ISBN 978-4-909675-35-4
2

Executive summary

Health care-associated infections (HCAI) and related deaths, together with increased costs due toextended hospitalization and medical treatment, have become serious problems both in developed
and developing countries.
As seen in cases of Ebola, hospitals can be high-risk places of infectious disease outbreaks. Notable
example which is still fresh in our memory is the HCAI caused by medical personnel who were in chargeof the treatment of the Ebola virus disease in West Africa, as a reminder of this urgent issue globally.
However, the damage caused by these infectious diseases can be mitigated or minimized by thoroughimplementation of appropriate control measures. Moreover, improving the quality of HCAI control isurgently required in order to prepare for a future pandemic.
Japan International Cooperation Agency (JICA) and National Center for Global Health and Medicine(NCGM) have conducted a Program for the Specialist of Healthcare-Associated Infection Control andPrevention since 2003

for the hospital administrator and the person in charge of HCAI control in theirrespective institution, as well trainers to their staff regarding HCAI control.
Participants shall have opportunities in Japan to understand the principles and practices of HCAI
control through a series of lectures, workshops and site visits, and moreover to formulate an action plan
to solve the problems related to HCAI control in their respective countries and hospitals.
Leveraging the opportunity of the program, JICA and NCGM organized Knowledge Co- creation
Session "Sharing the Experiences of Ebola Outbreaks".
As speakers, JICA, NCGM and participants of the above program from two countries (Liberia andSierra Leone) made presentations on the Ebola Outbreak Response. Ebola outbreaks took away many
health worker's lives. They talked about the reality of the frontline and how to protect their lives. JICA
and NCGM discussed about the cooperation for Africa and response systems for Ebola patients.
More than 50 people participated in this session. Sharing the Experiences of Ebola Outbreaks led us
to recognize the importance of preparedness for Ebola.
Lastly, we appreciate all participants and persons involved for their effort and collaboration forthis successful session and we hope that the session would nurture mutual collaboration among
participating countries and Japan by sharing knowledge and experiences in HCAI control now and in
the future.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

3

Contents

I.

Introduction

・・・・・・・・・・・・・・・・・・・・・・・・・・・・・

				
				
				

II.

				

				

III.

				

				

				

				

				

				
				

				

				
				
				

				

				

4

・・・・・・・・・・・・・・・・・・・

14

Shinsaku Sakurada
National Center for Global Health and Medicine, Japan
Bureau of International Health Cooperation

Akiko Saito
Associate Expert,
Health Team 2, Health group 1, Human Development Department
Japan International Cooperation Agency (JICA)

・・・・・・・・・・

17

Masiray Colojumah Kamara
Doctor in charge, Isolation Unit, International Medicine Dept.,
Connaught Hospital, Ministry of Health and Sanitation

Matron Fatmata Kargbo

Acting Matron, Nursing, Ola During Children's Hospital,
Ministry of Health and Sanitation

After the Session

22

Musa Zuanah
Medical Director, Curative Services, Tellewoyan Hospital, Ministry of HealthJean Kokoi Kaly
Medical Director, PSHC-AI&P, Matha Tubman Memorial Hospital, Ministry of HealthResponse for Viral Hemorrhagic Fever in NCGM

			

VII.

6

Ebola Outbreak Response in Liberia ・・・・・・・・・・・・・・・・・・

				

VI.

・・・・

Sharing Experience on Ebola Outbreak in Sierra Leone

				

V.

Course Leader, National Center for Global Health and Medicine, Japan
Bureau of International Health Cooperation

JICA’s Response to Ebola Outbreak

				

IV.

Jun Moriyama

Risk Management in Response to the Ebola Virus Disease Outbreak

				

5

・・・・・・・・・・・・・

28

Nozomi Takeshita
National Center for Global Health and Medicine, Japan
Disease Control Center・・・・・・・・・・・・・・・・・・・・・・・・・・・

33

I.

I.

Introduction

Introduction
Jun Moriyama
Course Leader, National Center for Global Health and Medicine,
Bureau of International Health Cooperation

Course Contents
Sharing the experiences and processes of HCAI Control and Prevention in Japan	

ImplemenBng  Partner:  NaBonal  Center  for  Global  Health  and  Medicine

Japanese  Health  System
Universal  Health  Coverage,  Surveillance  ,  Tuberculosis,  Medical  Waste  Management.
Principles  of  HCAI  PrevenBon  and  Control

Outsourcing  ・5S  Management
・Architectural  Engineering
・AnBmicrobial  Stewardship・Health  management  of  Healthcare  staﬀ
・  Surveillance・Clinical  Laboratory
・Medical  Waste  Management

HCAI  PrevenBon  and  control  in  NCGM
AcBviBes  in  each  Department
・ InfecBon  Control  and            PrevenBon  ・ Pharmacy
・ Clinical  Laboratory
・ Central  Medical  Supply
・ Medical  Engineer
・ Radiology
・ AcBviBes  of  ICU,  ER  and            General  Ward

Knowledge
Co-­‐creaBon

HCAI  PrevenBon  and  control    in Yurin  Hospital(Mid-­‐size)
・Experience  of  the  outbreak  in      Yurin  Hospital・Staﬀ  EducaBon  Regional  Network
・ InfecBon  Control  Network  in              Nagasaki  Prefecture
・Experience  of  the  outbreak  in    
    Nagasaki  University  Hospital

Making Action Plan in your own country	

Mr. Moriyama:

Ladies and gentlemen, now, we would

Now, I will introduce Dr. Sakurada, Bureau of International

like to start the Knowledge Co-Creation Program Sharing

Health Cooperation. He is a chairman of this session. Please,

Experiences of Ebola Outbreaks. I’d like to welcome you

Dr. Sakurada.

all and thank you everybody for coming. My name is Jun
Moriyama. I am in charge of course leader this program.
First of all, let me introduce the course program. This

Dr. Sakurada:

Good afternoon, everybody. I clearly

remember, when I worked in this Institute of NCGM, we

Ebola session is one of the JICA program for the specialist

formed task force for Ebola virus disease and I studied

of Healthcare-Associate Infection Control and Prevention.

what Ebola virus disease was. However, I was dispatched toParticipants came from eight countries, Laos, Myanmar,

Pakistan as a JICA expert for starting Immunization Project.

Malawi, Zambia, Uganda, Tanzania, Liberia and Sierra Leone.

So I did not have any opportunity to visit the West Africa toThis program aimes to help the participants understanding

control Ebola virus disease. Today, we have two speakers

and implement more effective policies and practices forfrom African countries from Liberia and Sierra Leone. These

healthcare-associated infection control and prevention incountries experienced Ebola virus disease and I’d like totheir own facilities. In this Program, participants will share

share their experience because Asian country including

experiences with each other including Japan. In 2014,

Laos PDR, Myanmar and Japan have not experienced EVD.

West Africa has experienced the largest outbreak of Ebola.

So we need to share African countries’ experiences. This is

Many healthcare workers were also damaged by Ebola. We

very, very important opportunity, I think. So the first speaker

think these experiences are very important for the otheris myself.

participants and Japan. So we planned this session.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

5II. Risk Management in Response to		
the Ebola Virus Disease Outbreak			Shinsaku Sakurada
			National Center for Global Health and Medicine,			

Bureau of International Health Cooperation

PLAN of the PRESENTATION

2. Trainer’s  training  programme  by  MOH  of  DRC/
NCGM/JICA  for  8  African  francophone  countries
3. InfecHon  prevenHon  and  control  (IPC) in  EVD4. 5S-­‐KAÏZEN-­‐TQM  in  the  management  of  EVD  for  reducing    risk

Dr. Sakurada:

5S-KAIZEN-TQM in the management of EVD for reducing
risks. This is a map of entire Africa continent. In the central

1. INTRODUCTION

Africa, there are Congo and Uganda and in these areas,
their experience are less than 500 cases and green circle is
Sudan’s strain of Ebola virus and red circle is Zaire’s strain as
Zaire was previous country name of DRC. I heard this strain
was highly virulent compared to Sudan’s strain. I don’tknow why. This is West Africa including Sierra Leone andLiberia and the number of victims is more than 20000. It’s

Infec6on	
  Control	
  Training	
  16/10/01	
  Next topic is Infection prevention and control in EVD. Lastly,huge number actually.

I’d like to introduce NCGM and JICA

Knowledge and experiences
sharing by DRC to 8
francophne African countries

activities in French speaking African countries and title is“Risk management and response to Ebola virus disease
outbreak.” I requested Dr. Noriaki Ikeda to prepare theseslides. He is working in Democratic Republic of the Congo
as a senior advisor of Ministry of Health in Kinshasa. Actuallyoriginal slides were in French and he translated them from
French to English but still some words are French, actuallythese presentation slides are French-and-English mix. I’msorry for that. Please let me use a note because this slide
was sent just a couple days ago from DRC, okay? So this isoutline of the presentation.

•••

Preparedness:	
  Important	  role	  of	
  the	
  rou6ne	
  surveillance	
  system,	  	
  par6cularly	
  on	
  the  community  based  surveillance(CBS).
Outbreak  response:	
  Coordina6on,	
  	
  Risk	  management	
  in	
  both	  community	
  and	
  Ebola	
  Treatment	
  Centers,	
  logis6cs,	
  team	  building	  Training	
  :	
  Contextualiza6on	
  of	
  training	
  modules(introduced	
  5S/Kaizen/TQM	  )and	
  
SOPs	
  

So here are key points of this presentation. Knowledge

The history of EVD Outbreaks 1976 à 2016

and experiences were shared by DRC and eight otherFrancophone African countries; French speaking Africancountries. What is the most important thing regarding

>	
  20	
  000	
  cases	  Preparedness. Dr. Ikeda said, that is community based

Mali

surveillance in particularly resource limited remote areas.
	  <	
  500	
  cases	  	
  Espèces	  Number two: For outbreak response, coordination and risk
management in the both community and Ebola treatment
centers, hospitals and etcetera are important. Logistics,
team building and teamwork are also very important.

Nombre	  de	
  cas	  16/10/01	

Infec6on	
  Control	
  Training	Firstly, TOT (Training of Trainers) was conducted in
French speaking African countries, in the capital city of Côte
d’Ivoire, Abidjan and Kinshasa and the capital city of DRC.

6

Number three is training, contextualization of training andmodules introduced 5S-KAIZEN-TQM program and SOPs.

II.

Risk Management in Response to the Ebola Virus Disease OutbreakTrainer’s  training  on  EVD  co-­‐organized  by  MOH  of   CÔTE  D’IVOIRE    and  DRC

From	
  02	
  to	
  14	
  March	  2015	  Abidjan  /  Grand  Bassam	
  15/11/24	

DRC  EVD  MISSION  to  Cote  d’Ivoire,  March  2015

NCGMリーダー会議：池田	

SimulaHon  pracHce  at  Ebola  Care  Center  	First topic is TOT conducted in Côte d’Ivoire and DRC.

This is Dr. Ikeda. It is taken TOT, Simulation practice atThis is a picture taken in the Côte d’Ivoire. Can you see?

Ebola Care Center, also this is the one training for care ofThis person is Dr. Ikeda. She is also Japanese. This is a groupthe patients.

photograph taken in the Côte d’Ivoire after the training.

            Training  contents(7  days)	
•
•
•
•
•
•
•
•
•
•
•
•
•
•
	
  
•
•
•
•

	
  Core  CurriculumAn	
  Africa	
  without	
  EVD	  :	
  myth	  or	
  reality?	
  	  	  Experience	
  in	
  the	
  DRC	  in	
  the	  management	
  of	
  the	  EVD	  Epidemiological	
  surveillance	
  of	
  EVD	  	
  Follow-­‐up	
  contacted	
  persons	
  with	  pa6ents	  	
  Medical	
  care	  of	
  EVD	  	
  Emergency	
  logis6ques	
  in	
  case	  of	
  EVD	
  Universal	
  Precau6ons	  	  	  Overview	
  of	
  5S-­‐	  Kaizen	
  -­‐	
  TQM	  
	  Contextualizing	
  5S-­‐	  Kaizen	
  -­‐	
  TQM	  in	
  the	  EVD	  	
  Overview	
  on	
  Water,	
  Sanita6on	
  and	  Hygiene	
  -­‐	
  WASH	  	
  Communica6on	
  in	
  case	  of	
  EVD	  	
  Taking	  into	  psycho-­‐	
  social	
  care	  in	
  the	
  MVE	  	
  Organiza6on	
  laboratory	
  in	
  the	  management	
  of	
  the	
  MVE	
  	
  
Put	
  on	
  /	
  Remove	
  PPE	
  	
  
	
  
	
  Speciﬁc  themes+  SimulaHon  pracHces  in    ETC	  Surveillance	  	
  and	  Laboratory	  	
  Medical	  Management	
  Logis6cs	
  and	
  Wash	  	
  Psycho	  -­‐social	
  issues	
  and	
  communica6on	
  	
  	
  

16/10/01	
  Infec6on	
  Control	
  Training	
  Please look at this photograph. Dr. Ikeda pointed out,
Actually this Trainer’s training consists of two majorparts. One is core curriculum. This is common curriculum
and another is specific agendas and simulation practices in
Ebola Disease Treatment Center. So many agendas are here.

this situation is not so good because only one person is
working here. This person is just standing and watching. He
said this is not so good situation. So, working as a team isvery important to reduce risk, he said so.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

7

health workers died due to the Ebola virus disease so far insix of eight outbreaks. These Italian sisters died because ofEbola.

Funeral  prac2ces  as  transmission  risks  of  EVD  in  communi2es• Social	
  importance	
  of	
  the	
  death	  in	
  Africa.	
  	
  • Cleaning	
  of	
  bodies	
  by	
  friends,	
  rela6ves.	
  	
  • Expressions	  of	
  love	  and	
  friendship:	
  touching	
  and	
  kissing.	
  • Cucng	
  ﬁngernails	
  and	
  hair	  to	
  be	
  sent	  to	
  villages.	
  	
  This is training of undressing, the taking off PPE
and please look at this photograph. This photo is very
symmetric. I think one is for trainee and another is for

16/10/01	
  trainer.

