhanced.

The world experienced the largest epidemic of EVD known in extension and duration to date, since the virus was first identified back in 1976, with cases being reported beyond African borders [1–10, 20]. There was, as a consequence, a sharp increase in the number of research and publications related to vaccine candidates and the immunological aspects of EVD, among other aspects [1, 6, 8]. Although not particularly affected by a large number of cases in this current outbreak, the United States has played historically and continues to play on Ebola research, although other countries have also contributed. Also, cooperation played a key role among different nations, particularly between African, European, and North American countries, but this should be enhanced for future epidemics as already occurred in 2014, considering also the possibility in the future of suspected cases in Latin America and the Caribbean [1, 16].

#### **Author details**

Alfonso J. Rodriguez‐Morales1,2,3\*, Jaime Andrés Cardona‐Ospina<sup>1</sup> , Sivia Fernanda‐Urbano<sup>1</sup> , Katherinn Melissa Nasner‐Posso<sup>1</sup> , Stefania Cruz‐Calderón<sup>1</sup> , Carlos E. Calvache‐Benavides<sup>1</sup> , Yudy Lorena Delgado‐Pascuaza<sup>1</sup> , Juan Camilo Castillo1 , Maria Yamile Alvarez‐Ríos<sup>1</sup> , Hamilton A. Marín‐Rincón<sup>1</sup> , Liceth Urrutia1 and Alberto Paniz‐Mondolfi2,3,4

\*Address all correspondence to: arodriguezm@utp.edu.co

1 Public Health and Infection Research Group, Faculty of Health Sciences, Technological University of Pereira, Pereira, Risaralda, Colombia

2 Working Group on Zoonoses, International Society for Chemotherapy, Aberdeen, United Kingdom

3 Committee on Travel Medicine, Pan‐American Association of Infectious Diseases, Quito, Ecuador

4 Department of Pathology and Laboratory Medicine, International Hospital, Barquisimeto, Venezuela and the Laboratory of Biochemistry, Institute of Biomedicine/Venezuelan Insti‐ tute of Social Security (IVSS), Caracas, Venezuela

#### **References**

(10.4%), USA (9.0%), Argentina (7.5%), Canada (7.5%), Chile (7.5%), Colombia (7.5%), and Mexico (6.0%) (**Figure 4**). These findings were consistent with the risk assessment previously performed based on the migration and travel patterns from EVD risk countries from Africa to

Although the possibility of Ebola spreading to Latin America always has been low, as previous models have shown, concerns in regard to the capacity of healthcare institutions and labora‐ tories in the region are real. Even more, healthcare workers in the region are not prepared at all. Then, actions include reinforcement of infection control actions in healthcare settings and

The world experienced the largest epidemic of EVD known in extension and duration to date, since the virus was first identified back in 1976, with cases being reported beyond African borders [1–10, 20]. There was, as a consequence, a sharp increase in the number of research and publications related to vaccine candidates and the immunological aspects of EVD, among other aspects [1, 6, 8]. Although not particularly affected by a large number of cases in this current outbreak, the United States has played historically and continues to play on Ebola research, although other countries have also contributed. Also, cooperation played a key role among different nations, particularly between African, European, and North American countries, but this should be enhanced for future epidemics as already occurred in 2014, considering also the possibility in the future of suspected cases in Latin America and the

, Stefania Cruz‐Calderón<sup>1</sup>

, Juan Camilo Castillo1

1 Public Health and Infection Research Group, Faculty of Health Sciences, Technological

2 Working Group on Zoonoses, International Society for Chemotherapy, Aberdeen, United

3 Committee on Travel Medicine, Pan‐American Association of Infectious Diseases, Quito,

4 Department of Pathology and Laboratory Medicine, International Hospital, Barquisimeto, Venezuela and the Laboratory of Biochemistry, Institute of Biomedicine/Venezuelan Insti‐

, Sivia Fernanda‐Urbano<sup>1</sup>

, Carlos E. Calvache‐Benavides<sup>1</sup>

, Maria Yamile Alvarez‐Ríos<sup>1</sup>

and Alberto Paniz‐Mondolfi2,3,4

,

,

,

access to high‐quality diagnosis testing, among others, should be enhanced.

