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10 November 2014

Ebola: Are we able? - Travel notes

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Is Ebola Virus spread at a turning point? In August, I was deployed as a WHO clinical consultant to the Ebola Virus Disease (EVD) response team in Lagos in Nigeria. I was a bit worried. News coming from West African countries experiencing the dramatic increases of EVD cases were all over the front page of newspapers with distressing photos and stories. Moreover in Nigeria a high percentage of EVD cases involved healthcare workers.

My tasks were to provide technical advice on clinical care to the EVD Care Center at Mainland Hospital in Yaba, a district of Lagos, to augment infection prevention and control (IPC) practice training and to provide technical advice to other activities within the Nigerian response team. I was aware that it would take a day or so to orient on arrival.

Lagos is a city with 21 million inhabitants. Before leaving to Lagos I was informed not to walk alone there and to be very careful when travelling on the roads. Since the beginning of my stay at Lagos I understood that it was better to follow all this advice.

The isolation facility for EVD suspected/confirmed cases is in a compound for tuberculosis patients; when the Ebola crisis will have been over, tuberculosis will still be there. The isolation facility is located in the back of the compound with three wards, one connected to its own entrance gate that can accommodate 8-10 isolation beds (this was previously dedicated to multidrug-resistant tuberculosis paediatric patients), one inside with 14 beds for suspects, and another deeper in the compound with 14 beds for confirmed patients. There is another construction project next to this facility as well as other expansion options on the campus. I replaced a WHO doctor who is well experienced in the care of EVD suspected and infected cases almost since the highest peak of EVD case occurrence in Lagos. Medicins Sans Frontieres (MSF) volunteers joined the response team a few days after his arrival, with an outbreak assessment and support team that included a team lead (a clinician) with 2 years of EVD outbreak care experience, and a logistic person familiar with the usual water/sanitation issues.

I found a relatively well organized facility. Thanks to the joint coordination of the MSF/WHO groups, provision of personal protective equipment (PPE) was guaranteed, and the logistics/water sanitation equipment in the facility ensured a safe work environment for clinicians, nurses and housekeepers. Nigerian participation in care was increasing with some doctors and nurses staffing the care center, and others being trained to. For trainees besides epidemiological, IPC and clinical training, a scheduled observation shift and then three scheduled shadow shifts were expected.  They were all young, willing, friendly, and aware that only a coordinated action of all the professionals could be successful. However, sometimes their presence was unpredictable.

I do not want to say that everything was perfect. The medical team shared a large room without the possibility to rest or to have focused meetings. There was a bustle of people during the entire day, and sometimes I preferred to discuss the clinical cases with my MSF colleague in the garden in front of the isolation facility.

The other problem was the relative shortage of local staffing to cover management and three shifts. But, day-by-day more people joined the staff.

I was immediately destined to join the case management team within the international response team. The daily routine included a morning briefing at the general response team meeting, navigating to the isolation facility in a traffic jam, meeting with the MSF and Nigerian local staff, providing clinical care of suspected/confirmed patients, training of attendees who shadowed during the shift, discussing main critical issues, talking with parents and relatives of the patients, talking with local consultant specialists about any needs - including psychologists, social workers, psychiatrists, neurologists, lab workers and managers, waiting for lab response for deciding on patients’ location (those who resulted positive should move to the confirmed cases ward) or eventually their discharge. The day ended with another dive into a traffic jam to the response team evening meeting where all the teams reported on their activity. Even though the majority of people attending this meeting were tired after all the day’s activities, everyone paid close attention to each updated information including the overall number of suspected and confirmed cases, contacts to be traced or already traced and rumours on likely cases. Strategic issues, including points of entry measures, contact tracing, logistics, media and social networks were also discussed by national and international experts, including WHO, MSF, UNICEF, CDC, etc...

However, the more exciting activity for me was the care of patients. The complex procedure of dressing, heat, humidity and sweating, the continuous disinfection with chlorine, the difficult approach with the patients due to the complete dressing that covered any part of my body, the poor diagnostic tools, the dangerous and hard undressing procedure all contributed to make a the care of patients a challenge, and sometimes to be frustrating. However, all frustrations disappeared and were fully rewarded when a previously very sick patient improved and was discharged. This was the case of a woman who, exiting from the dedicated passage of the isolation facility to the “normal world” where her kids were waiting for her, cried “Thanks God”, and sent us a smile of gratitude.

My experience, even though short, was intense; it was a life lesson. For the fight against EVD in Nigeria ample financial and material resources, as well as well-trained and experienced international and national staff have been provided. However, I learnt that any efficient organization, with a coordinated and strong commitment is successful thanks to the joined efforts of normal people who act with great humanity and self-sacrifice.

For Nigeria, the fight against EVD was a spectacular success story that shows that Ebola can be contained.

If the question is “Are we able to fight Ebola?”, the lesson from Nigeria is “Yes, we can”.

(PS. When I returned home, I avoided kissing my family members and shaking hands with my parents, relatives, friends, colleagues and patients for 21 days – in Nigeria we used to greet with our elbows…)

Nicola Petrosillo
National Institute for Infectious Diseases “L. Spallanzani”, Rome, Italy

Last update: 11 November 2014