Infec6on	
  Control	
  Training	
  This slide is for funeral practices in African countries.
Social importance of the death in Africa; I think this is very,

Extention of the EVD
Diﬀérents*stades*d’émergence*zoono3ques!

very an important thing everywhere but maybe in African

Risk management of the EVD both in community and healthfacilities(hospitals/ Ebola treatment center)

REVIEWS

NATUREjVol 447j17 May 2007

Community
Stage
IPC/Safely  burying  Stage 5:exclusive
human agent

is very important practice and expressions of love andOnly fromhumansStage 4:long outbreakfriendship: touching and kissing dead body and cutting

From animalsor (many cycles)

Behavioral
changefingernails and hair to be sent to villages. So behavioral

humans
Universal
precautions

Stage 3:change was necessary in village.

From animalsor (few cycles)
humansBy  courtesy  of  Prof  limitedoutbreakMuyembe  TJJ,  2015
Stage 2:
primary
infection

countries they have some characteristic culture, I mean
cleaning of dead bodies by friends, relatives, families. This

Transmission
IPC  in  hospitals/ETC
to humans

EVD = Socio-cultural disease

Only from animals

Importance  of  Community  based  surveillance  as  preparedness	

Infec6on	
  Control	
  Training	
  16/10/01	
  Stage 1:
agent onlyin animals

None

RabiesEbola

DengueHIV-1 M

(now acquired only fromSo here is mirror image. Extension
ofhumans).
the EVD. Here is

Wolfe!et!al.!2007!
Figure1 | Illustration of the five stages through which pathogens ofanimals evolve to cause diseases confined to humans. (See Box 1 fordetails.) The four agents depicted have reached different stages in the1

process, ranging from rabies (still acquired only from animals) to HIV-1

community and here is hospital. In the communities, mostworld until the steep rise in human numbers that began around
Supplementary Note S7). Why do temperate and tropical human
11,000 years ago with the development of agriculture1,9. Hence thediseases differ so markedly in their animal origins? Many (4/10)
crowd epidemic diseases of the temperate zones must have evolved
tropical diseases (AIDS, dengue fever, vivax malaria, yellow fever)since then.
but only 1/15 temperate diseases (hepatitis B) have wild non-humanprimate origins (P 5 0.04). This is because although non-human
Of course, this does not mean that human hunter/gatherer comprimates are the animals most closely related to humans and hence
munities lacked infectious diseases. Instead, like the sparse populapose the weakest species barriers to pathogen transfer, the vast majortions of our primate relatives, they suffered from infectious diseases
ity of primate species is tropical rather than temperate. Conversely,with characteristics permitting them to persist in small populations,few tropical but many temperate diseases arose from domestic aniunlike crowd epidemic diseases. Those characteristics include: occurmals, and this is because domestic animals live mainly in the temrence in animal reservoirs as well as in humans (such as yellow fever);perate zones, and their concentration there was formerly even moreincomplete and/or non-lasting immunity, enabling recovered
lop-sided (see Supplementary Note S8).
patients to remain in the pool of potential victims (such as malaria);
and a slow or chronic course, enabling individual patients to conA final noteworthy point about animal-derived human pathogens
tinue to infect new victims over years, rather than for just a week oris that virtually all arose from pathogens of other warm-blooded
two (such as Chagas’ disease).
vertebrates, primarily mammals plus in two cases (influenza A andultimately falciparum malaria) birds. This comes as no surprise, conPathogen origins. (See details for each disease in Supplementarysidering the species barrier to pathogen transfer posed by phylogenNote S10). Current information suggests that 8 of the 15 temperateetic distance (Box 2). An expression of this barrier is that primatesdiseases probably or possibly reached humans from domestic aniconstitute only 0.5% of all vertebrate species but have contributed
mals (diphtheria, influenza A, measles, mumps, pertussis, rotavirus,
about 20% of our major human diseases. Expressed in another way,smallpox, tuberculosis); three more probably reached us from apes
the number of major human diseases contributed, divided by the(hepatitis B) or rodents (plague, typhus); and the other four (rubella,number of animal species in the taxonomic group contributing thosesyphilis, tetanus, typhoid) came from still-unknown sources (seediseases, is approximately 0.2 for apes, 0.017 for non-human priSupplementary Note S6). Thus, the rise of agriculture starting
mates other than apes, 0.003 for mammals other than primates,
11,000 years ago played multiple roles in the evolution of animal
0.00006 for vertebrates other than mammals, and either 0 or else
pathogens into human pathogens1,4,10. Those roles included both0.000003 (if cholera really came from aquatic invertebrates) for anigeneration of the large human populations necessary for the evolumals other than vertebrates (see Supplementary Note S9).
tion and persistence of human crowd diseases, and generation oflarge populations of domestic animals, with which farmers came into
Geographic origins. To an overwhelming degree, the 25 major
much closer and more frequent contact than hunter/gatherers had
human pathogens analysed here originated in the Old World. Thatwith wild animals. Moreover, as illustrated by influenza A, theseproved to be of great historical importance, because it facilitatedRisk
the
EVD bothin community
andhealthdomestic
animalserved management
as efficient conduitsoffor
pathogenthe European
conquest of the
New
World (the Americas).
Far more
NATUREjVol
447j17herds
May 2007
REVIEWS
transfers from wild animals to humans,facilities(hospitals/
and in the process may haveEbola
Nativetreatment
Americans resisting
European colonists died of newly introcenter)evolved specialized crowd diseases of their own.
duced Old World diseases than of sword and bullet wounds. Those
It is interesting that fewer tropicalthan temperate pathogens oriinvisible agents of New WorldTransmission
conquest were Old World microbes toCommunity
IPC  in  hospitals/ETC
Stage
ginated from domestic animals:
not more than three of the ten tropwhich Europeans had
both someacquired immunity based on indito humans
IPC/Safely  burying  ical diseases of Supplementary Table S1, and possibly none (seevidual exposure and some genetic resistance based on population

important thing is safely burying and for that, behavioral
change is necessary. In the hospitals, IPC implementationis very, very important. Risk management of the EVD bothin community and health facilities, hospitals and Ebola
treatment centers is necessary. EVD is socio-cultural disease,actually viral disease but this disease have...

Extention of the EVD
Diﬀérents*stades*d’émergence*zoono3ques!

281

Stage 5:exclusive
human agent©2007 Nature Publishing Group

Only fromhumansStage 4:long outbreak

From animalsor (many cycles)

Behavioral
changehumans
Universal
precautions

Stage 3:

From animalsor (few cycles)
humansBy  courtesy  of  Prof  limitedoutbreakMuyembe  TJJ,  2015
Stage 2:
primary
infection

EVD = Socio-cultural disease

Only from animals

Infec6on	
  Control	
  Training	
  16/10/01	
  Stage 1:
agent onlyin animals

Noneranging from rabies (still acquired only from animals) to HIV-1
Here are five Italian sisters.process,
Unfortunately
in DRC, 1the(now acquired only from humans).
RabiesEbola

DengueHIV-1 M

Wolfe!et!al.!2007!
Figure1 | Illustration of the five stages through which pathogens ofanimals evolve to cause diseases confined to humans. (See Box 1 fordetails.) The four agents depicted have reached different stages in the8

world until the steep rise in human numbers that began around
11,000 years ago with the development of agriculture1,9. Hence thecrowd epidemic diseases of the temperate zones must have evolved
since then.
Of course, this does not mean that human hunter/gatherer communities lacked infectious diseases. Instead, like the sparse populations of our primate relatives, they suffered from infectious diseases
with characteristics permitting them to persist in small populations,unlike crowd epidemic diseases. Those characteristics include: occurrence in animal reservoirs as well as in humans (such as yellow fever);incomplete and/or non-lasting immunity, enabling recovered

Supplementary Note S7). Why do temperate and tropical humandiseases differ so markedly in their animal origins? Many (4/10)
tropical diseases (AIDS, dengue fever, vivax malaria, yellow fever)but only 1/15 temperate diseases (hepatitis B) have wild non-humanprimate origins (P 5 0.04). This is because although non-humanprimates are the animals most closely related to humans and hencepose the weakest species barriers to pathogen transfer, the vast majority of primate species is tropical rather than temperate. Conversely,
few tropical but many temperate diseases arose from domestic animals, and this is because domestic animals live mainly in the temperate zones, and their concentration there was formerly even more

16/10/01	
  Infec6on	
  Control	
  Training	
  Next, community based surveillance. Please look at thisphotograph. This is meeting of community surveillance
team.

II.

Risk Management in Response to the Ebola Virus Disease Outbreak

Background of CBS in DRC

Challenges• Surface : 2.345.000 Km²• Population: +70millions inhabitants.
• 26 Provincial Health Departments, 517
health zones and 8628 health areas• Curative care usage rate: 20%• Several epidemics :EVD, YF, cholera,meningococcal meningitis, Rabies, otherviral hemorrhagic fever, Measles• Late identification of the cases in healthcenters

1. How to maintain and improve
community based surveillancein post periods, interepidemics ?
2. Formalize community
surveillance tools
3. How to improve reports
promptness ? Real timereporting ?

16/10/01	
  Kinshasa	
  du	
  13	
  au	
  21	
  Août	  2015	
  17	
  16/10/01	
  Background of Community Based Surveillance in DRC.
As you know DRC is a huge country not like Japan. The

Dr. Sakurada:

Kinshasa	
  from	  August	
  13	
  to	
  21	
  2015	
  19	
  Local authority, daily supervision, daily

meeting of the surveillance commission and weeklyarea is I don’t know how many squares. Anyway, it’s aevaluation but actually we have some challenges: howhuge country and population is more than 70 million. So

to maintain and improve community based surveillancemany people live in Kinshasa, capital of DRC. 26 Provincial

in post periods, inter epidemics. Particularly formalizing

Health Departments and 517 health zones and 8628 healthcommunity surveillance tools as the format, etc.

areas. Curative care usage rate is 20 percent. This is DRC

Number three: how to improve reports: promptness,experience, several epidemics including EVD, yellow fever,timeliness or completeness? These are always problems

now, yellow fever is a very big problem in DRC, and cholera,in surveillance: lack of timeliness and/or completeness inmeningitis, measles and other virus hemorrhagic fever.

everywhere. So real-time reporting is very important but

The famous one is Crimean-Congo hemorrhagic fever andit’s very difficult. There is also some strong resistance frommalaria, etc. and measles. And late identification of thecommunity.

cases in health centers is a problem.

Training Content

CBS activities during outbreak• Daily follow-up of contacts
üDoor to doorüVillage to village• Daily meeting at community

MODULE  FOR  COMMUNITY  BASED  SURVEILLANCE  STRENGTHENING  IN  THE  HEALTH  AREAS  IN  THE  FRAMEWORK  OF  RESPONSE  TO  EBOLA  VIRUS  DISEASES  üCommunity Relay (Relais)üTitular nurse (Charged nurse )üLocal authority• Daily supervision• Daily meeting of the surveillance
commission• Weekly evaluation
16/10/01	
  Kinshasa	
  from	  August	
  13	
  to	
  21	
  2015	  16/10/01	
  Kinshasa	
  from	  August	
  13	
  to	
  21	
  2015	
  

20	
  

18	
  

They developed training content. This is module forCBS, Community Based Surveillance activities during
outbreak. Number one: daily follow-up of contacts: door todoor, village to village. Saying is easy but implementation

community based surveillance strengthening in the healthareas in the framework of response to Ebola virus diseases,
we developed this.

is very hard during outbreak. Number two: daily meeting at
community: community relay and titular nurse. I’m sorry I
don’t know the meaning of this words. This is from South?
Dr. Kaly:

Nurse in charge or supervisor.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

9

Risk  management  in  a  Ebola  Treatment  Center  introducing  5S/Kaizen	Infec6on	
  Control	
  Training	
  16/10/01	  Mode  of  transmission  in  treatment  and  care-­‐PaHents  to  personnel  -­‐PaHents  to  family  member-­‐  Through  work  enviroment

16/10/01	
  Infec6on	
  Control	
  Training	
  These pictures are also very common. You know, it’s alittle bit messy. These are used globes but put on the desk.
Please look at syringes, needles and etc. This boy has asyringe with needle.
R i s k m a n a g e m e n t i n E b o l a Tr e a t m e n t C e n t e r :Thank you for thinking
about me for protecting
against risk!

Introducing 5S-KAIZEN. I think the five S is introduced inmany African countries and I think you’re very familiar with
5S, right? Not so familiar?
Audience:

Some of us are.

Dr. Sakurada:

Okay. In management of EVD, thepositive attitude and leadership are very important. Dr.
Ikeda says 5S-KAIZEN-TQM could be applied to improvecountermeasures of EVD like this: improving work
environment, team work, time waste and reducing disorderand etcetera.
Audience:-­‐PaHents  to  personnel  -­‐PaHents  to  family  member-­‐  Through  work  environment

Infec6on	
  Control	
  Training	  Dr. Sakurada: Please look at these photographs. I think it’svery common. Friends, family, relatives always visit patients.

Actually they care but the virus could be transmitted
patients to healthcare workers and also patient’s family,

10

Actually I saw very serious scenes in Pakistan: children
garden of healthcare center. I saw it and I was shocked.

Mode  of  transmission  in  health  faciliHes

friends, relatives.

Infec6on	
  Control	
  Training	
  were playing with syringes with needle like that in theYes.

16/10/01	
  16/10/01	
  II.

Risk Management in Response to the Ebola Virus Disease Outbreak

Change organizational culture by 5S-KAIZEN-TQM. I
don’t know if it’s easy or not maybe not easy but we can.
I hope so. Improving work environment, development ofwork teams, optimizing available resources.

Work	
  in	
  team	  PILOTE	  and	  COPILOTE	  Infec6on	
  Control	
  Training	
  16/10/01	
  Waste  management  using  color  cording

Triage  of    waste  (S1)Everyone’s	
  responsability	
  Infec6on	
  Control	
  Training	
  16/10/01	
  Cutting object

bottles

Soft waste

Organs

He is a pilot and this is a copilot. This is a team. Teamworking is very important.
So, I have too many slides. I need to skip and I need toaccelerate.
Infec6on	
  Control	
  Training	
  16/10/01	  5S-KAÏZEN-TQM IN REDUCING RISKOF EVD
principle

S1

Sort and Separate, Remove
unnecessary items and keep the only
necessary items in the workplace for thecurrent production, Work on free area.
Eliminate contaminated objects or
any risk of / potential contamination• Case Definition• Contacts tracing

16/10/01	
  Infec6on	
  Control	
  Training	
  16/10/01	
  

S1 (Seiri, Sort)• save space in theworkplace• help to identifying thepotential hazards• Triage in ETC• Biomedical waste sorting• Discard any contaminatedobjects
Infec6on	
  Control	
  Training	
  Next is waste management using color-coding. This is

S1 is 5S’s first S and sorting or separating. In Japanese,very important segregation by color-coding. I think now,

it’s seiri. Saving the space of work place and help identifying

many hospitals are implementing this color-coding like this.

potential hazard. This is very important.

