What is it like responding to the ongoing Ebola outbreak in the Democratic Republic of Congo and deploying to emergencies?
By:London School of Hygiene & Tropical Medicine https://lshtm.ac.uk/themes/custom/lshtm/images/lshtm-logo-black.png
Monday 8 July 2019
Working in the UK Public Health Rapid Support Team
Olivier le Polain is the senior epidemiologist and deputy director for operations of the UK Public Health Rapid Support Team (UK-PHRST).
He has been a member of the team for just under two years and in that time has deployed to Madagascar to respond to an outbreak of pneumonic plague, to Bangladesh amidst the Rohingya refugee crisis and most recently to the Democratic Republic of Congo. The latter was to support the response to two consecutive Ebola virus disease (EVD) epidemics, one in Equateur Province (May – July 2018) as well as the ongoing large outbreak which has affected the Eastern provinces of North Kivu and Ituri since August 2018.
The UK Public Health Rapid Support Team is funded by the UK government and was launched in 2016 as a partnership between the London School of Hygiene & Tropical Medicine (LSHTM), Public Health England and a wider academic consortium including the University of Oxford and King’s College London.
The UK-PHRST strives to improve outbreak response capacity through its triple mandate of deployment to international outbreaks, capacity building and operational research to improve epidemic response in low- and middle-income countries.
Olivier talks about his experience on the ground in the DRC during the ongoing Ebola epidemic, the importance of working in partnership with other countries and organisations and his experience on the UK-PHRST so far. This interview took place on June 13 so numbers included are for up to this date, but the situation is continually changing.
How long have you spent in DRC and what is the current situation like?
I spent the best part of 2018 in the DRC and almost two months in 2019. I was deployed first to an Ebola outbreak that occurred in the Équateur Province, from May to July last year, together with two other epidemiologists from the team. We were on the ground for about six weeks, working with the World Health Organization (WHO) on an Ebola outbreak that was rapidly brought under control, with a total of 54 cases reported.
Within a week of that outbreak being declared over, another Ebola outbreak was declared in North Kivu in Eastern DRC, along the border with Uganda, on the opposite side of the country.
I was deployed to Beni in North Kivu in August 2018 as part of an initial mission, and went back again from mid-October to December and in January and February 2019, for what has now become by far the largest Ebola epidemic that has occurred in DRC and one of the most challenging epidemics to respond to.
Over 2000 cases have now been reported in DRC. This week three people were confirmed with the infection in Uganda (this interview took place on 13 June and the situation is changing daily), on the border with DRC, in a family who travelled from DRC and had recently lost a relative from Ebola. This is unfortunate but not unexpected, given the proximity of the Uganda border, and Uganda was ready to respond quickly, but it brings yet another layer of complexity to this response.
The context is challenging for many reasons. The region has been affected by a protracted civil conflict and political instability, bringing significant security and other challenges to the response. Unlike most previous outbreaks in DRC, which occurred in relatively rural settings, this ongoing outbreak is affecting densely populated cities and towns, from which people move in and out for work, trade, and other reasons, making outbreak control very difficult.
There is also a large network of both formal and informal healthcare facilities operating, with reasonable access but general poor infection control practice. Transmission of Ebola within healthcare facilities has fuelled the epidemic to some extent, with about a quarter or two-thirds of patients infected through exposure in those facilities.
The fact that healthcare workers are still becoming infected today, despite ongoing efforts to improve infection prevention and control (IPC), is a worry. Engaging communities and healthcare workers has also been complex here, due to some level of mistrust in the government, but also the response as a whole, in the context of decades of conflict and protracted humanitarian crisis.
In the earlier months of the response, there were security challenges related to the ongoing conflict, but not directly targeting the response. But recent months have seen a shift with Ebola responders and frontline workers directly targeted by attacks and violence from particular groups, bringing another layer of complexity to a response that was already extremely difficult. Each attack brings the response to a standstill or slows it down significantly, leading to flare-ups in transmission, and negatively impacting progress.
How is this affecting the ability of the response to control the spread of Ebola in traditional ways?
One of the critical elements to control an Ebola outbreak is to identify and isolate cases as soon as possible, to reduce the potential for onward transmission in the community. This also increases patients’ chances of survival. We do this by strengthening surveillance in healthcare settings and communities, but also by identifying all relevant contacts of each case and by following them up for 21 days as part of contact tracing activities.
Identifying the correct contacts is also essential for Ebola vaccination, which is now an important tool in the Ebola control toolbox. But in North Kivu, identifying contacts of cases has proven particularly challenging as people may travel to numerous places, attend informal and formal healthcare settings during illness where patient records are poorly kept, or simply because of active reticence from communities, or violence, which prevents responders from accessing communities.
