DEMOCRATIC REPUBLIC OF CONGO (DRC)
Within the SACIDS network countries DRC has experienced several episodes of Ebola and the related Marburg disease. Following its first appearance in 1976, in Yambuku (Equateur Province), Ebola occurred again in 1995 in Kikwit (Bandundu Province), in 2007 and 2009 in Kampungu and Kaluamba, respectively, both in Kasai Occidental Province. All these outbreaks were caused by the Zaire Ebola strain.
Five years following the Kaluamba outbreak, Ebola appeared again but this time in Isiro (Oriental Province) and was induced by the Bundibudyio Ebola strain. In all these areas, the disease was observed only once. A single retrospective case was also reported in Tandala (Equateur Province) in 1977 without causing massive infections.
During all these outbreaks response strategies were developed by the national health ministry in collaboration with the international community. What lessons have we learned so far as to improve the surveillance and control of this deadly and highly infectious disease?
- About the spread of the infection in humans
- During the Yambuku outbreak in 1976, drug administration using multiple usage needles facilitated the spread of the virus
- Funeral ceremonies using traditional practices increased the risk of infection for the mourners; this was observed in Yambuku 1976 and Kikwit 1995
- In Kikwit 1995, lack of hygiene and respect of biosafety measures in health care facilities played a major role in amplifying the virus transmission
- About the outbreak coordination
- The coordination of an outbreak should better be conducted by an experienced national leader, with the assistance of international experts
- Field activities should absolutely be carried out by national experts although assistance of international bodies is highly required for expertise and resources
- Care should be taken to adequately involve the local community for the strategies to be adopted
- About the communication
- In all cases local languages should be used for communication with the local communities
- As much as possible the communication should involve opinion leaders, religious leaders and community leaders in the communication process for the community to accept easily the information
- Involvement of international media is crucial to sensitize international community
- About the surveillance
- During the outbreak strategies, involving active and passive surveillance is highly recommended
- The availability of a mobile laboratory is highly beneficial for an efficient surveillance system during the outbreak as well as during the inter epidemic period
- Training of the health care personnel on biosafety and viral haemorrhagic fever clinical identification is absolutely necessary to prevent infection and for a rapid detection
Concerning the preparedness, several strategies have been put in place for a rapid case identification of viral hemorrhagic fever (VHF) infections in the human population in DRC:
– Sensitization of medical doctors working in the health care facilities for a full involvement of their personnel to the surveillance network
– Reinforcement of the surveillance system whereby all the VHF suspected case samples are sent to the National Institute for Biomedical Research (INRB), the DRC Biomedical Reference Laboratory, where a mobile laboratory is established for a rapid diagnostic service using molecular tools
– Organization of training of health care personnel in selected sites
– Organization of press conferences to communicate on VHF and other disease to the public.
NOTE: Recently Prof Jean-Jacques Muyembe and the health minister organized a meeting with the heads of institutions involved in the surveillance and control of emerging infectious disease in DRC to discuss about strategies to be put in place as a response to the threat related to the spread of Ebola in West Africa.
The Centre for Emerging and Zoonotic Disease (CEZD) of the National Institute for Communicable Diseases (NICD), department of the National Health Laboratory Service (NICD/NHLS) has developed capacity for mobile diagnostic laboratory deployment in areas affected by outbreaks caused by highly dangerous pathogens. The NICD Mobile Laboratory Unit (MLU) for EVD diagnosis was established in Sierra Leone, Freetown-Lakka in the second half of August 2014.
Some of the advantages of the MLU include: (i) provision of rapid diagnostic capacity on the scene of EVD outbreak; (ii) alleviating the problem of logistics that may lead to delayed testing during outbreaks in remote areas when specimens have to be shipped to regional or international reference laboratories for testing; and (iii) aiding in patient management.
