Ebola Outbreak in Sierra Leone Provides Valuable Experience

Maj. Laura Lester, U.S. Army Veterinary Corps, returned in November from Sierra Leone where she performed Epidemic Intelligence Service (EIS) duties with the Centers for Disease Control and Prevention (CDC) in support of the Ebola virus disease (EVD) outbreak. The Veterinary Corps is a key component of Army Medicine in collecting and assessing epidemiological data.

Lester served as an advisor in support of epidemiology and surveillance efforts in Kenema District in southeastern Sierra Leone. Sierra Leone is on the west coast of Africa, and Kenema municipality is about 80 miles from the Atlantic Ocean. The estimated population of Kenema District exceeds 500,000. Because of the population levels and local cultural practices, the potential for EVD to spread was extremely high. According to the World Health Organization (WHO), the EVD outbreak has caused nearly 10,000 deaths, including more than 3,500 in Sierra Leone.

Lester reports there were multiple hats to be worn and partners to work with, an exercise in learning that will aid in managing future crises.

Partners in the effort with the U.S. Army and CDC included Kenema General Hospital (which had a triage and Ebola holding center and provided laboratory services), the International Federation of Red Cross and Red Crescent Societies (IFRC), whose Ebola Treatment Center was 17 kilometers outside of Kenema township, the WHO, and Sierra Leone Ministry of Health and Sanitation.

Lester managed the data collected by the surveillance team and entered it into a viral hemorrhagic fever database. She also conducted case analysis and data management for use by CDC for the district, the Ministry of Health and Sanitation, and the WHO.

Lester worked under a number of constraints that taught the need to be flexible and adapt to the deployed environment. Working space was initially very limited and shared with the CDC and other staff. Internet connectivity was unreliable or non-existent; heat in the work environment was a problem because of electrical power issues. Electricity was available through solar panels and generators, which often lacked fuel.

Ongoing issues with infection prevention and control were critical. Management of patient movement from triage through laboratory to ward, discharge, or transfer to the IFRC treatment center required painstaking diligence. Improving clinical care of potential EVD patients required changes to the general design of the center. At one point, the Kenema General Hospital isolation ward was temporarily closed for decontamination because of the overwhelming number of infections and deaths of health care workers during the peak of the outbreak.

Data collection issues, which Lester addressed and is critical to patient care, included duplicate and mismatched names or laboratory identification numbers, misinterpretation of lab results, and misidentification of patients. In addition, effective epidemiological assessment requires accurate dates and locations of onset of disease, dates of admission, dates and results of tests, and patient outcomes. All or some of this information was often missing.

Controlling EVD requires significant understanding of local cultures and practices as well. Transmission can occur within a household because of a lack of space to isolate exposed individuals. Information on sanitary practices often did not reach those for whom it was intended; as a result, food, mattresses, and clothing were not properly handled, further increasing the potential for transmission of EVD. Some chiefdoms hid possible EVD patients from surveillance officers. In addition, unsafe burial practices, such as washing and handling the deceased, increased the risk of exposure for family and communities.

Even matters such as lack of availability of cash to support logistics and the supply chain for CDC staff needed to be addressed. Petty cash was needed for fuel for vehicles and generators; for unloading deliveries, assembling office furniture, and office renovations; and to support surveillance team investigators with everything from office supplies to rubber boots and ponchos.

Lester helped resolve some of the logistical issues. She created a tracking system to improve patient flow and improved coordination between the holding center at Kenema General Hospital and IFRC for transferring patients and reporting outcomes. The data management office was relocated to another building closer to the Ministry of Health and Sanitation surveillance office that had better connectivity and new equipment, making her job of data management easier.

Lester collaborated with IFRC, WHO, and Ministry of Health and Sanitation to open a center to observe children exposed to Ebola patients for 21 days; she also encouraged the use of healthcare workers who survived EVD to care for the children in this center.

She also assisted with development of draft standard operating procedures on guidance for care and monitoring of asymptomatic children under age 5 whose primary caregivers are suspected EVD patients.

The work by Lester and the entire international team of professionals are critical for ending the current epidemic and providing a blueprint for how to respond in the future. As a result of the experience in Sierra Leone, epidemiologists, medical logisticians, and other health care professionals of Army Medicine are better trained and will be ready to go when the next call for help comes.