This article was originally published on RedR UK.
On 8 May 2018, the Ministry of Health of the Democratic Republic of Congo (DRC) declared an outbreak of Ebola virus disease, after laboratory tests confirmed two cases of the disease in the town of Bikoro, in the northwest region of the country.
Although there are regular outbreaks of Ebola in DRC, this most recent instance became of greater concern after cases occurred in Mbandaka, an urban area of over one million people close to the Congo river, which flows to Kinchasa with a population of 11 million and connections all over the world.
RedR UK Member Paul Jawor recently returned from DRC where he was working as a water and sanitation specialist for Médecins Sans Frontières as part of the Ebola response. Paul explains his humanitarian background and his work on the ground in DRC:
Ebola response: Itipo and Iboko
“I originally trained as a highway engineer, before joining RedR UK as a member in the 1990’s. I’ve worked on six different responses to Ebola outbreaks, including Uganda in the early 1990’s and more recently as part of the response to the 2015 outbreak in West Africa.
My specialism is in Water and Sanitation, and Infection Prevention Control (IPC) which also includes “bio safety”. I make sure that aid workers wear the Personal Protection Equipment (PPE) suits correctly so there’s no chance of getting infection. When the infected person has been in a place I clean the area; I wear a suit and I spray the area with chlorine solution and wipe it all down and make sure that no one else catches the disease. You can catch Ebola from the surface of a table, so things have to be cleaned very carefully and thoroughly.
In DRC, we were working in Itipo and Iboko; two villages in the northwest of the country. Itipo was one of the main centres of the outbreak and we suspected that there might be more cases coming from Iboko as it’s a very remote, rural region and the people there had very little knowledge of the disease and how to stop it spreading.
There was already a health centre in Itipo, but they didn’t have a specialist isolation ward. The initial idea was to hold any suspected infected patients in Itipo and Iboko, for blood testing, then send them on to Bikoro the Ebola Management Centre. But the patients coming to Itipo didn’t want to travel any further, so we had to build a centre in Itipo too.
From an engineering perspective, one of the initial challenges was trying to get building materials into the villages; we were in the middle of the bush and the roads were very muddy and difficult to access. We ended up using helicopters to move materials around! There was also no electricity and no Wi-Fi, so I resorted to drawing rough designs on bits of paper and then sending photographs of my drawings through whenever I had a chance.”
Construction design in the field
“Designing a management centre is a bit like designing a cholera camp: you have a low-risk and high-risk area. In the high-risk area, you have to wear full PPE and you always have to move in a circulatory motion – you can’t go back on yourself and you get sprayed down and disinfected with a chlorine solution on the way out.
The isolation wards should have 24-hour light, a water supply for washing as well as drinking water. It has to have two lines of fences with two metres in between and an area where you can dress and undress in PPE safely. It’s also really important that the isolation ward is visible, so that friends and family who are visiting can see the patient.
In order to design the centres, I used a set of guidelines developed by MSF over many years of working in Viral Haemorrhagic Fever response.The guidelines help us to build constructions that are quite simple; they’re designed to be built as quickly and effectively as possible and you’ve got to make them easy to clean. The first set of guidelines was developed in 1994 and has since become more widely used by the sector, we’re continually updating these as our knowledge and understanding improves.”
Ebola response: challenges and solutions
The Ebola virus is a haemorrhagic fever that kills many of its victims — (often with a mortality rate of 50%) – especially in low-resource countries like DRC. Ebola’s symptoms – fever, headaches, muscle pain, bleeding- can show up between two to 21 days after someone comes into contact with the disease, meaning that people need to be constantly monitored. Raising awareness among vulnerable populations with little understanding or experience dealing with the disease is critical. Paul discusses some of the challenges faced by the MSF teams in the initial days of the response and how they worked with local communities and national staff to overcome these challenges:
“With every outbreak of Ebola, the identification of the patient is quite difficult. The initial symptoms of Ebola are very similar to other common diseases in the area, such as malaria, so in the early stages it can be hard to tell if someone has been infected with Ebola or something else. The region we were working in was also very remote and difficult to access, which means that it’s much more difficult to get treatment for those people who are infected.
Another challenge was trying to get local communities to understand what the disease was and how dangerous it was. If someone was infected with the disease they would initially go to a local faith healer, or to a church rather than the Ebola centre. Some of them were afraid of being stigmatised by the community, or they were afraid of being sick and not being with their family. This meant that people were getting sick and dying at home, which increased the chance of the disease spreading. Another danger was that people with other illnesses wouldn’t come to the health centres because they worried that it had been contaminated with Ebola. This increased the risk of people dying from diseases like malaria, that would otherwise be curable by going to the health structure.
We have a team of hygiene promoters and anthropologists who work with local communities to build acceptance and understanding of our projects. Their roles are vital to the success of the Ebola response. When you’re wearing the PPE suits, it’s quite a strange thing to see, you can look quite alien. When I go to a village I wear my normal clothes and then put on the PPE suit in front of the whole village so that they can see me getting into it and they understand what it is. When I am disinfecting a house after a death in the home I invite a member of the family to put on part of the PPE suit and come with me into the house, so they can see what I’m doing inside.”
Capacity-building for Ebola response
The largest known outbreak of Ebola occurred between 2014-16 in three main countries in West Africa when around 28,000 cases and more than 11,000 deaths were reported in Guinea, Liberia and Sierra Leone. In 2014 and 2015 RedR UK contributed to the UK-led response to the Ebola epidemic in West Africa by training NHS volunteers – along with Danish, Norwegian, and South Korean medical teams – to work as effectively and safely as possible in Ebola Treatment Centres (ETCs) in Sierra Leone. Paul discusses the importance of capacity-building for an effective Ebola response:
“The MSF teams have now finished building the Ebola management centre in Itipo and Iboko and we’re now training MSF staff on Ebola; how to dress properly, how to do safe chlorine solutions, how to do the construction. We’re also training local people so that if it ever breaks out again they know what to do.
For every 1 patient in an Ebola ward you need up to four members of staff. Every time you go in to visit an infected patient you go in two at a time; two cleaners, two water people, two medics, three times a day as well as all the support staff. Building capacity is vital in order to respond effectively and contain the outbreak.”
In DRC, a recent report from UNICEF confirmed that follow up of the last suspected case of Ebola in Bikoro after 21 days was completed on 25 June, 2018. The overall response to the Ebola outbreak in Equateur Province continues with follow up of suspected cases continuing in Itipo and Iboko.