Evaluation of the OCG Response to the Ebola Outbreak
Claire Bayntun & Stuart Alexander ZimbleApril 2016
Lessons learned from the Freetown Ebola Treatment Unit, Sierra Leone
Managed by the Vienna Evaluation Unit
Acknowledgements
• All contributors – Thank you for being so generous with your time, insights and information• Dorian Job, Monica Rull, Mathieu Soupart, Roberta Petrucci - For kindly sending us additional documents• OCBA Office in Sierra Leone – Thank you for our office space• Survivors – Thank you for sharing your experiences and insights• Vienna Evaluation Unit – For your kind support• To all the MSF staff who have dedicated their work to managing the Ebola crisis, December 2013 to the current day.
The authors of this report benefit from the wisdom of stakeholders’ insights. We hope to have captured the commitment of a group of individuals who have dedicated months and years to support the affected populations of West Africa, individuals from both within and beyond MSF. They are the experts for this report; our task has been to prompt, collate and, in so doing, let their work and experiences form this document. The recommendations are born from their voices.
“From people of Sierra Leone we want to thank MSF. Otherwise, I would not be sitting here. Really nice humanity, ready for anywhere in the world” (Mr ABK, Survivor).
VIENNA EVALUATION UNIT
The Vienna Evaluation unit started its work in 2005, aiming to contribute to learning and accountability in MSF through good quality evaluations. The unit manages different types of evaluations, learning exercises and anthropological studies and organises training workshops for evaluators.More information is available at: http://evaluation.msf.at.Electronic versions of evaluation reports are available on Tukul: http://tukul.msf.org.
“People in Sierra Leone appreciate MSF – they were visual and vocal with a strong message. MSF is seen as the lead organisation, as they were here
first. Sierra Leoneans, and the Government, respect this” (NERC).
Disclaimer: The views expressed in this publication do not necessarily reflect the views of Médecins Sans Frontières or of the Vienna Evaluation Unit.
©2016 MSF Vienna Evaluation Unit. All rights reserved. Dissemination is welcome, please send a message to the Vienna Evaluation Unit to obtain consent.
Cover picture: At the Ebola Treatment Centre in Freetown; ©Yann Libessart/MSF
©2016MSFViennaEvaluationUnit.Allrightsreserved.Disseminationiswelcome,pleasesendamessagetotheViennaEvaluationUnittoobtainconsent.
Tableofcontents
Executivesummary..............................................................................................................................1
Acronyms.............................................................................................................................................4
1 Introduction....................................................................................................................................5
1.1 Background.............................................................................................................................5
1.2 Timeline–keybackgroundanddocumentation....................................................................6
1.3 Methodology...........................................................................................................................7
1.4 Limitations...............................................................................................................................8
2 Findingsandconclusions................................................................................................................9
2.1.1 Infrastructure................................................................................................................9
2.1.2 Findings.........................................................................................................................9
2.1.3 Conclusions.................................................................................................................14
2.2 MedicalandNursingcaremanagement...............................................................................16
2.2.1 Findings.......................................................................................................................16
2.2.2 Conclusions.................................................................................................................20
2.3 Epidemiologicalcontrolmeasures........................................................................................21
2.3.1 Findings.......................................................................................................................21
2.3.2 Conclusions.................................................................................................................23
2.4 CommunityEngagement.......................................................................................................24
2.4.1 Findings.......................................................................................................................24
2.4.2 Conclusions.................................................................................................................26
2.5 Capacitybuilding...................................................................................................................27
2.5.1 Findings.......................................................................................................................27
2.5.2 Conclusions.................................................................................................................29
2.6 Relationshipswithotheractors............................................................................................30
2.6.1 Findings.......................................................................................................................31
2.6.2 Conclusions.................................................................................................................33
2.7 Research,monitoringandevaluation...................................................................................34
2.7.1 Findings.......................................................................................................................34
2.7.2 Conclusions.................................................................................................................37
3 Discussionandover-archingconclusions......................................................................................39
4 Recommendations........................................................................................................................41
4.1 Infrastructure........................................................................................................................41
4.2 Medicalcaremanagement...................................................................................................41
©2016MSFViennaEvaluationUnit.Allrightsreserved.Disseminationiswelcome,pleasesendamessagetotheViennaEvaluationUnittoobtainconsent.
4.3 Epidemiologicalcontrolmeasures........................................................................................41
4.4 Communityengagement.......................................................................................................42
4.5 Capacitybuilding...................................................................................................................42
4.6 Relationshipswithotheractors............................................................................................42
4.7 Research,monitoringandevaluation...................................................................................42
5 Annex............................................................................................................................................43
5.1 Termsofreference................................................................................................................43
5.2 Listofinterviewees...............................................................................................................43
5.3 Samplequestionnaire...........................................................................................................45
5.4 EbolaRegulatedReferralSystem(v3.1)................................................................................45
5.5 Proposedplan–SimplifiedEbola10bedisolationunit........................................................45
5.6 References.............................................................................................................................46
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ExecutivesummaryTheevaluationidentifiedtheresponseachievements,cultureandeventmilestonesoftheMSF-OCGinterventioninSierraLeoneduringtheEbolacrisis.
MSF-OCGcommissionedtheevaluation;theMSFViennaEvaluationUnitmanagedanddirectedthereport.TheevaluationfocusedonthePrinceofWalesSchoolEbolaTreatmentCentre,Freetown,anditsrelatedoutreachactivities,fromDecember2014toendofFebruary2015.TheaimwastoassessMSF-OCG’s response, practice and ability to incorporate lessons learned during the ongoingmanagementof theoutbreak– thechallenges,adaptationsandstrategyofMSF-OCG’sEbolacrisisresponse.
Theevaluationfocusedon:• Infrastructuremanagement(includinglaboratories)• Medical&nursingcaremanagement• Epidemiologicalcontrolmeasures• Communityengagement&mobilisation• Capacitybuilding• Relationshipwithotheractors• Research
Thisdocumentcapturestheexperiencesandperspectivesof65keystakeholdersandpartners:
• MSF Staff (MSF-OCG Headquarters staff; MSF-OCG national staff; MSF ex-/field staff,includingotherOCs)
• Beneficiaries(survivors/EbolaTreatmentCentrecaregivers)• Response coordination bodies (Ministry of Health and Sanitation; Sierra Leone National
EbolaResponseCentre;SierraLeoneDistrictEbolaResponseCentre-WesternArea;Britishmilitary;OCHA;ECHO;DFID)
• Other actors working with MSF-OCG in the field (Save, GOAL, KSLP, Welbodi, HandicapInternational,ADRA)
• Researchpartners(institutionsandresearchboardpartners;EbolaadvisorstoWHO)
Intervieweeswere selected to represent a rangeof important stakeholders. They candidly offeredtheir scrutiny and experience, allowing the emerging themes to be identified for the evaluationprocess. The report documents these findings, draws conclusions that are consistent with thecollateddata,andmakestherequiredrecommendationstoenableimprovementstothepractice.
KEYFINDINGSANDCONCLUSIONSTheEbolacrisisexposedthestrengthsandweaknessesoftheMSFmovement;itsstructuresanditsculture.MSF-OCG’sactivitiesevolvedoverthecourseoftheoutbreak,inrecognitionofthecomplexdynamics of the response. This report documents the key successful innovations, achievements,delays,andfailuresofOCG’sresponseinparticular,andhowtheysitwithintheoverallforcesoftheMSFmovement.Itidentifiesareasforreflection,andmakesrecommendationsforaction.
ThedecisionforasingleMSFsection(OCB)toleadtheresponseneededbetterlegitimisationbytheothersectionsinordertofosterimprovedlevelsofcollaborationandcommunication.Thedemandswerehighon theCentralisedOCBTaskForceand the findings suggest that therewere insufficientformal structures to support their work. Devolving decision-making to other Operational Centres,anddowntothefield,wherepossible, increasedinnovationandadaptationtothedynamicsofthecrisis.
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At the time of Prince of Wales Ebola Treatment Centre (POW ETC), MSF-OCG had gained inconfidenceandexperiencewithmanagingEbola,andevolvedoperatingmoreorlessindependentlyoftheCentralisedTaskForceduringthistime.TheOCGEbolaexpertswerealsoover-burdenedwithdecision-making responsibilities by the large number of requests and the lack ofmore formalisedsystemsofinformationmanagement.Thefield-to-HQdecision-makingneededtobestructured,andwhereappropriate,fieldmedicsneededtobegiventheauthoritytomakeadaptationsaccordingtotheirlevelofcompetenceandexperience.
OCGdidencourageacultureofinnovationandadaptationfromfieldtoHQlevelsandthisflexibilitywasnecessaryinorderfortheresponsetokeepupwiththechangedynamicsoftheoutbreak,inanattempttomeetthepopulationneedsastheywereidentified.
AllactorswelcomedthearrivalofOCGinFreetown,buttheyregrettedthatMSFhadnotmobilisedits intervention inFreetownearlier in theoutbreak.ThePOWETCwasconstructedandopenedbyOCG rapidly after the decisionwasmade. The visible activities and family visiting facilities helpedbuild trust and minimise tensions with the surrounding community. Importantly, it also providedcriticalreassuranceforthepatientsandtheirfamilies.
PatientcareatthePOWETCwasimprovedcomparedtopreviousETCsduetotheincorporationoflessons learned, suchas the innovative layoututilising safecorridorsandpointof care equipment.Althoughexternal laboratory serviceswereweak,MSF-OCGhad successfullyallocatedanavailableNigerian mobile lab facility to support the POW ETC, allowing for rapid, reliable diagnostics andenhancedbiochemicalmonitoring,whichmadeimprovementstopatientcarepossible.Additionally,survivors taking the roleof staff caregiverswereconsidered important for thewelfareofpatients,especiallytheyoung.TheSurvivorsClinicwaspioneeredbyOCGandeveryoneconsidersittobeanimportantMSFcontribution.
OCGofferedexcellentclinicaltrainingsessionsandaccesstotheETCforotheractorstoobserve,butwas late in recognisingweaknessesandgaps inoutreachwork.OCG’s interventioncouldhavehadmore impact if it had been able to initiate community engagement with experienced healthpromoters faster and to expand its role in epidemiological data collection and contact tracing inFreetown.
Afterinitialtensions,MSF-OCGactivitiesbecamemoretrustedbythecommunity.Strategiessuchasthe use of locally recruited outreach staff (able to link with the ‘auntie network’), and thereintegrationofsurvivors,resultedinstrongerrelationshipswiththecommunity.
Prioritisation of relationships with key non-MSF stakeholders in the future will be important forimprovingoverall coordination, and should result in increasedeffectivenessof the crisis response.Therewas criticism thatwhileMSFwas the leaderof the tactical implementation, it hadexcludeditself from strategic leadership and response coordination in Sierra Leone. The role of theIntersectionalLiaisonandAdvocacyOfficersupportednetworking, informationsharingamongMSFsectionsandwiththeotheractorsintheresponsecommunity.
Under the coordination of the Centralised Task Force, MSF engaged with operational researchrelatively late and generally failed to systematically document and collect data using standardisedtools and frameworks. By sharing OCG’s data with other researchers, pooled data from differentsourceswillenablealltolearnasmuchaspossibleabouttransmissionfactorsandclinicaloutcomes.New collaborations with research institutions and advisory networks were a positive, progressivefeatureofthisoutbreak,whichshouldbedeveloped.
TheOCGGeographicInformationSystem(GIS)unitsuccessfullyfast-trackedtheirproducttosupporttheoverall responseoftheMSFmovementandutilisedasecurewebportal foreasyaccesstothemaps.
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An organised information system to share knowledge more broadly, such as a managed webplatform, allowing the posting of guidelines and other emerging useful information, would haveassistedMSFandotheractorsintheirresponse.
MSFnowhasalargereservoirofstaffexperiencedinthemanagementofEbola(ormoregenerallyViralHaemorrhagicFever)andotheremergingdiseaseoutbreaks.Theexperienceofthiscohortisyettobefullycaptured(throughworkshops,forexample)andtheircommitmenttoMSF'sworkneedstobenurturedbytheHumanResourcesDepartment.
OCG must continue to use its strength of versatility. Successes during this outbreak include theimplementationofadaptedmodelsandapproachestotheclinicalcareofpatients.Inthefuture,itisnecessary to maintain confidence in response flexibility, ensuring that approaches reflect thegeographicallocation,theculturalcontext,thescaleoftheoutbreak,evolvingtransmissiondynamicsandemergingknowledge.
KEYRECOMMENDATIONS1
• EstablishthestructureandfunctionofaCentralisedTaskForceforcrisisresponsewithallMSFsectionsbeforeanotherlarge-scaleresponse.ConsideraMSFsectiontotaketheleadinagivencountry, for major/complex scenarios, to allow for consistent representation with non-MSFstakeholders.
• Develop decision-making structures and procedures to ensure accountability and efficiency infinalising decisions; this structure should support innovation and delegate decision-making tothefieldaccordingtostaffexperienceandcompetence,withinspecifiedboundaries.
• Future interventions should deliver a full outbreak response package encompassing Water,HygieneandSanitation(WHS),contacttracing,healthandhygienepromotion.
• Implementstandardisedeffectiveandefficient tools forepidemiologicaldatacollectionacrossMSFteamsandallowprojectionstoinformMSF’sstrategy.
• Invest resources indeveloping capacity in contact tracing forbothurbanand rural settings toallow OCG to become a leading strategic advisor, or implementer, of the contact tracingprocesses/mechanisminfutureoutbreaks.
• Train and guide other actors on ETC set-up andmanagement, community outreach activitiesfocusedonhealthpromotion,WHSandcontacttracingmethods.
• Contribute to national level strategic coordinating bodies to influence policy decisions, andconsider MSF’s regional/global strategic advisory roles in future crises. Invest in developingsenior staff’s (field and HQ) skill sets in global health leadership, strategic planning anddiplomacy.
• Recruit‘informationmanagement’personnel(field,HQandTaskForcelevels)toidentify,collateandsharedatawithinandoutsideofMSFtofosterinformeddecision-makingandenhancedailyimprovementstoactivities.
• Develop an OCG Research Board for ethics, protocol advice and research prioritisation. Thisshould include–andformaliseexisting–research institutepartnerships(insideandoutsideofMSF,suchasDNDi,LUXOR,LSHTM,SwissTropicalandPublicHealthInstitute).
• Integrateoperationalresearchfromthebeginningoffutureoutbreakinterventions.
1Thisisaselectionfromthefulllistofrecommendations,Chapter4.
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Acronyms
ADRA AdventistDevelopmentandReliefAgencyAST Aspartat-aminotransferaseCDC U.S.CentreforDiseaseControlCK CreatineKinaseDERC SierraLeoneDistrictEbolaResponseCentreDFID UKDepartmentofInternationalDevelopmentETC(orETU) EbolaTreatmentCentre;EbolaTreatmentUnitEVD EbolaViralDiseaseGoSL GovernmentofSierraLeoneHI HandicapInternationalHoM HeadofMissionHP,HPs HealthPromotion,HealthPromotersICU IntensiveCareUnitIFRC InternationalFederationoftheRedCrossKSLP KingsSierraLeonePartnershipLSHTM LondonSchoolofHygieneandTropicalMedicineMH MentalHealthMoH&S(orMoH) SierraLeoneMinistryofHealth&SanitationMSF MédecinsSansFrontièresNERC SierraLeoneNationalEbolaResponseCentreNGO Non-GovernmentalOrganisationNS NationalStaffOCs OperationalCentres(theMSFSectionOffices/Teams)OCA MSFOperationalCentreAmsterdamOCB MSFOperationalCentreBrusselsOCBA MSFOperationalCentreBarcelona/AthensOCG MSFOperationalCentreGenevaOCP MSFOperationalCentreParisPOWETC PrinceofWalesSchool,EbolaTreatmentCentre–OCGPPE PersonalProtectiveEquipment‘Save’ SavetheChildrenFoundationVHF ViralHaemorrhagicFeverWatSan Water/SanitationWHS Water,HygieneandSanitation
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1 Introduction1.1 Background
On22March2014, an Ebola epidemicwasofficially declared inGuinea. In the courseof thenextyear, thevirus infectedmore than25,000people innine countriesand claimedmore than11,000lives, dwarfing all previous Ebola outbreaks. For comparison, the largest previous outbreak had atotalof425cases.
Threeofthecountrieshavesufferedmajorepidemics:Guinea,LiberiaandSierraLeone.
OCG first initiated the response in Guéckédou, Guinea, and handed over the operationalmanagement toOCBas the section traditionally leadingViralHaemorrhagic Fever (VHF) response.OCG andOCB jointly responded to the crisis from the onset, joined later byOCA andOCBA.OCPsubsequently joined the intervention with a focusmore on non-Ebola related diseases (access tohealthcareandmalariaprevention).
InFreetown,SierraLeone,OCGmanageda100-bedEbolaTreatmentCentre (ETC) fromDecember2014untilendofFebruary2015.Thecentreservedasacapacitygapfillerinthecapital,whileotherorganisation'scentrestobecomeoperational.
AIMOFTHEEVALUATIONThis evaluation aims to assess OCG’s response and practice in the Freetown ETC from December2014 until end of February 2015. Specifically, it intends to reflect onMSF’s ability to incorporatelessonslearnedduringtheongoingmanagementofanoutbreak.
Specifically,wewillconsiderthefollowingareas:
● InfrastructureManagement(includinglaboratories)● Medical&NursingCareManagement● EpidemiologicalControlMeasures● CommunityEngagement&Mobilisation● CapacityBuilding● RelationshipwithotherActors● Research
IMPORTANCEOFTHEEVALUATIONThefindingsofthisevaluationwillbevaluableinpreparationforthenextVHFoutbreak,epidemicorother (re-)emerging infectiousdisease scenario. Inaddition, the recommendationsmaybeused toelaborate‘outbreakresponse’and‘Ebolaresponse’guidelines.
Importantly,theevaluationexplorestherigidvsflexiblecultureoftheOCGresponse,informingMSF-OCG about its ability to incorporate developments in the midst of a crisis. Thus, therecommendationswillserveOCGbeyondtheoutbreakscenario.
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1.2 Timeline–keybackgroundanddocumentation
BASELINEKNOWLEDGEONTHEMANAGEMENTOFEBOLABelowisalistofsomeoftheVHF/Ebolaguidelinesavailableatthestartof,andduring,theoutbreak.