CHANGE ORGANIZATIONAL CULTURE
by 5S-KAÏZEN-TQM / EVD
Diﬀérents*stades*d’émergence*zoono3ques!
Risk management of the EVD both in community and healthfacilities(hospitals/ Ebola treatment center)

REVIEWS

NATUREjVol 447j17 May 2007

Community
Stage
IPC/Safely  burying  Transmission
IPC  in  hospitals/ETC
to humans

Stage 5:exclusive
human agent

Only fromhumansStage 4:long outbreak

From animalsor (many cycles)

Behavioral
changehumans
Universal
precautions

Stage 3:

From animals

Stage 1:
agent onlyin animals

Nonelimitedor (few cycles)• Mission	  -­‐	
  Stop	
  transmission	
  chain	
  &	
  case	  management	
  outbreakhumans• 5S-­‐  Kaizen	
  =	
  opera6onal	
  approach	
  Stage 2:
primary
Only from animals
	  Improving	  	
  work	  environment	
  infection
	  Development	
  of	
  work	  teams	
  resources
16/10/01	
   	
  Op6mizing	  available	  Infec6on	  Control	
  Training	
  RabiesEbola

DengueHIV-1 M1

Wolfe!et!al.!2007!
Figure1 | Illustration of the five stages through which pathogens ofanimals evolve to cause diseases confined to humans. (See Box 1 fordetails.) The four agents depicted have reached different stages in theprocess, ranging from rabies (still acquired only from animals) to HIV-1(now acquired only from humans).

world until the steep rise in human numbers that began around
11,000 years ago with the development of agriculture1,9. Hence thecrowd epidemic diseases of the temperate zones must have evolved
since then.
Of course, this does not mean that human hunter/gatherer communities lacked infectious diseases. Instead, like the sparse populations of our primate relatives, they suffered from infectious diseases
with characteristics permitting them to persist in small populations,

Supplementary Note S7). Why do temperate and tropical humandiseases differ so markedly in their animal origins? Many (4/10)
tropical diseases (AIDS, dengue fever, vivax malaria, yellow fever)but only 1/15 temperate diseases (hepatitis B) have wild non-humanprimate origins (P 5 0.04). This is because although non-humanprimates are the animals most closely related to humans and hencepose the weakest species barriers to pathogen transfer, the vast majority of primate species is tropical rather than temperate. Conversely,

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

11

5S-KAÏZEN-TQM IN REDUCING RISKOF EVD
principle

S2

Set-in-order,
Decide the designatedplace to keep necessary
items in the workplace,where it is easy to access
them.
Then they are found
immediately and returned
easily or replenishedproperly.

S2 (Seiton, Set-in-order)• saves time as required inemergency,• reduces the risk of confusion/
error, risk of contamination,• limits movements of staff• strengthens the security ofstaff

5S-KAÏZEN-TQM IN REDUCING RISKOF EVD
principleStandardize
Establish the 3 first S as routine(by using Sort, Set-in-order, andShine activities)
Continuous use of protocols,visualization

S4

Infec6on	
  Control	
  Training	
  16/10/01	  5S-KAÏZEN-TQM IN REDUCING RISKOF EVD

principle

S2

Infec6on	
  Control	
  Training	
  16/10/01	  5S-KAÏZEN-TQM IN REDUCING RISKOF EVD

S4 (Seiketsu,
Standardize) :• making rules in order tomaintain successful
practices and theworkplace security• Developing habits workin teamprinciple

Set-in-order,
Decide the designated place
to keep necessary items in
the workplace, where it iseasy to access them.
Then they are found
immediately and returned
easily or replenishedproperly.

Standardize
Establish the 3 first S asroutine (by using Sort,
Set-in-order, and Shine
activities)
Continuous use of
protocols, visualization

S4• Mapping of villages• Compartments of Suspected
Cases / Confirmed Cases• Zoning: High risk and low risk
• Well-organized care table• Storage and ranking of
medicines, records and other
inputs• Protocols, SOP• Use of Check list
• Visualization of the process• Signalling, Visual Indication (to attract attention to the danger), Colorcoding• ETC Circuit : patient circuit, care staff circuit• Staff turnover

Infec6on	
  Control	
  Training	
  16/10/01	
  Infec6on	
  Control	
  Training	
  16/10/01	
  Number tow is S2: setting order, seiton in Japanese.

Number four : standardization is very important. It’s

Save time is required in emergency. Reducing the risk ofseiketsu in Japanese. Making rules in order to maintainconfusion, error, risk of contamination. Limit movement of

successful practice. This is practicing Ebola Treatment

staff and strengthen security of staff like this. This is Ebola

Center.

Treatment Center.

5S-KAÏZEN-TQM IN REDUCING RISKOF EVD

5S-KAÏZEN-TQM IN REDUCING RISKOF EVD
principe

principle

S3

Shine, Clean, Disinfect,
Cleaning up the workplace/environment

S3 (Seiso, Shine) :• essential in reducing the risk ofhuman-to-human transmission• Safety burial• Hand washing

16/10/01	
  S5• Decontaminate theenvironment• Systematic use of
footbath, chlorine solution
0.05% or 0.5%
• Laboratory Diagnosis(precision)

Sustain
Make a self-disciplined habitof maintaining rules,
procedures andarrangements of theorganization
Keep applying the 4 first S,
Sustainability of theachievements

S5 (Shitsuke, Sustain) :• Maintains all successful
practices over the time
• Develops organizational
culture16/10/01	
  Infec6on	
  Control	
  Training	
  Number three: shining, cleaning and disinfecting. This is
critically important IPC. This is seiso in Japanese.

5S-KAÏZEN-TQM IN REDUCING RISKOF EVD
principle

S5

Sustain
Make a self-disciplined
habit of maintaining rules,
procedures andarrangements of theorganization
Keep applying the 4 first S,
Sustainability of theachievements• Community Sensitization • Training of healthproviders• Use/Involvement ofcommunity leaders and • Instructionsof “champions”
16/10/01	
  

12

II.

Risk Management in Response to the Ebola Virus Disease Outbreak

Last one, S5 is sustain. Everybody knows that to sustain
the things is very important but very difficult. shitsuke inJapanese. Shitsuke is discipline in English word, maintaining
the all successful practice or time and developing
organizational culture. I think that you had 5S lecture by Dr.
Handa, very impressive lecture, right?
Audience:

Yeah.

More than 200 hospitals in 15 Africancountries introduces 5S since 2007 	
Maroc	

Mali	Niger	

Senegal	
Burukina	  Faso	Benin	RDC	Burundi	15	
  Countries！	
03Sept/2015	

Dr. Sakurada:

IKEDA,NCGM,Tokyo,Japon	

Madagascar	

39	

Okay. I’m not an expert of 5S. That’s why I

do not mention the principle of 5S here but this is practicein Ebola Treatment Center. So 5S has been introduced in 15
counties in Africa now. This is the last slide. Thank you verymuch.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

13III. JICA's Response to Ebola Outbreak			Akiko Saito
			Associate Expert,
			
Health Team 2, Health group 1, Human Development Department,			Japan International Cooperation Agency (JICA)

Ms. Saito:

Good afternoon, ladies and gentlemen. It’s

JICA’s	  response	
  in	
  =me	
  framework
	

my honor to be here. My name is Akiko Saito from Japan
International Cooperation Agency, JICA. Now, I’m goingWHO	

to talk about JICA’s response to Ebola outbreak. My

Aug.	
  4th	  2014	  
PHEIC	

presentation may not cover for all the JICA’s response to

MoFA	
  

JICA	

Evacua=on	
  alert	All	
  Japanese	
  staﬀs	
  evacuated	  from	
  Liberia,	
  Sierra	
  Leone,	  and	
  Guinee	

Ebola outbreak. So you can ask any questions after theFirst	  contact	
  missions	  to	
  Liberia	  and	
  Guinea	  (Feb.	
  2015),	
  and	
  Sierra	  Leone	  (May	  2015)	

presentation and my colleagues can also help answering
your questions.
In this presentation, first, I’ll talk about what is JICA and

2015	
  
PHEIC	  removed	

JICA’s theme and then I’ll talk about JICA’s response in time

Evacua=on	
  alert	  removed	Re-­‐start	
  of	
  all	
  projects	
  and	
  trainings	
3	

framework and then, I’ll give you some examples of ourcooperation and maybe some challenges we’ve faced andat last, I’ll give you some ways forward.

How we acted to the Ebola crisis in time framework?
In August 1st, 2014, WHO issued PHEIC. So following that,Japanese government, Ministry of Foreign Affairs, also

What  is  JICA?	
• JICA	
  is	
  one	  of	
  the	
  world	
  largest	
  bilateral	
  development	
  agency,	  in	
  charge	  of	
  Oﬃcial	
  Development	  	
  Assistance	  (ODA),	
  which	  aims	
  to	
  
ﬁnd	
  solu=on	
  to	
  reduce	  poverty	
  in	
  developing	
  countries	
  through	  u=lizing	
  human	
  and	
  ﬁnancial	
  resources	
  and	
  technology.	
  	  • Vision  of  JICA:	  	          “Inclusive  and  Dynamic  Development”
Bilateral	
  Grants	  	
  Oﬃcial  Development  Assistance  (ODA)�Technical	  Coopera=on	
  Grant	  Aid	
  Bilateral	
  Loans	  	
  Contribu=ons	
  to	
  Interna=onal	
  Organiza=ons	  2	

issued evacuation alert. Then all JICA’s, Japanese staffs
evacuated from Liberia, Sierra Leone and Guinea and after
the peak of the Ebola outbreak was gone, first contact
missions to Nigeria and Guinea was sent in February
2015, and Sierra Leone in May 2015 and early 2015, WHOremoved PHEIC. So also Japanese Government, Ministryof Foreign Affairs, removed Evacuation Alert. So following

JICA

that, JICA restarted all the project in these countries andalso receiving the trainees and participants like you fromthese countries.

So first, what is JICA? As you may know, JICA is one of
the world largest bilateral development agency, in chargeof Official Development Assistance, ODA, which aims to find

JICA’s	  coopera=on	
  in	
  Ebola	
  outbreak	
  solution to reduce poverty in developing countries throughutilizing human and financial resources and technology.
Our vision is “Inclusive and Dynamic Development.” So JICA
has some schemes such as bilateral grants, bilateral loans
and technical cooperation and grant aid. We used theseschemes to achieve our vision. Please remember that JICA
is not funding agency or emergency responding agency, so
we operate our activity in normal condition.

• In-­‐kind	
  contribu=on	  	
  • Personnel	
  contribu=on	
  • Technical	
  Assistance	
  for	  Preven=ng	
  further	
  4	

So ethese are the just simple illustration to show likein which countries we have done the operation regarding

14

III.

JICA’s Response to Ebola Outbreak

Ebola outbreak not only the three countries like Liberia,

institution in Ghana. This institution was built by Japanese

Sierra Leone and Guinea, we also supported some countries,

ODA and we have been supporting for many years. So inneighboring countries as well as some countries in Asia andthis institution, there were some tests done for Ebola. So

we also conducted these variety of cooperation as I wrote a

we supported these institutions and also at the border

little bit on the bottom. There’re some in-kind cooperation.

and the airport, for example, we trained those staff such as

We provided some protective material like equipment andpolice officers in Côte d’Ivoire. We also provided trainings

also personnel contribution by dispatching some expert tofor medical staff in Ghana, Benin and also Ethiopia as

the WHO mission.Also we did some technical assistance forwell as conducted activities for awareness rising. Here we

preventing further spread of Ebola.

distributed some brochures in Nigeria. These are someexamples. And after the peak of the Ebola outbreak had

Ebola	
  Responses	
  and	
  Involvement:	
  -­‐	
  Sierra	
  Leone,	
  Liberia,	
  Guinea	  and	
  other	
  countries	

gone, at the era of the post-Ebola, we restarted all the
projects and started receiving the participants of theIn-­‐kind  contribuEon  training. So in Sierra Leone, we have three things going on.

• A	
  total	
  of	
  720,000	
  sets	  of	
  personal	
  protec=ve	
  equipment	
  (PPE)	
  	
  donated	
  to	
  Sierra	  Leone,	
  Liberia	
  Guinea,	  	
  other	
  countries.	
  • Other	
  equipment	
  and	
  materials	
  such	  as	
  tents	
  and	
  water	
  ﬁlter	  for	
  medical	
  response	
  were	  provided	
  (total	
  value	
  89	
  million	
  JPY	  (850,000USD))	
  • 28	
  motorbikes	
  to	
  be	
  used	  for	
  surveillance	
  were	  donated	
  to	
  Sierra	
  Leone	  The first one was the project for strengthening
supportive supervision system. This project was there

Personnel  contribuEon

before the Ebola outbreak and now, it has restarted.