The NICD MLU in Sierra Leone is fully operational since 25 August 2014. The current optimal maximum Ebola diagnostic capacity of the laboratory is 58 specimens/per day. Specimens from suspected EVD cases are submitted throughout the day, sometimes until late night. The MLU operates in excess of 12 hours daily, and the major daily activities include: (i) operational checklists of bio-containment devices, preparation of decontamination solutions, logistical arrangements to ensure uninterrupted operation (e.g. timely purchasing and delivery of petrol for the generators, diesel for incinerator); (ii) reception of specimens, data logging and matching of blood samples with EVD case investigation forms; (iii) hot processing and aliquoting of specimens; (iv) RNA extraction and RT-PCR Ebola virus testing; (v) Interpretation, recording, and updating of Ebola report database; (vi) reporting and consultation of results to the National Disease Prevention Center, the WHO Ebola Coordination Center, local doctors and hospitals/Ebola treatment facilities; (vii) incineration of laboratory bio-waste, and (viii) training of local staff: 4 local staff members are trained in RT-PCR Ebola diagnostic, data capture, MLU operation and logistics, including bio-hazard protection and bi-waste disposal.
During the period of 25 August to 21 September 2014 (four weeks of operation) the NICD MLU tested 910 specimens (752 whole blood samples, and 158 oral swabs) from EVD suspected cases originating from north and west regions of Sierra Leone. Of the total of 910 suspected EVD cases, 548 (60. 22%) were positive by RT-PCR,. Of the total of 158 buccal swabs, 62 (39.2%), and of the total of 752 blood specimens, 486 (64.62%) were positive. On average 32.5 specimens were tested daily, increasing from 18.43 in the first week of operation to 51.29 in the fourth week of operation. During the latter optimal maximum daily diagnostic capacity was exceeded on two occasions from 58 to 85 specimens. By allocating extra working time this increasing demand for testing could be addressed, but such effort is not sustainable for a longer period of time. The increasing demand for Ebola diagnosis and high expectation for shorter turn-around time necessitates up scaling the operation of the NICD MLU in Sierra Leone. This could be only achieved by provision of additional funding, training and deploying of more staff, the use of additional PCR and other related laboratory equipment, including automated system for RNA extraction.
One of the major problems encountered during the first 3 weeks of operation was the lack of consistent electricity supply. In fact during the first 3 weeks of operation, bio-containment negative pressure chamber, refrigerators, laboratory equipment, and including two Smart Cycler PCR machines were most of the time run using the generator shipped from South Africa. During the 3rd week of operation the SA generator broke down after 24 hours run for 6 consecutive days, resulting in suspension of MLU operation for half a day on the 4th of September. Extraordinary efforts were made by local authorities to supply an emergency generator and eventually the MLU resumed its operation the same day late at night. Since then the building where the NICD MLU operates is directly connected to the national electricity power grid as well as to emergency generator provided by the Sierra Leone Government. Communication via internet, including reporting of results is very time consuming due to highly inefficient 3G cell phone network.
The government of Tanzania has ordered a strengthening of the existing surveillance mechanisms and has resorted to the team put in place two years ago when the Ebola threat was reported in neighbouring Uganda. No Ebola case has been tested in the country, where as number of measures has been taken including formation of the task force, which includes officials from the WHO, UNICEF and US-Centers for Disease Control and Prevention (CDC) as international partners and institutions under the ministry of Health and Social Welfare, is working around the clock to ensure that the disease does not enter the country.
Measures taken include filling in special forms on passenger details at the Kilimanjaro International Airport and Julius Nyerere International Airport and border entry points. Moreover, the passenger manifests are being used to track the place of departures to all passengers before landing to exhibit symptoms as preventing and control measure.
To ease the work among health workers, the ministry has ordered importation and fixing of thermal scanners at the airports and entry points to detect early symptom for a person with the Ebola virus. Moreover, the ministry has deployed a team of health workers with needed personal protective gears; the equipment has also been distributed to all district, regional and referral hospitals. More than 12,750 protective gears have been purchased by the government and distributed as they expect more from Zimbabwe, courtesy of the World Health Organisation.
The ministry has also earmarked isolation units in every region should the outbreak enter the country, in Dar es Salaam, an isolation centre has been set at Temeke Hospital. Southern Africa Centre for Infectious Disease Surveillance (SACIDS), plays a crucial role in Risk communication by producing several Radio Spots with key messages on Ebola for wide spread in the country.
The Zambian government has stepped up surveillance controls in all major points of entry to detect any signs and symptoms of the Ebola disease to screen all people entering the country. The government has since trained health personnel in all major points of entry in response to either suspected or confirmed cases of the Ebola disease. The government has called on members of the public to report any signs of Ebola disease to the relevant health authorities.
Find out more: http://www.sacids.org/oweb/sacids/home