➢ InfectionControlforViralHaemorrhagicFeversintheAfricanHealthCareSetting(CDC&WHO.Peters,Rodier,Lloyd,andPerry.Dec1998)1Thisisanearlypubliclyavailableguideline.ComponentsofthisguidelinecanbeseeninthemuchmorecomprehensiveMSFguidefrom2007.
➢ Ebola&MarburgOutbreakControlGuidanceManual,Version2(PeterThomson.MSF.May2007)2Thiscomprehensivemanualmaybeausefulreferenceinre-formulatingnewguidelines.Themanualoffersadviceoncoordinationwithotheractorsandthecommunity,discussingbeforeplanningaction,andhastwotrainingmoduleoutlinesintheannex.Thisdocumentattemptstoincorporate,indetail,allactivitiesforalldepartmentsforthe‘start’ofanintervention.
➢ FilovirusHaemorrhagicFeverGuideline2008(EstherSterk.MSF.2008)3Thisguidelineoffersausefulsummaryofthe2007GuidanceManualandincorporatesadditionalknowledgeandlessonslearnedfromoutbreakinterventions.ItdoesnotintendtoreplacethefullGuidanceManualforthosedeployingtomanageanoutbreak.
➢ DraftNewGuidelineFilovirusHaemorrhagicFevers–18April2014(MSF.Nocredits)4Acollectionof23documents(shortchapters)bydifferentauthors.Itretainsaspectsofthe2007GuidanceManual,updatedwithadvancesinoutbreakmanagementexperience.
➢ ClinicalManagementofPatientswithViralHaemorrhagicFever:APocketGuidefortheFront-lineHealthWorker15October2014.Interimemergencyguidance-genericdraftforWestAfricanadaptation(WHO.March2014,updatedOctober2014;widelydistributedinSierraLeoneDec2014)5Thisguideislimitedtoclinicalguidelines.TheMSF2008Guidelineswereusedincombinationwiththisguide,astheMSFdocumentoffersguidanceonthebroaderoutbreakresponseactivities.
KEYMILESTONES–EBOLAOUTBREAKSIERRALEONEANDOCGDate Event
26/05/14 1st confirmed caseof EbolaVirusDisease (EVD) in Sierra Leone (froma ‘governmenthospital’inKalaihundistrict–borderingwithGuinea)6
June2014 1stcaseEVDreportedinFreetown(WHOdata),nofacilitiespresentatthattime.7
6/8/2014 NationalstateofemergencydeclaredinSierraLeone8
1/9/2014 September2014–significantsurgeincasesinFreetown,alongwithPortLoko,BombaliandTonkolilidistricts.“...MoHwasworkingnearlyalone…”9
30/11/14 BoETChandedoverfromOCBtoOCA10
10/12/2014 POWETCwith40beds(twowards)available11
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17/12/14 “Governmentprocessofcase‘surge’”began12
10/1/2015 FreetownPOWETC(100beds–30forsuspectedcasesand70forconfirmed)declared“totallyoperational”13
3/02/2015 SurvivorsClinicwasopenedinFreetownbyOCG14
16/02/2015 DecisiontoclosethePOWETCwasfinalised15
23/02/2015 LastPOWETCpatient,the83rdsurvivor,wasdischarged16
28/02/2015 Freetown POWETC closed. Focus continued on Survivors Clinic,Water, Hygiene andSanitation(WSH),andHP17
1/3/2015 TheSurvivorsClinicmovedfromtenttoabuildingontheschoolcompound.OCGhadtheiroffice,andtheclinicwasinthebasement–(fromakeyinterview)
8/5/2015 OCGdecidestoclosemissionin6weeks18
15/06/2015 OCGactivitiesstopped.SurvivorsClinichandedovertoOCBandmovedofftheschoolcompound–(fromakeyinterview)
30/06/2015 OCGclosesmission–“BytheendofJune2015themissionclosesafterasevenmonthinterventionintheCountry”19
07/11/2015 SierraLeoneannouncedEbola-freebyWHO(BBCWorldService)
1.3 Methodology
We used an ex-post evaluation approach to analyse aspects of the management of the EbolaoutbreakattheFreetownETU,ranbyMSF-OCG(usingqualitativemethods).Theevaluationprocessconsistedofdistinctphases:
● Collation and review of relevant documents supplied by theMSF Vienna EvaluationUnit andOCG,andthoseavailableinthepublicdomain.o OCGdata sourcesprimarily included,butwerenot limited to: SitReps, visit reports,Endof
Mission reports, Ops meeting minutes, reports from strategic meetings and workshops,clinicalguidelines;reviewsofhealthpromotion,water,hygieneandsanitationactivities.
● Document analysis of key papers for information and themes specific to the evaluationobjectives.
● Semi-structured interviewswereconducted intheperiodof22Octoberto23November2015withkey informants,purposefullysampledbyOCGcommissioners, theMSFViennaEvaluationUnitandtheevaluatorsaccordingtorolesmappedtothescopeoftheevaluation.
The65individualsconsultedincluded2:o KeystakeholdersatGenevaHQ.o KeyinformantsinSierraLeone○ Ministry of Health & Sanitation, Sierra Leone National Ebola Response Centre (NERC),
international NGOs, MSF-OCG, OCA, OCB and OCBA national and international staff(currentandpast),survivors.
o OtherkeyinformantsbySkypeinterview(worldwide)andinperson(London).● Typingofinterviewnotesandcross-checkingbetweenevaluators.● Thematicanalysisof(principally)typedinterviewnotestoaddresstheevaluationaim,mapped
toscopeareas;triangulationperformedbetweeninterviewees’perspectivesandfindingsfromdocumentaryanalysis,whereverpossible.
● Writingupfindings,conclusionsandformulationofrecommendations.2Pleaserefertotheannexforthefulllistofinterviewees.
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1.4 Limitations
Weconductedanex-postevaluation,meaningthatweexaminedinformationandactionsfromaspecified,completedperiodintime.Therearetheinherentlimitationsofrecallbias,datalossandaccesstosomeinformants.OtherMSFOCs remain present and active in Sierra Leone;whilewe ensured that our informantswereawarethatourfocuswasframedwithinthespecifiedperiodforMSF-OCG’swork,otherNGOactors, theNERCand theMinistryofHealthandSanitation (MoH)oftenwanted to respondabouttheir experience of the MSF movement’s response in general. We have captured this within thereport,whererelevant.
Not all information captured in the interviews could be triangulated with other resources orinterviewees, but we largely found consistency. The principal themes for each scope area werestrong, andwe reached thematic saturation onmany issues.Wehave provided quotationswherecommentswereparticularlyrelevantincapturingkeyissues.Astheinterviewswerenottranscribed,wehavereliedonourjointnotetakingduringtheinterviews,anddigitalrecordings,toensurethattheseareasaccurateaspossible,buttheymaynotbeverbatim.
Thisevaluationhasbeenconductedwithina limited time frame.We interviewedmore individualsthan was initially planned, each providing breadth and depth to this work. Interviewees weregenerouswiththeirtimeandresponses,resultinginalargeamountofinterviewdatatobeanalysed.Whilewehadorganisedtheinterviewstoensurecoverageofallthescopeareas,someareaselicitedmoreemergingthemesthanothers,whichinturnprompteddeeperexamination.
There was a lack of formal documentation of decisions and organised data collation conductedduringtheoutbreak.Thislimitedourabilitytoanalysetheimpactoffieldactivitiesandadaptationsonpatientoutcomes,andrepresentsanareaofweaknessintheOCGresponseforwhichwesuggestrecommendationsforimprovement.
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2 FindingsandconclusionsEachofthefollowingsub-chapterscontainsrespectivefindingsandconclusions.Recommendationsarepresentedattheendofthereport.
● Infrastructure● Medical&NursingCareManagement● EpidemiologicalControlMeasures● CommunityEngagement&Mobilisation● CapacityBuilding● RelationshipwithotherActors● Research,MonitoringandEvaluation
2.1.1 Infrastructure“MSFarealwaysready–theyhaveeverythingyoucanthinkof–theyare excellent!... They say – ‘wait aminute’ – and then they have it!”(OCGnationalstaff).
Infrastructureinthecontextofthisevaluationencompassesmorethanphysicalstructures,reflectingthe themes,which emergedduring the evaluationprocess. It includes an analysis of the responseinfrastructure at the arrival of OCG in Freetown, theMSF crisismanagement structure, theOCG-specific crisis management structure, infrastructure innovations of the POW ETC, alternativeinterventionmodelsforthefutureandlaboratories.
2.1.2 Findings
RESPONSEINFRASTRUCTUREATTHEARRIVALOFOCGINFREETOWN“MSF were doing a great job in Bo and the Eastern Region, but weneededMSFinFreetowntwomonthsearlier”(DERC/NERC).
MSF’s decision to intervene in Freetown was late. By September 2014, there was a shortfall ofisolationbedsinFreetownandthewholeWesternArea.TherewereseverebottlenecksforpatientsinHoldingCentresandpatientsweredyingofEbolawhileunderquarantineintheirhomes.The‘117’hotline was unable to send ambulances as there were no beds available. This crisis situationcontinued for months; MSF-OCG sent an assessment team in November 2014. There was regretwithinOCGthattheyhadnotcometoFreetownatleastfourweeksearlier.
ThegovernmenthadinitiallyplannedthattheWesternArea(whichincludesFreetown)wouldhaveisolationfacilitiesprovidedbytheMinistryofHealthandBritishorganisations(includingtheSavetheChildrenETC,supportedbytheUKDepartmentofInternationalDevelopment[DFID]andtheBritishmilitary). However, actors tasked to build the new ETCs were not able to increase the speed updeliverytomeetthehighdemandforisolationbeds.OCGOperationsexplainedthattheopeningofaMSFactivityinFreetownhadbeendiscussedwithOCBandthesubsequentCentralisedTaskForceinthe months from June to September. There were delays to decision-making due to “... a lack ofstrategywithinMSF...and internaldebateswithothersections”, inpartdue toconcerns thatMSFdid not have the HR capacity. However, interviewees confirmed that all MSF sections ultimatelyagreedwithOCGopeninganETCinFreetown.
TheSierraLeoneangovernmentaskedOCGtosetupanETCinFreetown,andinNovember2014theMinistry of Health assisted the OCG assessment team in identifying the location and gainingcommunity approval for the site at the ‘Prince of Wales School’ (POW). The Memorandum ofUnderstanding (MoU) with the government, signed on the 24th of November, included the exit
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strategy: "Once the ETC is no longer needed (epidemic decreasing or sufficient beds available inpermanent centres) MSF-OCG will remove the ETC and return the premises to the schoolauthorities..."3
OnceOCGdecidedtointervene,theyactedrapidly.TheOCGETCwasbuiltintheschoolcompoundin12days,admittingitsfirstpatientonthe6thofDecember2014.Allactorswereimpressedwiththeefficiency with which the POW ETC was designed, constructed and open to admit patients. TheachievementdemonstratedMSF’s crisis experienceandeffectiveness, andOCG’sdedication in thefieldandatHQ.Bythe18thofDecember2014,thenumberofbedsavailableintheWesternRegionmetpatientdemandforthefirsttimesinceSeptember2014.
TheOCGprojectprioritiesweredescribedas1)providebedsforisolationandtreatmentofcasesofEbola, and 2) provide outreach services. There was a reduction in the number of Ebola cases inFreetowninthefirstweekofJanuary2015.TheadmissionrateatthePOWETChadfallentoabouthalf itsprevious rate in the thirdweekof January.While thesesecularchangeswerehappening inFreetown, OCG had also increased its outreach activities (health promotion and communityengagement) locally to the POW, and introduced support services for survivors and their families.The impact of these outreach activities on transmission rates in the local community cannot beassessed retrospectively, butmay have supported the virtuous circle of reduced transmission andfewercases.SurvivorsgreatlyappreciatedtheservicesoftheSurvivorsClinicwhenitopenedinthefirstweekofFebruary.
The ETCwas intended as a ‘stop-gap’,with the school to be handedback by the endof February2015. The government of Sierra Leone decided to re-open schools inMarch/April 2015. The ETCclosedattheendofFebruary,whichwasfollowedbydecommissioningofthesite,delayingthePOWschoolre-openingbyoneweekbehindotherlocalschools.
OCGcontinuedtoruntheSurvivorsClinic,withallcomplimentaryservices(medical,mentalhealth,psycho-social support, and health promotion) until the end of June 2015. The decision that OCBwould take over the Survivors Clinic fromOCGwasmade during the EbolaWorkshopmeeting inDakar(11-13June2015).
THEMSFCRISISMANAGEMENTSTRUCTURE“The Centralised Task Force approach was not agreed with othersectionsat the start – In not sharing the vision, Sectional Leadswerenotallonthesamepage”(OCGHQstaff).
The Centralised Task Force, formed by OCB, led MSF’s regional Ebola response. Intervieweesidentifiedchallengesrelatedtothisstructure,whichincludedconcernsthatthestyleofmanagementwas not alwayswell accepted by otherMSFOCs. Undoubtedly, thosewithin the Centralised TaskForcecarriedunprecedentedresponsibilitiesrelatedtotheclinicalchallenges,andtherequirementfornegotiation,advocacyandcarefuldecision-making.
Intheearlyphasesofthecrisis,alldecisionsrequiredvalidationfromtheCentralisedTaskForce.TheTaskForcewasdescribedasbeingconservativeandslow,largelybecauseitwasoverwhelmedwithrequests:“Decisionsthatshouldhavetakenanhourtookmanydays”(OCGHQ).Individualsreportedthat their proposals for new approaches were rejected due to a lack of sufficient evidence: “TheCentralisedTaskForcewaslikeablockade–therewaslackoftrust”(OCGHQ).However,allinvolved
3TheagreementincludedadonationofageneratortothePOWschool,buttheremovalofelectricalinfrastructuremadethegenerator“useless”andunfortunatelycreatedtensionsbetweenthePOWschooladministrationandMSF-OCG,accordingtonationalstaff.
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recognise the challenges faced by the Task Force in balancing the risks under these difficultcircumstances.
Someintervieweessupportedthenotionofasingleleadsectionduringmajorcrisesand/orcomplexmulti-sectionalresponses.MSFusedanalogiestothismodel inAfghanistanandinNorthernSudan.“TherewasanoldagreementinthemovementthatOCBweretoleadonVHF.AsingleOCleadcouldhavefunctionedbetterbutbecauseoflackofpeoplewithEbolaexpertiseandotherlowcapacities,itwasimpossible”(OCGOperations).Eventually,allfivesectionstookaroleintheresponse,withsomeOCschoosingtofocusonnon-Ebolainterventions.
InSierraLeone,inadditiontoOCGworkingatthePOWETCinFreetown:
● OCBhadETCsinthenortheastofthecountry,buthandedtheseovertoOCAinOctoberandNovember2014inordertoconcentrateontheGuinearesponse.
● OCBA provided mass distribution of anti-malarial medication before opening an ETC formaternitypatientswithEbola.AlthoughitwasanimportantclinicalservicefortheWesternArea,itwasalsolate(openedinJan2015,closedApril2015)andthedemandwaslowduringthatperiod.
Earlyintheoutbreak,theperceptioninSierraLeonewasasMSFasoneactor.LaterpeoplebegantodistinguishbetweendifferentMSFsections.WhenthegovernmentaskedOCBtore-opentheBoETCandhavestaffavailableincaseofreoccurrencesofcases,thedecisionfromOCBandOCBAwasthatitwasnotanappropriateuseof resources.Thegovernment thenapproachedOCAwhoagreed tothe request, causing frustration between sections about the lack of consistency in operationalplanning.Wewere told that thisdecision resulted in130staffbeingon ‘stand-by’ inFebruaryandMarch2015.
TheMSFmovementstruggledwithHRcapacitywithregardtonumbers,experienceandcompetencyin managing this crisis. In spite if this, individual MSF staff were considered to have a sustainedpresence in the field – MSF-OCG was “consistent compared to other organisations” (WelbodiPartnership).FromaHRperspective,thereweretoofewindividualswithsufficientEbolaexperienceboth in the fieldand inHQ.Overall, interviewees felt thatgoodmanagementand leadership skillswere‘lacking’inthefield,withsomenamedexceptionsthatwere‘excellent’.
Despitethechallenges, theMSFmovementearnedagoodreputationwithkeystakeholders:“MSFalwaysknewwhattheyweredoing–whyandwhattheywilldeliver.RecruitmentbyMSFisgood”(NERC).
TheMSFmovementbenefitsfromhavingthediversedynamicsofthedifferentOperationalCentres.Itenables theMSFmovementtohavecompetingapproachestoaproblemandstillmaintaintheircoremandate.Inacrisis,thestrengthsofthismodelmustbeallowedtoflourish.20
THEOCGCRISISMANAGEMENTSTRUCTURE“OCGmanageddecentlyundertheconstraints”(OCGstaff)
The hierarchical decision-making structures within OCG were well defined. OCG Ebola expertdecisionswerevalidatedtransversallybetweendirectors.Ifaspecifictechnicalissuearosethatwasdepartmentallyspecific,thedirectorofthatdepartmentwouldmakethedecision.ItispossiblethatalackofaspecificEbolacrisismanagementcelltoconsolidatetheOCGHQoperationalteamsinoneplace,combinedwiththefrequentfielddeploymentsoftheEbolaexperts,mayhavecontributedtothe slowing down of communication related to protocol questions, changes and validation ofproposals. The demands on the OCG Ebola expert staff were considerable and warrants formalacknowledgement. It has been suggested that a medical Head of Mission (HoM) would beadvantageous; however, an experiencedmedical coordinator could give this type of support to a
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non-medicalHoM.Themission’smedicalresponsible,whetheritistheMedcoortheHoM,needstohavetheexperientialweighttonetworkandinfluenceatalllevels.
Therewas appreciation from the field for the hands-on support HQ offered. However, individualswouldlikemoretransparencyaboutvisits.Forexample,aTermsofReferenceregardingavisitcouldbesentinadvancetoensurerolesandschedulesarecleartoallparties–thosetravelling,andthosereceivingthevisit.
Staff described tensions between the field staff and HQ with regard to the closure of the OCGintervention,andmoregenerallythelackofflexibilityorengagementonthisissue.Furthermore,aninitial lackof commitment fromOCGHQdelayed theplanningof theSurvivorsClinic,whichwasafield-driveninitiative.ThisclinicfinallyopenedthreeweeksbeforethePOWETCwasclosedandwascontinuedbyOCGuntilJune2015,whenitwashandedovertoOCB.