• Total	
  16	
  experts	
  dispatched	
  to	
  par=cipate	
  in	
  WHO	
  missions.	
  Secondly, dispatching a expert of strengthening nursing

Technical  Assistance  for  PrevenEng  further  Spread  of  Ebola  in  18  countries  (120  million  JPY  (1,141,000USD))

skills on newborn and child health care and this one• Ebola	
  Response	
  Hubs-­‐	
  e.g.	
  Noguchi	
  Ins=tu=on	
  in	
  Ghana	  • Border,	  Airports	
  –e.g.	
  training	
  for	  police	
  oﬃcers	
  in	
  Cote	  D’Ivoire	
  • Health	
  Facili=es/Health	
  Workers-­‐	
  e.g.	
  trainings	
  for	
  medical	
  staﬀ	
  in	
  Ghana,	
  Benin,	  Ethiopia	
  5• Awareness	
  Raising-­‐	
  e.g.	
  Ebola	
  brochures	
  in	
  Nigeria	
  was also there before the outbreak but it was stopped
because of the outbreak. So she is going to be in Sierra	
   this slide, I’ll give you some examples of ourIn	
  cooperation especially in these three counties and a little bit	
  cover for the other countries. Other in-kind cooperation, we
have provided a total of 720,000 sets of personal protective
equipment, PPE, to Sierra Leone, Liberia, Guinea and othercountries. Also other equipment and material such as tents
and water filter for medical response and 28 motorbikes
to be used for surveillance in Sierra Leone were provided.
Furthermore, personnel contribution in Asia: Total of 16
experts dispatched to participate in WHO missions. As I said,
JICA is not emergency responding agency, we did not have

Leone next month. Thirdly,rehabilitation of health facility
is going on. In Liberia there’s a project for management
capacity development for health services and this project
was also there before the outbreak. This project and thefirst one for Sierra Leone, these’re aiming to strengthen
the health system. After the Ebola outbreak, we didrealize that strengthening health system to be resilience
for the outbreak or any those kind of projects are very
important. So now, we are very committed to these kindof the projects.In Guinea, Japanese government provided
diagnostic kits for Ebola. So JICA provided technical support
to use this kits.

anything like JICA standalone mission during crises but wedispatched some experts to WHO mission. Those experts
were epidemiologists and so on.

• Accelerated	
  implementa=on	
  of	
  IHR	  in	
  a	
  integrated	
  manner	
  among	
  GHSA	  and	
  other	
  works	
  and	
  ini=a=ves	
• Support	
  IHR	
  capacity	
  building	
  in	
  align	
  with	  priori=es	
  of	
  partner	
  countries	
  ,	
  as	
  an	
  integral	
  part	  of	
  health	
  systems	  strengthening	
  toward	
  achievement	
  of	
  UHC.	
  	• Support	
  to	
  build	
  pandemic-­‐resilient	
  socie=es,	
  through	  coordinated	
  mul=-­‐sector	
  investments	
  and	
  ac=vi=es	
  and	
  global	  learning.	
• Strengthen	
  regional	
  and	
  in-­‐country	
  surveillance	
  response	
  capacity	
  Africa	
  (Noguchi	
  Ins=tute	
  in	
  Ghana,	
  ECOWAS	
  CDC)	
  	
  Technical	
  Assistance	
  at	
  post	  Ebola	  -­‐Sierra	
  Leone,	
  Liberia	
  and	  Guinea	  	• Sierra  Leone  	  -­‐	
  Project	  for	  Strengthening	
  	
  
	
  	
  	
  Suppor=ve	
  Supervision	
  System	  	  	  -­‐	  Dispatch	
  Expert	
  of	
  Strengthening	
  	
  
	
  	
  	
  Nursing	
  Skills	
  on	
  Newborn	
  and	
  Child	
  Health	
  Care	  	  -­‐	
  Rehabilita=on	
  of	
  health	
  facili=es	
  (EmONCs)	
  • Liberia-­‐ Project	  for	  Management	
  Capacity	
  Development	
  for	
  Health	  Services	  • Guinea-­‐ Provision	
  of	
  	
  Rapid	
  Diagnos=c	
  Kits	  for	
  Ebola	  Way	  Forward	There’re some difficulties for JICA because we’re not7	

emergency responding agency or funding agency but we

6	Technical assistance for preventing further spreadof Ebola in 18 counties. We have the lab called Noguchi

tried to find our way to cooperate to tackle the situation.
What we found out from this experience werethat 1)
accelerated implementation of IHR in an integrated

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

15

manner among GHSA and other works and initiatives, 2)
support IHR capacity building in align with priorities of

Only urgent questions or comments

because we’ll have discussion time after all presentation,

partner countries, as an integral part of health systems

okay? But if you have urgent questions or comments,

strengthening toward achievement of UHC. These are aboutplease. Don’t hesitate.

the projects I mentioned in the previous time. And also3) support to build pandemic-resilient societies throughcoordinated multi-sector investments and activities andglobal learning. Finally, 4)strengthen regional and incountry
surveillance response capacity in Africa, for example,
Noguchi institution in Ghana and ECOWAS in Nigeria, these
two labs could have to cover the whole regions in that area
in Africa. Thank you very much.

16

Dr. Sakurada:

Dr. Kanai:

Excuse me. I have a comment.

Dr. Sakurada:
Dr. Kanai:

Please, Dr. Kanai.

Thank you. I would like to add one commenta b o u t P P E , 7 2 0 , 0 0 0 P P E s w e r e d o n a t e d b y To k y oMetropolitan Government. Thank you for that.

IV.

Sharing Experience on Ebola Outbreak in Sierra Leone

IV. Sharing Experience on Ebola Outbreakin Sierra Leone
Masiray Colojumah Kamara

Doctor in charge, Isolation Unit, International Medicine Dept., Connaught Hospital,
Ministry of Health and Sanitation

Matron Fatmata Kargbo

Acting Matron, Nursing, Ola During Children's Hospital,
Ministry of Health and Sanitation

SITUATIONAL  ANALYSIS  OF  EBOLA  OUTBREAK  IN  SIERRA  LEONE	  • Ebola	
   Viral	   Disease	
   (EVD)	
   is	   a	   severe
haemorrhagic	
   fever	
   disease	
   cause	
   by	   a	   virus(Filoviridae)	
  with	  a	
  90%	
  death	  rate	  (WHO,CDC
and	
  MOHS	
  2014).

Dr. Kamara:

Good afternoon, everyone. I’m excited toI’ll just brief introduction of Ebola virus disease. Ebola

be here this afternoon to share experience of the country

virus disease is hemorrhagic fever caused by a ilovirus. It’s

and I like revisiting from Sierra Leone. We appreciate

90 percent death rate according to WHO, CDC, and Ministry

this opportunity given to us. I am Dr. Masiray Colojumah

of Health in 2014.

Kamara giving you the presentation of my experience on
Ebola Outbreak in Sierra Leone alongside of my colleague,
Ms. Fatmata Karbo, from Ola During Children’s hospital.
We’re all working with the Ministry of Health and Sanitation.
So Ministry of Health and Sanitation in Sierra Leone. Outlineof the presentation is going to be like this: sharing with thesituation in Sierra Leone during Ebola outbreak. We’re goingto write what it was like in Connaught hospital and Ola
During Children's Hospital where most staffs are working
and to highlight the protection and safety management of

SITUATIONAL  ANALYSIS  OF  EBOLA  OUTBREAK	  • This	  deadly	
  disease	
  invaded	
  S/L	
  from	  the	
  eastend	
  in	
  May	  2014.
• It	  was	  a	
  chaoRc	
  situaRon	
  that	  could	
  be	
  viewedwith	
  both	  	
  challenges	
  and	
  opportuniRes.
• Challenges	
   are	   develop	
   from	
   the	   fact	
   thatSierra	   Leone	   is	   a	   Post-­‐	
   war	   country,	
   Low
Income	  Country	
  and	
  High	  infant	
  and	
  maternalmortality	
  rate	  etc.

that during the Ebola outbreak by health workers. We’ve
been providing treatment of patients in Ebola Treatment
Centers and to share with you experience we had during
the Ebola outbreak.

SITUATIONAL  ANALYSIS  OF  EBOLA  OUTBREAK	  • In	
  terms	
  of	
  opportuniRes,	
  the	  recent	
  outbreak	  of	
  Ebola	  in	
  Sierra	
  Leone	  served	
  as	
  an	
  eye	
  opener	
  to	
  
the	
  weak	  health	
  system	
  of	
  our	
  country.
• DetecRon	
   of	
   the	   disease	
   was	   diﬃcult,	
   as	
   early	
  symptoms	
   are	   hard	   to	   disRnguish	
   from	
   those	
   of	  malaria	   or	
   typhoid	
   common	
   ailments	
   during	
   the	  raining	
  season.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

17

SITUATIONAL  ANALYSIS  OF  EBOLA  OUTBREAK	  INCIDENCE	  	
  • W i t h	
   d i ﬃ c u l t	
   d e t e c R o n ,	   i s o l a R o n	
   a n d	
  containment	
  of	
  EVD	
  cases	
  was	  a	
  big	
  challenge.	
  
• 	
  To	
  the	
  public	
  ,	
  it	
  was	
  hard	  to	
  accept	
  that	  Ebola	  is	
  real.	  	
  • Their	
   percepRon	
   was	   that	
   Ebola	
   is	   a	   deliberate	
  design	  to	
  kill	  people	
  (SIERRA	  UPDATE	
  2015).	
  	
  • Resistance	
  to	
  go	
  to	
  health	
  faciliRes	  	
  • AZacking	
   health	
   workers	
   during	
   the	   early	
   stages	
  of	
  the	
  outbreak.	
  	
  • RejecRon	
  and	
  sRgmaRzaRon	
  of	
  vicRms	
  are	
  other	  factors.	
  • First	
   diagnosed	
   case	
   was	   in	
   late	
   May	   2014	
   from	
  Kailahun	  District;	
  East	  of	
  Sierra	
  Leone	  • By	
   June	   2014	
   there	
   were	
   158	
   cases,	
   in	
   late	
   July	  2014	
  533	
  cases.	
  • The	
   ﬁrst	
   case	
   was	   reported	
   in	
   the	   on	
   the	   19th	  July,	  2014	
  • Kialahun	
   District	
   was	   heavily	
   aﬀected	
   and	   was	  referred	   to	
   as	
   the	   “Birth	
   place	
   of	
   an	
  outbreak”(	  Muller,	
  2014)	
  	
  In May 2014, we had first cases of Ebola diagnosed in
East part of the country that is Kailahun which as borderwith
Liberia and Guinea. That was difficult time because at thattime, it was difficult to recognize the first cases because

INCIDENCE	  	
  • Among	
   health	
   care	
   workers	
   where	
   221	
   Nurses	
  Ebola virus disease which have share symptoms and signsand	
   11	
   Medical	
   Doctors	
   lost	
   their	
   lives	
   (CDC,	
  but similar to the most common causes like several illness2015)	  	
  like malaria, typhoid fever and other diarrhea like symptoms
which manifested by Cholera.
So it was very difficult because it was first time. So
recognizing it was a problem and accompanied without• The	
  outbreak	
  of	
  Ebola	  in	
  the	
  country	
  infected	
  8706	
  people	  of	
  which  3956  died,	
  (CDC	  2014	
  that against by poor or inadequate IPC standards at thattime because before Ebola, IPC was there but awarenessand adherence IPC measures in the Health facility was not
as it is now to be and also lack of confidence by the public
in seeking treatment in our facilities.
This was due to the first thing with that the public lackconfidence to go to the hospitals because that’s Ebola
thing is not actually disease from God. It was like a weapon
want by scientist just to wipe off all human race and also
because they noticed that people were providing care at
the hospitals; another health facilities were dying of Ebola.
So how come we go to these hospitals? Those aresupposed to provide care for us dying. We’re not going

Eventually by 2015, when they declared serious Ebola,
we had 8,760 confirmed cases, out of which 3,590 thatwas 41 percent of the total confirmed cases data and4,051 survived and among these figures, we have totalof 296 Ebola confirmed cases among healthcare workers
and among which 75 percent died including 11 medical
doctors. Imagine the continent that was so stuffed. In termsof medical personnel, we didn’t have enough doctors andnurses at that time. Losing this kind of number was big
problem for us.

there. And also because of cultural beliefs and practices.
That’s we’re discouraged during the time of trying tocombat like tell them not to touch dead bodies and as I was• It	
  was	
  crucial	
  to	
  understand	
  the	
  nature	
  of	
  the	  saying the culture, when you lose your relative, you pay

disease;	
  how	  it	
  is	
  transmiZed	
  and	
  how	  to	
  them the last respects, you touch them and you wash theprevent	
  it	
  from	  spreading	
  further.	
  	
  dead bodies and perform other ceremonies. Some cultures
don’t preserve that body like bury the body and family
come. So those cultures we’re discouraged because of thecontact and it was very, very serious if you touch a deadbody. So they refuse to believe a couple of other things. So
this factors actually let to the serious outbreak.

18

ACTION	  	
  • Above	
  all;	
  how	  to	
  protect	  the	
  health	
  workers	
  and	
  care	  givers.	
  	
  • Hence,	
  knowledge	
  on	
  Ebola	
  for	
  risk	  reducRon	
  was	
  the	
  focus.	
  IV.

Sharing Experience on Ebola Outbreak in Sierra Leone

like four rooms and several times, he has been advised

ACTION	  	
  to stop. That’s why that kind of practice. So when he got• InternaRonal	
  Non-­‐governmental	  OrganisaRons(INGOs)-­‐WHO,UNICEF-­‐
NGOs,MOHS,MDAs	
  (ministries	
  departments	
  and	
  agencies)in	
  a	
  collaboraRve	
  eﬀort	  came	  together	
  to	
  
ﬁght	
  against	
  these	  major	
  challenges.	
  • MulRple	
  assessments	
  were	  quickly	
  made	  by	
  partner	
  organisaRons	
  and	
  MOHS.	
  	
  • Centres	
  were	  established	
  for	  trainings	
  on	
  Ebola.	
  • 	
  The	  BriRsh,	
  Chinese	
  and	
  other	
  naRons	
  had	
  centres	
  to	
  train	
  and	
  capacitate	
  Health	
  workers,(both	
  local	
  and	  internaRonals),Local	
  authoriRes,	
  Youths	
  etc.	
  on	
  the	
  ﬁght	
  against	
  EVD.	
  • 	
  Massive	  	
  and	
  rapid	
  sensiRzaRon	
  about	  the	  disease	
  was	  enhanced	
  infected, it would be due to that but rest of other people
including those like Ola During, we have three care workers
and two nurses and one medical doctor who was second
pediatrician. It was second we just it just specialized andwent to help and he died. It was direct infection because it
was working in the wards trying to catheterized patients.
Because of the deficiency, IPC did not provide face shield,
and it got directly into his eyes, got infected and died.
Because of the high infection in the country at that time
and we have not enough treatment centers. A treatment

ACTION	  center we has where in the East. And whatever it is and• An	
  Interim	
  emergency	
  guidelines	
  Sierra	
  Leone	
  adapted	  • Rapid	
  training	
  of	
  the	  121	
  PHUs	  (peripheral	
  Health	
  Units)	
  and	  the	  district	
  terRary	
  hospital	  	
  staﬀs	  was	
  
done	
  on	
  the	
  following	
  topics:	  	
  • InfecRon	  Control	
  and	
  standard	
  Universal	
  PrecauRons.	
  • Ebola	
  case	  deﬁniRon.	
  • Protocols	
  on	
  how	  to	
  alert	  the	
  DHMT	
  about	
  a	
  suspected	
  Ebola	
  case.	
  • Protocols	
  for	
  isolaRon	
  of	
  suspected	
  Ebola	
  cases	
  wherever it is, the case is detected. Most of them died.