People who have been exposed may also fear coming forward and instead hide and travel away to other villages or towns, where new outbreaks can occur as a result. There were a few incidents like that when I was there.
The situation remains very complex and it is difficult to predict how things will evolve. There is no doubt that improving engagement with the community is essential. Ensuring that healthcare workers understand the threat, the response, feel engaged and are fully on board in the response in an appropriate way is vital, but this does not happen overnight, and will require continued engagement, certainly from local experts as the response moves forward.
Looking at the recent epidemiological trends and indicators there are a few signs that things may steadily be improving in some areas, although recent events in Uganda will need to be closely monitored, and it is certainly too early to show optimism in a response that will certainly last for many more months.
Which agencies have you worked with and how have you worked together?
I was deployed with the WHO through GOARN, the Global Outbreak Alert and Response Network, who help coordinate international partners working on outbreak response.
We are in close contact with the GOARN Secretariat to ensure that we can provide technical expertise in outbreaks and emergencies when needed. On the ground, myself and other team members have been working with WHO, in support of the DRC Ministry of Health. Since August, the RST has deployed a total of six staff members to the response in DRC.
We are only a small part of a very large national and international response but have provided technical expertise where we can. We have helped and led on the setup of an epidemiological analytical cell, which provides routine and advanced analyses for the strategic coordination of the response, and are currently still involved in that work. This means providing analytical support, working closely with WHO and the DRC Ministry of Health but also other partners including UNICEF, Medecins Sans Frontieres and the World Food Programme to name a few.
The work has expanded from its initial epidemiological focus to a larger analytical remit fielding demands from multiple partners. It involves curating, collating, compiling and analysing surveillance, patient and operational data, from the early warning system in place – also called ‘alert’ system, to contact tracing and so on.
What was the nature of your work when you first deployed to this outbreak?
In the initial phases of any emergency or outbreak of this nature, coordinating and response agencies need to rapidly put in place control mechanisms and response pillars, whilst gathering more information on the nature and scale of the outbreak. As an epidemiologist my role has been varied, and changes depending on the need. I have worked on helping to strengthen the surveillance and health information architecture, including collection and quality of data, and try to analyse and translate data into relevant public health information.
Regardless of the type of outbreak, work is always fast paced in these contexts. At the start of an outbreak the challenge is that very often data will be incomplete and clear reporting mechanisms may not be in place. This means we have to work on ad hoc solutions to make best use of available data and have meaningful information to interpret, while simultaneously working on existing surveillance systems and establishing new ones, including response-specific tools, where needed.
What have you learned from this particular deployment?
Every deployment brings learning, not just from the work on the ground and the nature of the public health crises I have responded to, but also from the organisations and individuals I have had to opportunity to directly work with. This is something I love about my job.
This outbreak is no different in that respect, and I have learned a lot from working in this complex setting, with all its unpredictability and all the unexpected challenges that have arisen. There will always be many challenges and frustrations, but being able to overcome them as part of a team on the ground, and have an impact in a response, even if it is small, is rewarding.
All of your deployments must have been very different, but are there some common principles you apply to each one?
One common feature of every deployment is the need to be flexible. We may arrive with a defined role but in these environments you need to be able to adapt your work at pace. So, there is certainty of meeting uncertainty in each deployment.
While specific tools and control mechanisms obviously vary, core principles of epidemiology and public health remain relevant to every crisis that we have supported to date. We try to be able to use and implement a number of different outbreak response tools, be it for the laboratory, surveillance, data analytics or others, to ensure that we can provide relevant technical support when and where needed.
How is the UK Public Health Rapid Support Team developing?
We are a small but growing team which is expanding and there is a recruitment drive happening now. We had 12 reservists join the team this year and we are currently recruiting another set of reservists from wider organisations within the UK. We hope to have a pool of technical experts ready to deploy to provide support in the different specialty areas that we provide. These include for example microbiology, data science, epidemiology, social science, case management, IPC, and logistics experts who are essential in our bilateral deployments, in particular.
We would like to have sufficient bandwidth to engage in the acute operational needs of emergencies, without losing focus on our capacity building and research agendas, including research during outbreaks, which is vital. That’s why expanding the team is so important.
Can you sum up your experience of being part of and helping to lead this team so far?
Being part of this project has been a great opportunity. My experience has been incredibly rich in terms of the deployments I have undertaken but also from my work in London with the team and I have learned a huge amount. It is a new team and there are lots of challenges that come with setting up a project like this, but it’s motivating and encouraging to see the team developing.
This interview was first published on Public Health England's Exposure.