A health worker checks a blood sample for Ebola at the Kenema Government Hospital in eastern Sierra Leone
FREETOWN/DAKAR, 12 November 2014 (IRIN) – Critical gaps in “behind-the-scenes” infrastructure are hampering Ebola response times and containment efforts in Guinea, Liberia and Sierra Leone, aid agencies and health workers say.
In addition to the obvious need for more beds, medical equipment, and qualified doctors, nurses and lab technicians, they say the ability to quickly and accurately confirm or deny suspected Ebola cases is vital to getting this outbreak under control.
“The country really needs to ramp up its access to diagnostic capabilities,” said Alan Kemp, head of South Africa’s National Institute for Communicable Diseases, which is running a mobile laboratory at the Lakka Ebola Treatment Centre in Freetown. “And that’s not just for Sierra Leone, but for the whole West Africa region.”
While for a long time there was a backlog of samples needing to be tested, there are now 13 laboratories – five each in Sierra Leone and Liberia and three in Guinea – that have the capacity to test up to 1,170 samples per day, according to the World Health Organization (WHO).
But even as the number of functional labs increases, diagnosing a patient remains difficult.
“The challenges are not so much in the laboratory, as the situation with getting the specimen that needs to be tested,” Kemp told IRIN.
Collecting a specimen from someone suspected of having Ebola – usually blood from the living or a saliva swab from the deceased – is a highly risky procedure, which must be performed by specially trained doctors or nurses while wearing full personal protective equipment (PPE).
Each sample must be triple packaged in special watertight containers and then decontaminated before being sent to a laboratory.
“The chain of systems to obtain samples. and transport them to and from the labs has been difficult,” said Margaret Harris, a WHO spokesperson in Sierra Leone. “From the moment the sample is taken, sometimes it is not packaged properly or not labelled clearly,” she said, explaining that this is often the result of reduced dexterity while wearing the PPE.
Some of the samples are not usable. Other times, mislabelled samples mean that the lab might not know who to return the results to, delaying diagnosis.
Overwhelmed referral hotlines and a lack of ambulances mean that many people can’t make it to treatment centres for testing, Médecins Sans Frontières (MSF) says. Other people are still scared to be tested.
“Fear is not quite infrastructure, but it’s still a challenge in getting people to the centres, which are often shrouded in mystery,” said Natasha Reyes, a medical coordinator for MSF in Liberia.
Obtaining samples from the deceased poses particular problems, as many communities still resist body collectors, often refusing to let them take samples from the body for cultural reasons.
“In the case of collecting swab samples from dead bodies, the burial teams have at times had to choose between getting into a confrontation with the family or quickly burying the dead – the priority in stopping transmission – and getting out of town,” Harris said.
In many treatment centres, there are now on-site labs, which mean samples need only to move within the unit or to a neighbouring building for testing.
Problems arise, however, when there is no lab nearby. Only 62 percent of Ebola-affected districts across the three countries have access to lab services, according to WHO.
“The logistical challenges are similar to any area with poor infrastructure. We need to access remote villages, over difficult terrain…which may only be 10 miles [away] but take several hours [to reach],” Harris said.
In big cities, traffic jams and accidents can delay testing by hours if a sample must be sent across town. Sometimes even finding a vehicle to transport the samples is a problem.
“What’s important is to have the treatment centre near the diagnostic centre,” said Noel Tordo, a virologist with the Institut Pasteur in Guinea. “You can’t really accelerate the sending of the sample because of road conditions and other transportation issues. You can give the results by phone, but if the diagnosis centre is far away, the time that you will need to get from one to the other is difficult to reduce.”
Once samples arrive at a lab, it takes technicians 4-6 hours to get preliminary results.
While new technologies are being tested, such as a finger-prick test, which would diagnose Ebola within as little as 30 minutes and without the need of a lab, they are not yet widely available, and have not yet been thoroughly tested for accuracy or sensitivity.
For now, positive cases are logged into a system, which then initiates a chain of measures such as contact tracing, quarantine procedures, and food distribution, before the result is finally sent to the clinic.
Passing on the results to families and burial teams can take even longer.
In Sierra Leone, one of the major challenges that burial team volunteers face is that they are often sent to collect bodies that haven’t yet been confirmed as Ebola-positive, Patrick Massaqoui, a spokesperson for the Sierra Leone Red Cross Society, told IRIN.
While health officials say it’s better to err on the side of caution and suppose that all suspected cases are positive, collecting the bodies of those that died from malaria or other diseases with similar methods, is taking away valuable time and resources in areas where burial teams already cannot keep up with the rising death toll.
Other times, there is a delay in collecting bodies that have been confirmed as positive for Ebola.
There are now 140 trained burial teams, of about 8 people each, on the ground across the three countries, WHO says. But 528 are needed and there are often delays between the time a body is reported and the time a team arrives to collect the body and take a sample for testing.
“It’s not that our team delays to collect bodies, but early in the morning we have to wait for calls from our focal point at the Ministry of Health and Sanitation because they are the ones that are taking the lead,” Massaqoui said.
In both instances, responders say that if the timetable to test for Ebola was sped up, it would allow them to react more quickly and more efficiently.
The WHO’s Laboratory Technical Working Group in Sierra Leone says it has just approved a plan to increase the speed with which lab results are reported back, by harmonizing databases and integrating lab teams into the central Western Region Command Centre. They also plan to train 50 lab technicians and 20 drivers on protocol for sample collection, packaging and safe transport.
But even with improved speed and accuracy in confirming suspected cases, health workers say that beyond infrastructure challenges, containing the outbreak will depend a lot on people themselves.
“Through public information campaigns, there is significant awareness of what Ebola is,” Harris said. “However this has not translated into a change in behaviour. The pull of cultural traditions continues to be stronger than the statements by public officials,” she said.