insight

Inside the National Ebola Response Centre

17th October 2014

In early November, a series of deaths was reported in a remote part of Sierra Leone’s Koinadugu district. The district surveillance teams had to travel by motorbike and canoe to get there, take blood samples, and try to get patients to a hospital along roads so bad no ambulance can use them.  By the time the lab had confirmed the patients had Ebola, over 50 had caught the disease; 30 of them eventually died.

Ebola is a hidden killer. To fight Ebola, you need to isolate sick people as soon as possible, give them fluids, and bury them quickly and safely if they die. But the brave people fighting Ebola are crippled by a lack of information. 
 
Why is the information so poor? First, the virus has a long incubation period: it takes a week or more from being infected to developing symptoms. Second, many Ebola cases are not picked up by the health system, and less than half ever get confirmed in a lab test. Third, there are many different organizations working on the response to Ebola, and while they talk to each other, they rarely share data.
 
Ebola started as a public health emergency, but with 500 new cases a week just in Sierra Leone, it is now much more than that.  When a confirmed Ebola patient is taken to hospital, their families need to spend 21 days in quarantine so they can be monitored and can’t infect anyone else. This needs police to set up and enforce the quarantine, aid workers to provide food and water to those families, and social workers to take orphaned children into care.  It is a complex operation that demands coordination. When I arrived in Sierra Leone a few months ago coordination happened through long, difficult meetings. There were many opinions in the room, but few facts; nobody had a shared view of the disease or the response.
 
On 17 October, that began to change. The President appointed his Minister of Defence to lead the National Ebola Response Centre, and asked the military to join the fight. The new boss asked to set up a situation room - a central location to receive, manage and share information. I joined a team of Sierra Leoneans, British military and UN staff to make it happen.

Over the course of a week, the government identified a building, and the UN brought in furniture and generators to power it. We started working there on Friday, when the internet connection went live. 
 
On Saturday, we designed a reporting system for the 14 districts in Sierra Leone. We asked them call or email us once a day with information on the response. We didn’t ask them how many Ebola patients they had: the Ministry of Health knows that already. But we did ask how many safe beds they had, how many calls they got every day to investigate a case, and how many people had died, because everyone who dies needs to be given a safe medical burial.
 
On Sunday, we had just one report, from the capital Freetown. On Monday, we had reports from eight districts, and we invited the Minister of Defence – now known as the CEO – to twice daily briefings, one in the morning and one in the evening. On Tuesday, we had reports from twelve districts, and all 14 by the end of the week.
 
As the reports came in, we started making sense of them and spot gaps. We saw that burial teams in Freetown were able to respond to most of their calls on the same day, whereas in rural areas they were often a day or too late. This matters, because dead bodies are highly infectious. The figures made the case for more burial teams which the UK government has helped to provide, funding and training additional staff, and providing more vehicles. There were around 50 burial teams working in Sierra Leone in early October; there are over 100 now.
 
After a month of reports, we started to see the impact the response was having. We saw that safe burials slowed the disease, but didn’t stop it in its tracks: too many people still get infected from contact with live cases. We saw that new beds were opening every week, but it wasn’t enough: on some nights, people have to stay in the community because there aren’t beds for them. On 3 December, President Koroma told a press conference that Sierra Leone had just a third of the 1,500 beds it needs to defeat Ebola, and needs four more laboratories in the next month. 
 
Every day, the Situation Room reports the progress against that target. 300 beds were due to open in the first two weeks of December, two-thirds of them in Freetown. If those are delayed, even by a few days, the CEO will know about it, and ask the doctors, donors and other parties together to fix it.
 
There is a lot of media focus on the international response to Ebola, but 99% of those fighting it in the field are Sierra Leoneans. Their government needs to lead that fight. The Situation Room provides them with the information to do so. Data is now helping us chase Ebola when before we were chasing data. 
 
The CEO likes to remind us that the situation will get worse before it gets better. But the beds, the burials and behavioural changes are starting to work. Ebola has been almost eliminated in the rural, eastern districts where it started. Cases are falling in Liberia. It is too early to say when the numbers will start to fall in Freetown and the northern districts. But human ingenuity has beaten the virus before, and will do so again. I count myself lucky to have been able to join in the fight.

