In 1995, in a city of 400,000 people some 450 miles outside Kinshasa, Democratic Republic of Congo, there was an Ebola outbreak never before seen since the first Ebola outbreak in that country in 1976. The World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC) in the United States, and a team of Zairean medical professionals converged on the city of Kikwit to contain the Ebola virus. Like in Liberia now, elders and family members of those infected with the virus in Kikwit insisted on burying their dead using cultural practices that characterized their tradition. The sick would be hidden from authorities in fear of the social stigma attached to contracting the virus. With cases and deaths mounting, the Ebola containment team devised a strategy of a house to house search in the most endemic parts of the city of Kikwit. The Kikwit plan included teams of medical students, health workers, and community members who isolated the sick and collected the dead for burial. They also used the house to house search efforts to provide Ebola awareness, counseling, and social support. In about 3 months, the virus was contained and eliminated.
The total number of cases in Kikwit, as reported by the World Health Organization, was 315 with 285 confirmed deaths, an 81% death rate. According to the Ministry of Health and Social Welfare, as of August 4, 2014, the number of confirmed, suspected, and probable cases in Liberia stands at 508, while the number of deaths is 271, a 53.3% death rate. While the death rate in the Liberian outbreak may appear less than Kikwit’s, the spread of the virus in Liberia is unabated with the cumulative incidence or measure of risk to the population of Liberia alarmingly trending upwards. Liberia needs to adopt an elaborate version of the Kikwit Ebola containment and elimination strategy. The level we have reached with this outbreak is more than a national emergency; the existence of the Liberian state is now at risk. We can quickly reverse course with the adoption of a containment and elimination strategy that includes but is not limited to the following suggestions:
1. Establish a national case identification and investigation team that will include
volunteers from civil society, students from the medical school at the University of Liberia, community leaders, the military and the police.
2. Create Ebola search and rescue zones throughout Monrovia and other Ebola endemic regions in the country. Each community should be designated as a zone. For example, New Kru Town will be a zone; Logan Town will be another zone, and so forth. Build an Ebola monitoring and testing center in each zone fully equipment with the necessary protective gears for health workers and case identification teams. The strategy of zoning harnesses the resources of the community and gets the community involved.
3. Assign case identification teams to each zone with the mandate to go from house to house to identify suspected cases (any one with suspected Ebola symptoms) and separate the cases from the community by moving them to the zone's monitoring center. Suspected individuals are examined for diseases such as malaria, typhoid, meningitis, and cholera with symptoms similar to Ebola. This process will allow Ebola cases to be separated from other common diseases in Liberia. Contact tracing can then be done on each identified case through the capture of past movements, relations, and contact information in a zone Ebola registry. That information is then used to trace case movement, relations, and contacts. Treatment can then be administered to the Ebola cases. The military and police should be part of each zone team to provide support in the event confusion develops with recalcitrant community members. Each zone will then be able to submit reports to the national task force on suspected, probable, and confirmed cases and deaths.
4. Establish a mass burial site preferably on solid grounds or in areas with low water table. Establish burial teams similar to the case identification team for each zone to collect the dead from homes, streets, and monitoring centers for burial. The burial teams should be trained and protected.
5. Counties that have had no Ebola cases should be protected by establishing checkpoints on major roads leading to those counties to monitor movement of people. As is being done for travelers leaving the country, temperature should be measured for people leaving Ebola endemic counties to Ebola free counties.
6. All marketers selling “bush meat” should be identified and their inventory confiscated and burned. A reasonable compensation should be provided for the confiscations. The army and the police should play a pivotal role in ensuring that all “bush meat” in all of our markets are seized and burned.
7. In is important that public health authorities embark upon public awareness and communicate to the public every two days on the findings from each zone. The report will show any progress being made and the government’s efforts in fighting the virus. This will help calm public anxiety if the number of cases and deaths begins to reduce.
8. Mineral water and food should be supplied to community zones as the house to house search efforts and the current lockdown of the city will create starvation that could lead to some unintended consequences.
The current fire brigade model or approach to containment will not work. We have to go to the community in a house-to-house campaign to identify cases and pick up the dead.
The author is a Doctoral student at Walden University studying Public Health – Epidemiology. He recently served as a panelist together with scientists from the Centers for Disease Control and Prevention (CDC) on an Ebola awareness program organized by the Liberian Association of Metropolitan Atlanta (LAMA). He can be reached at firstname.lastname@example.org
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