INFRASTRUCTUREINNOVATIONSOFTHEPOWETCThegrowingindependenceofOCGfromtheCentralisedTaskForceovertheperiodoftheoutbreakresultedintheimplementationofmoreinnovativeadaptations,with“muchmoreinvolvementfrombothsides–HQandfield”(OCGHQstaff).
ThePOWETCdesignbenefitedfromlessonslearnedthroughtheresponsewiththe“luxuryofbeingpre-designfromthegroundup”(OCGHQstaff).PriortothePOWETC,otherNGOactorshadtakentheir ETC design from Bo, which was constructed under different circumstances and had manylimitations.
TheETCwasinnovative.KeyinfrastructureinnovationsofthePOWETCwere:
● The physical design and layout, enabling staff to access patients from the low-risk areawithoutenteringthehigh-riskarea.
● Nursingstaffwerelocatedclosertothepatients,allowingstafftorespondquickly.● Theuseofplexiglassinthehigh-riskareaallowing
○ more frequent direct observation by doctors of patients and colleagueswithin theward, enabling those outside the ward to give support to colleagues inside, andreducingthenumberofstaffrequired;
○ patients’ relatives to safely interact with their family member(s) as they werefacilitatedtoenter intotheETChigh-riskarea,protectedbytheplexibarrier,whenthepatientwastoounwelltogotothedesignatedvisitingarea;
○ toreducetheamountoftimemedicsspentinhotPPE.● Lowfencingwithinthelow-riskarea,creatingatwo-metersafe-distancezonebetweenstaff
andpatients.Thisimprovedtheinteractionandqualityofcarepossiblewithpatients–staffinthecorridorcouldusealighterversionofpersonalprotectiveequipment(PPE),whilealsobeingabletoaccesstheplexiglasscorridor.
● The‘safe’corridorsallowednursingstationstobepositionedwithaconstantviewintothewards.
ThedesignprocessofthePOWETCwascompletedatOCGHQwiththeinputfromstaffinthefield;therewereeightdraftdesignsaccomplishedwithinfourworkingdays.Whilethedesignprogressed,thelogisticsteampreparedthegroundforthetentstructures.Eventheorientationwasconsidered,allowingtheseaairtoblowthroughtheCentretomakeitmorecomfortableintheheat.
Thephysicaldesignimprovedtheexperienceforstaff,patientsandtheirfamilies.ThecombinationofdesignandincreasedHRcapacityallowedtheETCactivitiestobemoretransparenttothepatients’relatives. Innovations included safe visiting areas with counselling for family and friends and theprovision of separate benches for patients and visitors to show films on a screen in the evenings.These factorsmade the POW ETC accessible and ‘welcoming’ for families and friends of patients.“ThePOWwasthebestETCinthecountry–itwasreallygreat”(OCGfieldstaff).
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ThePOW layoutwasbasedonamass casualtyprinciple. The theorywas that40%of thepatientswhowere triaged as having better survival prospectswould be located in the Intensive CareUnit(ICU)areaswheretheETCtechnicalstaffwereconcentrated.Theremaining60%wouldbemanagedto allow a decrease in the ratio of medical staff to patients. The nursing station, with a 2-metreseparation barrier, requiring fewer staff,would oversee suspected cases. Survivorswouldmanagerecoveringpatients,withfewermedicalstaffrequired.Ifthenumberofpatientsincreased,theETCcouldkeep thesameratioofmedical staff topatients in the ICUwhile in thesuspectedcasesandrecoveryareas,thenumberofmedicalstaffcouldbedecreased.4
Some interviewees were concerned that while having advantages for the medical teams andimprovedpatientsupervision,thedesigninnovationhadtheunintendedconsequenceof
a. disincentivising medical staff from entering the high-risk patient cubicles. As a result,additional tasks fell to theWatSan staff– whowere required to enter the cubiclesmoreoftenforcleaning –suchasgivingoralrehydrationtopatientsanddoingotherbasiccareofpatients,whichwouldnotusuallybeconsideredtheirrole.
b. detrimentallyreducingthespaceinsidethecubiclewhichmadetheWHSworkmoredifficult.For example, a nurse had tripped over a stretcher due the restricted space in which tooperate.
Adaptationstooperationsmatchedthedynamicevolutionoftheoutbreak.Examplesinclude:
● TheCentrewasdownsizedasdemandforisolation/treatmentbedsdecreased.● Changesweremadetomedicalprotocolsasknowledgedeveloped.● Survivorswereemployedascare-givingstaff(requiringlighter,morecomfortablePPE),
furtherreducingthestaff-to-patientratio.Thiswasfelttobeparticularlyimportantforthewelfareofyoungpatients.
● TheclosureplanoftheETCwasdevelopedinconjunctionwithcommunityengagementactivities.
ThoseinterviewedfeltthatthePOWwasMSF’sflagshipETC.
ALTERNATIVEINTERVENTIONMODELSFORTHEFUTURE“Themodelneedstobeflexibletotheneeds,demandsandcontextoftheoutbreak”(OCGHQstaff).
Some interviewees felt thatcommunitycarecentres (CCCs)couldbepreferabletoETCs.Thesearesmaller Ebola treatment facilities, varying in size from five to thirty beds, which are closer to thecommunityanddevelopedwithcommunityengagementandfacilitation,oftenwithafamilymemberbeingthemaincaregiverforthepatient.Thismodelisintendedtomitigatethefearsassociatedwithloved ones being ‘removed’ to ETCs and offers a focal point for community awareness activities.SomeworkhadbeendonetodevelopasmallersimplifiedmodelinSeptember2014(seeAnnex5.5).This conceptwasused in the transit centreofanETC inMonroviaandalso in thePOWsuspectedcasesarea.
Formalisation of a home-based care model was discussed out of pragmatism at the peak of theoutbreakwhentherewasalackofavailabletreatmentbeds.Thismodeladdressestherealityofthesituation,whichcouldbefoundthroughouttheoutbreakwithfamilymemberseitherpreferringtocare for their infected loved ones at home, or having no alternative, sometimes while underquarantine. Families would receive information and material resources (PPE) to allow them toprotect themselves from transmission of the viruswhile nursing their familymembers. “Initially it4ThisinformationwasprovidedbyaseniorOCGHQstaff.
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wasdifficulttothinkoutsidetheETCset-up.LargeETCsneedlargeresourcesandaremorecomplextodeliver”(OCGHQstaff),thusthedynamicsofanoutbreakrequiresflexibilityinsupportingpatientcare.
Severalintervieweesvaluedthefutureconsiderationofsmall, localcaresolutionsasalternativestotheETC,yetthemodelsaboveremaincontroversialandlargelyuntested.CCCmodelsinLiberiawereintendedtobeevaluatedbySave,butthereweretoofewpatientsinthecentressotherewerenomeaningfulconclusions.Intheheightoftheoutbreak,epidemiologicalmodelling(byAdamKucharskiat LSHTM) suggested that the use of quickly scaled up CCCs would have reduced communitytransmission overall, outweighing the modest increase of transmission associated with the CCCmodel.21
Amasscasualty“EbolaRegulatedReferralSystem”approachwasproposedwithinOCG inOctober2014.Thismodelshouldbeconsideredforlarge-scaleinfectiousdiseaseoutbreaks,anditshouldbeconsideredforadaptationinothercrisescontexts.PleaserefertotheAnnexforafulldescriptionofthismodel.
The need for flexibility in approach is paramount; there is no one perfect solution. Further, “MSFshould be more able to go outside the norm” (OCG Operations). The specific location, culturalcontext, scale of outbreak and transmission dynamics of a future outbreak would determine themost suitable responsemodels–more thanoneapproachmaybe required. Thedynamicsof anyoutbreakwould require real-time review and projection in order to inform response adjustments.Therewasanoveralllackofprojection,planningandflexibilityinresponsebyallactorsinthisEbolaoutbreak.
LABORATORIES“ThelaboratoriesinSierraLeonewerechaotic”(OCGHQstaff).
Laboratory diagnosticswere slowandunreliable at thepeakof theoutbreak in Sierra Leone. Thiscreated bottlenecks in Holding Centres, resulting in them being described as ‘Ebola TransmissionCentres’.
OCG acquired an on-site laboratory, the European/Nigerian mobile lab, at the POW. This labprocessed the entire ETC samples from the second day of the POW’s opening, providing rapiddiagnoses for patients. The ‘mobile lab’ brought its own materials and equipment, operatingindependently of MSF. Additional biochemistry equipment was provided by MSF to improve itsinvestigativecapacity(thei-STATandPiccolo).Thislaboratoryservicewasasuccess.
However, it is relevant to note that Laurent Kaiser, deployed to the affected countries from theHôpitaux Universitaires de Genève (HUG), wrote in his report for OCG: “For the future I wouldstronglyadviseagroupof technicians/biologists trained inmoleculardiagnostics that could setupthis typeof lab, including haematology and chemistry. A training centremight be considered as ajointprojectbetweenMSFandourinstitution(LaurentKaiser,HUG).”22
AlthoughthisrecommendationwasnottakenupintimeforthePOWETC,MSF-OCGmayconsiderexpanding its own capabilities through such training, and thus increase independence for futureoutbreaks.
2.1.3 ConclusionsThereweretwoaspectsoftimelinesstoconsider:
● Anearlier interventionofMSF inFreetownwouldhavebeenbeneficial.ConstraintsrelatedtocapacityandinternalstrategicdisagreementdelayedthedecisionforanMSFpresenceinFreetown.Itispossiblethatanearlierarrivalmaynothavebeenabletobesuitablystaffed,
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but there is regret from all actors, especially OCG staff, that the POW facility and theassociatedoutreachactivitieswerenotavailableearlier.
● The speedofOCG’s delivery, once committed to the ETC, appears to beunparalleled. Thegreat effortwas appreciated and embeddedMSF’s reputation as being the experts in thisfieldofwork.
The MSF crisis management structures employed in this outbreak had their strengths andweaknesses.TheintensityandcomplexityofdemandsontheCentralisedTaskForceweresignificantbut despite the challenges, MSF (and OCG specifically) maintained an excellent reputation in itsresponseinSierraLeone.
● When one section leads a major response, other OCs could have pre-establishedparticipatoryroles(suchasfociofspecialty),withinamanagementsystemthatiscoherent,clearandacceptabletoall.
● The Centralised Task Force was responsible for both broad and detailed decisions, whichimpacted its decision-making ability. The demands were intensive and sustained overmonths.
● MSFsufferedfromalackofstaffwithsufficientskills,e.g.inclinicalknowledge,networking,negotiation, advocacy and coordination – activities which were vital in this multi-actor,rapidlyevolvingcrisis.
● CollaborationacrossOCmissionsinthefieldwasconsideredsuccessful.
IntermsoftheOCGcrisismanagementstructure:
● WorkingarrangementsacrossMSF-OCG,fromfieldtoHQ,weremostlyproductive.● Adedicated Ebola crisismanagement cell, consolidating theOCGHQoperational teams in
oneplace,mighthaveofferedamoresupportiveandorganisedplatformfortheOCGEbolaexpertsandwouldhavefacilitateddecision-making.
● InformationaboutthepurposeofMSFHQvisitsishelpfulforthefieldstaff.● MSF-OCGmayhavebenefitedfromsharingmoredecision-makingresponsibilitieswithsenior
fieldstaff.Thedecentralisationofdecision-making toOCGfield/HQ,when itoccurred,wasadvantageoustoinnovation.
TherewereimportantinnovationsatthePOWETCthataddressedpreviouslyidentifiedchallenges:
● Theplexiglass corridorallowed improvedsupervisionofpatientsandenabled their contactwiththerelatives.
● Visitor-friendly construction and provision of social events for patients’ relatives had apositiveimpactontheacceptanceofcare.
Otherimportantconclusionsdrawnwere:
● SuggestionsandideasweredrivenfromboththefieldandHQ.● TheOCGPOWmodelwasconsideredasignificant improvementonpreviousETC’s.Aspects
of the design and relevant operations may be built into guidelines for future infectiousdisease outbreaks, with a view that further innovations should be developed to addressrecognisedchallenges.
MSF-OCG,as it is currently led,appears toencourageacultureof innovationandadaptation fromfield toHQ levels.Flexibility inmodelsof responseand interventionareneeded inorder toevolvewiththespecificcontextanddynamicsofanyfutureoutbreak.
● Local-levelcaresystemsmaywarrantconsiderationinordertoincreasetriage,isolationandtreatmentcapacitymorerapidly(inbothlargeandsmall-scaleoutbreaks).Controversiesstillexistandconclusiveanalyseshavenotresolvedtheconcerns.
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● The “mass casualty” approach may offer an alternative model to large-scale outbreakmanagement.23
● Flexibilityinapproachneedstobepurposefullypursuedinfutureoutbreaks.Thesuccessfuladaptationwillbeafunctionofthespecificlocation,culturalcontext,scaleoftheoutbreakandtransmissiondynamics.
Externallaboratoryserviceswereweakandchaotic.MSF-OCGimportedamobilefacilitytosupportthePOWETC,allowingforrapid,reliablediagnosticsandenhancedbiochemicalmonitoring.
● MSF may want to further develop its own VHF/Ebola laboratory capabilities (e.g. inpartnershipwiththeHôpitauxUniversitairesdeGenève).
● Alternatively,duetothesuccessoftheEuropean/NigerianmobilelabatthePOWETC,MSFmayprefertoidentifyreliablepartnersforfutureworldwidedeploymentinadvance.
2.2 MedicalandNursingcaremanagement
“When told (about my diagnosis of Ebola),MSF was peaceful. Calm.Theywereunderstandable.Theytrytogivemethecourage.Sonicetomeaboutitall”(Survivor).
This section includes an analysis of the use of clinical VHF guidelines, theOCG validation process,patient care innovations of the POWETC, issues related to balancing staff safetywith progressivepatientcareandthecareofsurvivors.Thesewerethekeyemergingthemesconcerningmedicalandnursingcaremanagement.
2.2.1 Findings
CLINICALGUIDELINESANDKNOWLEDGEEVOLUTION“The heavy focus on protocols made sense with small numbers ofpatients(inpreviousoutbreaks),butthestrictrulesmadeitimpossibleto rampup tomeet thedemandsof treatingmuch largernumbersofpatients”(OCGHQstaff).
MSFhadarelativelycomprehensiveGuidanceManual(2007)that includesalmostallaspectsofanintervention,includingcommunityoutreach,healthpromotion(HP),mentalhealthactions,examplesoftrainingsandsoon.The2008MSFGuideline5updateskeyinformationfromthelarger2007reportof 296pages and offers a shorter guide of 134 pages. It has important updates but it was notintended to replace the 2007 guide. However, the OCG team referred to the summarised 2008Guidelines as the version primarily used byOCGduring this intervention, rather than to the 2007GuidanceManual.
MSFproducednewdraftguidelinesbetweenAprilandDecember2014.Thisappearstobeaneditofboththe2007and2008guides,withtheincorporationofnewknowledge.Whileverycompleteandadvanced incollating the latestknowledge, thesewereconsideredbysometobe toocomplicatedandunrealisticwhenitcametofieldimplementationinanemergencycontext.
TheWHOguidelinesadaptedforthisWestAfricaoutbreakwerebeingproduced inGuinea inApril2014 (in French), focusing only on clinical guidance, with an updated version (the WHO PocketClinical Guidelines) completed in October 2014. The WHO guideline is purely for the clinical
5MSFstaffoftenusedtheterms‘guidelines’and‘protocols’interchangeably.However,somestafftendedtouse‘guidelines’torefertothepublished/MSFguidelinedocuments,and‘protocols’inreferringtotheadaptationsmadetostandardprocedures.
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managementofpatients.ItdrewheavilyfromtheMSFguidelines,wasconsistentwiththem,butdidnot include other relevant guidance as for outreach activities,WHSmanagement and so on6. TheSierraLeoneMoH&SLeadfortheClinicalPillarinvitedMSF(priortoOCG’sarrival)tocontributetheirexpertise to the development of theWHO clinical guidelines, butMSF chose at that time to notengage–aviewconfirmedbyotherNGOactorswhodidcollaborateontheguidelines.TheWHO’sPocketClinicalGuidelineswereavailableandusedbyMSF-OCGstaffatthePOWETC"whentheMSFguidelinesfellshort”(OCGHQStaff).
TheMSFPaediatricClinicalGuidelinesproducedinJanuary2015wereadaptedfromearlierversions,withkeychangestotheuseofantibioticsandrehydration,basedonexpertconsensus(recognisedevidence was limited): “MSF intends to harmonise paediatric with adult clinical guidelines” (OCGpaediatricspecialist).MSFisinvolvedintheongoingWHOTaskForceforpaediatricguidelines.
Insummary,allversionsoftheMSFguidelineshadtheirlimitations.Thecasemanagementprotocolsinthe2008VHFGuidelineswereconsidered‘vague’and,whilethePaediatricEbolaGuidelineswerefelt to be a big improvement, theywere described as being “too symptom-focused.”24 Some staffconcludedthat“theMSFguidelineswereobsolete”(OCGHQ).OCGstaffconfirmedthattheywereawaitingfurtheremergingevidence,researchvalidationandpublicationbeforefurtherupdatingtheMSFguidelines.
THEOCGVALIDATIONPROCESS“ThePOWstaffweremorealertandchangesweremoreefficient–butyoucan’tmeasurethis”(HQstaff).
OCGHQstaffcommentedthatmanyadaptationstopatientcareemanatedfromthefield.OCGhaddiscussed opportunities to safely encourage clinical innovation: “... teams need to be givenresponsibility to address changing needs/innovatewithin defined boundaries; likewise, itmust beclearwhenadecisionisnotforthefieldteamtotake”(OCGEbolaworkshop,Geneva.Feb2015).25During the operational period of the POW ETC, there were updates to paediatrics, the care ofpregnantmothersandnutritionguidelines.
There was consensus for the validation process for new medical equipment and protocoldevelopments. The HQ medical director then validated requests agreed by the medical Ebolaexperts.Themedicalfocalpoint inthefieldwouldattimesfind itchallengingtohaveaproductivediscussion with the HQ expert, which “created frustration” in the field (HQ field staff). Moreformalised decision-making processes could have prevented these difficulties, such as ‘decisionconversations’betweenthefieldandHQeverythreedays,asopposedtoadhoccommunications.
ByJanuary2015,keymedicalstaffsenttothePOWETCwerebriefedtobemoreprogressiveaboutcase management. These staff were legitimated to take clinical decisions autonomously7. MajoradaptationstoclinicalguidelineswerestillvalidatedbyHQ.
