Miriam Alia, an MSF vaccination expert, has just returned from Equateur province in the Democratic Republic of Congo (DRC). Miriam worked as a medical referent in the area of Itipo, the epicentre of the recent outbreak. She explains how MSF took part in the ring vaccination against the disease and tells of her personal experience working with Congolese health workers.
For three weeks I was part of the MSF medical team responding to the Ebola epidemic in Itipo, a remote area south of the city of Mbandaka in the Democratic Republic of Congo, where a number of people had tested positive for Ebola. Besides caring for patients in the treatment centres we had set up in collaboration with the Ministry of Health, we implemented the other ‘pillars’ of an Ebola response. For instance, we were finding people who had been in touch with Ebola patients – patient contacts – and informing communities about the disease and how to prevent getting infected.
A key component of the response is to make sure that the health system continues to function properly during the outbreak. That means that health workers are protected and know how to identify suspect cases. If this is in place, we have a good chance to slow down and then stop the spread of the disease, and to avoid mortality linked to other medical conditions such as malaria. Often health staff can be afraid of treating patients due to the risk of infection from Ebola.
This year in DRC we had an additional tool to use against Ebola: an investigational vaccine. In Itipo, MSF, in partnership with WHO and the Congolese Ministry of Health, was in charge of vaccinating those most at risk of contracting the virus. This included not only the contacts of confirmed cases of Ebola and the contacts of these contacts but also those on the frontline in the fight against Ebola, health care workers, traditional healers, local religious leaders and motorbike taxi drivers. Sadly, the infection of health care workers is something that we see in many outbreaks of Ebola as they are obviously most at risk of catching the disease when sick people come to them for help. It was great to be able to offer them the vaccine and in turn some protection.
This vaccine against Ebola had already been used in clinical trials in West Africa during the 2014-2016 outbreak. But this was in in Sierra Leone and Conakry, the large Guinean capital city. In Itipo this year, we faced another kind of challenge. The area we were covering was made of eight health zones including 46 health centres and health posts, many of them located in remote villages. To reach them and vaccinate the health staff, we had to use motorbikes, pirogues (canoes) and sometimes go on foot for several kilometres through the forest.
Most of the health staff we vaccinated were nurses. Some of them were working completely alone in a remote health post others worked in groups of three or four in a larger health centre. We didn’t have to convince them to be vaccinated. They were quite afraid of the disease and knew very well that the head nurse from Itipo had just died of Ebola, along with 20 other people in the area.
Whilst we are confident that the vaccine works and had seen very promising data from other trials, we had to be sure to explain to the staff that they needed to continue caring for suspected Ebola patients with all necessary precautions. They needed to use the protective material that we provided them with and be aware that it takes five to 10 days after vaccination for the immune system to be activated and provide protection against the virus.
We also trained them about how to put in place a proper triage system and detect suspected Ebola patients at the clinic door. We explained that if they then detected a suspect case, they were to contact us and a properly trained ambulance team would come and collect the patient safely.
The dedication of these healthcare workers, who care for their communities with very little resources, is what impressed me the most during my time in Itipo. They show an amazing level of commitment to their patients.
I will notably remember George, a nurse from Itipo. His wife had been diagnosed with a confirmed case of Ebola and transferred to a treatment centre in Bikoro, another village where MSF was helping the Ministry of Health to run an Ebola Treatment Centre. But he chose to stay in his village and provide medical care to the community. He also volunteered to disinfect the houses of patients suspected of being infected with Ebola. During their 21-day follow up as contacts of a confirmed Ebola case, his son fell sick, which obviously worried him a lot, but fortunately, the boy tested negative. A couple of days after the child tested negative, the mother was discharged after beating the disease. All ended well for this wonderful man. Late, he joined our team as a nurse at the Ebola Transit Centre we were running in Itipo.
It is too early to know if the vaccination strategy helped control this outbreak, but it seems so far that none of the people who received the vaccine fell sick with Ebola. These positive results – and the fact that the outbreak is now almost over – are also the consequences of the solid implementation of all six pillars of the response, and the courage of our Congolese colleagues working in remote villages at the heart of the epidemic.