Engineering a response to Ebola

The director of Medecins Sans Frontières Spain’s Technical Task Force for Ebola talks about the role that engineering is playing in the battle against West Africa’s devastating Ebola outbreak.

The global number of cases in the Ebola outbreak has exceeded 10,000, with 4,922 deaths. Three countries with shared borders – Sierra Leone, Liberia and Guinea – account for all but 10 of the fatalities

The global number of cases in the Ebola outbreak has exceeded 10,000, with 4,922 deaths. Three countries with shared borders – Sierra Leone, Liberia and Guinea – account for all but 10 of the fatalities

Ebola is now like a forest fire. It is burning too intensely at its centres – the places where the disease first struck – so we are really working to contain it there.

The number of cases has been doubling every two weeks and some experts expect 20,000 by Christmas. It will be very difficult to extinguish it from the centre, so we’re also operating at the edges – countries like Ivory Coast and Mali – to stop it coming across the border and spreading further. (Currently there is an outbreak in Mali which I am responding to.)

We’re teaching and training people about sanitation, about hygiene measures and about how exactly to act if a case is suspected. We’re helping authorities to set up Ebola centres, and through broadcasts, leaflets and posters the governments are giving everyone a number to call if symptoms develop, so they can be picked up and transported to a centre by nurses and trained staff.

There are a large number of challenges, some more prosaic than others. The availability of beds is one major issue. In Liberia, there are 600 beds available but the need is for 1,700. In Sierra Leone, there are 300 beds but the real need is for 1,100. So there’s a massive shortfall.
Taxis

In Sierra Leone people reacted as sensibly as they could when they feared they might have Ebola. The ones that didn’t hide away travelled to their nearest medical centre. But the major problem was that many of them travelled by taxi, and if they were infected, then the next person to use the taxi was at risk.

So doing the ‘right thing’ – and it is vital that people go to their nearest medical centre if infected – was also spreading the disease.

The Government in Sierra Leone has now issued a number to call if you suspect you might have the disease so that people come to you. That’s far better, because it means we can get the info we need much easier, too, such as where people are based. But that requires a lot of personnel and resources.

I would really like an engineer to come up with an internal rubber spray that we can spray on the inside of ambulances, and that’s safe, quick, and easy to clean.

We’ve also been working on ‘Ebola-proofing’ ambulances. We can’t continually spray the inside of ambulances with chlorine spray to kill the virus because it corrodes the vehicles. So we have started to use heavy-duty plastic lining material to line the whole of the insides of vehicles and that seems to be a partial solution.

The issue here is that we have to strip out the plastic sheeting lining every time it’s used and burn it, which is very dangerous and expensive. I would really like an engineer to come up with an internal rubber spray that we can spray on the inside of ambulances, and that’s safe, quick, and easy to clean.
Preventing disease spread at medical centres

We’re working with governments to show them how to organise and sanitise hospitals and medical centres – and how new centres should be organised. Most of these governments don’t have any expertise in this whilst MSF first responded to haemorrhagic fevers in the early 80s

At many centres people are passing in and out of entrance areas. Some have Ebola but others don’t and the risk of cross infection is increased if people are waiting for tests in public areas instead of specially built centres.

In Democratic Republic of Congo (DEC) and Nigeria, we’re getting questions about how we can decommission treatment centres and return them to their original use. We can spray with chlorine, but that damages some surfaces, metals and electrical circuits and it’s difficult to be sure how to tell whether a building is clear of the virus. It would be good to see whether a new spray or chemical could be used, which might kill Ebola but wouldn’t damage anything else and which could also leave a trace so we could see everything was virus-proof. We are looking at every option now. If an engineer can help, we’d like to hear.

In Sierra Leone, one issue is that people were coming to centres because they feared they had Ebola but, in fact, had malaria (the symptoms can be very similar), and maybe contracted Ebola because they were processed as if they were Ebola patients and so mixing with those who had been suspected with the disease.

We’re planning to distribute anti-malarials and malaria treatments to people’s homes so they can treat their malaria without risk. We are also taking hygiene kits – chlorine and cleaning materials. The distribution will reach 250,000 people.

Hospitals are one of the biggest problems right now in Sierra Leone and Liberia particularly. People who have other diseases don’t want to go to hospital because they fear they will contract Ebola. So we’re advising authorities to build entirely new centres, out of tent or plastic sheeting in suitable locations. We’re trying to help make sure that those centres are triangulated, so each can serve a sector of their region.
Ebola’s weakness

Outside of the body, Ebola is actually very weak. It takes a chlorine solution around 10 times more dilute to kill Ebola than it does to kill cholera. Outside of fluids, for example on someone’s skin, the virus can actually be killed by soap and water. This is because its surface protection is only a fatty fluid.

We have no cure, but preventing its spread is possible as long as everyone works carefully.

Personal protective equipment is essential but can be cumbersome and incredibly expensive. Plus, it’s often not especially practical. I wore one of the suits that are being used for a few hours while I was in Nigeria and I lost two kg in weight. Outside, the temperature was 40°C, and inside the suit felt like 50°C.

We can’t carry on burning things that cost so much to replace. We need safe alternatives. Any ideas from the engineering community are welcome.

We use face protectors, but when it’s so hot and you’re working hard the goggles steam up far too quickly. It is said Teresa Romero Ramos, the auxiliary nurse who contracted Ebola and has since recovered in Spain, was wearing goggles and a mouth mask, but she contracted it because she wiped sweat from a gap between the goggles and her mask. The cheek is a very absorbent part of the face and she transferred infected fluid onto her face.

We’re burning vast numbers of protective suits – about 64 per day, in a normal camp. We keep the goggles, boots and gloves, but we’re burning so much at the moment and every one of those suits costs us 50 Euros to buy. We can’t carry on burning things that cost so much to replace. We need safe alternatives. Any ideas from the engineering community are welcome.

