RIGHT from the onset of this unprecedented and overwhelming Ebola virus disease outbreak, all affected countries in West Africa have been struggling to cope with the epidemic. There were a number of challenges. Health centres were not equipped to tackle this deadly virus since they did not have enough personnel, medicines, personal protective equipment (PPE), beds or isolation wards to handle the massive number of patients. Even doctors and nurses did not have comprehensive knowledge on how to manage and treat the disease.
Among the first agencies to offer technical support and manpower was the international health-care organisation Medicins Sans Frontieres (MSF), which responded to the outbreak of the disease in March itself.
In Foya district of Lofa county in Liberia, one of the worst Ebola-affected countries, the MSF set up a special facility. This was after the government hospital started to limit the number of patients being admitted following the death of five or six health personnel. They had caught the infection from patients. At that time, only 37 per cent of the patients survived.
Recognising the gaps in the system, the MSF put in place a string of treatment and prevention protocols at the health centre to ensure better treatment and to stop the transmission of the virus. Separate facilities were set up for suspected and confirmed cases.
In August, Dr Kalyani Gomathinayagam, a general physician from Madurai, volunteered to work at the MSF’s Ebola care management centre in Foya for six weeks.
Dr Kalyani did her medical specialisation from Christian Medical College, Vellore, and has been with the MSF since 2010. She started her career with the MSF as an emergency doctor in Haiti after the earthquake. This was followed by stints in Ivory Coast, Chad, Democratic Republic of Congo and Liberia. Before joining the MSF, she had worked for many years as a doctor in rural Thiruvananthapuram.
She was chosen as a doctor who could be involved directly with patient care in the Ebola virus management project because of her years of MSF experience even though she had relatively less experience in treating hemorrhagic fevers. According to the MSF, the identified medical staff are given an intensive 1.5-day training in its operational headquarters in Brussels where they are trained how to dress and undress in the PPE and also other treatment protocols.
“Initially, I was not sure whether I would be able to observe the strict protocols and withstand the stress and risks that Ebola poses for health personnel,” says Dr Kalyani. But her apprehensions ended once she started working with the team, which comprised health workers from the country along with other volunteers.
By the time she arrived, the system was already geared up to offer the best supportive treatment to patients and also to protect their relatives and health workers from getting infected. This helped in bringing down the mortality rate as well as prevented workers from catching the disease. Working with a team of 50 to 100 people at the centre, she was able to meet the strict standards of safety and provide optimal care to patients, she says.
Case management is very important to fight and control the Ebola virus, Dr Kalyani says. But the challenges were manifold. “The majority of the people in Foya were welcoming because they knew what the team was doing, but some of them were not. Initially, families were in denial and did not believe that the disease would affect them. Later, the fear factor linked to death was very high, which prevented many from sending their infected family members to the health-care centre because they believed that they would not return alive. This concern was fuelled by the death of four people. If you lose four members of your family, two at the hospital and two in the community, then you don’t have great confidence,” she says.
The MSF team ran several campaigns on health promotion to create awareness among affected families. It worked on building trust so that affected families would approach the system. Meetings were held to educate families and end the intense stigma attached to the Ebola virus.
Dr Kalyani cites one example of a patient whose family had insisted on conditions such as the patient should not be given injections or medication and that the family’s permission should be sought if he was to be given intravenous (IV) drips. Once the doctors agreed to first test him before beginning treatment, the family consented. Fortunately, he recovered after a prolonged illness, and this helped boost confidence in the community about the health system. People understood and accepted that people infected with the virus would have to go to hospital.
All rumours of possible cases are investigated at the community level so that no case is missed. “At homes, along with the patients, their families are also screened. Once the patient is identified, homes are sterilised to protect both other family members and the community. Cleansing continues once the ambulance brings the patient to the hospital, where it is sprayed with chlorine to clean it. Families are monitored as well and contact tracing is done, which makes it easier to identify new infections at the case management centre,” says Dr Kalyani.
The other challenge was distance. Many people faced a five-hour commute to the health centre. As a result, many patients reached too late for them to survive. Resources from various agencies were pooled to facilitate the transfer of patients to the medical centre. Ambulances were provided to pick up patients from their homes. Hence, whenever patients were on their way, the health centre was informed. When ambulances were not available, MSF team members picked up patients from their homes.
Many people who lost family members can now walk into the health facility for check-ups, just to ascertain whether or not they are infected. More people are being monitored, which ensures that the disease is detected early. This helps to save lives. After a patient is released, there are follow-up check-ups and protective kits are provided to the family. Early detection and proper treatment have brought down mortality rates. To prevent transmission, discharged patients are disinfected after exiting the isolation ward. Their cell phones, money and all other belongings are cleaned with chlorine.
At the medical centre, health workers follow strict safety protocols. They work in shifts, and all scrub suits are cleaned after the patients have been attended to. Nurses have to wear clean suits each time they treat patients. Once the nurses collect clinical data from each patient, the papers are transferred at the end of rounds and the data are handed over after the checks are complete. The health workers are not allowed to touch or exchange papers and have to be sanitised over and over again to ensure their safety.
“Treating patients under these conditions is complicated. Since there is no drug to effectively treat Ebola virus disease, supportive treatment is the only option to manage it. But health personnel are so restricted that it is hard to provide optimal quality of treatment. For instance, working with protective gear, it is difficult to check patients who are kept at a distance. It is hard to check pulse or blood pressure or assess how many times the patient has had diarrhoea or has vomited as they are too sick to speak. In this setting, it is essential to focus on rehydration since it is the cornerstone of therapy. It prevents them from going into shock syndrome and developing bleeding complications. But every invasive procedure has its own risks. Patients often throw out the intravenous drips because they are agitated,” Dr Kalyani says.
“Also, if the condition progresses rapidly it is hard to understand the status of the patient. If they start bleeding profusely and internal hemorrhage has begun, not much can be done because there is no intensive care at the centre, nor can laboratory tests be done to quantify the viral load. Since the patient’s recovery is dependent upon the patient’s immunity, whether someone will make it or not depends upon how much virus is multiplying inside them at that particular point of time,” she says.
In the event of a death, the health centre organises the burial. Families cannot be involved because they would be at risk of catching the infection, but they are allowed a glimpse of the face before the body is buried. The burial rituals entail close contact with the body. A large number of people have been infected in Africa because they came in contact with the bodies of relatives who died of the disease.
When Dr Kalyani joined the project, there were 100 patients in the preceding weeks. In the following weeks, the number came down to 60. When she left the Foya project after six weeks, there were seven patients. However, she says that the number keeps fluctuating depending on the chain of transmission, so it is critical to watch how the disease is evolving because even one case can restart the epidemic. “Even though the death toll is going down, it is too early to get complacent,” she says.
Mohuya Chaudhuri is an independent journalist based in New Delhi . She was formerly health editor at NDTV.
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