Planning and coordination
The purpose of the Ebola plan is to help with containment and mitigation of the disease through timely detection and prevention of outbreaks. Working with the general population in the villages and towns is an important endeavour without which we will have already lost the battle. You cannot mount strong surveillance strategies in human populations if you do not explain the strategies to the general population. The National EVD Preparedness Plan must explain how it is going to manage and meet the needs of patients and how it would reduce the consequences of the disease outbreak in the communities if it were to blow out of proportion. To achieve this imperative in a practical sense, different actors must be involved, such as households, chiefs, local companies, government departments and UN agencies, in the planning processes.
Preparedness response plans for Ebola will fall short on important aspects needed if they are not based on basic scenarios of preparations, such as how to increase service output in health facilities. Lessons must be learned from West Africa on the importance of ensuring that vital services are kept running, like how best to facilitate food security so that there are no food shortages during the outbreak, or ensure that the education system is continually sustained while water companies continue to work to provide clean water. It is important that plans’ overall goals are clarified in terms of how difficult decisions and choices would be made. Coordination among interested parties including health-care workers is essential if we are to win the battle. The authorities must demonstrate the extent to which these plans would be implemented.
Ebola surveillance, situation monitoring and assessment
While surveillance, situation monitoring and assessment are much needed to quickly detect and treat cases of Ebola to avoid deaths, the robustness of surveillance systems to send early signals for health service response are worrisome. The existing Integrated Disease Surveillance and Response (IDSR) is an important tool, but remains too weak to mount surveillance measures that are comprehensive enough to continuously detect the Ebola cases occurring in the human population. If contact tracing is really to work, we need to strengthen our surveillance so it is sensitive enough to pick up Ebola cases at borders and within the communities. The financial and human resources necessary to operate surveillance activities are inadequate to support regular diagnoses of Ebola while keeping track of all laboratory tests and people under contact tracing. Having enough effective and efficient referral laboratories in the country would improve surveillance activity and speed up situation monitoring, assessment and reporting. There is need for rapid test technology using a realtime reverse-transcriptase polymerase chain reaction (RT-PCR) test to be deployed in key areas.
Prevention and containment
Like surveillance, preventing and controlling EVD is important. Since there are no vaccines to fight Ebola virus, efforts must be directed towards implementing non-pharmaceutical interventions such as quarantine, travel restriction, closing schools and hygiene promotion. While institutional closure, forced treatment and isolation are useful measures, they lack the legal frameworks to support the enactments as required by the International Health Regulations of 2005. The Malawi Public Health Act (1948) is as inadequate as it is outdated and unable to support important enactments and current best practices in preventing and managing emerging challenges of Ebola outbreak. There is need to connect legal consistency between international (e.g. the International Health Regulations of 2005) and domestic laws (e.g. local public health laws).
Non-pharmaceutical interventions are common measures identified as efficient methods of mitigating Ebola outbreak, taking into account that these methods are cheaper although they require voluntary cooperation with patients. Quarantine and contact tracing have practical challenges associated with prevention and containment. For example, implementation of such interventions runs the risk of stigmatising the very population they are meant to protect. In the absence of sufficient hospital space and tents, community care may be encouraged by providing households with “home-care kits” to reduce the risk of within-home transmission. Since people will be afraid of catching Ebola in hospital, it should be expected that non Ebola patients will dessert to their homes or suspected Ebola patients will decide to remain in their homes due to lack of medicines in hospitals. Households looking after sick patients must be encouraged to wear makeshift protecting clothing where latex gloves or protective gowns are not available. Care management of Ebola patients with rehydrating fluids must not be understated. Most importantly, hospitals must be provided with medicines, fuel and generators. Mortality management such as the role of mortuaries and safe disposal of bodies must be addressed. Ebola assessment centres, including camps, must be established.
Communication strategies relating to priority settings of limited resources should not be overlooked and indicator guidelines must be publicized to ensure people are informed and able to gain insight or a glimpse of what is expected of them in light of scarce resources. The failure to take into account the need for communication not only produces non-beneficial judgement on the part of the policies, but significantly increases errors that subsequently rob the public social reality of expectations.
Information education and communications (IEC)
The success of planning for and response to Ebola rests clearly on three inter-related themes: information, education and communication. To stop the epidemic, people’s behaviour must change too. We have seen how cultural practices have contributed to the spread of the disease in West Africa. There is much theory on communication for change that authorities can tap into and apply to change some cultural behaviour. The communication strategy on EVD messages can be implemented using different media channels, such as newspapers, television and radio. The MoH must establish a telephone hotline to inform the general public on issues relating to Ebola, such as protocols and triage decisions about who gets the limited drugs in moderate and worst-case scenarios when all would be eligible. The EVD planners may consider adopting a call data records (CDR) system to provide real time notification about areas that are affected or to predict spread of the disease. CDRs definitely hold potential as a planning and evaluation tool if structures can be created for passing information smoothly and rapidly from providers to the general population, researchers and policymakers. Any decision making process on Ebola will rely very much on timely information made available from various sources and communicated as response actions through channels that are equally effective. IEC strategies must attempt to address panic, rumours, fears and myths. In emergency situations there is no need for panic and stigmatisation. The national IEC strategy must maintain multi-sectoral communication capacity to respond to the needs of the Ebola patients with implementing stakeholders.
Health system response
The Ebola epidemic would place a significant burden on health-care systems due to increased rates of patient visits seeking care across the country. The current operational nature of everyday activities of the health services is already overwhelmed with scores of operational and logistic problems due to Malaria, HIV/AIDS and TB. Additional health services due to Ebola Virus Disease are more likely to mount extra burden on the already distressed health service operatives. Strengthening the health service’s capacity is necessary to enable it to continue with the routine handling of laboratory specimens, implementing its hospital infection control policies, and providing safe transport and pharmaceutical logistics. To ensure health professionals turn up for work every day in the event of Ebola outbreak, they need to be supported, assured and motivated.
Any preparedness, response strategies within the health-care systems requires money so it can acquire materials such as Personal Protective Equipments (PPEs) that protects the health professionals while coordinating their work during the Ebola outbreak. It is perfectly sensible for health workers to be scared of treating Ebola patients if they are not sufficiently protected with PPEs. Enough funding must be made available to maintain specific activities, such as raising awareness and strengthening the training of health-care workers and the communities on the best methods of avoiding and treating Ebola patients. Hospitals need to be properly coordinated, with enough staff, although many rural clinics lack much-needed resources such as patient beds, medicines and nursing staff. Hospital protocols must be in place upon which the health service can initiate the call to action. Alternative medical services must be clearly articulated, detailing what actions hospitals or clinics should take when overwhelmed with patients. It is also important to know whether the health sector would engage traditional healers, or simply engage volunteers from the non-health sector in reducing the demand and burden of patient care if they had a large influx of patients.