SITUATION  AT  WORKPLACE• At	
  Ola	
  During	
  Children’s	  Hospital	
  where	  I	
  work	  the	
  bed	
  capacity	
  was	
  reduced	
  from	  250	  to	
  180.	
  There	  was	  no	
  ETC	
  but	  there	
  was	  an	
  IsolaRon/
holding	
  unit	  constructed	
  	
  • Suspected	
  cases	
  Isolated	  • Conﬁrmed	
  cases	
  transferred	
  to	
  ETC	
  • From	  November	
  2014	
  to	
  December	
  2015	  there	  was	
  3667	
  suspected	
  cases	  of	
  which	  162	  were	
  conﬁrmed	
  posiRve	
  and	  transferred	
  to	
  
ETC	
  

ACTION• SensiRzaRon	
  of	
  the	
  public	
  on	
  the	
  signs	
  and	  symptoms	  of	
  Ebola	  • Hand	  washing	
  with	  0.5%	  chlorine	  or	
  soap	  and	
  water	  • Periodic	
  market	
  centres	
  were	  closed	  • Movement	  was	
  limited	
  between	
  the	
  main	
  outbreak	
  areas	
  and	  the	
  city	  • Check	
  points	
  mounted	
  along	  the	
  main	  highways	  • Temperature	
  monitoring	  • More	  isolaRon	
  centres	
  were	  created	  • Laboratory	
  faciliRes	
  were	  established	
  to	
  fast	  track	  tesRng	  of	
  Ebola	  specimen	
  obtained	
  from	  suspected	
  paRents	  SITUATION  AT  WORKPLACE• Among	
   the	   staﬀ	
   two	
   nurses	
   and	   one	   of	
   the	  vibrant	
   medical	
   oﬃcers	
   was	   directly	
   infected	
  and	
  died	  • Non	
   of	
   the	   staﬀ	
   working	
   at	
   the	   isolaRon/
holding	
  unit	  was	
  infected	
  So I’s just like to give you brief overview on Connaught
and Ola During hospital in relation to the effect of Ebola
since this among health.
In Connaught hospital where I’ve worked, it seemedcare workers including three doctors, nine nurses, twohygienists, one ambulance driver and a revenue collector
with two securities were infected, most of them diedbut there is only one evidence among all these numberthat actually a lot affected working in the isolation units
but one of the hygienists, one of the nurses was actuallyinfected this morning and he died and also other one of thehygienists, actually it was not evidenced, it is believed thatit could have be infected in the isolation room because he
was in the habit of collecting budget for patients charging

Patient who are coming to the hospital, you need toisolate. At that time, there was no idea about isolation in thehospitals but you tend to have cases coming as suspectedcases instead of sending them back to the community, we
have to keep them in the facilities that waiting for the result
to send health center or treatment center.
So the idea of setting up an isolation facility in all
healthcare facilities started. In Connaught hospital, westarted on 16 bed facility isolated and the end of the July
2014 to March 2015, we had total number of 1,125 cases
isolated and 51 percent were positive. All of them were

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

19

sent to treatment centers. And in the Ola During Children's
Hospital, we had 23 bed facilities, isolated patient and we
had 3,667 cases which are sent to the treatment center.
November 2014 to December 2015. So this kind of numbers
you’re seeing here. Like we said, that’s kind of facilities andisolated patients. These patients infected more and more
people in our communities. So idea of isolation was very
important and up to now, all the major healthcare facilities
including a facility we are still maintaining isolation,
facilities as we had to do during Ebola outbreak.

IMPACT  OF  EBOLA  VIRUS  DISEASE  IN  SIERRA  LEONE  
• From	  the	  incepRon	
  of	
  the	
  Ebola	  in	
  May,2014	
  o	
  
the	
  Rme	  it	
  ended	  in	
  November	
  7th	  2015,	
  Sierra	
  Leone	  is	
  perversely	
  aﬀecRng	
  in	
  the	  	
  following	
  sectors:	
  • Health	
  sector	  • EducaRonal	
  sector	  • Agricultural	
  sector	  • Commercial	
  sector	  • Social	
  sector	
  ADVERSE	  EFFECT	
  OF	
  EBOLA	
  VIRUS	  DISEASE	  	
  PROTECTION  AND  SAFETY  MANAGEMENT  OF  HEALTH  WORKES  AT  ETU  CENTERS	  • Intensive	  trainings	
  of	
  	
  staﬀs	
  on	
  IPC	  • Refreshers	
  training	  • Special	
  treatment	
  centers	
  for	
  health	
  workers	
  (Kerry	  town)	
  • Expatriate	
  working	
  along	
  side	  naRonals	
  on	
  the	
  
use	
  of	
  PPEs	  regarding	
  donning	
  and	
  doﬃng	  	
  • Adherence	
  to	
  protocols	  • Daily	
  monitoring	
  of	
  health	
  workers	
  health	
  status-­‐	
  (temperature	
  checks)	
  • CollaboraRve	
  work	  among	
  staﬀ	
  PROTECTION  AND  SAFETY  MANAGEMENT  OF  HEALTH  WORKES  AT  ETU  CENTERS• MoRvaRon	
  of	
  staﬀs	  in	
  the	
  form	  of	
  risk	  allowances,	
  three	  meals	
  provided	
  a	
  day.	
  So all these things, it actually hits all country because
more people are dying. But because of the outbreak, it
became eye-opener for us and they highlighted problems
within the health sector which including lack of IPC
infrastructure, evidence by inadequate or inappropriate
personal protection equipment at healthcare facilities
which we want to say thank you to JICA because we didn’t
have time for outbreak. We didn’t have anything in stock interms of personal protection but other developing counties
or developing donors, they came into aid like JICA, we sent

So as a result of all this the things I was talking about, it
actually exacerbated already inadequate human resources
for health in our county and this reduction in service
delivery to the community and it reduce the confidenceof the community in seeking help and help facilities
and subsequently there was reduction of utilization ofhealthcare facilities because of the doubts and all thethings up against health sectors if we fall into the traditional
herbalist to provide care for them, although some died.

a host of PPE country. So we want to say thank you for that.
And hand hygiene stations that’s idea, it was not the part ofculture or practice because before the time of Ebola, people
even died, Phlebotomists, we take large samples without
putting any globes and areas where you’re supposed toprotect yourself, we don’t take that as serious issue. Hand
washing was not part of this. Washing our hand was reallywanted and system for waste management was very poorat that time. We’ve just kept everything anywhere. You
see the virus and the needles left on the infusion. Palms
exposed actually accidentally like just injured any healthworker. So that idea was not there and concept of screening
and triage was in lack before Ebola. Lack of IPC knowledge
among healthcare workers and no IPC policy before. So thatwas like an eye-opener for us.

20

IV.

Sharing Experience on Ebola Outbreak in Sierra Leone

Key points for the National IPC Policy for healthcare

LESSONS  LEARNT

workers: it’s emphasized hand washing, waste• Ebola	
  exposed	
  our	
  weak	  health	
  system	  • There	  is	
  need	  for	
  every	  health	
  facility	
  to	
  have	  a	
  triage	
  which	  has	  not	  been	  in	
  place	  before	  the	
  outbreak	
  • InfecRon	  PrevenRon	
  and	
  Control	
  knowledge	
  that	
  was	
  lacking	
  was	
  improved	
  • The	
  need	  to	
  strengthen	
  the	
  Water,	
  SanitaRon	
  and	
  Hygiene	
  systems	
  in	
  health	
  faciliRes	
  was	
  revealed	  management, sharps injury and incident reporting sharps
injury management and incident reporting, cleaning of theenvironment because protection starts from that point andhow to cleaning up spills.
During the time of Ebola, I’d like to share with you howhealth workers were working in Ebola. Training healthcare
workers on IPC, there is ongoing support and IPC mentors
for us. We have like key partnership we’ll be doing fromtime to time. Screening staffs during staffs are working
anytime you’re going to the hospital, temperature is taken.
That is done in all health facilities and monitoring of health

LESSONS  LEARNT

status healthcare workers if you don’t come work or not• I	  learnt	
  the	
  lesson	  of	
  how	
  importance	
  is	
  

somebody will call and “what is wrong with you?” Maybe

community	
  mobilizaRon	
  in	
  combaRng	
  an	
  

you’re monitoring when you’re awake and working inoutbreak	
  short shifts because we appreciate system because of theexhaustion. WASH system were introduced so that we don’t
overloaded health worker. Also we had the buddy system
in which people working in twos. The one is watchingback. Maybe get dizzy so that you don’t expose yourself
and enhancing environmental safety by cleaning. Closure

As a result of that, Ministry of Health and Sanitation
actually developed the PIC hospital program. So wedeveloped national IPC program which was initiated by the
Ministry of Health and Sanitation and another development
partners in March 2015 and the key objective hospital
program was to establish a national IPC system in the
country so that be in charge of any other outbreak to takecare of that.
And key achievements so far because of the hospital
program are set up by the Ministry of Health, we set up a
structure which IPC committee headed by coordinator and
IPC training program for all health staffs and essential items
needed for personal protection I believe whenever wewanted. Assessing and monitoring IPC practice within thehospital: mostly this is done by the link nurses in the wards
so that we can tie up to IPC practice and improving WASH
infrastructure and facilities in hospitals. As a result of all thisthing, ended up we had opportunity of having IPC policy in
the Ministry. I brought here copies of them. The importanceof IPC at the national level, want to creates culture of safety
in healthcare facilities, protects patients and healthcare
workers from healthcare associated infections. It would
serve us lessons, document for IPC best practices andalso promotes culture of continuous improvement in all
healthcare facilities. It is intended for all healthcare workers.

of facilities which are not actually meeting IPC standards,
mostly that’s affected private hospitals and setting up of
IPC committees to monitor IPC activities. Screening patientsand visitors and isolating suspected cases. So far thelessons learned we’ll never wish miss again and prepare tohandle any outbreak similar to Ebola because we know the
deficiency that we had actually affected was not being able
to curtail outbreak and because of all the experiences, welearned this lesson that we should always prepare to handle
whatever it is. That is going to attack Sierra Leone. Thankyou.
Ms. Maureen:

Probably it’s not a question but it’s

a comment. Good afternoon, everyone. I’m Maureen.
From Zambia, also came from African country where also
experienced epidemics. I used to hear it on radio during
the outbreak. But I heard from Sierra Leone firsthandinformation is so touching and there’re such a number ofhealth workers in the continent and I think we just want to
say thank you for support and received from developing
country. I think it’s so touching. I almost shed tears. Thankyou.
Dr. Sakurada:

Any other question or comment, only

urgent? If not, thank you very much, Dr. Kamara. Next
speaker is Dr. Musa from Liberia.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

21

V. Ebola Outbreak Response in Liberia
			Musa Zuanahz			Medical Director, Curative Services, Tellewoyan Hospital, Ministry of Health			Jean Kokoi Kaly
			Medical Director, PSHC-AI&P, Matha Tubman Memorial Hospital, Ministry of HealthDr. Musa:

Good afternoon. My name is Dr. Musa Zuanahflies in many part of Africa. This is the fruit bat. It is majorfrom Liberia and I’m here with Dr. Jean Kaly, medical

host of Ebola virus. It goes to fruit like mango and otherdoctor from Liberia as well. I will be presenting on behalf ofthings, eat the mango probably dropped from the tree

Liberia as directed by Dr. Kaly who originally planned thison to the ground and get taken by animals and eaten by

presentation today. Before get started, I want you to see

animals and animals come across what aim on. That’s how

that’s what called Ebola virus. I mean many of you’ve seen

we can get it physically from those animals. That’s partly

that already but just give you a snapshot that you can see

what we show you.

there. This is a virus but as you can’t see, it’s a fruit bat like

Situation of Ebola outbreak in Liberia. It was very
difficult road coming from high amount of infection to
Ebola to zero. The problem of Ebola virus came from

Situa(on	  of	
  Ebola	
  outbreak	  in	
  Liberia	  Overview	
  of	
  the	
  Response	  in	
  Liberia	  Overview	
  of	
  Pillar	
  Ac(vi(es	
  	
  
The	
  response	
  Workforce	  	
  Guinea total of count in Liberia as my colleague rightly said
that it came from Guinea. Guinea, Liberia are always shareborder and I like what Dr. Sakurada said it is socio-cultural
kind of disease because basically these three countries
share common tribes and common tradition, beliefs andcultural values because of that. So what happened in Sierra
Leone is brought to Guinea and Liberia. What happened in
Guinea will go to Liberia and Sierra Leone. What happed in
Liberia will go to Sierra Leone because we have constant
movement from those three countries.

•

	
  
•

	
  
•

	
  
•
	
  

22

THE  LONG  ROAD  TO  ZERO  No  NEW  CONFIRMED  CASES  IN  LIBERIA………	
  The	
  Ebola	
  Virus	
  Disease	
  was	
  ﬁrst	  conﬁrmed	
  in	
  Liberia	
  in  March  2014.    
The  ﬁrst  case	
  was	
  iden(ﬁed	
  in	
  Foya  –  Lofa  County  –border	
  with	  Guinea.	
  The	
  EVD	
  epidemic	
  started	
  with  imported  case  from	
  Guinea	
  in	
  March	  2014	
  and	  in	
  May	  2014	
  from	  Sierra	
  Leone.	
  Liberia	  remains	
  the	
  worst  aﬀected  country	  in	
  terms	
  of	
  the	
  highest	
  number	  of	
  EVD	
  reported	
  cases	
  and	
  deaths	
  out	  of	
  the	
  current	
  	
  6	
  aﬀected	
  countries	
  in	
  
West	
  Africa.	
  Liberia	  completed	  42  days  with	
  no	
  new	
  conﬁrmed	
  case	  and	  was	
  declared	
  “EVD  Free  “  on  May  9,  2015  .	
  