Opportunitiestoprogressthevalidationoftreatmentsmayhavebeenmissed:“MSFcouldhavebeenquickerinusingsomepromisingtreatmentsandtakingsomeriskswithuntesteddrugs.Leavingasideexperimental treatments, therewereanumberofoff-labeldrugs that couldhavebeenusedeventhoughtheireffectivenessforEbolawasnotclear”(OCGEbolaWorkshop.Geneva.Feb2015).26
6RefertotheMSF‘DraftNewGuidelines2014’,whichhas23topicchapters.7Thedecisionprocesswasbasedon:expertiseofstaffinthefieldandcase-by-caseapproach;Availabilityoflabresults;DiscussiononprotocolsusedbycolleaguesfromtheETCmanagedbytheEmergencyNGO.Thisprocessclinicallyledto:SystematicandaggressiveuseofIVfluids;Managementofspecificclinicalconditions(rhabdomyolysis,renalfailureandsepticshock).TheseinnovationswerecapturedinameetingendofFebruary2015(GarciaGuerrero,A.(etal).ClinicalLessonslearnedandManagementRecommendationsforPatientswithEbolaVirusDisease.MSF.February2015)
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PATIENTCAREINNOVATIONSOFTHEPOWETC"[The POW ETC] was innovative...it incorporated clinical careimprovements,suchasintravenousfluidadministration,electrolyteandbiochemistrymonitoring”(OCGEbolaOperationsAdvisor).27
There had been insufficient capitalisation from recent outbreaks in terms of patient care. EbolaexpertisewasconcentratedintheCentralisedTaskForceduringtheearlystagesoftheoutbreak,butat the timeofPOWETC,MSF-OCGhadgained inconfidenceandexperiencemanagingEbola.OCGbeganoperatingmoreindependentlyandwasabletobemoreinnovative.
The POWETC benefited from improvements tomedical equipment. The introduction of theDosi-Flow intra-venous infusion system allowed 24-hour fluid inputmeasurement, reducing the risk offluidoverload. In spiteof theCentralisedTask Forcehaving concerns, “it turnedout tobe a goodintervention” (OCG HQ staff). Other adaptations were implemented, such as retractable needles(orderedwithin2daysofthefieldrequest),the‘Piccolo’pointofcarebloodbiochemistrydiagnostictool (previously used at the Foya ETC) allowing Rhabdmyolysis to be diagnosed, as happens withsomeviral infections.8 Inaddition,theiSTATbiochemistrydiagnostictool(thathadpreviouslybeenapprovedforuseinFoyaETCbutfailedinhightemperatures)wassuccessfullyusedinthePOWETC.The implementation of biochemistry analysis at the POW ETC resulted in a period of rapidadjustments to clinical protocols. Some of these changes were resisted by field staff whoappropriatelyneededtimetostabilisebetweenalterationsinworkpractice.
PatientcaredevelopedduringtheperiodofthePOWETCduetotheopportunitiespresentedbythenewdesignofthecentre,thedynamicsoftheoutbreakandadvancementsinknowledge.Intermsofclinical management, the ETC aimed to treat patients early, with more intensive management offluids, and with close monitoring and treatment for acute kidney injury, sepsis, dehydration andacidosis, as recommended byGarcia Guerreroet al. in ‘Clinical Lessons learned andManagementRecommendationsforPatientswithEbolaVirusDisease’.28
Mental health serviceswere successfully integrated into the POW ETC. This offered an importantcomponentofcare thatwasnotgenerallyavailable inotherETCs, for thebenefitofpatients, staffand survivors. OCG drew on experience from Liberia, where the late arrival of theMental Health(MH)Team resulted indifficultiesof integrationand trainingof the team (MHadvisor,MSF-OCG).AlthoughapsychologistwasinsitufromthePOWopening,itwasfeltthatthework“tookawhiletogetgoing”(OCGfieldstaff)butbecameacriticalpartoftheservice.Itincludedcounsellingsurvivors,supportforthereintegrationofsurvivorsintothecommunity,andofferingaservicetonationalstaffinregardtostigmaandworkstress. Inaddition,amemberoftheMHteamwouldbepresentwiththe family during the viewing of the deceased, which was considered essential and was highlyappreciated(MHadvisor,MSF-OCG).
The use of survivors as caregivers was controversial betweenMSF sections. Therewere concernsregardingtheriskofstigmatisationandsafetyof thesurvivors.OCGhademployedcaregiversonasmallscaleinFoya,andthenformallyatPOW.Therole“wasveryimportantfortheyoungerpatients(children)”(Survivor,OCGnationalstaffcaregiver).
ThePOWETCincorporatedpaediatriccaretofilltheservicegapinFreetown.SpecificcategoriesofEbola patients were referred to other centres – patients needing ICU facilities were referred toEmergency(ItalianNGO);maternitypatientstotheOCBAETC(afteritopenedinJanuary2015);andallinfectedstafftotheBritishMilitaryICUfacility(withinSave’scompound).
8ThisincludedthemeasurementofelevatedCreatineKinase(CK),elevatedAspartat-aminotransferase(AST)andelevatedCreatinine,coupledwithconsistentchangesintheurine.
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MSF-OCGwasconstrainedbyalackofcapacitytoadequatelyrespondto‘non-Ebola’patients.Suchpatientsweredischargedwithan'Ebola-freecertificate'andreferredtootherservices,ifrequired.
Interviewees felt that patient care at the POW represented the culmination of lessons learned todate,benefitingfromstaffwillingtoimplementnewdevelopments.
BALANCINGSTAFFSAFETYWITHPROGRESSIVEPATIENTCARE“Inthisoutbreak,adilemmabetweenapproachesto‘staffsafety’and‘patientcare’arosethatdidnotneedtobethere”(OCGHQstaff).
As the outbreak progressed, with continuing high case fatality rates at ETCs, theMSFmovementrecognised the requirement toadvanceamorepro-activeapproach to theclinicalmanagementofEbolapatients.Secularshifts inclinical treatmentstrategy, includingmore intensive rehydrationofpatients,werediscussedinternallywithinMSF,amongstotheractorsandinpublications.29
Atthepeakphaseoftheoutbreak(namelyAugusttoSeptember2014,particularlyinELWA3ETC),itwasfeltthattheemphasisonstaffsafetymayhavecompromisedpatientcare.TheMoH&SinSierraLeone wanted treatment to bemore progressive and still had a persistent perception that “MSFpracticewastooconservative–forexample,innotgivingIVfluidtoeverydiagnosedpatient”.
ThePOWETCwasopenedwithaviewtoembedamoreprogressiveculturetopatientcare.Infectioncontrolpracticecontinuedtobeprioritised–theuncertaintyaboutthevirus’abilitytotransmitandpersistintheenvironmentnecessitatedarigorousapproach,whichwassupportedbyinnovationsinthePOWdesign.
However, the interviewed survivors wanted to share two examples of their care which wereneglected.Firstly,intermsofETCdesign,thesurvivorsfeltthatthetoiletswerelocatedtoofarawayfor patients who were weakened by their illness. Secondly, the patients described the accidentalmisuse of chlorinated water by patients, due to poor labelling of the tank taps. The 'disinfectionsolution'tankwaslocatednexttotheotherwatertanks(fordrinkingandwashing)andnotsecuredagainst mistaken use by the patients. Patients reported that being sick with Ebola affected theirthinking – so they did not realise that they were burning their skin and throat by using thedisinfectionsolutioninsteadofwater.Itwassuggestedthatthesetanksshouldhavebeenfittedwithamechanismtolockthemofforlocatedseparatelyfromthedrinkingwatertanktoprotectpatientsfromharmingthemselveswiththechlorine.Weweretoldthatstaffmembersweremadeawareoftheissues,buttheproblemhadnotbeenaddressed.
THECAREOFSURVIVORS–SURVIVORSCLINIC“The staff were so nice – Doctors, other staff and security.Igotencouragementandconfidencefromthestaff”(Survivor).
OCGwerethefirstactorstoprioritiseandprovidefortheneedsofsurvivors.MSFbeganreturningsurvivors to their communities in January 2015. Survivors could also meet in the Survivors Clinicwhen itopened inFebruary2015,wheremedicalcare,counsellingandmentalhealthservicesandmaterialassistance(suchasthedistributionofhomehygienekits)wereprovided.
The Survivors Clinic was of great importance to survivors. Interviewees confirmed that there was100%utilisationbysurvivors.Anoutreachcomponentincludedhealthpromotionandpsychologistsvisiting survivors at their homes to discuss other residual issues such as stigma. (Please refer tosection 2.4 Community Engagement for further details). MSF-OCG arranged monitoringappointmentsforsurvivorsinregardtoEbola-sequelaeeyecomplications.
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OnesurvivorrelatedananecdotalexperienceofabreachofpatientconfidentialitywithintheETC.Hiswifeoverheardother staffdiscussinghisdiagnosisbefore thepairhadbeenofficially told; thisimpactedonherdetrimentally.Thisbreachwasapparentlynotaregularorsystemicissue,buthadcausedgreatdistresstothissurvivorwholaterlosthiswifetothedisease.
ItwasfeltthatMSFcouldhavehadaroleinadvocatingforbetteroverallstandardsoftheoutbreakmanagementactivities.Forinstance,itwasknownthatcontacttracers(non-MSF)regularlyoperatedwithout sensitivity for patient confidentiality. Neighbourhoods were frequently made aware of amember’sEbola test resultsbefore thepatient’s familywas told. Forexample, a survivor recalled:“TheycalledoutinthestreetthatIhaveEbola”.NERChademployedstudentsascontacttracers,anditwasgenerallyfeltthatallaspectsoftheirpracticewereinadequate.PleaserefertoEpidemiologicalControlMeasuresSectionformoredetailsonMSF-OCG’scontributiontoContactTracing.
2.2.2 ConclusionsClose coordination within the MSF movement will be necessary to develop a comprehensivecollection of Ebola/VHF guidelines to include all aspects for a future outbreak response. All workneedstobebasedonresearchevidenceandthewidespreadexperiencegainedinthisoutbreak.
● MSFshouldkeeptheguidelinesupdatedandadjustedtothefieldneeds.● MSFshouldcontributetothedevelopmentofWHOGuidelines.● OCG/MSF needs to remain vigilant to ‘topic fatigue’, which slows down the research and
guidelineassemblythatneedstobecompleted.
TheclinicalpracticevalidationprocessinOCGwascleartostaff,butwasnotnecessarilyefficient.Ithad been intended that field medics could have had more authority to make adaptations toprotocols, which fell within safe boundaries. This intentionwas fulfilled to some extent: EvidencesuggestedthatmostdecisionsstillsoughtHQapprovalduringtheperiodofthePOWETC.
OCGimplementedinnovationstopatientcareatthePOWETC,benefitingfromnewequipmentforbiochemicalanalysisandadvancedknowledge.However,staffneededtimetotrainandstabilisetoprotocoladjustments.
● ProvisionofpaediatriccareinthePOWETCwasimportant.● Theemploymentofsurvivorstoworkascaregiversofferedimportantpsychologicalsupport
forchildpatients.● Additional laboratory equipment (Dosi-Flow, Piccolo and i-Stat biochemistry) allowed
improvementstopatientcare.● Therewaslimitedattentiongiventonon-Eboladiseaseresponse.
ThePOWETCsuccessfullyimprovedthefocusonthemanagementofpatientcare,whilemaintaininggood infection control practices. However, staff did not adequately prevent patients and childrenfromunintentionallyusingthechlorinesolutionsinsteadofwater.
TheSurvivorsClinicwaspioneeredbyOCGandisconsideredtobeanimportantMSFcontribution.
● The Survivors Clinic and associated services and activities may be critical for clinical andpsychologicalwelfare(stigmatisationmanagement).AmodelplanforaSurvivorsCliniccouldbeintegratedwiththeEbolatreatmentguideline.
● Survivorhomevisits,counselling,supportforthemonitoringofEboladiseasesequelaeandtreatmentforcomplicationsareimportantMSFactivities.
● MSF shouldadvocate for improved standardsof confidentiality andoutbreakmanagementactivitieswheneverandwhereveritidentifiesfailings.
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2.3 Epidemiologicalcontrolmeasures
The Epidemiological Control Measures section identifies key issues regarding thecompartmentalisationofoutbreakmanagementactivities;epidemiologicaldataandcontacttracing;andtheuseofanenforcedquarantinepolicyinSierraLeone.
2.3.1 Findings
COMPARTMENTALISATIONOFOUTBREAKMANAGEMENTACTIVITIES“We were not good at throwing the net out to find out what washappeningoutsidethePOW”(HQstaff).
ThePillarsystemofoutbreakcoordinationadoptedwithinSierraLeoneresultedinsiloedactivitiesbyactors. Intervieweesexplained that therewasminimal interactionbetween theactors, so that theneedsof thepopulationand thebenefitsof synergisticactivitieswerenot identified.Forexample,therewas some delay in the OCG team recognising and adequately responding to the difficultiesfaced by communities under quarantine: “OCG initially trusted partners toomuch to do theworkproperly” (OCGHQ staff). Contact tracing and line listing9, as part of epidemiological surveillance,wasmanagedbytwoactors,WHOandUNFPA,whofailedtoactandcoordinateeffectively,whichresulted in inadequate tracingandconfusionof information.MSF-OCGattempted to createbetterinteractionandintegrationofthecommunity-levelactorsandservices.
Thefailures inthecommunity-levelresponsecreatedsignificantrisksof infectiontransmission.Keyexamples included themixingof sickpatientsandwithasymptomatic relatives inambulances, thelackofsegregationfacilitiesatHoldingCentresanddelaysindiagnosticsduetofailuresinlaboratoryservices.OCGrecognisedthatitalsoneededtoaddressthesefailuresinorderto"servethemainaimwhichistosaveasmanylivesaspossible”(OCGEbolaworkshop,Geneva.Feb2015).30
TheHPteamrecognisedthatpeoplefromthelocalcommunity,whereMSFstaffhadbeenbuildingrelationsandtrust,preferredto‘self-report’totheOCGstaff,ratherthancallthe‘117’service.OCGwere open to this approach and it proved effective - it was observed that “…MSF-OCG healthpromoterscallingthehotlinewereabletoachievefasterresponsetimes”.31 OCGhadalsoagreed,fromthebeginning,withtheneighbouringcommunitythattheycould‘walk-in’foradmissiontotheMSFcentreifthepatientwasambulatory.
EPIDEMIOLOGICALDATAANDCONTACTTRACING“Fieldepidemiologywasnotusedenough”(HQstaff).
IntervieweesfeltthatMSFshouldnothavereliedonotheractorsforsurveillancedataandcontacttracing. There were disagreements between MSF and WHO/CDC regarding the approach toepidemiological surveillance and contact tracing. There were opportunities to use MSFepidemiologiststocollecthigherqualitydataandtooffertrainingtootheractors.
Goodqualityepidemiologicaldataisrequiredtomakeinformedstrategicdecisionsandtoavoidadhoc changes in activities and priorities. “Epidemiological data should have been used more9Linelistisanimportantproductofthecontacttracingactivity:"Alinelistisatablethatsummarisesinformationaboutpersonswhomaybeassociatedwithanoutbreak.Eachrowrepresentsasingleindividual,andeachcolumnrepresentsaspecificcharacteristicaboutthatperson.Columninformationincludesidentifyingdemographic,clinical,andotherepidemiologicinformation,includingriskfactorspossiblyrelatedtotheillness.Alinelisthelpsorganisepreliminaryinformationgatheredduringtheearlypartofanoutbreakinvestigation..."(Definitiontakenfromhttp://foodborne.unl.edu/public/role/epidemiologist/lineLists.html).
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progressively,andMSFhas in-housecapacitytodo it...MSFshouldhavecollaboratedwithothers”(OCGHQstaff).MSF-OCGepidemiologist (fromEpicentre) successfully collaboratedwithLSHTMtomake projections for NERC; other opportunities could have been explored to support OCG’sinterventionplanning.
TheOCG teamwas late to adequately address theneed for improved contact tracing, reflecting afailingofthelargerresponse.“Therewasnotenoughfocustofindsolutionstomakecontacttracingwork effectively early during the outbreak response... Thiswas amistake – stopping transmissionrequireseffectivecontacttracing"(EbolaAdvisoryGrouptoDirector-GeneralWHO).
Once mandated, OCG designated six nurses to conduct contact tracing. The nurses visited thecommunity to capture information of better quality than the information identified by the officialcontracttracers(studentsusedbyWHO/UNFPA).WeunderstandthatOCGengagedwiththe‘auntienetworks’tohelpincreasethequalityoftheseactivities.Whilethereisnospecificrecordeddata,therecollections and opinions of both international and national staff was that the ‘auntie networks’wereveryusefulinbuildingtrustandtracingcontacts.
OCG has recognised its potential contribution to surveillance systems. Epidemiology will receiveincreased priority in future outbreaks. MSF “needs to consider contributing to prospectivesurveillance systems in at-risk countries, and thenhaving strong surveillancequickly set up at thisfirst signs of epidemic. But not taking on absolute responsibility that belongs to the state. E-preptoolboxneededfornextepidemic”(OCGEbolaworkshop,Geneva.Feb2015).32
QUARANTINE“Thequarantinesystemwasanextremehealthhazard,anddangerousforthepeopleinsidequarantinehouseholds”(OCGfieldstaff).
GOAL,ConcernandOxfamtoldMSF-OCGstaff that theywantedMSF to leadagainst theenforcedquarantinepolicy.However,OCG“wastoosilentaboutthis”(HPActivityManager).MSFwastrustedasaleader;theopportunitytocoordinateadvocacystrategiesacrossNGOswasmissed.
