Public Health on the Frontlines of an Outbreak: SPHTM responds to Ebola

National healthcare workers in Kenema, sierra Leone receive training on the use of personal protective equipment by the International Federation of the Red Cross

National healthcare workers in Kenema, Sierra Leone receive training on the use of personal protective equipment by the International Federation of the Red Cross

From parsing out the genetic components of Ebola to participating in the overarching global and policy response, it’s no surprise that Tulane faculty and alumni are part of the response to the outbreak of Ebola virus in West Africa. Their experiences emphasize that controlling the outbreak will require tools from every aspect of public health and medicine: detailed logistics, community involvement, surveillance, contact tracing, equipment, training for staff safety, and developing treatments and vaccines.

Tulane researchers have been tracing hemorrhagic fever in Sierra Leone for 10 years as part of the Viral Hemorrhagic Fevers Consortium. The focus of the project is Lassa fever, which closely resembles Ebola at the initial point when humans are infected. The infrastructure and experience developed during a decade of research on Lassa enabled a knowledgeable response to the first signs of Ebola in Sierra Leone.

“At first, there were none of the usual players who respond to an outbreak,” says Lina Moses, field sites manager for the Tulane Lassa Fever program. For several weeks in Sierra Leone, the Tulane program staff were standing in the breach, trying to get a handle on the earliest signs of outbreak.

The Epidemiologist: Lina Moses, PhD

Moses and her staff first began hearing about Ebola cases in bordering Guinea in late March 2014.

“We were responding to rumors and going and investigating them to see if there was evidence of Ebola on the borders of Sierra Leone,” she recalls. They found only one man who had died of Ebola, but then the outbreak appeared to be slowing in Guinea. Moses returned to New Orleans, only to hear that three cases of Ebola were diagnosed in Sierra Leone’s Kenema Government Hospital, one of the partners in the Viral Hemorrhagic Fevers Consortium, in one day.

“I flew right back,” she recalls. She turned her Lassa tracking skills to Ebola, training teams in interviewing techniques and contact tracing, making sure ambulances and trucks were available as needed, communicating between lab technicians and care teams, crunching data, and making sure suspected Ebola cases were moved to wards set up especially to handle them.

ebola_tents

One of the many tents that transformed the hospital grounds in Kenema.

“Then when Ebola began to crop up into the Kenema district, I switched and supervised the surveillance teams for the district,” she says. She became intimately involved in case investigations. Early in the outbreak, surveillance teams experienced hostility from families they visited. At worst, people threw rocks and sticks at the teams, at best they just laughed at them. Moses explains that they had to interview suspected cases, observe them for Ebola symptoms, and get a list of contacts, which sometimes ran to 40 names. Each contact would then need to be visited daily for 21 days. And at no time were team members to touch anyone, go in homes, sit on chairs, or stand close enough to be exposed to bodily fluids. Moses had been working on Lassa in Sierra Leone since 2009, but now faced grueling 14 to 16 hour days as she and her colleagues fought Ebola.

Sierra Leone has a population of about 6 million people, and Ebola has now been reported in every district in the country. During her work in Sierra Leone, Moses saw six team members succumb to the disease. She and her colleagues were in grief, but also facing the reality of losing the expertise of health care workers who had been with the consortium for a decade.

At the same time, the people of Sierra Leone were terrified. Moses witnessed two riots outside the hospital grounds while she was there. But she also has been working with teams to find ways to interview families and patient contacts in ways that are less intimidating.

“Gradually in each community you’d see different phases that they would go through. They’d be in denial, get hostile and violent, and as this outbreak would grow, they would have to accept that it was happening because so many deaths had occurred. And unfortunately it’s at that point that surveillance teams get access to the community, and at that point it’s difficult to control,” she says. Fear of Ebola also is making it hard to recruit people to work with response teams or in the clinics, she says. But in her view, local participation is key to ending the outbreak.

“With this Ebola outbreak, controlling it does depend on the surveillance, and that is just good old fashioned epidemiology,” she says.

Continued: The Doctor Susan McLellan, MD, MPH

Madeline Vann

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About Tulane University SPHTM

Tulane's School of Public Health and Tropical Medicine is the oldest school of public health in the country and the only American school of tropical medicine. Our mission is to advance public health knowledge, promote health and well-being, and prevent disease, disability, and premature mortality. This is accomplished through academic excellence in education of public health professionals, rigorous scientific research of public health problems, creative partnerships to advance the practice of public health, and innovative service to the local, national, and international public health community.
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