3	
  

V.

Ebola Outbreak Response in Liveria

First case of Ebola started in Liberia in March whichpoor structure we have,, plus one was shown to the world,came from Guinea. It went to Lofa County in Foya to beshown to us that our healthcare system was poor, was notvery precise. It started with important case from Sierraorganized, it will prepare whatever we saw in front of us,

Leone and Guinea as I say area. However, among thenothing. That’s why we’re exposed from very beginning.

three countries are affected, Liberia was most affected

Liberia completed 42 days with...

among them all. I think my colleague mentioned so manyof them why Liberia, Sierra Leone, Guinea got affected.
The reason why we have the worst case because of all the•Dr. Kaly:

No new confirmed case.

The	
   journey	
   to	
   zero	
   was	   diﬃcult	
   and	   took	
  many  lives  • The	
  total	  cumula(ve	
  cases	   	
  and	
  deaths	
  as	
  of	
  
the	
   week	
   of	
   May   9,   2015   :      conﬁrmed   EVD  cases:  3,150  • Deaths  :  4,785  • 378   healthcare   workers   were	   infected	
   with	  EVD,	
  and	
  192  deaths• All	
   coun(es	
   in	
   Liberia	
   reported	
   EVD	
   cases	
   at	
  diﬀerent	
  (mes	
  within	
  the	
  outbreak	
  period	
  	
  
	
  
• We	
  adjusted	
  and	
  adopted	
  various	
  strategies	
  across	  the	  thema(c	  areas	
  to	
  get	  to	
  Zero	  	  • The   IMS   and	
   the	   	
   Presidendal   advisory  commieee  on  Ebola  (PACE)    had	
   to	
   make	
   to	  hard	
  call	  painful	
  decisions	
  to	
  save	  the	
  state	  	
  • From	   resistance   to	   Community   partnership  for  response	
  Dr. Musa:

Yes. From Liberia, the total cumulative casesand deaths as of the week of May 9, 2015, we had 3,150

4	
  Dr. Musa: We say Incident Management System to get the

Presidential advisory committee on Ebola and reason for

confirmed cases confirm Ebola positive. Deaths in Liberia

that because case were actually far gone beyond Ministry

are 4,785 deaths. This confirm was 3,150 those were notof Health alone. Our Ministry of Health could not handle

confirmed to die but there was just tested them all because

outbreak. They waited for Presidential advisory committee

it was all of the countries we have that number. Everyon Ebola, then it’s the management.

counties in Liberia, 378 healthcare workers were infectedwith EVD, and we lost about 192 deaths. 192 healthcare

As I told you, this is Liberia. That’s Republic of Guinea

workers died as a result of this EVD in Liberia. All counties

and that’s Sierra Leone. So you see from here, it’s closein Liberia reported cases of Ebola in Liberia. As a result of

to Liberia. From here, it’s close from here to Sierra Leone.

outbreak, we have what we call the IMS which was the,These three countries share common border as you can see

what was it?

there. We see why our three countries got infected. That

Dr. Kaly:

was a reason why because of that.
Incident Management System.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

23

During the infection in Liberia, there was a very big

away and health workers refused to go to hospital because

peak beginning of August, there was beginning of June,

there was no way to control disease how to do it, what toJuly in Liberia. So many people died up to this time. We

do and I’d like to say in our counties,citizens are very poor,

want to say thanks to international community because

sometimes low material. I remember I’m not coming acrossthe incident of Ebola started only it had started in Liberia,

what it’s called this complete PPE. I did not it was existed

we’re very confused. We have not come across before. Weor didn’t know how to use them before. So we didn’t know

didn’t know it. We didn’t know how to respond it. Many ofthe magnitude of the virus infection was coming our way.

health-cares just pulled down and many health workers ran

Dead	
  body	  management	  	
  BURIAL	  TEAMS:	
  Montserrado  (19)  –supported	
  by	
  	
  IFRC/Global	
  Communi(es.	
  Within	  the	
  OTHER    COUNTIES  there	
  was	  a	
  total	
  of	
  45  teams.  

SAFE  BURIAL  to    SAFE  AND  DIGNIFIED  BURIAL
NONE  OF  THE  TEAM  MEMBERS  GOT  INFECTED  !!!!!
6	
  

24

What did we do when it has started? Before it started,to our country, people were dying. What we’re going to

we had people are dying everywhere every corner. So first,

do? People died yesterday, today, tomorrow but we don’tManagement System are very active. Before you comeknow what to do. So we had multi system of attack, weV.

Ebola Outbreak Response in Liveria

call Burial Teams now. Burial Teams were set up but werelatives get ill, don’t touch them.” This is not. “Don’t touch

say there was a problem: beliefes, attitude, religion. For

them? Why? It’s not possible. We can’t do it.” So we see

example, most of people talked about it African setting.

first resistance. They said “No, we can’t believe because we

Like Dr. Sakurada said early on, so many patients on thehave been doing for ages of memorial. What and why thisbed. That’t a typical African setting. If someone gets ill, alldisease can catch someone?” “Listen, don’t touch them.”of the African relatives visit the person and when they’re“Oh, it’s not possible.” We found the team in Liberia to go

visiting, sit on the bed. Now, it was a long-term practiceand visit a community to talk them about Ebola. They stole

for African. When someone is ill, you look after the person.

our car, damaged it and threatened because they felt what I

When the person die, you wash the person, and give themwas saying to them was not true. They didn’t believe us. So

proper burial. There is ton of memorials. Then all of the

we sent all burial team. They took care of this situation.

sudden, you come to here and “Listen, someone like your

COMMAND  AND  CONTROL  STRUCTURE• The	
  GOL/MOH	
  showed	
  the	
  leadership	
  and	  poli(cal	
  commitment	
  required	  in	
  the	  EVD	
  response	  • 	
  IMS	
  set	  the	
  pace	  for	
  cridcal  decision  making  and	
  strategic  planning-­‐	
  led	  the	  	
  coordinadon	
  of	
  the	  response	
  along	
  with	  its	  partners• Themadc  chairs  and	
  teams	  	
  led	  the	
  pracdcal  implementadon  +coordinadon	
  por(on	
  of	
  
the	
  	
  response	  • PACE	  managed	
  the	
  strategic	
  and	  poli(cal	
  bit	  	
  • A	
  new  EOC  constructed  to	  for	
  enhanced	
  coordina(on	
  post	  –EVD	  7	
  Then what happened next? It was command andfor proper decision-making whereas the Presidential

control structure where the Liberia government from theadvisory committee took care of this strategic and politicalpresidency had the structure that was there to respondaspects where you have to mobilize calling for assistanceeffectively to this situation. So that’s how structureand etcetera to the situation. You can see there wascame about. Incident Management Center was set up

coordination command center that we organize in Liberia.

What did we do to get out this situation to continue
and get information? Now the organization have had

OVERVIEW  OF  PILLAR  ACTIVITIES

experience from this Ebola situation. Our partners wereafraid to join us and then JICA were also here and sent usmaterial. We didn’t know how to use the materials. It’s for

WORKING	
  	
  
IN	
  
PARTNERSHIP	  nothing and we didn’t know how to use them “check the
body, check the body” and take it away but partner let tous. It was life-saving situation. You don’t have to run away,
we can fight it together. we fought together and it was very8	
  good experience for us in Liberia.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

25

community? He said, no, it was not there. We’re talking and

Epi/Surveillance	
  
•
	
  
•
•
	
  
	
  
•

	
  
•
	
  
•

talking but no, we don’t have any of them like that. TwoThe	
  Team	  provided	
  the	
  evidence  for  decision  making  .

hours after we saw dead body coming to outside from theirWe	
  had	
  maps,	  graphs	
  ,tables	
  and	
  tree	  of	
  chains	
  of	
  transmission	
  house. They’re hiding people because they said that “whenpeople died we’re going to bury them. Some believe that ifThe	
  Sit-­‐Rep	
  is	
  being	
  produced	
  on	
  a	
  
daily	  	
  basis	  	
  the doctor gives disease to their people.” So they’re against

Liberia	
  went	  from	  about  60  conﬁrmed  cases  per	
  day	  to	
  zero	  cases	  of	
  Ebola	
  with	  complex	  chains	
  of	
  infec(on	  at	  the	
  ﬁnishing	
  line	  them. So what we did intervention with contact tracing.
Whenever someone had ill, we will do contact tracing. If

Montserrado	  County	
  (Monrovia)	
  accounted	
  for	  the	  majority	
  of	
  cases	  The	
  outbreak	
  was	
  geographically	
  widespread,	
  with	  cases	  being	  transported	
  out	  of	
  Monrovia	
  to	
  the	  other	
  coun(es	
  someone came to a hospital, we’ll test them and we’ll send
to isolation and we’ll send to them to do contact tracing9	  and check if everybody have Ebola and fear that one day,

Surveillance: we’re from Liberia team. In Liberia team,what we did? Most of the people was not allowed to bury
their body. We said “No, because they wash their bodythen pray before they bury it. So they didn’t allow Muslim

all people can be contact that particular patient. We’ll bemonitoring over a period of 21 days until we’re clear andshowed there was no more infection and we kept them for
21 days.

to bury it, they didn’t allow person to bury it and someperson allowed to bury the body. So what did we do? We
contacted the mosque. “Okay, we want you to give us
maybe four or five people, we’ll treat them to become aburial team.” And most of them died. They were buried
person. Same thing we did with the churches as well. We
have a burial team, doctor burial team where we had burial
team everywhere to respond the situation. This was theProtec(on	
  and	  safety	  management	
  of	
  healthcare	
  workers	
  trea(ng	
  Ebola	
  pa(ents	
  How	
  can	  we	
  protect	
  ourselves	
  from	  Ebola	  disease	
  infec(ons	
  structure of command. I mean she is not Liberian, she is oneof the NGOs or structure of command.

  Priorides  in  Acdve  Surveillance  Phase  
	
  
•

•

	
  
•

Ensuring	  that	  contact	
  tracers	
  can	  be	
  mobilized	
  again	
  on	
  short	
  no(ce	
  should	  another	
  case	  or	
  outbreak	
  arise	
  1.

Working	
  with	  Sierra	
  Leone	  and	  Guinea	  at	
  every	
  level	  	
  to	
  stop	  contacts	
  from	  ﬂeeing	
  these	
  countries	
  and	
  entering	
  Liberia	
  Contact	
  tracers	
  have	  been	  transi(oned	  to	
  ac(ve	
  case	  ﬁnders	
  	  –	  there	  are	
  currently	
  more	  than	  10,000	
  in	
  the	
  country	
  
10	
  

26

Iden(fy	  and	
  isolate	
  suspected	
  cases	  of	
  Ebola	  2. Protect	  yourself	
  and	
  your	  pa(ents:	  Perform	  hand	  hygiene	  Wear	
  personal	
  protec(ve	
  equipment	
  Stay	
  more	  then	
  3	
  feet	  from	  pa(ents	
  Keep	
  pa(ents	
  more	  then	
  3	
  feet	  from	  each	  other	  Do	
  not	
  touch	  pa(ents	
  unless	
  essen(al	  Do	
  not	
  touch	  other	  healthcare	
  workers	
  Do	
  not	  do	
  procedures	
  unless	
  necessary	  and	
  prac(ce	
  them	  safely	  Prac(ce	
  proper	
  environmental	
  cleaning,	
  disinfec(on,	
  and	
  waste	  management	  It’s a map before Liberia .What did we do as a priority

Last thing we did was we’re the one that are taking

during the outbreak of Ebola? We formed burial team. We

care of people. People have sick and come to hospital.

formed surveillance team. We formed these social group.

How do we protect ourselves? We didn’t know how to do

All of these teams were put aside to go and access in theirit. We have sent burial team. We have sent contact tracer

communities taking care of this situation. This is burial team

but people were coming. Fever was is part of Ebola. People

doctor not contact tracers. We have active contact tracing,have malaria symptom as well. So how do we know that

we have passive contact tracing. What they did was going

this is maybe could be malaria symptom or something else

their communities to go and fish out people who are ill

different? Ebola can be bleeding from nose. Some people

because I remember myself was part of the team, one time

had a pressure and bleeding from nose. How can we dowent to look for someone who was ill and said, was there ait? But before we can do that, we decided to train our own

V.

Ebola Outbreak Response in Liveria

people how to protect themselves. Many people cameto help us for massive training of every hospital after thepresent time. Now we want to enter entire system for Ebola
infectious disease situation. Now we’ve all prepared for thatand thank goodness.