Interviewees suggested that MSF lacked evidence to advocate against enforced quarantine.However, the suffering caused by the strategy was visible and documented by MSF-OCG. Forexample, “Health Promoters (HPs) were responsible for knowing about and checking in with allquarantinedhouseholds/clustersintheirassignedareas.Thisstartedasanefforttoconductaninitialassessment of the humanitarian situation inside the quarantines but grew into a larger activity asshortagesofbasicneedsincludingwater,food,andlatrineswerenearlyuniversalproblems”.33
IntervieweesfeltthatthelackofclarityfromtheMSFmovementontheenforcedquarantinepolicyresulted in the OCG team delaying full engagement with the needs of families and communitiesplacedundermilitary-enforcedquarantine.OCGeventuallydeveloped responseactivities: “TheHPteamfocusedontwokeyareas:1)documentingthehumanitarianneedsofthoseunderquarantine–reportingthecrisistotheEbolaCommandCentre...and2)buildingtrustbetweenourstaffandthoseunder quarantine to reduce the amount of time betweenwhen a person fell sick andwhen theywouldreporttheillness...”34
MSF-OCBAprovided ‘homeprotection kits’ to families in quarantine.MSF-OCBhaddeveloped thekitsforuseinLiberiaandsurpluskitswerebroughttoSierraLeone.Thekitscontained,amongotheritems,facemasks,gloves,andsurgicalplasticgowns.Theywereintendedtoallowpeopletoprotectthemselvesifsomeonewithinthequarantinedhouseholdfeltunwell.Theywerenotintendedtobeusedashome-basedcarekits.
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2.3.2 ConclusionsDespite the Pillar systemof outbreak coordination adoptedwithin Sierra Leone,which resulted insiloedactivitiesbyactors,MSFchosenottoprioritiseattentiononallthecomponentsrequiredforsuccessfuloutbreakmanagement.Inretrospect,thiscanbeseenasafailing.
● Arriving late toFreetowncompounded thedelay in recognising the failuresof responsebyotheractorsandOCG’sattemptstoaddresstheneedsofthelocalcommunity.
● MSF should have played a stronger role in preventing health service-associated diseasetransmission.
● MSF could have used their influence on the global stage to address the critical need forproperly managed laboratory diagnostics, the care and segregation of patients in holdingcentresandthesafeuseofambulances.
OCG should have given greater priority to epidemiological data collection and contact tracing inFreetown.
● OCGdidnothaveadequatein-houseepidemiologicalhumanresourcecapacity.Standardiseddatacollectiontoolswouldhaveallowedmoreaccurate,timelyepidemiologicalmonitoringtobetterprojecttheoutbreakdynamicsandenablecomparisontotheregionalcontext.
● Improvedcontacttracingcouldhavereduceddiseasetransmission.OCG’suseofnursesfromthe communitywashelpful, but thisworkneeded tobe conductedearlier andona largerscale.Managedproperlybytheauthorities,contacttracingshouldeliminatetheneedfortheexpensiveandharmfulenforcedquarantinestrategy,whichnotonlybreachedtherightsofthepopulation,butalsocausedalienationandunnecessarysuffering.
● Voluntaryquarantinehasarole;toachievethis,authoritiesneededtheengagementofthepopulation, which had been lost early in the outbreak. By contrast, enforced quarantinepractices - with the lack of provision of basic services for those under quarantine -compoundedthis lackofcommunityengagementwithdetrimental impact(casesnotbeingreportedduetofearoftheenforcedquarantine).
● PublichealthHRcapacitieswithinMSFseemtobelacking;publichealthskillswouldimprovestrategicplanningandoperationalactivitiesacrossalllevelsofoutbreak/crisisresponse.
● ThereweremissedopportunitiesasmedicsshouldjointheWHS/HPsinoutreachactivitiestoidentify emerging disease patterns in the community, and assist with identifying healthneedsoffamiliesinquarantineforreferral.
● There were missed opportunities to have medical epidemiologists working with healthpromotersincontacttracingactivities.
● MSFplanstodeveloptoolkitstoenhanceEpidemiologicalControlMeasures.
AllMSFOCswereweakinadvocatingagainstquarantineandfailedtosuggestalternativesolutions.
● MSF failed to invest the time and resources to better understand and respond to theenforcedquarantinestrategy(operationallyandthroughhigh-leveladvocacy).
● MSFshouldhavespokenoutagainstquarantinebeingusedasasubstitutetogoodcontacttracing.OCGcouldhaverespondedearliertosupportthefailuresinherenttothequarantinestrategy,assistingcommunitiesinisolation.
● SomeactorsconsideredtheMSF-OCBAdistributionof‘homeprotectionkits’toquarantinedhomesprogressively;thesekitsmayplayaroleinfutureoutbreakresponses.
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2.4 CommunityEngagement
"We need professional people to come house-to-house with healthpromotionmessages”(Survivor).
This section will describe the findings concerning early failings in community engagement, OCG’sworktogaincommunityengagementandapproachestoimproveengagement.
2.4.1 Findings
EARLYFAILINGSINCOMMUNITYENGAGEMENT“…I was told the ambulancewill come the next day, but nothing. Soafter two days I went to the security guard and told him... if noambulance, I will open the gate and takemy family to hospital. Thiscaused so much panic in the community… In two hours, twoambulancesarrived.Everyoneinthestreetcomeouttowatchandseetheambulances.ThiswasinDecember.”
PatientdistributiontothevariousETC'swasmanagedbytheDistrictEbolaResponseCentres(DERCs)inthisoutbreak.Familiesoftendidnotknowwhathappenedtotheirlovedones–whethertheyhaddiedorwheretheywereburied.Clotheswereburntandpossessionsathomewereoftendestroyed,without proper consultation, as part of the decontamination process. These insensitive householddecontaminationpractices,coupledwith loudambulancesirens inresidentialareasandthefearofquarantine, resulted ina lackofvolition tocontact ‘117’when individualsdevelopedsymptomsofEbola.
Rumours, conspiracies and misinformation were widespread. Public Health messages wereinconsistent,negative innatureandcausedfear,suggestingthattherewasnotreatment forEbolaandthatinfectionswillresultindeath.SurvivorssaidtheyhadnotbelievedEbolawasreal;theyhadbelieved rumours suchas that if peoplewent to seedoctorswith symptomsof Ebola, theywouldhavean“injectionintheirbigtoetokillthem”(Survivor).Therewaslaterecognition(Feb2015)thatthe use of loudmegaphones for healthmessages created fear for residents. Therewas a generalfailuretogivepositivemessagestopromotebetterhealth-seekingbehaviour.
Communications materials and messages were developed and adapted to the rapidly changingsituationonlyslowly,whichincreasedconfusionwithinaffectedcommunities.Forexample,thecorepublichealthmaterialswere taken fromthosedevelopedbyMSFandsubmitted to theMoH&S inKailahun in July 2014. “Thesemessages, developed for a rural population, were simply rolled outacross the country and never adapted to the urban environment of Freetown by MoH&S andUNICEF”(HPActivityManager).
OCGenergised itsHP team togain specific insights in the thirdweekof Jan2015by conductingarapidhouseholdsurveyof400+personstoassessthecurrentunderstandingoftheurbanpopulationwith regard toEbolaandEbola responseactivities.35This survey revealed that those inquarantineoften had little or no provision of food, water, and healthcare. OCG thus increased its focus oncommunityengagement,communicationsandoutreachactivities.
When OCG began to understand the depth of the gapswith regard to outreachwork and it wasevident that theWHOguidelines forhouseholddecontaminationwerenot as rigorousas thoseofMSF, there was a further incentive for OCG to partner with select NGOs.MSFWHS and HP stafftrained other actors in household decontamination (see ‘Training’ sub-section in the ‘CapacityBuilding’ sub-chapter). MSF-OCG developed a highly regarded system for vehicle and ambulancedecontamination,whichwasvalidatedbytheWHO.
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OCGWORKTOGAINCOMMUNITYENGAGEMENT“Behaviour change work lacked investment generally, but MSF hadgood intelligence on community values and engagement – this wasneededtostoptransmission”(NERC).
OCG’sPOWETChadasignificanttasktogainthetrustoflocalcommunities,inspiteofthelocalandalumni endorsement for the location of the ETC at the school. Prior to the POW ETC, family andfriendsofpatientstypicallystayedawayfromETCfacilitiesasthefocuswasonpatientisolation.HPstaffreportedtensionswiththecommunitylastingthroughDecember2014,buteventuallythePOWETC’sinnovativeapproachtoencouragefamilyvisitswassuccessful.
ThenumberofHPstaffwasincreasedfromfourtofifteenbyJanuary2015.ThisallowedtheHPteamto split, with the larger teams working within the community, assisting with householddecontamination,supportingfamiliesforburialsandsharingpositivehealth-seekingmessages.OtherHP staffworked in theETC, speakingwith families andpatients in the low-risk areas (wearing thelight PPE). These activities, in addition to the locally recruited nurses tapping into the ‘auntienetworks', had successfully increased trust within the community. There was an opportunity tofurtherenlistthesupportof‘women’ssecretsocieties’,butthisapproachwouldhaverequiredmoreinputfromexperiencedanthropologists.
APPROACHESTOIMPROVEENGAGEMENT“MSFneedstobetransparentinEbolaactions”(HPstaff).
AcertaintransparencyofactivitywasbuiltintothedesignofthePOWETCasdescribedearlier(seethe‘Infrastructure’section).Thesefactorssuccessfullyreducedtensionswiththecommunity.Therewere opportunities for visitors to don PPE and enter the high-risk zone, but this was notsystematicallyofferedandcouldperhapshavebeenbetteraccommodated.
From late January 2015, HP staff accompanied survivors to their homes in the communities. Thisprovided opportunities to share positive health promotion, infection control advice, and also toaddressother specific complaints at the community level. TheHPandMentalHealth Teamwouldfollow up with patients regularly, such as at 2 weeks and at 4 weeks post discharge, or at theSurvivorsClinic.Itwasfeltthatthisfacilitatedsurvivorreintegrationintotheircommunities,reducingstigma, and should have been prioritised earlier in the outbreak as many survivors had sufferedrejection.
Interviewees suggested additional outreach components. For example, OCG WHS householddecontamination teams could have offered a householdmember the opportunity to don PPE andjoin theteamduringtheirhouseholddecontamination; thiswasoffered inother interventionsandwasimportanttomaintainrespect.AnHP,andapsychologist,accompanyingWHSteamsforburialsandhouseholddecontaminationactivities,couldgivefurthercriticalsupport.
OthersecularfactorssupportedthesuccessofPOW’scommunityengagementwork:
● ‘Safeanddignifiedburials’werebecomingmainstreamandacceptedbycommunities.● Due tobetter andearlier clinical intervention,more survivorswere returninghome, giving
hopetofamiliesandcommunities,thusincreasingimprovedhealth-seekingbehaviours.
Thesecombinedfactorscontributedtoavirtuouscircleandareduction incases intheregion; it isdifficulttoascertainthequantitive impactofOCG'soutreachactivitiesbutqualitativereportswerepositive.
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TheOCGteammadeconsiderableeffortstogaincommunityendorsementthroughamorepositivepresence with supportive messages. However, there was limited communitymobilisation10 workmentionedbyinterviewees.OneexamplewastheinvitationofcommunityleaderstovisitthePOWETCsothattheycouldhelpbuildconfidenceintheETCandtacklestigma.Thisrepresentsattemptsto mobilise the community to take their own grass-root action to prevent transmission of thedisease,ratherthanmerelyactonmessages.
2.4.2 ConclusionsCommunity outreach is an essential component of outbreak management. Specific activitiespreventingtransmissionshouldhavehadthesamefocusastheactivitiesforisolationandtreatmentduringanoutbreakofthisscale.MSF-OCGoutreachactivitiesneededbetterprioritisation,resourcingandstrategicplanning.
● OCGcontributedtoarespectfulapproachtohouseholddecontamination– ifnotmanagedwell, the residentswill not adequately inform the teams about the affected areas in theirhomes.
● OCG lacked social science capacity (anthropologists/other social scientists) to enhanceunderstanding of and engagement with culturally determined health behaviours,superstitionsandreligions,duetotheirinfluenceondiseasetransmission.
● Rumoursandmisinformationwerenotappropriatelyidentifiedandmanaged.● Positivemessagesneededtobedevelopedtoencouragebetterhealth-seekingbehaviour.
Afterinitialtensions,MSF-OCGandthePOWETCbecamemoretrustedbythecommunity.Theuseof locally hired nursing staff linking with the ‘auntie network’ built trust, enablingMSF to accesscontacttracinginformationthatwouldotherwisehavenotbeenaccessible.
● Adequate numbers of HP staff, recruited from the local community, improved links tocommunitynetworks,reducingcommunitytensionsandfearsinreportingcases.
● TheHPteam(teamsplitbetweenETCworkandcommunityactivities), successfullyappliedlessonslearned,filledgapsandfoundsolutions.
MSF recognises theneed to investearly incommunityoutreachandengagementactivities,as thisincreases confidence in the responseand improveshealth-seekingbehaviour, benefiting individualand public health outcomes. However,MSF struggled to deliver this pillar to quality standards attimesduringtheoutbreak.
● Accessibility at the ETC, such as family visiting facilities, helped remove tensions with thecommunity,andprovidedcriticalreassuranceforthepatientandtheirfamilies.
● Engagement activities with the community were successful in breaking down barriers –examplesincludedcommunityleaderinvitationstotheETC,andthereturningofsurvivorstotheirhomes.
● Allthecommunity-levelwork,andthesurvivorreintegrationprograminparticular,ledbytheHPandMentalHealthteams,were importantactivities inreducingstigmaand inprovidingpositivehealthmessages.
● Thereweremissedopportunities incommunitymobilisationthroughworkwithcommunityadvocacygroupsorstudentandwomen’sgroups,whichwerenotpursuedbyOCG.
10Communitymobilisation:“Acapacity-buildingprocessthroughwhichcommunityindividuals,groups,ororganisationsplan,carryout,andevaluateactivitiesonaparticipatoryandsustainedbasistoimprovetheirhealthandotherneeds,eitherontheirowninitiativeorstimulatedbyothers.”(Howard-Grabman,L.andSnetro,G.2003.Howtomobilisecommunitiesforhealthandsocialchange.Baltimore,MD:HealthCommunicationPartnership).
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2.5 Capacitybuilding
“Ebolaemphasisedalotofproblemsthatwe(MSF)haveeverywhere–Ebolawasquick,hugeandputthingsunderthelight”(OCGHQstaff).
CapacityBuilding in this evaluationanalysis the trainingof staff inpre-deploymentandduring thecrisis, the need to develop the profession of HP staff and activities, emerging issues related tomaintaining the capacity of national staff and the need for information sharing and knowledgemanagement.
2.5.1 Findings
TRAINING“MSFshowedthattheycanbeleadersintraining”(MoH&S).
Pre-deploymenttrainingwasconductedeveryweekinGeneva.MSF-OCGcollaboratedwithIFRCtodeliver these sessions. Some interviewees felt that there was too much emphasis on practicingdonninganddoffingof PPE, andnot sufficientdetail on clinicalmanagement. Thoseproviding thetraining explained that the intention was to provide a short, accessible course on transversallyrelevant issues, which also included three ‘clinical’ lectures about the disease, symptoms andtreatment. In addition, pre-departure ‘e-briefings’ for international staff were provided by MSFCanada,withinputfromOCG.
Nationalstaffreceivedinitialtrainingincountry,includingthe‘MSFInduction’,oncetheywerehired.Fieldstafffelt“invigoratedwhenatrainingteamcamefromHQ”(OCGfieldstaff).TheHQTraining&Education Team visited ETC’s every 4 to 6 weeks. National staff reported that the trainings were‘perfect’,withrefreshersessionscovering“allsensitisation,knowledgeofEbola,whatitis,howyoucatch it...” (National staff). Trainingon 'CommunityDialogue’wasdevelopedandorganisedby theOCGHP team and conducted forOCG andOCBA staff.36 All national staff interviewed asked for a‘certificateofparticipation’fortheirworkportfolios.ThesewerenotconsistentlyofferedbyOCG.
MSF reported the overall lack of experienced humanitarian actors with the required emergencyresponsecapacity (seeMSF report ‘Where IsEveryone’, July2014).WatSan staffprovided trainingforotheractorsandreportedaqueueofpeople (externalactors)wanting tovisit theMSFETUs.37Both formal sessions and ‘on the job’ trainingwasprovidedbyMSF-OCG for otherNGOs, such asHandicap International (HI) and the Adventist Development and Relief Agency (ADRA). Topicsincluded household decontamination, disinfection of vehicles and health promotion. The threeformal two-day training sessions benefited 60 HI and ADRA staff: “We saw a big improvement inworkdoneasaresultoftraining”(MSFfieldstaff).
MSF-OCG shared guidelines with NGOs they were mentoring in the field and the MoH&S alsoprovided training for NGOs, but some preferred to be trained by MSF: “As a result, differentorganisationswere learning slightly different guidelines,which then became difficult to integrate”(MoH&S).Forexample,MSFuseddifferent,morerigorous,protocolsthantheWHO;thisresultedinHIfieldstaffbeinginconsistentwithwhichguidelinestheyfollowed.
Interviewees felt that MSF should have been involved with Ebola intervention capacity-buildingearlier.“ItfeelslikeMSFwasconsideringmoreitsownemergencyresponse,ratherthantheneedtobuildcapacityforajointmulti-stakeholderstrongerresponse.Onlyattheendof2014didMSFstarttounderstandandhavethetime,capacity,andwilltosharetrainingwithothers”(MSFfieldstaff).Otherssharedthisview:“Thetrainingsysteminthefieldwasgood,butitshouldhaveengagedotherOperational Centres and non-MSF personnel earlier. It tookmonths for the inclusive approach tohappenwhichwasnecessaryforthescaleandcomplexityoftheresponse”(OCGHQstaff).
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PROFESSIONALDEVELOPMENT-HEALTHPROMOTION“Wewould sit with them (the international staff) and discuss;we alllookatpossiblewaysandworkedtowardsit”(OCGHPnationalstaff).
ExperiencedinternationalstaffstressedthattheMSFHealthPromotion(HP)humanresourcepoolislimitedinnumberandthishadconstrainedMSFintheircommunityoutreachactivities.Additionally,therewerenostandardMSFguidelinesforHP.AnationalstaffHPteamleaderdescribedreceivinghis training from colleagues who had worked in Liberia, making it an exchange of personalexperienceratherthanaformaltraining.However,HPteamsbenefitedfrommutualsupport:“Icantext (to theHP international staff lead) in theeveningandgeta response if there is something toreport…Weworkedwelltogether”(HPstaff).
HPstaffusedtheirownclothes for theircommunityvisits.HPstaff suggestedthataworkuniformshouldbeprovided forHP staff towear for communitywork. Itemswouldneed tobedurable forregularwashinganddisinfection.
MAINTAININGTHECAPACITYOFSTAFF“TherewasnotsufficienteffortbyMSFtosupportnationalstaffinthefaceofstigma,althoughtherewasabig improvement inthewaythiswasmanagedbetweenLiberiaandthePOW.”(MSFHQstaff).