Alfonso J. Rodriguez‐Morales1,2,3\*, Jaime Andrés Cardona‐Ospina<sup>1</sup>

\*Address all correspondence to: arodriguezm@utp.edu.co

University of Pereira, Pereira, Risaralda, Colombia

tute of Social Security (IVSS), Caracas, Venezuela

, Liceth Urrutia1

potential countries in LAC region, as described.

Caribbean [1, 16].

62 Ebola

**Author details**

Kingdom

Ecuador

Katherinn Melissa Nasner‐Posso<sup>1</sup>

Yudy Lorena Delgado‐Pascuaza<sup>1</sup>

Hamilton A. Marín‐Rincón<sup>1</sup>


[25] Rodríguez‐Morales AJ. Zika: the new arbovirus threat for Latin America. The Journal of Infection in Developing Countries 2015 June;9(6):684–5.

[13] Henao DE, Abella-Marquez LM, Failoc-Rojas VE, Lagos-Grisales GJ, Rodríguez-Morales AJ. In the current context of emerging infectious diseases, it should join the global health teaching in medical programs in Latin America? Salud Pública de México.

[14] de La Vega MA, Stein D, Kobinger GP. Ebolavirus evolution: past and present. PLoS

[15] Pan American Health Organization/World Health Organization. Preparedness and Response for introduction of Ebola virus disease (EVD) in the Americas 2014.

[16] Ter Meulen J. Priorities for research on tropical viruses after the 2014 Ebola epidemic. Journal of Clinical Virology 2014. J Clin Virol. 2015 Mar;64:107–8. doi:10.1016/j.jcv.

[17] Bogoch II, Creatore MI, Cetron MS, Brownstein JS, Pesik N, Miniota J, et al. Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 west African outbreak. The Lancet. 2015 Jan 3;385(9962):29–35. doi:

[18] Chen T, Ka‐Kit Leung R, Liu R, Chen F, Zhang X, Zhao J, et al. Risk of imported Ebola virus disease in China. Travel Medicine and Infectious Disease 2014;12(6PA):650–658.

[19] Gomes MFC, Pastore y Piontti A, Rossi L, Chao D, Longini I, Halloran ME, et al. Assessing the international spreading risk associated with the 2014 West African Ebola outbreak. PLOS Currents Outbreaks. 2014. Available at http://currents.plos.org/ outbreaks/article/assessing‐the‐international‐spreading‐risk‐associated‐with‐the‐

[20] World Health Organization. Ebola and Marburg virus disease epidemics: prepared‐ ness, alert, control, and evaluation. Interim version 1.2, August 2014. Geneva: World Health Organization, 2014. Available at http://apps.who.int/iris/bitstream/ 10665/130160/1/WHO\_HSE\_PED\_CED\_2014.05\_eng.pdf?ua=1&ua=1 (Accessed:

[21] Clouet‐Huerta D, Alfaro‐Toloza P, Rodriguez‐Morales AJ. Chikungunya in the Americas: preparedness, surveillance and alert in Chile. Revista chilena de infectología

[22] Rodríguez‐Morales AJ, Paniz‐Mondolfi AE. Venezuela: far from the path to dengue

[23] Alfaro‐Toloza P, Clouet‐Huerta DE, Rodríguez‐Morales AJ. Chikungunya, the emerg‐

[24] Rodriguez‐Morales AJ. Dengue and chikungunya were not enough: now also Zika

and chikungunya control. Journal of Clinical Virology 2015 May;66:60–1.

ing migratory rheumatism. Lancet ID 2015 May;15(5):510–2.

2014‐west‐african‐ebola‐outbreak/ (Accessed: November 9, 2014).

2015 July–August;57(4):296–7.

Pathogens. 2015;11(11):e1005221.

10.1016/S0140‐6736(14)61828‐6.

November 5, 2014).

2014;31(6):761–2.

arrived, 2015 April–June;11(2):e3.

2014.12.008.

64 Ebola

[26] Rodríguez‐Morales AJ, Paniz‐Mondolfi AE. Venezuela's failure in malaria control. The Lancet 2014 August 23;384(9944):663–4.

**Phylogenetic Analysis of Ebola Virus**