The	
  ‘heart’	
  of	
  the	  response-­‐	  THE	
  WORKFORCE	
  	
  
•
•

	
  
•
	
  
•

	
  
•

CATEGORY  OF  TEAMS
1. Ebola  Treatment  Units• Health	
  Workers	
  and	  Support	
  staﬀs	  2.	
  Roudne  Health  Workers  and	
  support	
  staﬀs	  We	
  ra(onalized	
  the	
  current	
  workforce	
  to	
  get	  the	  response	
  into	
   3  .  Response  Teams• Case	  Inves(ga(on	
  
gear	
  –	
  health	
  care	  workers	
  were	  divided	  between	
  –EVD	  Response	  • Ambulance	  and	
  Rou(ne	  Health	
  care	  services	  	
  • Disinfec(on	  • Burial	
  	
  	
  
• Laboratory	
  	
  
More	
  workers	
  were	  recruited	  ,	
  trained	
  ,deployed	
  and	
  paid	  during	
   • Contact	
  tracing	
  	
  
the	
  response	  • EPI/Surveillance	  • Psychosocial	  	
  • Health	
  Promo(on	
  /Social	
  Mob	  Managing	
  the	
  workforce	
  was	  a	
  challenge	
  we	
  struggle	
  with	  through	
   • Dispatch	  the	
  response	
  especially	  	
  payment	  • Port	  Health	  	
  issues	  	
  • Coordina(on	
  (County	
  level)	
  • Gate	  Screening	  We	
  have	  learnt	
  well	  the	
  need	  for	  • Community	
  care	  center	  	
  proper	
  HR	
  Planning	
  and	  monitoring	
   4.	  Other  support  staﬀs  –	  EOC	
  ,coordina(on	
  and	
  
13	
  
for	
  future	
  response	  	
  response	
  support	
  teamsThe	
  response	
  started	
  with	  a	
  prior	
  month	  HEALTH	
  WORKERS	
  STRIKE	  	
  Strategies	
  for	
  Maintaining	
  Zero	  •INFECTION  PREVENTION  AND  CONTROL– Monitor,	  regulate,	
  and	
  enforce	
  IPC	
  standards	
  in	
  all	
  public	
  and	
  private	
  facili(es	  	  – Con(nue	
  training	
  staﬀ	
  in	
  schools	
  and	
  maintaining	
  supply	
  chains	
  for	
  hand	  washing	
  equipment,	
  thermometers,	
  and	
  other	
  screening	
  and	  preven(on	
  tools	
  
	
  

•

– Ensure	
  (mely	
  referral	
  of	
  all	
  febrile	
  cases	
  for	
  tes(ng	
  and	
  treatment	  DEEPENED  COMMUNITY  ENGAGEMENT

	
  
	
  

– Con(nue	
  community	
  involvement	
  eﬀorts	  (near	
  and	
  across	
  borders	
  )	
  to	
  sustain	  gains	
  and	  minimize	
  resistance	  – Prevent	  new	
  cases	
  and	
  support	
  health-­‐seeking	
  behaviors	  – Use	
  current	
  social	
  mobiliza(on	
  strategies	
  to	
  encourage	
  ongoing	
  vigilance	
  

14	
  

How we’ve been training primary priority begin started
when you suspect of Ebola, one symptom, fever or one
or two symptom, we have to isolate you. Every suspected
case, you have to isolate person in suspected cases andany ill person you need to be protected. We need to isolate
and protect ourselves.
Thank you so much. Thank you, JICA, for presenting thisopportunity. I appreciate that.

confirmed cases, we did that. We also emphasized all self-

Anyway, finally, I want to say to you thank you all for

protection because we, healthcare workers cannot abandon

editing them. I want to say thanks for the support and as far

the hospitals to run away. So what we did was that we

as Liberian are concerned, this is what we stand up againstemphasized to every healthcare workers before you can see

depressing time. Thank you so much.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

27

VI. Response for Viral Hemorrhagicin Fever		in NCGM
			Nozomi Takeshita			
National Center for Global Health and Medicine,			Disease Control Center

Dr. Takeshita:

Good afternoon. My name is Nozomi

Takeshita. I work for this hospital and my department is
Disease Control and Prevention Center. My specialty is
Clinical Infectious diseases . We have infectious disease	  	
  Quaran'ne	
  sta'on	

special units in Japan. If suspected cases of Ebola or MERS
or some specific disease are mostly translated this hospital.
It is one of main task of our department. My department has

国際感染症センター	

main task of job. So today, I’ll explain responsible for viralhemorrhagic fever in NCGM Japan. NCGM is my hospital’s
name.

So we have already collaborate with NIID, Japanese

Problem  for  VHF  in  Japan�

government and WHO and quarantine and Tokyo            Target  diseases  of  the  Infectious  Disease  low  in  Japan�

Metropolitan Government. So we have already share theü       It  is  high  impact  in  public  health,  not  only  personal  health��ü�ow  incidence,  poor  specific  findings  �üPoor  e�perience  for  health  pro�iders  in  Japan�

information and some trainings or some methods.

Classification of Infectious Disease Law in Japan2	

We have some problems for viral hemorrhagic feverin Japan. Japan is not endemic country for these diseases.
So most of cases is transported from other countries. So
one of problems is poor experience for health providers in

Category 1(7)

Category 2(7)

Category 3
(5)

Viral
Hemorrhagic
Fever

Tuberculosis
MERS
SARS
Avian flu
(H5N1/H7N9)
Polio
Diphtheria

choleraTyphoid fever

EVD
Lassa Fever
CCHF
Marburg
diseaseSouth American
Hemorrhagic
FeversCategory 4(44)

DengueZika
Chikungunya
Dysentery
Yellow Fever
EHEC infection Hepatitis A
Legionellosis
SFTS
Rabiesetc…
Paratyphoid fever

PlagueSmallpox

Japan and these diseases are no specific symptoms. If wedefined suspected case of viral hemorrhagic fever, specificlaboratory is necessary to identify. So most EVD suspectedcases are transported to infectious disease institute:
National Infectious Disease Institute in Japan (NIID).

This is Classification of Infectious Disease Law in Japan.
We categorized and separated into four. Category 1 is themost severe disease. Ebola hemorrhagic fever is included
here and Lassa fever, Crimean-Congo hemorrhagic feverand Marburg are in same category and Smallpox and
Plague are same. Category 2 is MERS, SARS and Tuberculosisand Avian Flu. Category 3 is public health high-impact
foodborne disease: Cholera, Typhoid Fever, Dysentery and
EHEC, O157 are included here. Category 4 is these disease.
Dengue, Malaria, Zika, Yellow Fever, Chikungunya and moreother tropical disease are included in here.

28

VI.

Medical institutions designated for type I infectious
diseases

Classification of Medical Centerin Infectious Disease Law in JapanNew	  Infec'ous	
  Diseases	  ４Category I
Infectious
DiseasesCategory II
Infectious
Diseases

Response for Viral Hemorrhagic Fever in NCGM

Others49 Hospitals locatedalmost every prefectures

Medical institutions designated for speciﬁc infectious
diseasesinstitutions
49 Medical
designated for category I infectious diseases
Medical institutions

for category II
340designatedinfectious diseases

not designated

In Japan, infectious disease specific hospital is threeCategory 1 infectious disease is 49. This is each district

groups. Hospital in the category for New Infectious Disease

but not all. Please check here. This is Miyazaki Prefecture.

have specific Infectious Disease Ward like this hospital.

I was born here but his district doesn’t have category 1

These hospitals are four hospital in Japan. Next one is

infectious disease hospital. Most of district has category 1

category 1 infectious diseases. Category 1 diseases is 49,

infectious disease hospital.

category 2 is 340. We have the hospital but trained notenough.

August 2014
Networking & Sharing

Medical institutions designated for specific infectious diseases

Hospital
Staff	

FETP-Alumni
4 Hospitals locatednear international airports

Rinku Medical Center(Kansai Airport: KIX)DCC

ICN ofDesignatedHospital

Narita Red Cross Hospital(Narita Airport: NRT)Media

Politician
Public HealthCenterNCGM(Haneda Airport: HND)
Tokoname City Hospital(Centrair Airport: NGO)

This Ebola virus hemorrhagic fever, al timing of
disease outbreak, at first, we made network and sharing,This is medical institutions designated for specificinfectious diseases. This specific means sometimes for
new infectious diseases. Avian Flu is one of examples.
first,

At

we don’t include Avian Flu in infectious disease law

because it’s a new disease. Because we needed time tocommunication with these groups: politician, Public HealthCenter and FETP which is a surveillance team in Japanand the hospital staffs and media and ICN of DesignatedHospital that means category 1 specific infectious disease
hospital near Tokyo and some famous hospital.

revise this law, we categorized in specific infectious diseases
at first. Now it’s a revised infectious diseases law again thatavian flu moved to category 2. These hospitals near to theinternational airports. Narita Airport is near to Narita Red
Cross Hospital which has one of the specific infectious
diseases hospital. NCGM is near to Haneda and other two isnear to Osaka and Nagoya. This is a big international airport.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

29

September 1st, we had Media Seminar. Because at that

September 2014

time, one staff went to Liberia from WHO from our hospitalMedia Seminarafter he came back Japan and presented the situation ofthat time. Japanese government made case management
protocol at the time.

Case management protocol for people with a travel history to EVD endemic countries

Euro Surveill. 2015;20(44).

So we can define suspected case by travel history frompeople were checked the travel history of endemic area andendemic area and fever. These two points are main focus. If

had fever. They transferred to this hospital or some other

patients fit for these points, patients were moved to these

specific hospital in Japan.

specific hospital. For example, in an airport quarantine,4	
  suspected	
  EVD	
  cases	
  at	
  NCGM	  30

Cases	
  

date	
  

countries	
  ebola	  PCR	
  dura'on	  of	
  isola'on	
  ﬁnal	
  diagnosis	
  

40s M

2014/10/27	
  unknown	
  -­‐ve	  3	  days	  unknown	  60s M

2014/11/7	
  Liberia	  -­‐ve	  2	  days	  Streptococcal	
  pharyngi's	
  

30s M

2014/12/29	
  Sierra	  Leone	  -­‐ve	  2	  days	  sinusi's	
  

70s F

2015/1/18	
  Sierra	  Leone	  -­‐ve	  3	  days	  inﬂuenza	  A	
  This is a case management protocol. We have foursuspected cases, not true cases. So these four cases are in
October, November, December and January, final diagnosisof all suspected cases were not EVD. One is pharyngitis andanother is sinusitis. This case is first case in Japan. So many
media were hysterical and surrounded around this hospital.
Many media: newspaper or TV camera had surrounded
here.

VI.

12 34

Response for Viral Hemorrhagic Fever in NCGM

Fear, Anger, Blame

Pa#ent  ,  Staﬀ  (other  department)

Ci#zen,  Media	

MMWR Morb Mortal Wkly Rep. 2015 Sep 11;64(35):981-4.

9	
  suspected	
  EVD	
  cases	  in	
  Japan	  These pictures are first case of EVD transmitted toour hospital. One of the big issue was actually media
communication because we’re panic. Many media cameto this hospital. And all these people were concerned andcame over to monitor the movement in the hospital. So
we’re surrounded by these so many media. That was one of
the big serious issues for us. Dr. Takeshita:

Because at thattime, Ebola patients were found out and identified in othercountries. That is reason which public attention was so highNo EVD cases in Japan during this period	

Euro Surveill. 2015;20(44).13	
  Total of nine suspected cases of EVD in Japan. Five cases
are transferred to other hospitals. One of final diagnosis
is case of Malaria. After moved to the specific hospital wechecked malaria at first. Nine of four suspected EVD cases
are in this hospital.

even in Japan around here.
Suspected patient’s personal information were releasedby media or social media though we didn’t know yet. Those
private information have already not leaked from us but
gained by public broad media in those days. Currently wehave 800 beds here and also we have many outpatients perday. Number of ambulance of this hospital are also highest
in Tokyo. So, we need explain many information not only
for patients but also for staff of this hospital.

Face shield

goggleFor the people near here, their concerns had risen so

N95 mask

much. That is one of reason which we had certain timing
to explain the exact situation for to the outpatients anddouble gown

inpatients in this hospital to let them calm down. We
have received some Ebola suspected patients in here anddouble grove

we received and accepted them. However, we have still

PPE in our instituteenough capacity to take care of other serious patients ofother diseases. We wanted to send this message to thepeople.

shoes coverbootThis is our institute’s PPE: face shield, glasses, N95 mask,
double gown, double groves, shoes covers and boots. In
this time, we have only mild cases. So we use only this one.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

31

This is one of the examples. This is some example
for suspected patient to be brought into certain isolated

Management	
  process	
Change	  	
  Guidelines	
  
and	
  	
  
Manual	route from the entrance brought by an ambulance. We
established this guide and the map for easier understanding

Educa'on	
  because not always the same person handle this one. So
anybody can handle the order for that easily, we established

Assessment	that guideline or map.

Training	  We prepared protocol for severe EVD disease patient.
For example, communicating with intensive care unit

Prac'ce	16	

We basically followed this management process flow.
Actually new facilities to accommodate infectious diseaseor epidemic diseases patients, it was established at the timeof the SARS. Then at the time, we established at certain
guidelines to take for SARS, Avian Flu and we revised it aswell. After the SARS outbreak we established guidelines, we
proceeded this procedure. So we regularly have education
not only to this hospital but also to other hospitals how tohandle such diseases in Japan. We’ve continued to educate
and train.
Now, we faced to Ebola suspected cases. Thenafterword, we have meeting to access the results. For the
next outbreak, we will repeatedly followed this guidelines.

specialist or how to use Favipiravir or how to use globulin.
But this time, we have only experienced suspected case or
mild case.

Main	
  Working	
  for	  EVD	  		  ü	  communica'on	
  
	
  	
  	
  	
  	
  	
  	
  pa'ent,	
  staﬀ,	
  ci'zen	  ü	  transporta'on	
  	
  
	
  	
  	
  	
  	
  	
  	
  pa'ent,	
  samples	
  üHand	  hygiene	
  &	
  PPE	
  	
  
	
  	
  	
  	
  	
  	
  	
  training,	
  training	
  ,training……….	
  
	

18	

This period, our main working for EVD is communication,transportation and hygiene, PPE. Now we’ve preparedfor skill up of PPE for EVD. PPE: double grove, double

Transporta'on	
  from	
  ER	
  to	
  ID	
  ward	2014.8.26現在	

gown. We are training every week. Tomorrow, fourradiologists, and two medical engineer, one ID fellow, one
emergency department doctor will join, and next week,

新中央棟 2階	

other nine people will join. So every week, continuously
we do it and we simulate every two or three months with
communication tool and transportation. If we have chance,③ 結核患者搬送用
エレベーターで2階へ②業務用
エレベーター
前の通路	

① 陰圧室	
新中央棟 1階	

32

I’ll show our department in detail. Thank you very much.

VII.

After the Session

VII. After the Session■

Questions and Answers

Dr. Sakurada:

specific hospital and we’d cared by the PPE before thediagnosis. After the diagnosis and check the PCR negative,

Thank you very much, Mr. Takeshita. Next is

we’d transferred to the normal ward or sometimes

discussion time. Any comment or question from floor?

discharge.