Nationalstaffsuggestedthataboutone-halfoftheOCGnationalstaffmovedoutoftheirownhomeswhileworkingatthePOWETC.ThesedecisionswereduetoreasonsrelatedtofearofEbola.Manysharedaccommodation,whilethosewhoremainedintheirfamilyhomestendedtoliveinadifferentroom,toensurephysicalseparationfromtheirfamiliestoreducetransmissionrisks.Somedescribedthat they regularly slept in or on the hoods of cars close by the ETC. The stigma was such thatmembersoftheircommunityofsomestafftoldtheirpropertyownerstoremovethem,astheywereconsideredatransmissionriskduetotheirworkattheETC.
While some interviewees responded that “OCG did everything it could and should have done forstaff”,theprovisionofon-siteaccommodationfornationalstaffthatneededit,wouldhavereducedtensions.TheHPteamformallyintervenedinabout10casesofstaffstigma.However,thenationalstaffweinterviewedindicatedthattheyhadnotbeenawareoftheHPsupportavailableforthem.Others suggested that the provision of a daily nutritious meal for staff in the ETC would haveresolvedsomeissues(suchasthecontroversysurroundingpacketsofbiscuitsbeingtakenawayfromtheETCbystaff); staffdescribedbeingunable toeasilybuyoreatcookedmealsdue to theirETC-imposedworkingandlivingarrangements.
Systematicstressmanagementsessionsandgroupsessionsforstaff(nationalandinternational)hadnotbeenallocatedfromthebeginningofthePOWintervention.TheworkloadoftheMHteamandneed for continuous follow-up and supervision of local counsellors were a large constraint fordevelopingbetter support for staff.AMHadvisor (MSF-OCG) suggestedMSF includeadesignatedspecialist(separatefromtheteamaddressingpatientneeds)tobeabletofollowandsupportstaff.
MSFnationalstaffretrenchmentandsalarydecreases(duetofallingdemandfornumbersofstaffattheETC)werenothandled ina sensitive, standardisedmanner. Forexample, theMSF-OCG ‘ballotdrawing’fordismissalwasperceivedasunfairtostaff.Intheeventthatjobperformanceevaluationsarenotpossible, the ‘first in– lastout’methodwouldhavebeenmoreacceptable to thenationalstaff interviewed. Whichever dismissal system chosen, it should have been transparent andconsistentfromrecruitmentonwards.
WeweretoldthattherewasnofinaldebriefingorworkevaluationprocessforOCGnationalstaff,but they reported being satisfied with the quality and frequency of the daily teammeetings andbriefings.
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INFORMATIONSHARINGANDKNOWLEDGEMANAGEMENT“It happens easily thatwe forgetwhatwe have been doing – in twoyearsfromnow,wecouldhaveforgotten.ThisisaproblemwithMSF–notjustaboutEbola.”(OCGHQstaff).
Recognised structures, systems and processes regarding information collation and disseminationwerelimitedwithinMSF-OCG.DisseminationofinformationfromHQtofieldhasbeendescribedasbeingprimarily“…byemail,anditwasexpectedtobeappropriatelydisseminatedinthefield”(OCGHQstaff).EndofMissionandVisitReportsdescribethesituationchallenges,thesuccessfulsolutionsimplementedand recommendations for further improvement. Excellentexamples include thoseofAnjaWolz and EllaWatson-Stryker of OCG, and Rosa Crestani of OCB. These rich reports provideinsightful recordsof thecrisisandMSF’s response; theyoffer technical,valuablereal-time,on-the-ground experience. Due to the absence of rigorous documentation of decision-making during thiscrisis,theseandothersimilardocumentswillbehelpfulforfutureresponsepreparation.
With the exception of the relatively consistent weekly SitReps, email exchanges were a commonsubstitute foramore formalised reporting scheme.This isunderstandable considering theeaseofemail exchangesunder the intense circumstances,butemails arenotefficacious fordata collationandarerarelyrevisitedtoeditandcompileinto‘reports’,resultinginlostdocumentation,experienceand information. There was not a formal, systematic and structured process to share new oremergingknowledgewithinMSF(orwithothers)regardingEbolaortheoutbreakcrisisasawhole.
Given that this crisis embodied the need for knowledge building, more so thanmany otherMSFactivities, itwas proposed that a dedicatedMSF InformationManagement team shouldbe taskedwithcollatingevidenceandresourcestosharethroughformal,publicisedplatforms.“Thereneededto be an Information Management person within the Centralised Task Force to collectepidemiological results and information on contexts thatmay affect performance, and to analyseresults to present to the high level platform of decision-makers... This type of role needs to bepresentalsoatthefield level,abletoclarify inter-Sectionaldecisionsbasedonevidence,withdatamanagerswithineachproject”(OCGfieldstaff).
Save the Children proposed that a public web-platform for sharing and disseminating knowledgeregarding Ebola was needed in this crisis. Other actors similarly felt that this could includecommunity engagement guidelines and resources (data, research), which would have helped toensurethatbestpracticewasmoreaccessibletoalltheactors.“MSFevolvedaccordingtoMSF,andnot according to the situation –MSF needs to absorbmore the larger situation, account for andconsiderall informationcomingfromoutsideactors,andhavingdiscussionsanddecisionsnotonlybasedonMSF”(OCGOperations).
2.5.2 ConclusionsThecrisisallowedsuccessfulcollaborationsbetweenactorstoflourish,throughbothpre-deploymentandinthefieldtrainingactivities.
● National staff should be issued ‘certificates of participation’ for all their training activities;thiswasnotdoneconsistentlyduringthecrisis.
● MSFofferedtrainingtootheractorsandcouldbeproactivelydeveloped.FormaltrainingofotherNGOactorsearlier inthecrisismayhaveofferedtheopportunity for increasedactorcapacityandconfidencetoassistintheoutbreak.ThisapproachwouldhaverequiredMSFtodevelopadifferentstrategicvisiontoitsresponse.
● TheMSFTrainingandEducationTeamwaswidelyappreciated,althoughitwasover-tasked.Increasing the size and capacity of this team could have resulted in better coverage ofspecifictrainingsandmorefrequentprecocityofprotocolrefreshertraining.
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TheHProlecouldbe‘professionalised’.TheroleoftheHPteamincommunityengagement, intheETC and with the WHS household decontamination teams, is important in controlling diseasetransmission.
● ThecapacityoftheHPteamwasincreasedonlyafterthefirstmonthoftheETCactivity, interms of numbers of national staff, the addition of an experienced international HPsupervisor,intrainingandinidentifyingworkroles.
● InvestmentintheprofessionalizationHealthandHygienePromotionwillbenefitresponseinfutureoutbreaks.
● Formaltrainingmechanisms(andguidelines)needdeveloping.● HPstaffworkclothes/‘uniforms’providedbyMSFneedtobeconsideredforthedailyworkin
thecommunity.
Thecapacityofstaffshouldbemaintained.
● National staff haddifficulties concerning accommodation andmeals. It couldbehelpful toprovidetheseservicestostaffworkingwithinfectiousdiseases.
● Staff (national and international) needed more support with issues related to stigma; allwould have benefited from improved access to HP support, education and mentalhealthcare.
● Thenationalstaffhiring/firingpracticewasnotconsideredtobeconsistentoracceptablebymostnationalstaff.
● Finalevaluationsand/ordebriefingsof(all)staffwerenotimplemented.Theseprocessescanprevent the escalation of concernswhile allowing for continual improvements in practice.Reflectiononpracticescanbenefitallparties.
Thereisaprioritytocapture,documentandsuitablydisseminateknowledge.
● Therewasnota recognisedsystemofdisseminationof informationduring theEbolacrisis,bothwithinMSF-OCGandbetweentheMSFOCs.
● TherewasaneedforadedicatedteamofInformationManagerstooperateacrossalllevelsofMSF.
● Itwasproposedthatamanagedknowledgeplatform,accessibletoorganisationsworkinginthe field, would have benefited the sharing of emerging information, data and protocolsduringthecrisis.
2.6 Relationshipswithotheractors
“MSF's heart is always in the right place – their priorities are thepatients in the community... MSF does not coordinate well, but is achampionoftheirownbeliefs”(NERCstaff).
ThekeythemesthatemergedconcerningMSF’sandOCG’srelationshipswithactorswererelatedtoMSF’s roles in coordination, supporting other actors, inter-actor dynamics and the relevance ofliaisonactivitiesduringthecrisis.
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2.6.1 Findings
COORDINATIONROLES“AscasenumbersescalatedinFreetown,everyonewasrelievedtoseethe POW ETC running so quickly and professionally” (WelbodiPartnership).
MSF-OCGfeltthattherewerereasonablygoodcoordinationstructuresinFreetown,ascomparedtoexperiences in Guinea. The NERC was described as being dynamic and responsive. There wereconcernsthatthe6pillarstructureresultedinsiloedactivities,althoughothersfeltthatitprovidedan important coordination framework for the response.However,NERC lackedamedical strategy,theMoH&Swas leftoutof the structure,andWHOdidnot successfullyorient themedicalactors.TheNERCand relevantDERC leddecisions in regard to the response for theWesternArea,whichincludedFreetown.DFIDwerehighly influentialas theyheld the fundsandcontrolover resources,including the BritishMilitary. The U.S. Centres for Disease Control and Prevention (CDC) had thetechnical expertise, but unlike Liberia, they were not involved in implementing patient care oractivitiesinallpillars.
Due to the limitationsof these responsebodies,OCHA,amongothers, suggested thatMSF shouldhave been involved in the strategic coordination of the outbreak in Sierra Leone from the start.However,othersexplainedthat“MSFwouldbedelayedbybeingtooinvolvedinthesegovernment,donor,andUNdrivensystems”(OCGHQstaff).SomeMSFstaffregrettedthedisengagementofMSFfromtheresponsecoordinationmechanismsandotheractorsinvolvedintheEbolaresponse.SomedescribedthatthescaleoftheoutbreakinfluencedMSF’sdecision:“Insmalloutbreaks,MSFshouldcoordinate the response – if big, then MSF needs to stake our limits – it’s not our mandate tocoordinateahugeoutbreak”(OCGHQstaff).
MSF was part of the coordination mechanisms, to different extents, in Liberia and Guinea. TheCombinedJointInter-AgencyTaskForce(CJIATF),thepredecessorofNERCinSierraLeone,includedDFID,theBritishMilitaryandUNMEER,butnotthethenpresentMSFsections.Thiswasdescribedaswhen“MSFlostitsspaceatthetableinSierraLeone”(OCGfieldstaff).Asaresult,NERCperceivedMSFasan‘implementingpartner’ratherthanasa‘strategicpartner’.
WHO leadersmetwithMSF inOctober2015 todiscussMSF’s futureengagement in Sierra Leone.MSF(OCGnotpresent)agreedtoworkmorecloselywiththeWHOandtheMoH&S,withafocusonEbolasurvivors.MoH&SsuggeststhatMSFcouldhavemanyrolesforthetransitionandthefuture,suchasmotherandchildprogrammes.
Importantly,notonlyOCGbuttheentireMSFmovement,mustdecideonitslevelofparticipationatthegloballeveltotheWHO-proposedreformsfor‘EmergencyMedicalTeams’and‘ForeignMedicalTeams’(EMTsandFMTs)toformaregisterofpre-qualifiedandpre-certifiedpersonnelforcrisisandoutbreaksurgecapacity.Perhaps these reformswillensure theevacuationof international staff infuturecrises,anissuewhichwasafrustrationtoMSFduringtheoutbreak.
SUPPORTINGOTHERACTORS“GOAL would not have been able to open their treatment centrewithoutthesupportofMSF”(GOAL).
NERCdescribedMSF-OCGasinfluentialoverotheractorsforclinicalandtacticaldirection.ThePOWteam provided ETC support to International Medical Corps, Save the Children and other MSFsections.MSFalsoprovidedadviceandinformationtoDFID,theChineseteamsandCDC.
InAugust2014,SavetheChildrenwereaskedbyDFIDtosetupanETCinKerryTown,butstruggledtodeliverbyNovemberashadbeenplanned.TheOCG teamwasasked toassist Save,anddid so
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within24hoursoftherequest.TwoOCGstaffwenttotheKerryTownSaveETCinpersonandspenttwo days reviewing work and providing advice: “It was extraordinarily productive” (Save theChildren).OCG finally chosenot to get involved in the clinicalmanagementof the ETCdue to thepotentially risky division of responsibilities within the ETC between the various DFID contractedpartners.
INTER-ACTORDYNAMICS“MSFhasaparticularculture–Ifyoucan’tkeepupwiththem,orwon’tdoittheirway,thentheyarenotinterested.”(Save).
MSFwascriticaloftheinternationalandnationalresponse.DespitethegovernmentwelcomingOCGto Freetown,MSF in general, and OCG in particular, consistently described a difficult relationshipwith the government in Sierra Leone: “Many problems existed working with MoH&S” (OCG fieldstaff).OCGconsideredgovernmentrelationsbetterinbothGuineaandLiberia.Onekeycauseofthepoor relationswas that therewas a lack of experience and negotiation skills among some of theseniorMSF staff. “Citing previousmission experience does notmean that an individual is good athigh-levelmanagementskill”(OCGfieldstaff).
TensionswiththeMoH&SincreasedinMarch2015whentheMSFInternationalOfficecriticisedtheGovernmentofSierraLeonefor itspoorresponseefforts.Whilesuchdecisionstoexpresscriticismwerethought throughat thehigher levelsofMSF,ontheground itwas felt that themessagewasdamaging:“Inthemedia,MSFwassuggestingtheyweretheleaderandthatthegovernmentwerecreatingbarriers.However, on the ground the governmentwantedmore collaboration fromMSF”(OCGfieldstaff).ItwasfeltthatMSFwassoconfidentthattheydidnotcollaboratewithactorswithdifferentopinions.“MSFbecamesomethingofan island,ratherthanstrengtheningcapacitywithinMoH&S”(NERC).
TheMoH&SwantedmoreMSFparticipationintheClinicalManagementPillarandatthehigherlevelinNationalCoordination:“MSFwerereallygood(attechnicalandoperationalinput)whentheycametothetable–buttheyoftenwouldn’tcome”(High-Levelexternalactor).ThisattitudeseemstohavechangedastimewentonandMSFimprovedtheirabilitytoparticipateintheresponsemechanisms:“MSF reporting and presence at the daily NERC Evening Briefings was consistent, important andrespected”(NERC,reportingOCGengagement-fromDec2014onwards).
TheKing’sSierraLeonePartnership(KSLP)feltthatMSFwasdisconnectedfromthewiderresponsesystem.“TheMSFattitudetends tobeabit inflexible in itsprinciplesaboutnotcollaboratingwiththe government and official systems and structures; they tend to have their own protocols andguidelines with small capacity to vary and adapt” (KSLP). Partners felt that MSF-OCG had greatresources and facilities, good standards of care, guidelines and protocols; however, MSF did notalwaysseemtorecognisethe limitationsof thestatehealthcaresystemwhenreferringpatientstostate facilities. Other comments described “a lack of sharing of data, of cases with unusualpresentation, during the outbreak with partners” (KSLP). It was not possible to triangulate thisexperience with other actors. Nonetheless, referral practice from OCG perhaps warranted bettercommunication.
Morebroadly,KSLPhadpraiseforMSF’scontribution:“Weareextremelygratefulforeverythingthathas been done and appreciate the hard work and big effort made by MSF”. Others shared thispositive message: “We appreciated MSF coming with all their knowledge of what to do – theyresponded fast! Yes, at timesMSFwas at oddswithMoH&S, but regardless, the people of SierraLeonewere really grateful and theywerenot concernedabout theMSF criticismsof theMoH&S”(NERC).
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LIAISON“Inthisoutbreak,allactorssawproblemswithothers,andyetfailedtoseetheirownfailings.”(OCGfieldstaff).
AllpartnersheraldedtheInter-SectionalAdvocacyandLiaisonOfficerrole(hereafterreferredtoasthe ‘Liaison Officer’) as solving some of the representational confusions typical for MSF. SomesuggestedthattheLiaisonOfficerroleshouldbecomestandardwithinothercountrieswheremorethantwooperationalsectionsareactive.Thereweresuggestionsabouttheremit,suchasidentifyingthemeetingsmost relevant for specificMSF individuals to attend: “There couldbeup to tenMSFpersonnelcomingfromthedifferentsections.Thisneededcoordinating”.(MSFfieldstaff)
The Liaison Officer should be responsible for managing the information emanating from regularmeetings, to document and share emerging issueswith allMSFHoMs andMedCos, and speakonbehalf of all in-countryOperational Sections. In practice, the LiaisonOfficer “did not have enoughauthoritytospeakonbehalfofallthesections,duetothedifficultinternalMSFpolitics.90%oftherolewasbuildingrelationships(notadvocacy),butthiswasappreciatedwithinandoutsideofMSF”(OCG field staff). The Liaison Officer successfully built bridges with themajor actors. TheMoH&SsuggestedthatitwouldhavebeenidealtohaveamedicallytrainedMSFliaisonpersonworkingmorecloselywiththegovernment:“Therewasapaucityofrigorousadvice”(MoH&S).
2.6.2 ConclusionsMSF has important opportunities to increase its influence for the welfare of populations if itcontributesatthestrategicandhigh-levelcoordinationlevelincrises.Itispossiblethatthisoutbreakcouldhavebeenleddifferently,andbetter,withanMSFpresenceintherelevantnationalstrategiccoordinationplatforms–particularlyinSierraLeonewhereMSFwasabsent.
● MSFhasfutureopportunitiestobeinvolvedatsomelevelintheEMT/FMTnetworksofpre-qualifiedandpre-certifiedmedicalteams,aspartoftheWHOEbolareforms.
MSFshouldseektomaintainitsexemplaryreputationfor‘show-how’supporttootherorganisations.As the leading humanitarian medical NGO with the greatest capacity, MSF is suitably positioned,particularly following the Ebola crisis, to encourage and support other humanitarian actors tobecomeoperationalforfutureemergencyoutbreakresponses.
Inter-actordynamics:
● There were tensions with key stakeholders, such as the MoH&S. These importantinstitutional relationships would have benefited from better prioritisation and skilledmanagementformtheoutsetoftheoutbreakinSierraLeone.
● GiventhefeedbackfromNGOpartners,MSFmayneedtoadjustitspatientreferralpracticesaccordingtothecontext,ensuringthatMSFcollaboratesandcommunicateseffectivelywithotheractors.