In early November, a series of deaths was reported in a remote part of Sierra Leone’s Koinadugu district. The district surveillance teams had to travel by motorbike and canoe to get there, take blood samples, and try to get patients to a hospital along roads so bad no ambulance can use them.  By the time the lab had confirmed the patients had Ebola, over 50 had caught the disease; 30 of them eventually died.

Ebola is a hidden killer. To fight Ebola, you need to isolate sick people as soon as possible, give them fluids, and bury them quickly and safely if they die. But the brave people fighting Ebola are crippled by a lack of information. 

Why is the information so poor? First, the virus has a long incubation period: it takes a week or more from being infected to developing symptoms. Second, many Ebola cases are not picked up by the health system, and less than half ever get confirmed in a lab test. Third, there are many different organizations working on the response to Ebola, and while they talk to each other, they rarely share data.

Ebola started as a public health emergency, but with 500 new cases a week just in Sierra Leone, it is now much more than that.  When a confirmed Ebola patient is taken to hospital, their families need to spend 21 days in quarantine so they can be monitored and can’t infect anyone else. This needs police to set up and enforce the quarantine, aid workers to provide food and water to those families, and social workers to take orphaned children into care.  It is a complex operation that demands coordination. When I arrived in Sierra Leone a few months ago coordination happened through long, difficult meetings. There were many opinions in the room, but few facts; nobody had a shared view of the disease or the response.

On 17 October, that began to change. The President appointed his Minister of Defence to lead the National Ebola Response Centre, and asked the military to join the fight. The new boss asked to set up a situation room - a central location to receive, manage and share information. I joined a team of Sierra Leoneans, British military and UN staff to make it happen.

Over the course of a week, the government identified a building, and the UN brought in furniture and generators to power it. We started working there on Friday, when the internet connection went live.

On Saturday, we designed a reporting system for the 14 districts in Sierra Leone. We asked them call or email us once a day with information on the response. We didn’t ask them how many Ebola patients they had: the Ministry of Health knows that already. But we did ask how many how many safe beds they had, how many calls they got every day to investigate a case, and how many people had died, because everyone who dies needs to be given a safe medical burial.

On Sunday, we had just one report, from the capital Freetown. On Monday, we had reports from eight districts, and we invited the Minister of Defence – now known as the CEO – to twice daily briefings, one in the morning and one in the evening. On Tuesday, we had reports from twelve districts, and all 14 by the end of the week.

As the reports came in, we started making sense of them and spot gaps. We saw that burial teams in Freetown were able to respond to most of their calls on the same day, whereas in rural areas they were often a day or two late. This matters, because dead bodies are highly infectious. The figures made the case for more burial teams which the UK government has helped to provide, funding and training additional staff, and providing more vehicles. There were around 50 burial teams working in Sierra Leone in early October; there are over 100 now.

After a month of reports, we started to see the impact the response was having. We saw that safe burials slowed the disease, but didn’t stop it in its tracks: too many people still get infected from contact with live cases. We saw that new beds were opening every week, but it wasn’t enough: on some nights, people have to stay in the community because there aren’t beds for them. On 3 December, President Koroma told a press conference that Sierra Leone had just a third of the 1,500 beds it needs to defeat Ebola, and needs four more laboratories in the next month. 

Every day, the Situation Room reports the progress against that target. 300 beds were due to open in the first two weeks of December, two-thirds of them in Freetown. If those are delayed, even by a few days, the CEO will know about it, and ask the doctors, donors and other parties together to fix it.

There is a lot of media focus on the international response to Ebola, but 99% of those fighting it in the field are Sierra Leoneans. Their government needs to lead that fight. The Situation Room provides them with the information to do so. Data is now helping us chase Ebola when before we were chasing data.

The CEO likes to remind us that the situation will get worse before it gets better. But the beds, the burials and behavioural changes are starting to work. Ebola has been almost eliminated in the rural, eastern districts where it started. Cases are falling in Liberia. It is too early to say when the numbers will start to fall in Freetown and the northern districts. But human ingenuity has beaten the virus before, and will do so again. I count myself lucky to have been able to join in the fight.

Rupert Simmons worked for AGI’s team in Sierra Leone, from early October 2014. 

Photo Credit: Yasmina Guerda