Clean water is absolutely vital in any situation. We have to make sure people can access clean water.

The major thing Ebola does is to make you really dehydrated with diarorra and vomiting. When you’re weakened, the virus then sweeps through your body almost unchallenged, and can take hold and kill you in a few days.

If no one in the affected countries touched anything or anyone else in the affected countries for 25 days, this outbreak of Ebola would be wiped out.

People in treatment centres need reliable, and very regular, access to clean water. But if they use their hands to turn taps on and off, that’s a serious concern, as it can pass the virus on very quickly. So we are finding different ways to do things.

One pretty simple solution could be taps that can be controlled by foot-operated buttons. It means you are not touching infected things with your hands, and then putting fingers in your face, contaminating yourself. Most people wear shoes, plus the skin on the feet is much less absorbent and unlikely to allow Ebola through.

Use of hands and touching is important. No one would ever suggest it of course, but if no one in the affected countries touched anything or anyone else in the affected countries for 25 days, this outbreak of Ebola would be wiped out.

Goggles, boots and gloves are the only items of protective clothing that aren’t burned after use

Source: European Commission DG Echo

Goggles, boots and gloves are the only items of protective clothing that aren’t burned after use
Further Challenges

Another simple, but very serious, challenge is that if someone infected with Ebola uses the toilet the next person to sit on it can contract the disease. Septic tanks also pose a problem. How can we treat the waste of people who have Ebola so it doesn’t pose an immediate threat to anyone who may come into contact with it or the environment?

We also have to consider the issue of vectors: there is a great deal of disagreement over which animals spread the disease. That is, not that they have the disease, but for example imagine a situation in which a rat runs through a pool of infected blood and then runs across someone in a hospital. Of course, no one wants rats in a hospital anyway, so the solution here seems pretty clear, but the point is that we have to be sure whether animals act as external vectors in the Ebola crisis.
Community

The crisis is very serious, so much so that in some cases we have maybe forgotten or not worked hard enough to remember the people who live in West Africa. Not those who have the virus, but those who do not.

These countries cannot cope alone, but there’s real suspicion from the local people in some cases. We have had stones thrown at us by people, tents and centres burned and people preventing us from burying the dead.

They see these foreign people arrive, take away their family members and then they are never allowed to see or touch them again, even when the people who have been taken away have died. That’s incredibly difficult to comprehend.
Burial

Burial is another vital issue and the bodies just aren’t being buried fast enough. The virus doesn’t die in a dead body, and the longer bodies are left, the more likely it is that as fluid builds up in the stomachs of those bodies, they will burst and scatter infected fluids.

The virus doesn’t die with the body so rapid burial is vital

At the worst times there were buildings with maybe 20 bodies just piling up. We have to body bag each of them twice just to prevent the infected fluids seeping out and spreading the contamination everywhere.

We have to find the right locations for burial, and many people will not let their land be used for it because they fear coming into contact with contaminated bodies, and there are serious considerations about the water table and possibly contaminating a region’s water just by burying the contaminated dead.

Cremation is the best answer. But many communities oppose this: it’s really crossing a cultural boundary for them. So bodies may be left for days, increasing risk.

It can also be hard to find incinerators big enough: most hospital incinerators are used only for bags of hospital waste, and are not big enough for bodies.
Lessons learned from other outbreaks

It’s difficult to take too many lessons from the way the outbreaks in Senegal and Nigeria have been confined.

In Senegal, the outbreak was very limited. The person in question was already sick when he crossed the border, and died very soon after. In Nigeria, a guy went to the doctor, and passed it on to her. Then she died.

But the major lesson to remember is to respond and react right away. Treating a patient is absolutely vital, but we must also really quickly find the people who that first patient has been in contact with.

We cannot afford to lose one single day, because one person will infect others who will then spread the disease further. We have to question the patient, then trace the people they have contacted using the answers they give. It’s quite an art, but with the right approach, it can be done.

There have been some very interesting technological developments, including GPS tracking systems in mobile phones

There have been some very interesting technological developments, including GPS tracking systems in mobile phones, which have enabled us to learn more about areas where people have had the disease and helped us focus on the people who have been visited by those who have contracted the disease.

It will be good to see if we can develop tracing technology, so that we can give people mobile phones to see where they go and who they meet, so if they come down with the disease we can talk to the people they have met.

We have also developed an Ebola app for mobile phones, which includes info about the disease and what to do if you or someone else contracts it. A game is also being developed, which tests your knowledge about the disease and you can link your score to social media. They should be launched very soon, and are a great means of making sure people know what to do.
When will it end?

We believe that this will not end until after next summer. Even with a vaccine it will keep going into 2015. Those countries affected: Liberia, Sierra Leone and Guinea, have such a high density of cases that it will be really difficult to control.

Medical services in Sierra Leone, Guinea and Liberia were totally ruined before Ebola struck. It’s a condition of poverty and the health system.

There is no cure for Ebola, but if you keep people hydrated and give them antibiotics to fight some of the symptoms you are at least giving them the best possible chance of overcoming it themselves.

Another effect of poverty is that some people just give up. They simply don’t believe that anything can be done to help them. In this way, perhaps more people die of the disease and perhaps spread it, where people who believe something can be done would not.

MSF has more than 500 expats working on this crisis, and 3,000 local staff. They can only work in two-month stretches because it’s so stressful right now. 13 people working for us have so far died. It’s really tragic. Those people have given their lives for what they believe in. It’s an heroic thing.

Source: http://www.theengineer.co.uk/engineering-a-response-to-ebola/1019476.article#ixzz3LKatzoCY