The Intersectional Liaison and Advocacy Officer role was important for networking, meetingattendanceandsharinginformationamongstMSFsections.WithsupportfromOperationalSections,thereisanopportunitytodeveloptherole’sadvocacyremit,presentingastronger,clearer,unifiedMSFvoicetoincreaseMSF’sinfluenceandminimisetheriskofairinginternalMSFdisagreements.
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2.7 Research,monitoringandevaluation
“MSF were open to doing research – quite a change” (ScientificAdvisoryCommitteeonEbola,WHO).
TheEvaluationanalysedtheemergingthemesofMSF’spositionregardingresearchduringthecrisis,researchopportunitiesandopportunitieslost,researchcollaborationsandweaknessesinmonitoringandevaluationduringthecrisis.
2.7.1 Findings
MSF’SPOSITIONREGARDINGRESEARCHDURINGTHECRISISMSFcollaboratedonresearchatthegloballevelduringthecrisis.However,manywithinMSFreportthat the movement failed to adequately conduct research for the benefit of patients. A total ofapproximately16,000patientswithEbolainWestAfricaweremanagedbyMSF,yetthereisstilllittleknownaboutthediseaseanditsoptimalmanagement.Tomany,thisrepresentsalostopportunity.
Interviewees explained that therewas little or no pre-set agenda for operational research and noformalisedMSFguidanceforresearchinemergenciestouseduringthisoutbreak.MSFtooktoolongtorecognisetheneedforcollaborations,andtoworkthroughtheethicaldilemmasconcerningtheirinvolvementinanti-viralandvaccinetrials.
OtheractorshavebeenmorecomplimentaryaboutMSF’srole.ExamplesincludeMSFbeingwillingto use off-label drugs, and being proactively involved in the “high-level work developing genericprotocolsforfutureresearchincrises”(DNDi).
In October 2014, MSF Medical Directors formed a research platform to support and coordinateresearch activities. This was the first time such a MSF structure had formed external high-levelcollaborations,bringingtogethersenior-levelexpertiseanddecision-making.Itwasgenerallyseenasasuccess,demonstratingMSF’sadaptabilityandintendedcommitmenttoresearchinthiscrisis.Theplatformpledgedthat“effortswillbemadetoensurethattheMSFcollaboratingstudies’resultsarepublished in established peer-reviewed journals (open access) and disseminated via themedia toinformtheglobalcommunityaffectedbytheEbola”.38
CommentsconfirmedthatOCGseniorshadrealinterestinresearch,buttheprocessesforresearchproposalswere too slow. Inparallel, “attempts toprogress researchwereat timesdelayedby thehigh workload demand on field staff who resisted additional responsibilities” (OCG HQ staff).Research skills were also lacking in the field: “We need trained staff to collect good data, set upresearchandsuperviseit,otherwisethedataispoorandtheresearchwillcollapse”(OCGstaff).
Duringthecrisis,someintervieweesfeltthattherewasinconsistentsupportforresearchandsurveysfrom OCG HQ. A more formal OCG research platform, if permanently created, could improveefficiency and provide more expert input into ethics and protocol design. OCG could cultivateestablished relationships with individuals at research institutions such as LSHTM and the SwissInstitute Tropical and Public Health Institute via this platform. Partnerswould necessarily need tohaveanunderstandingofthelimitationsofworkinginthehumanitariancontext.Identifyingsuchateamwiththemostappropriateskillsetneedstobedoneinadvanceofthenextcrises.
RESEARCHOPPORTUNITIESANDLOSTOPPORTUNITIESMSF prioritised its research investment in four antiviral drugs. However, they had limitedeffectivenessinthepopulationunderstudy.Inhindsight,itwasfeltthatMSFshouldhavefocusedonrapiddiagnosticsandvaccines–wheretherewasmoreprogress–andtheuseofnon-licencedandexperimental treatments. TheWHOhadgivenethical guidanceandagreed that the risks forusing
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these treatments were justifiable, but MSF did not overcome internal resistance. Although someinfluential medical and operational OCG personnel were in favour of using novel treatments inNovember/December2014,OCGdidnotimplementtheplanatthePOWETC.
The compassionate use of vaccine forMSF staffwas considered (in collaborationwith a Canadianinstitution), but as the crisis escalated it became difficult to progress due to the burden of theresponse.TheWHOhadapprovedthecompassionateuseofvaccineforhealthcareworkersbythetimeoftheopeningofthePOWETC,but“MSFhadnotreachedagreementonthisissueseeminglydue to a resistance in some layers of OCB. If vaccination trials had been faster, other non-Ebolahealthstructurescouldhaveopenedfaster”(DNDi).
OCG’s‘chanceresearch’affectedpracticewithinthecrisis.TheFoyaETC(Liberia)hadastockruptureof CoArtem anti-malarial and the team used the ASAQ (Art + Amodiaquine) combo for a 12-dayperiod. This resulted in a clinical observation that prompted attention. MSF-OCG analysed themortality ratedata forbefore,duringandafter theanti-malarial change,andestimated thatwhileusingASAQthecasefatalityratedecreased.MSFproceededwithASAQintheirprotocolasitposedno greater risk to patients, and was possibly protective (OCG HQ senior staff). This accidentaldiscovery justified further research and MSF subsequently lobbied the WHO to investigate thefinding.
OCG also pioneered the rapid deployment of the newOCGGeographic Information Systems (GIS)Unit, using data from MSF, WHO and CDC. OCG’s Logistics Department operationalised the GISmapping team to support theoverall outbreak response, providing importantmapping services toMSF(andotheractors)forallofthethreemostaffectedcountriesintheregion.Themapsprovidedvaluablegraphicaloutputsofdemographic,geographic,andepidemiologicaldata,whichwereopenlysharedwithresponsepartners.TheseOCG-producedGISmapsareavailablethroughawebportalforMSFusers (http://mapcentre.msf.org/en/login). This confirmed the valueofGISmapping forMSF;thedepartmentcouldbedevelopedandusedforotherscenarios.
ThePOWETCwasseenasthe idealsettingtotrynewtreatmentsandconductresearch.However,decreasingnumbersof patients anda lackof staffwith research training acrossdifferent levels atOCGlimitedtheexecutionofsomeopportunities.
OCGsuccessfullyparticipatedinarangeofresearchprojects.Theseincluded:
● CollaborativeresearchtoimprovePPE–atrialaimedatprovidinglighter,coolerandfewerPPEitems.Theinitialtrialofnewmaterialsdidnotelicitmuchchangeintheexperiencefromtheusers’perspective.
● OCG initiated the collation of data concerning Ebola disease clinical sequelae through theservicesoftheSurvivorsClinic.
● Asurveyassessedtheimpactofreducedhealthserviceaccessonall-causemortality.● A study to assess the virus’ persistence in the environment (referred to as the ‘infectivity
study’) was conducted at the POW ETC. This OCB-led research identified that thecement/concrete flooring of the POW ETC held active virus after cleaning with regularsolution chlorine. This finding was taken into consideration in the decommissioning anddecontaminationproceduresattheclosingofthePOWsite–includingprolongedsoakingofthecementinstrongerchlorinesolution.Itwasproposedthatinthefuture,aspecificresincoatingshouldbeappliedtotheflooringofETCs.
However, trials of the Brincidofovir treatment (in collaboration with Oxford University) wereconsidered too late to implementatPOWETC;patientnumbershaddecreasedand theclosureofthesitewasplanned.
Acohortofpatients’clinicalrecorddatawascollectedbytriallingtheelectronicpens/papersystem.Thesystemrequiredthatthedatacouldonlybeenteredonaspecialisedpaper,withtheuseofthe‘e-Pen’.Theblank formshad tobeona special substrateandcouldonlybeprinted inGeneva,50
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pagesatatime,whichimpactedthepracticalityofthetool.Furthermore,thepensdidnotworkasanticipated,andtherewaslimitedandslowsupportfromSertal,thecompanydevelopingtheE-Pensystem.TheOCGE-PenrawdataisunderthecontrolofHQandisproposedtobeavailableviaadatasharingplatform.11
ThereremainresearchopportunitiesforwhichMSFisparticularlywellpositionedtoprogress.
o Duetotheinfectionpreventionandcontrolactivitiesthroughoutthecountry,morbidityandmortalityamongunder-fivesfromdiarrhoealdiseasesreducedduringthecourseoftheEbolaoutbreak. Additionally, therewas no cholera outbreak, as there had been previous to theEbola outbreak. Important researchwould be to identify the culturally appropriate healthpromotion activities that can sustain these improvements in Public Health in the Ebola-affectedcountries,andbenefitrelatedprojectselsewhere.
o Someisolationstrategiesusedinthisoutbreaklackedevidence.Intervieweesexplainedthat“holdingcentresvariedfrom‘ok’to‘verydangerous’,duetoriskoftransmissionfromEbolacases tonon-Ebola cases”, and“…unfortunatelyMSF, ingeneral,didnot feel theyhad therequiredevidencetoadvocateagainsttheuseofquarantine”(OCGfieldstaff).Areviewoftheevidenceontheseisolationstrategiescouldbeusedtoinfluencefutureresponse.
o OtherresearchareasMSF/OCGhaveaninteresttoexplorewithresearchinstitutesinclude:issues regarding viral load; transmission rates; the impact of multiple generations of viraltransmission in humans; viral persistence in survivors and so on. Interviewees were notconfidentthatcollaborationsforsuchworkwerebeingpursued,butfeltthatMSFhadboththedataandtheinteresttobeinvolved.
OCGhassuggestedasetofresearchareaswhichwouldsupportworkinfutureoutbreakresponse:“Environmental studies; Biological studies in pregnant and breastfeeding women; Feasibility andaccuracyofpoint-of-carediagnostictools,suchasrapiddiagnostictest;Feasibilityandacceptabilityofdifferentstrategiesof isolationofsuspectedcases/quickfixmeasures(individualroom)”(Ebolaworkshopsummary,Geneva.Feb2015).39
RESEARCHCOLLABORATIONS“MSFwasabitnaïve”(OCGHQstaff).
ThereweremanyboldstepstakenbyMSFinthiscrisis.ThisoutbreakrepresentedthefirsttimeMSFwas involvedintheearlyexperimentalstageofclinicaltrialsoftherapies. ItwasthefirsttimeMSFwascloselyinvolvedwithoutsideresearchactors.
Interviewees confirmed that OCG was open to collaborations with other research institutions.However, identifying themostappropriate linksproveddifficultasprioritiesdiffered.Forexample,weweretoldthatacademicsputmethodsfirst,whereasMSFputpatientsbeforetheresearchaims:“AcademicstendtohaveafocusonRCTs,butexcellencyinmethodsandresultsarenotcompatiblewiththesecontexts”(OCGHQstaff).
The intervieweesconcluded thatMSFshouldestablishcloser linkswithacademic institutionsawayfromthecrisissituation,throughmutualtrainingandresearchwork.Researchinstitutionsproposedfor collaboration purposes included the London School ofHygiene and TropicalMedicine (LSHTM)and Ecole Lausanne. LSHTM supported MSF in research and the deployment of staff during theoutbreak, and would welcome a longer term, formalised collaboration (in interview, LSHTMDirectorate).LaurentKaiser,HopitauxUniversitairesofGeneva,alsoofferedaninvitation:“Atraining
11WedidnotconfirmifthisisonlyforinternalOCGaccess,otherMSFsections,orselectedresearchinstitutions.
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centre (re lab work) might be considered as a joint project between MSF and our institution”(HopitauxUniversitairesofGeneva).40
MSFcouldalsofurtherdevelop itssharingofresearchandmonitoringoutcomeswithotheractors.Intervieweesat theMoH&SwerenotawareofanyexampleswhereMSFhadshared theirdataorresearch. This lack of recall does not necessarily reflect reality. OCG staff confirmed sharing theirworkwiththeMoH&S,butthismaynothavebeenappropriatelydisseminatedwithintheministry.
Thereareopportunities to increase researchcapabilities forMSFstaffbeingdeployed to the field.There is a long-standing arrangement for MSF-OCG staff to complete the Trop-EdDiploma inAdvanced Studies in Health Care Managementcourse at the Swiss Tropical and Public HealthInstitute,prior todeployment.Theremaybeopportunities for the Institute tooffera short course(e.g. five days) in data collection and research prior to the field deployment of staff. Similaropportunitiescouldbeofferedtonationalstaffincountry.
MONITORINGANDEVALUATION“MSF is bad and inconsistent at collecting and compiling data.Outbreakafteroutbreakthedatacollectionwasnotdonewellenough”(OCGHQstaff).
Monitoring and evaluation was a weak point at the POW ETC. Interviewees struggled to giveexamplesoftheseprocessesotherthantheline-listingofpatientsandtheirclinicaloutcomes(datawasanalysedvia thedailyEpiCentre line listing).TheHPteamcompleteddaily report formswhichweretransferredtocomputerbytheHPsupervisor,butno informationwas fedbacktotheteam;staffwereunawareoftheuseofthedatathattheycollected.
2.7.2 ConclusionsThelackofavailabledatadoesnotpermitameaningfulanalysisoftreatmentoutcomesatdifferentstages of the intervention and in connection with different activity components, such as thedevelopments in community engagement. There are complex confounding factors and seculardevelopments rendering any interpretation of the limited data invalid. The data OCG does haveshouldbemadeavailabletoresearcherswhocananalysepooleddatasourcesto learnasmuchaspossibleabouttransmissionfactors,clinicaloutcomesandtheimpactofinterventions.
MSF/OCGcouldhavefurtherdevelopeditsroleinoperationalresearch.MSFneedstopromotetheinterests of beneficiaries in academic and corporate researchwork. This crisis has highlighted theneedforimprovedcoordinationframeworks,earlierprioritisationandresourcingofresearchduringcrises.
● The Medical Directors Board for Research was important for opening opportunities forresearch decision-making and high-level collaborations. An analogous Ebola ResearchPlatform at OCG level could improve the efficiency, consistency and expert input foridentifyingandsupportingOCG-specificresearchopportunities,andmayincludetheinputofcollaboratorsfromresearchinstitutions.
● Research response could have been improved by having dedicated research personnelintegrated across all levels of OCG/MSF. These individuals could be tasked with themaintenance of data collection tools (standardised spreadsheets, databases), develop pre-deployment research training, develop ToRs and ethical reviews for research projects andidentifyandmanageresearchcollaborations.
● Researchproposalsneeded tobeprioritisedaccording to impactand relevance, suchas toconnect it to the focus of field activities. For example, research aimed at improving
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equipment andmaterials to support field staff in their activities, and research to improvepatientoutcomes.ThiswillimprovetheengagementoffieldandHQstaffinresearchstudies.
OCGhasstruggledtoconducttimelyresearchandanalysisofcollecteddata.
● OCGmissedtheopportunityto initiateorcontributetoimportantoperationalresearch,forexampleregardingenforcedquarantineversusrobustcontacttracingmethods.
● TheOCGGISUnitprovedthat itwasable to fast-trackan innovativeanddedicatedtool tosupportresearchandtheoverallresponseoftheMSFmovement.
Currentresearchopportunitiesthatinclude
● Identifying realistic and effective alternatives to the isolation strategies (enforcedquarantine)inanoutbreakofthisscale,
● Identifyingmechanismstoefficientlydocumentandcollectpatientdata insidethehigh-riskward(egelectronictablets),
● Confirming Public Health benefits of improved community-level infection control practiceand
● FurtherdevelopmentofarrangementstoshareMSFdatawithresearchpartnerstobenefitwiderresearchagendas.
ResearchpartnershipsarecrucialtoimprovethesuccessoffutureMSF/OCGresearch.
● OpportunitiesforinstitutionalcollaborationsalreadyexistduetotherelationshipsthatwereadvancedthroughtheEbolaoutbreak–suchaswithHUGandLSHTM.TheMSFLuxembourgOperationalResearchUnit(LUXOR)couldalsobefurtherengaged.
● ThereareopportunitiestotrainmoreMSFstafftoconductoperationalresearchinMSFfieldprojects. Forexample,bydevelopingOCG’s linkswith theSwissTropicalandPublicHealthInstitute,whichcouldprovideshortcoursesondatacollectionforresearchinhumanitarianandoutbreaksettings.
MonitoringandevaluationinMSFisdirectlyrelatedtotrackingprojectprogressandachievementofoutcomes.
● OCGneedstoembedmonitoringandevaluationinallOCGactivities,particularlyintimesofcrisis.Formal frameworksandphysical toolsshouldbedevelopedto improvetheeaseandquality of data collection and analysis. It will be useful to conduct data collection withresearchuseandguidelinedevelopmentinmind.
● Dissemination of monitoring, evaluation and research findings to staff in the field couldincreasethemomentumforimprovingthequalityofdatacollection.
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3 Discussionandover-archingconclusions
Therewasanacuteneedfor isolationbeds inFreetownwhentheOCGPOWETC inFreetownwasopened. At the invitation of the Ministry of Health and Sanitation in Sierra Leone, MSF-OCGsuccessfullydesigned,builtandopenedtheirflagshipETCatthePOWSchoolwithin12days.Thiswasanimpressiveachievement.
ThePOWETCwasinnovativeindesignandpractice.Patientclinicalcarewasprioritisedalongsideastrongfocusoninfectioncontrol.
Theengagementofthecommunitywasrecognisedfromthebeginning.Approvalforthecentrewassought from the local community in advance of construction, andHP staff were recruited locally,strengthening important networks. Trust was built through the transparency of the ETC layout,facilities for visitors and health promotion work within the community. Surveillance, householddecontamination,quarantinemanagementstrategiesandcontacttracingactivitieswerepoorinthenational response. OCG household decontamination actions were of high quality, albeit relativelymodest in implementation.MSF-OCG did recognise these gaps and further implemented trainingsandsupporttootherNGOpartnersinthiswork.
TheMSF-OCGresponsewasinnovative,dedicatedandcapable.
However, preparedness for similar outbreaks is required. This evaluation has identified areas forprioritisation.
First, decision-making processes should be efficient and structured - both internally and betweenOperationalCentres.Inamajorcrisis,theburdenofdecision-makingshouldbesharedwiththefieldlevelwiththesupportofidentifiedgroupswithspecialistexpertise,asrequired.Itisatfieldlevelthatthespecificcontext,thesetofavailablecompetencesandchallengescanbemostaccuratelyjudged.Thissystemshouldaimforsafe,yetaccountable,flexibilityinoperations.