Dr. Hoshi: Thank you very much. I’m very much impressed

Dr. Musa:

manager of Yurin hospital. I will meet to all of you on

actual response was when the outbreak started in yourby your lecture. My name is Sakuo Hoshi. I’m from generalAugust 9th at our hospital. Anyway, my question is that itwas not the past time to occur Ebola in Africa but it was afirst time to occur Ebola outbreak in Africa. So I want to ask
you why some papers said WHO does not respond quickly
at first. Others said Ebola occurred at rural area but thistime, it was a first time to occur at urban area. So many
patient moved around by cars or something and some ofyou said it was the first time to meet Ebola patient at yourcountry. So I want to know why, what the most important

My question is to Japanese. I know there wasn’t

outbreak of the SARS virus. I just want to know what yourcountry.
Dr. Takeshita:

At that time, at first, this hotspot is China

near to Japan. So we prepared. I only heard the situationof SARS later. At first, we prepared public response teamand specific ward because we had infectious disease
specific ward by infectious disease law. For example,
smallpox or some viral hemorrhagic fever, SARS were nocase in Japan. SARS is one of the turning point because

reason. Why outbreak occurred?

outbreak area is near to Japan and spread to world. So

Dr. Musa:

these diseases and establish a new word or new laboratory

Japanese government changed the policy to prepare forThank you very much. Before my colleague talk,first, let me correct this. We say Africa compared to Japan.
Africa more than 52 countries. So something is happening
in Uganda or happening Liberia, maybe you would say East
Africa. What is happening in East Africa, it’s not in West
Africa. It’s very large. So I very first time went to Liberia,
Sierra Leone and Kenya. It’s the very first time, so we didn’tknow about anything about anything before. There wasmethod.
Dr. Teo:

I’d like to respond to a clarification to important

issues. One of the questions was asked why WHO didn’t
declare the outbreak in West Africa. The issue is that
especially answer that the disease in West Africa was thefirst time but again, well communication we need to dodifference in it. Thank you.

was surveillance system for information. So possibly during

Dr. Hoshi:

well and Africa.

Okay. Thank you.

Dr. Sakurada:
Dr Phone:

March and April, of course, I’ve worked in West Africa as
So during those days, even Sierra Leone and Liberia did
not recognize that this is Ebola. So it was not easy for them

Other questions or comments?

to report WHO. Who is announcing outbreak or not? So it

I came from Laos. If you have suspected caseof Ebola, foreigner visitor only nine cases but what did you
do? After suspected, you’d been to hospital, you wear worn

was not that much clear if this is Ebola. That just that why
there was delays. Although, this is not concrete answer
which was supposed to be given but I know because I was

PPE or something else?

there as well. Another point is that Dr. Sakurada said “I don’t

Dr. Takeshita:

one of them is only standing.” If one person enter in Ebola

know why in these photo, only person was standing while

These nine cases are all transferred to the

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

33

treatment unit, possibility of contaminating is high. So thethat is probably has virus in its body. So for now, people

current protection mechanism you need to have somebody

are still eating them but generally you don’t know maybe

is called buddy. All of the buddy is to observe infection

if what you’re eating do not have virus in their body andprevention precautions. So I will be there wearing PPE but

also because of the awareness and campaigns that we’reobserving what my buddy is doing and I need to instruct

going on to avoid eating bushmeats. Up to now, mostthis buddy is okay because this is really highly contagious

people avoid eating them. I know most people eating themdisease. But another thing is you may be supporting andbut maybe they’ve fortunately not be exposed to that but

documenting some patients but you cannot touch thefor now, people are so conscious and avoiding to eat any

patients. So currently nobody is entering ETU alone, not lessbushmeats. So probably that is reason why the animals arethan two persons going. So this is the answer to why thehere but anything outbreak happened. Thank you.

other one was just standing. He’s not standing, observing
for IPC. Thank you.
Dr. Sakurada:
Dr. Rich:

I have one question. How did you manage

the first case? Because identification is very important toThank you very much.

Ebola is previously carried by mangos and bats.

After people eat mangos and bats, chance is there; weprevent outbreak. So how do you check first case?
Dr. Kamara:

We all know that it was difficult to identify

suspected cases because at the time of the outbreak, wewould infect Ebola. As of today, people are still mangos andhad no mechanism of this to do the testing, no facilities

bats. Why are they not contacting Ebola?

or treatment and even in the community, people were

Dr. Kamara:

34

Dr. Takeshita:

not aware of Ebola virus. So the first case I suppose for all
Good afternoon, again. Thank you very muchaffected countries, we got them, confound after they died

for that question. The picture that colleague was trying

most cases in early cases, we had. It was opened when they

to wear is transmission boot of infection. Raw animals

died and subsequently when we started tracking someand plants or fruits are not affected by the diseases but ifof those cases, we actually some cases we were fortunate

you eat any of those animals, you’ll expose yourself to bethat like early reporting, depending on the symptoms

infection and we require just one contact with that to haveor stages, sometimes it’s possible for you to be treatedan outbreak among humans. So, for now, declaration weand you survive depending on the time of going to the

did was end of human to human transmission but yet still,

hospital. Sometimes you try because when you’re waiting

we still have monkeys and bats still existed. That’s why it isfor the results. The patient is been treated symptomatically,

ongoing that people stop eating those animals in the bush

you take care of temperature or fever and everything. So

because we might be unluckily to feed on one of them

fortunately depending on the timing to go to the hospital

VII.

After the Session

and on your immune status at that time, you might survivethat even after this post-Ebola era, financial or technical or

but high death rate related to Ebola was as a result ofphysical investment and cooperation is very much needed.

polymerase chain reaction because of the similarity ofThank you very much.

infection to other factious diseases and rare diseases. So
most of the first cases, we’re not able to manage them.
We’ve got to know about them through community
mobilization. People tell you to know that there is a deadbody there and you go and you take the swab that’s how

Dr. Kanai:

Dr. Kanai, please.

Thank you very much for good comment,

Dr. Takenaka. I’m also working for the JICA headquarters.
My name is Dr. Kaname Kanai working for the humanwe actually find out most of the early cases. Thank you.
Dr. Kaly:

Dr. Sakurada:

development department. I’d like to share my experiences
In addition about that, now after Ebola, post-

and also my idea. I joined the contact mission to Guinea. It

Ebola now, Now, we don’t have any active case but wewas 2015 February. At that time, we joined the government

have rapid response team. Their rapid response team is

mission. Nine members from Ministry of Health, Ministry of

now effective. We don’t say because we don’t have Ebola.

Foreign Affairs, Ministry of Defense and other organization,

Everybody we saw was composed by contact tracing. We

also JICA. Seven member out of nine medical doctors. So

have to help promotion and social mobilization. Just if wewe saw the conditions of Guinea and medical center, Ebola

continue to maintain this rapid response team free fromtreatment center in Conakry and MSA handling and also weany outbreak. Thank you.

saw Ebola treatment center French military handled. One

Dr. Takenaka: Thank you very much for your presentation.

Ebola treatment center was handled by AU, African Unions.
So we knew some countries had experienced, some doctors

My name is Dr. Hiro from JICA in Tokyo. I have visited Sierra

were specialist of Ebola. So in Africa, they share experiences.

Leone four times before and after the outbreak and I’m

In the Ebola treatment center handle by AU, doctors frominstitutional gynecologist. I want to share my experience as

Congo, Uganda and Zambia joined and treated there. So

a gynecologist. In January this year, I have visited Freetown.

at that time, I could see the patients three meters away.

I was working in PCMH. This is the tertiary hospital in

So I felt like it’s safe but if you don’t know what we canFreetown for the maternity. One day, we have received one

be infected. That must be fear. Anyway, my opinion orcase, full-time pregnancy with previous Cesarean section

JICA’s idea: capacity building, capacity of human power.

in shock. We have suspected the uterine rupture. I wanted

You are here. Also capacity building with laboratory andto buffer of the Cesarean but very much unfortunately thesurveillance is important. So if you have any idea, pleaseprevious day, just one case of Ebola was appeared in thelet us know. We’re working for it together. Thank you very

northern part of Sierra Leone. So the operation team wasmuch.

refused the case to let the patient into the operation theater
until negative result is proved. It took two hours. The patientdied before going to room. I very much understand theDr. Sakurada:

Thank you very much, Dr. Kanai. PersonallyI think it is very, very difficult to develop anti-Ebola virus

situation but what we need to know is Sierra Leone, directly

agent and vaccine compare to developing vaccine of HIV,provided Ebola virus is about 4,000 including 200 medical

malaria and dengue. Why we have not such compound

workers but in the back of the number, indirect case ofor vaccine for long time? I think that is just simple reason.

Ebola might be double or triple. Now the international

That is benefit for pharmaceutical companies, right? But itsociety is claiming that resilient health system is needed inis the time to develop such medicine or vaccine. This is my

the African continent but we also need to know that if we

personal opinion.

compare the number of the medical workers, for example, if

Is there last question or comment, last one? Thank you

we compare the number of the medical workers with Sierravery much. Time is over. Now we released from our duty.

Leone and Japan, we have 60 times numbers of doctors andThank you very much, everybody.

60 times numbers of nurses. It means we cannot tolerate
again in the African continent because in this situation,
like I think, now, vaccination or the treatment medicine is
not commercially available for Ebola, right? So prevention
is very much important and rapid response is very much
important. I think that every member of us should recognize

Mr. Moriyama:

Thank you very much, Dr. Sakurada. We

would like to conclude this Ebola session. Thank you forkind participation and cooperation. Thank you very much.
All:

Thank you.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

35

■Participants' Comments

Ms. War:Just for Ebola, I have no experience at all.

Ebola virus patients but your kindness of sharing Ebola
experience, I have many, many knowledge and I use in IPC.

I think you told us to situation what we talkabout. We realized that it get respond in Tokyo. The healthworkers in Liberia was delivered between Ebola virus
disease team and health workers but it’s not work place asmuch as we can see. Most of the health workers have theirThank you very much.

job away because they’re not motivated. Motivation is not

Ms. Deborah:

Everybody was afraid. That means we have this relation we

For me as a person, what I discovered fromlecture is that during Ebola time or during this outbreak,the work is too much for us and some health workers ran
away. So when they ran away even though we’re few, thework had become too much for us and our government, forus like ours, they don’t even consider the work which we
do because the doctor was trying to tell us. They were noteven motivated and even that’s what happened in Uganda,
even if they might be there. We did not even get it. So what
I’m saying is that we should, our government also should
motivate us so that we do. Motivation is not only throughmoney, even appreciating itself is enough for people to be
motivated but maybe those who went to Liberia, they’reaware they received it but those others for our districts, we
do not see. So I think our government should know thatwhen we have offered to care for these patients, we’re
clearly offered otherwise many people run away from there.
Health workers, they run away and they leave patients.

36

Dr. Kaly:

just one issue but appreciation. They don’t appreciate..
got to implement the proper system. We don’t have but I
suggest we always do the inception report presentation.
You have 125 hospital beds while you have just two medical
doctors. We took 125 hospital beds and still we have nurses
got ill in over 125 hospitals, patients is died. I think teachingwhat to do is proper training. Thank you.
Dr. Richard:Thank you for the comments. Lastly, fromLao.

Dr. Phonedavane:

For me, I have learned about Ebola

management from Sierra Leone, from Uganda. In ourcountry, we have found out this and we tried to our wayof, we tried to prepare. I really not know how hard you’re
working for fighting with this Ebola. Ebola disease is reallyserious. Today, I heard from your report many, many
people was dying. 50 percent died for Ebola. We lost ourVII.

After the Session

close friends and we lost our medical doctors. It’s really
big loss for our medical and health service. I think rightnow, we’ve already solved this problem. How about inthe future? We have to prepare. We don’t know when it
occurs or which country is going to occur this even, but I
think after this cause we already know how to prevent orcontrol infections. That’s be together a few how to manage
y infectious disease. I think first, we should have what
we’ve already learned about pyramid of management, allright? I think we start from here especially doctor from here
Japanhe keep us lectured what we’ve learned with people
because he tell us they has nine case suspects. Many, many
people want to know and then came here, want to what
happened, it’s really Ebola or the other disease that means
they have to do as people, for media to know what Ebola isand other serious infectious disease. I think we try to do thebest infectious control. Thank you.
Ms. kargbo:

Dr. Nozomi’s presentation, they respond inconnection with nine suspected cases which maybe they
do communicating to the general public. To bring down
their fears, anger, the blame. So when we go out there toeducate them, we get their cooperation. So we believe as
said I think the management process which our beloved
country Japan took is very good to pick up to make a copy

and represent our countries. How they did, suspectedcases they had, fears, anger, believe, to education, training,practices, assessments and changing of man behavior, I
think the consequence of Ebola in our countries would
have been much better.
Dr. Richard: Thank you. That’s the end of today’s program.
I have a coordinator for tomorrow’s great forum.

Knowledge Co-Creation Session 2016 ■ Sharing the Experiences of Ebola Outbreaks

37

Program for the Specialist of Healthcare-Associated Infection Control and Prevention
Knowledge Co-Creation Session “Sharing the Experiences of Ebola Outbreaks”

Introduction

Jun Moriyama
Course Leader, National Center for Global Health and Medicine, Japan,
Bureau of International Health Cooperation
Risk Management in Response to the Ebola Virus Disease Outbreak
Shinsaku Sakurada

National Center for Global Health and Medicine, Japan
Bureau of International Health Cooperation
JICA's Response to Ebola Outbreak
Akiko Saito

Associate Expert,
Health Team 2, Health group 1, Human Development Department
Japan International Cooperation Agency (JICA)
Sharing Experience on Ebola Outbreak in Sierra Leone
Masiray Colojumah Kamara

Doctor in charge, Isolation Unit, International Medicine Dept., Connaught Hospital, Ministry of Health and Sanitation
Matron Fatmata Kargbo
Acting Matron, Nursing, Ola During Children's Hospital, Ministry of Health and Sanitation
Ebola Outbreak Response in Liberia
Musa Zuanah

Medical Director, Curative Services, Tellewoyan Hospital, Ministry of HealthJean Kokoi Kaly
Medical Director, PSHC-AI&P, Matha Tubman Memorial Hospital, Ministry of HealthResponse for Viral Hemorrhagic Fever in NCGM
Nozomi Takeshita

National Center for Global Health and Medicine, Japan
Disease Control Center

This report was prepared by:
Jun Moriyama
Shinsaku Sakurada

National Center for Global Health and Medicine, Japan
Bureau of International Health Cooperation
1-21-1 Toyama, Shinjuku, Tokyo 162-8655, Japan
Tel: 81-3-3202-7181 / Fax: 81-3-3205-7860
info@it.ncgm.go.jp
http://kyokuhp.ncgm.go.jp/
Issued in January, 2017
©National Center for Global Health and Medicine, Japan All rights reserved.