Second,processestoallowtherapidset-upofaCentralisedTaskForcesystemshouldbeagreedinadvance of future major crises. Defined set-up procedures and operating frameworks, with thelegitimacyofallMSFsections,arerequiredforsuchastructuretooperateeffectively.
Third, MSF-OCG data collection, documentation and information systems warrant attention. Thisrequires trainingall staff in the importanceofmonitoringandevaluation,and thedevelopmentofstandardised data collection and analysis tools. MSF should recruit experienced InformationManagementpersonnel(field,HQandTaskForcelevels)tosupportdecision-makers.Thiswillensurethepossibility for regular frequent reviewof indicators,whichwill result in improvements toMSFpractice.
Fourth,capturetheMSFcombinedhumancapitalemanatingfromthiscrisis–theEbolacrisiscohort.MSF staff, now dispersed, gained skills in politics, negotiation, crisis coordination, communityengagement, media work, construction design, equipment innovation, guideline development,humanresourcemanagementandsoon,whicharetransferabletoarangeofMSFactivities.
Fifth,investmentinstaffisneeded:
● Across levels of the MSF movement, there is a lack of robust skills in strategic planning,networking,diplomacy,negotiation,managementandcoordination.
● The role of the Inter-Sectional Liaison and Advocacy Officer, to support and represent abroaderrangeofMSFprogrammes,hasprovedtobeuseful.
● Theroleofhealthpromotersprovedcriticalinthisoutbreakandrequiresprofessionalisationtoensuremorerobusthealthpromotionandoutreachactivitiesinfutureoutbreaks.
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● Theoutbreakmanagementexpertiseofprofessionalpublichealthpractitioners is lacking intheMSFworkforce.
Sixth,thesuccessfulresearchcollaborationsdevelopedduringtheEbolacrisisofferopportunitiesforexpansionsuchaswithotherNGOactorsandwithresearchinstitutions.
Seventh, innovation in MSF activities, while maintaining the tried and proven MSF operationalmanagementstructures,improvedcomponentsofpatientcareandotherresponseactivities.
Finally,ata timewhenglobaldemandson themovementareconsiderable,MSFshould reflectonhowtopositionitsvaluablecontributioninmajorcrises,developingitsstrategicvision.
ThepoliticalinfluenceofMSFwaschallengedearlyintheEbolaoutbreak,whenglobalactorsfailedto respond toMSF’s International President’s demand for an urgent international crisis response.Echoesofthistensioncanbeobservedatmorelocallevels,withMSF-OCGlackingconsistenttraction(and engagement) with the Ministry of Health and the National Ebola Response Centre in SierraLeone.
In preparation for the next major crisis, MSF may want to reflect on its remit and develop itsmandateandskillbaseaccordingly,tooptimiseitsinfluenceandimpactforthefuture.
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4 Recommendations
4.1 Infrastructure● Establish the structureand functionof aCentralisedTask Force for crisis responsewithall
MSFsectionsinadvanceofanotherlarge-scaleresponse.ConsideraMSFsectiontoleadinagivencountry,formajor/complexscenarios,toallowforconsistentrepresentationwithnon-MSFstakeholders.
● Designan‘EbolaTreatmentCentreKit’,drawingonexperiencesfromallMSFOCs,whichcanbepalletisedforair-freight/seacontainersanddeployedfortheefficientconstructionofanETC. Integrate opportunities to increase the acceptability of the centre for patients/familysuchasincorporatingvisitingareas,counsellingfacilitiesand‘cinemashowings’intotheETCdesign. Increase the capacity for MSF to provide its own independent laboratories, orestablish partnerships with mobile lab services with the capability for deploymentworldwide.
4.2 Medicalcaremanagement
● Contribute to guideline development with other actors12, incorporating rapid diagnostics,PiccoloandiSTATequipmentformaintaininginfectioncontrolandmonitoringbiochemistry.
● Ensureadequateprovisionofnon-Eboladiseasesupport; thismaybe throughpartnershipswithotherMSFsectionsorNGO/governmentactors. Includethe improvementof (nationalandinternational)staffaccesstomentalhealthsupportandensurethecapacitytorespondtoMentalHealthneedswithintheteampromptly.
● Developdecision-making structuresandprocedures toensureaccountabilityandefficiencyinfinalisingdecisions;thisstructureshouldsupportinnovationanddelegatedecision-makingtothefieldaccordingtostaffexperienceandcompetence,withinspecifiedboundaries.
4.3 Epidemiologicalcontrolmeasures
● Future interventions should deliver a full outbreak response package encompassingWHS,contacttracing,healthandhygienepromotion.
● Implement standardised effective and efficient tools for epidemiological data collectionacrossMSFteamsandallowprojectionstoinformMSFstrategy.13
● Investresourcesindevelopingcapacityincontacttracingforbothurbanandruralsettingstoallow OCG to become a leading strategic advisor, or implementer, of the contact tracingprocesses/mechanisminfutureoutbreaks.
● Develop a cohesive MSF position regarding the use of enforced quarantine in outbreakmanagement,securingevidencetosubstantiatethatcontacttracingandtheuseofvoluntaryquarantineismoreeffectiveandhumanethanthestrategyofenforcedquarantine.
12Otheractorstobeconsideredforcollaborationarethosethatdevelopedclinicalguidelinesoftheirown,suchasWHOandCDC,andspecialistinstitutionsforlaboratoryand/orrelevantuniversitydepartments.13Forexample,continuetherelationshipwiththeMathematicalModellingGroupatLSHTM.
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4.4 Communityengagement
● InvestintheprofessionalisationofMSFhealthandhygienepromotion(HP).Theirrolecanbeexpandedinfutureoutbreaks,andsupportedbytheearlydeploymentofsocialscientistsandanthropologists with the HP teams. HP and psychologists should accompany all survivorshomeforfamilysupportandstigmaalleviation.
4.5 Capacitybuilding● TrainandguideotherNGOsonETCset-upandmanagement,communityoutreachactivities
focusedonHPandWHS,andcontacttracingmethods.● Include theprovisionof accommodation andmeals for national staff,where indicated, for
increasedcapacityandstigmaminimisation(scaleandcontextspecific).● In future crises, whereMSF has particular unique expertise, develop andmanage a web-
based platform to share knowledge and make it accessible to other organisations foremerginginformation,dataandprotocols.
4.6 Relationshipswithotheractors● MSF should contribute to national level strategic coordinating bodies to influence policy
decisions,andconsiderMSF’sregional/globalstrategicadvisoryrolesinfuturecrises.Investin developing senior staff (field and HQ) skill sets in global health leadership, strategicplanninganddiplomacy.
4.7 Research,monitoringandevaluation
● Recruit ‘informationmanagement’ personnel (field, HQ and Task Force levels) to identify,collate and share data within and outside of MSF for informed decision-making and theenhancementofdailyimprovementstoactivities.
● DevelopanOCGResearchBoardforethics,protocoladviceandresearchprioritisation.Thisshouldinclude–andformaliseexisting–researchinstitutepartnerships(insideandoutsideMSF,suchasDNDi,LUXOR,LSHTM,SwissTropicalandPublicHealthInstitute).
● Operational researchshouldbe integrated fromthebeginningofoutbreak interventions inthefuture.
Weremembertheindividualswholosttheirlivesinthisoutbreak.
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5 Annex5.1 Termsofreference
ToR_draft_V3_21July2015 (1).docx
5.2 Listofinterviewees
Title/Firstname/Lastname Function
GenevaHQ
MrMathieuSoupart LogisticsDirector,OCG
DrMicaelaSerafini(byphone) MedicalDirector,OCG
MsAmandaTiffany Epidemiologist,Epicentre/OCG
DrIzaCiglenecki OperationalResearchCoordinator,OCG
MsClaireDorion WatSanReferent,OCG
DrDorianJob DeputyResponsibleofEmergencyCell,OCG
DrJean-ClementCabrol(byphone) DirectorofOperations,OCG
SierraLeone
MsSihamHajaj HoMMSF-OCBA(SierraLeoneafterPOWperiod)
MsAnnetteHearns
DirectorHumanitarianAffairsOfficer,OCHA
MsEsmeedeJong ex-MSFHPOCA;ECHO
MrJacobMaikere HoM&ex-Medco,MSF-OCB
MrOBSisay DirectoroftheSituationRoom,NERC
MsVictoriaParkinson WesternAreaDERC/laterNERCAdvisor(AGI)
MsAliArnall DirectorAdvisorNERC(AGI)
MrChrisWalker DIFDandUKStabilisationUnit
MrMusaTuray HPNationalStaffTeamLeader,OCG
MsJS SurvivorPOWETC
MrABK SurvivorandcaregiverinPOWETC
MrIdrissaAlieu MSF-OCGBaseLog(forPOWETCclosingperiod)
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OCGNationalStaff14(listisextensive;pleaserefertofootnote)
Pharmacists,securityguards,drivers,HR,electricianandothers
MrsYvonneAki-Swayer DirectorPlanning,NERC
DrSandraLako ClinicalLead,WelbodiPartnership
MsReginaBash-TaqiDrSergeEmaleuViewscollatedfrom:
-PhilipAmara-YayahCoteh
MinistryofHealth&Sanitation:HealthSystemStrengtheningHub,TransitionLead,ClinicalPillarLeadOthers:PlanningOfficer,MinistryofHealth&SanitationPartnerLiaisonOfficer,MinistryofHealth&Sanitation(nowinchargeofSLA)
Focusede-mailinterviews
DrMartaLadoCastro-Rialwithviewscollatedfromcolleagues
ClinicalLead,KingsSierraLeonePartnership
MrDavidKabbia,andcolleagues:JessicaDuffy,ElizabethTomenko,ElizabethFoulkes,IbrahimTuray,SamuelHubbard,DanielSao-Lamina,AssanBangura
HandicapInternational
Skypeinterviews
DrRobertaPetrucci MedicalOperationsSupportUnit,PaediatricsSpecialist,OCG
MrGianluigiLopes Ex-LiaisonandAdvocacyOfficer(Inter-Sectional),SierraLeone;WHO
DrMonicaRull OperationsHealthAdvisor,OCG
MsAnjaWolz EbolaOperationsAdvisor,OCG
MrMichaelvonBertele SavetheChildren(ex-DirectorofHumanitarianOperations)
MsEllaWatson-Stryker HPActivityManager,OCG
Focusedinterviews
DrHenryDowlenMBE ChiefofStaff,BritishMilitaryCoordinatorofNERC
ProfPeterPiot ChairofScientificAdvisoryCommitteeonEbolaResponsetoWHO;DirectorLSHTM
14Alimamy Bubu Kamara – Drug dispenser/Driver; Kabba Kargbo – Maintenance/Electrical; Sulaiman Kamara – Laundry; Unisa
S Conteh – Driver; Alimamy S. Kargbo – Security; Ibrahim Jabbie – Security; Aziz Kamara – Security; Abdul Aziz Conteh – Security; Ibrahim Monsoray – Outreach Driver; Darlington Tucker – Security; Sahr David Missah – Security; Samuel B Freeman – Liaison Officer MSF POW; Abdullai Bowrie – Supply Team; Bowland Noah – Procurement; Bornar Davies – HR Assistant; Musa Sesay – Pharmacy Storekeeper; Joseph Conteh – Security; Mamadou Barrie – Chief Guard; Ishmael S. Conteh – Driver
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ProfDavidHeymann ChairofAdvisoryGrouptoDirector-GeneralofWHO,ontheEbolaOutbreak;ChathamHouse;PHE
ProfMarcelTanner ChairDNDi;EmeritusDirectorSwissInstituteforPublicHealthandTropicalDisease
MrRichardGregory,DFID EbolaStrategyTeam(deployedinSierraLeone)DFID
MsGeraldineMcCrossan GOAL
MsMaureenO’Leary LSHTMcoordinatingresearch;NERC
5.3 Samplequestionnaire
Sample Questions - Interview.docx
5.4 EbolaRegulatedReferralSystem(v3.1)
Ebola-Reg ulated_Referral_System_V3.1.pdf
5.5 Proposedplan–SimplifiedEbola10bedisolationunit
2014Ebola10bedsisoaltion simplified unit30Sept2014v2.docx
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5.6 References1Peters,C.J.(etal)."InfectionControlforViralHaemorrhagicFeversintheAfricanHealthCareSetting."CDC.CDCandWHO,1Dec.1998.Web.9Dec.2015.<http://www.cdc.gov/vhf/abroad/pdf/african-healthcare-setting-vhf.pdf>.2Thompson,P.(etal).“Ebola&MarburgOutbreakControlGuidanceManual,Version2”.MSF(internal).May2007.)3Sterk,Esther(etal).“FilovirusHaemorrhagicFeverGuideline2008”.MSF(internal).20084Sprecher,A.(etal).“DraftNewGuidelinesFilovirusHaemorrhagicFevers”.MSF(internal).Apr2014thruDec2015.5ClinicalManagementofPatientswithViralHaemorrhagicFever:APocketGuidefortheFront-lineHealthWorker.InterimEmergencyGuidance-genericDraftforWestAfricanAdaptation.WHO-AfricaRegionalOffice.Mar2014.Ed.Oct2014.6“EbolaVirusDiseaseEpidemicinWestAfrica:UpdateandLessonsLearnt”.WHO(RegionalOfficeforAfrica).5Nov2014.7SierraLeoneFreetownPOWETCFinalReport(AnjaWolz)8“EbolaVirusDiseaseEpidemicinWestAfrica:UpdateandLessonsLearnt”.WHO(RegionalOfficeforAfrica).5Nov2014.9SierraLeoneFreetownPOWETCFinalReport(AnjaWolz)102014_week45OCA_SITREP11confirmedbyOCGNSfocusgroup12SL-Freetown-week2-12.01-sitrep13SL-Freetown-week2-12.01-sitrep14SierraLeoneFreetownPOWETCFinalReport(AnjaWolz)15SierraLeoneFreetownPOWETCFinalReport(AnjaWolz)16SierraLeoneFreetownPOWETCFinalReport(AnjaWolz)17EoMreportofBernadetteSchober,HRCo,30/06/2015.18EoMreport-FranMiller-14/07/1519fromEoMreportofBernadetteSchober,HRCo,30/06/2015.20“EbolaWorkshopDakar11-13June2015ExecutiveSummary”(Filename:ExecSummaryEbolaWorkshopDakar_FINAL_23June2015.pdf),MSF(internal).June2015.21Communitycarecentres:Anevolvingconcept.OlivierlePolain,LSHTM.Dec2014.Accessed18Dec2015at:https://www.futurelearn.com/courses/ebola-in-context/0/steps/484422Kaiser,Laurent.“ReportofthevisittotheMSFfacilitiesinMonrovia,FoyaandGuekedou–Focusonclinicalvirologyaspectsanddiagnosticissues–Aug30toSept72014”,Pg.4.HopitauxUniversitairesofGeneva.Sept2014(docembeddedinDorianJob’sEbolaStrategyPaper)23Soupart,M./Sterk,E.(etal).“EbolaRegulatedReferralSystem”.MSF-OCG(internal).Oct201424Lampard,B.“14.12.14-EbolaCaseManagementComments-BruceLampard”(Email).MSF(internal).14Dec2014.
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25“MSF-OCGworkshoponOperationalandMedicalprioritiesaroundEbola,followingthe2014-2015WestAfricanEbolaEpidemic:workshopsummaryandrecommendations”(filename:“OCGEbolaworkshopsummaryminutes_1”.MSF.27Feb2015(Geneva,Switzerland)26“MSF-OCGworkshoponOperationalandMedicalprioritiesaroundEbola,followingthe2014-2015WestAfricanEbolaEpidemic:workshopsummaryandrecommendations”(filename:“OCGEbolaworkshopsummaryminutes_1”.MSF.27Feb2015(Geneva,Switzerland)27Wolz,A.“SierraLeoneFreetownPOWETCFinalReport”(filename:PoWSLReport_V6).MSF-OCG(internal).17April2015.28GarciaGuerrero,A.(etal).“ClinicalLessonslearnedandManagementRecommendationsforPatientswithEbolaVirusDisease(EVD).MSF.(Datenotprovided).29Walker,N&Whitty,C.2015Tacklingemerginginfections:clinicalandpublichealthlessonsfromtheWestAfricanEbolavirusdiseaseoutbreak,2014–2015,JClinMedhttp://www.clinmed.rcpjournal.org/content/15/5/457.long30“MSF-OCGworkshoponOperationalandMedicalprioritiesaroundEbola,followingthe2014-2015WestAfricanEbolaEpidemic:workshopsummaryandrecommendations”(filename:“OCGEbolaworkshopsummaryminutes_1”.MSF.27Feb2015(Geneva,Switzerland)31 Watson-Stryker,E.“FreetownEbolaHealthPromotionOutreachEndofMissionReport”,MSF-OCG(internal).March2015. 32“MSF-OCGworkshoponOperationalandMedicalprioritiesaroundEbola,followingthe2014-2015WestAfricanEbolaEpidemic:workshopsummaryandrecommendations”(filename:“OCGEbolaworkshopsummaryminutes_1”.MSF.27Feb2015(Geneva,Switzerland)33Watson-Stryker,E.“FreetownEbolaHealthPromotionOutreachEndofMissionReport”,MSF-OCG(internal).March2015.34Watson-Stryker,E.“FreetownEbolaHealthPromotionOutreachEndofMissionReport”,MSF-OCG(internal).March2015.35Watson-Stryker,E.“FreetownEbolaHealthPromotionOutreachEndofMissionReport”,MSF-OCG(internal).March2015.36Watson-Stryker,E.“FreetownEbolaHealthPromotionOutreachEndofMissionReport”,MSF-OCG(internal).March2015.37Watson-Stryker,E.“FreetownEbolaHealthPromotionOutreachEndofMissionReport”,MSF-OCG(internal).March2015.38“ProjectManagementMSFEbolaExperimentalProductInvestigationPlatform”–MSFNotes39“MSFOCGworkshoponOperationalandMedicalprioritiesaroundEbola,followingthe2014-2015WestAfricanEbolaEpidemic:workshopsummaryandrecommendations”(filename:“OCGEbolaworkshopsummaryminutes_1”.MSF.27Feb2015(Geneva,Switzerland)40Kaiser,Laurent.“ReportofthevisittotheMSFfacilitiesinMonrovia,FoyaandGuekedou–Focusonclinicalvirologyaspectsanddiagnosticissues–Aug30toSept72014”,Pg.4.HopitauxUniversitairesofGeneva.Sept2014(docembeddedinDorianJob’sEbolaStrategyPaper)
