When the Sector Gets Hot: Rapid response to a positive Ebola case

When the Sector Gets Hot: Rapid response to a positive Ebola case
By Alice Urban, Global Communities

The Duport Road Health Clinic houses the Sector 4 hub in Paynesville.
Paynesville, Liberia – A man fell out of a beat-up taxi. It was more like he spilled out, according to observers. He seemed unwell, disoriented. Two young men saw this happen and ran to the man in the street. They picked him up and deposited him back into the car. The taxi drove away, and the young men disappeared into the crowded streets of Red Light, a neighborhood in Greater Monrovia.
In those few moments, the disoriented, symptomatic man – one of Liberia’s few but new positive Ebola cases in late January – came in direct contact with two more people he could have potentially infected. It happened fast, with no warning, and with no immediate repercussions. Several weeks later, a person matching the description of one of the young men died in a clinic; his death was a suspected homicide. On Feb. 4, his Ebola test came back positive. Another person matching the description of the other young man turned up positive but alive at an Ebola Treatment Unit (ETU).
The story doesn’t end there – there’s a gang, police, a bloody brawl and hesitant informants hiding from investigators – things you’d expect to find in a crime show. And that’s largely what Ebola contact tracing and case investigation look like, even when the police aren’t actually involved.

Global Communities Sector 4 Co-coordinator Josh Balser meets with the Ebola response team to map out the spread of a recent cluster outbreak and plan containment response.
“It’s a lot like being a detective,” said Josh Balser, Emergency Response Officer for Global Communities, a U.S.-based nonprofit. “We track individuals’ movements, question their families and monitor suspected cases.” He added that, of course, while a suspected Ebola case is a victim of a tragic disease rather than a suspect in a crime, the process to put the story together is very similar.  
Balser is co-coordinator of the Sector 4 Hub – a division of Montserrado County’s Ebola response system – based in Paynesville, a neighborhood on the east side of Capital City. Global Communities is the coordinator for the sector as part of the Montserrado County Ebola Response Consortium led by the International Rescue Committee and funded by USAID. The hub serves as a base for case investigation, contact tracing and active case search (important practices that identify, document and track at-risk populations), which are activities implemented by several Ebola-response organizations active in the sector. Coordinated by a Ministry of Health representative, the local response team at Sector 4 meets at the hub daily to share information and plan activities.
“The sector is hot,” said Balser at morning meeting on Feb. 5. The team is investigating the latest outbreak of the deadly and rapidly-spreading virus from a cluster of cases originating elsewhere in Montserrado County. The two young men who helped the man in the taxi are the focal points of the investigation – so far, they are two of three confirmed cases in Sector 4 with the same source case.
In less than 48 hours from Ebola confirmation on Feb. 4, the Sector 4 team identified more than 100 total contacts (individuals who came into contact with the young men and are at high risk of infection) and pieced together a more complete story of the their movement and symptom development. Now, they’re working to monitor contacts and find more. The team is providing food to the quarantined and disinfecting potentially infected homes and public spaces. They’re on the watch for anyone who develops a fever or otherwise becomes symptomatic. Ambulances are on call, and patients will be immediately isolated at an ETU. 
The sector team responded rapidly when the testing lab confirmed the positive Ebola case:
Wednesday, 5 p.m.: Balser gets a call from a fellow NGO worker alerting him of a confirmed case. A man named Eric*, believed to be one of helpers from the taxi incident, died in Red Light, and his death was investigated as a homicide. His post-mortem swab is confirmed positive for Ebola.
Balser activates contact tracers to launch a line list (identification and listing of individuals who came in contact with Eric). The same night, the team learns of another man, Steven, who was admitted to an ETU and may be the other person who helped the sick man into the taxi. They launch a line listing for him as well.
Thursday, 8:30 a.m.: The Sector 4 team meets. They map out what they know so far – the Ebola-positive men are identified as members of a local gang. Eric died without being treated for Ebola and was in a bloody brawl a few days earlier while he was symptomatic. With this information, the number of potential high-risk contacts increases. As gang members, the contacts will likely be difficult to track. The man at the ETU, Steven, is a confirmed friend and associate of Eric. Steven is still at the ETU, and contact tracers are identifying more of his contacts.
Thursday 10:35 a.m.: Contact tracers and case investigators hit the road. A team of 15 case detectors begin to identify Eric and Steven’s 100-plus possible contacts.
Thursday morning to late in the evening: Tracers meet with the police to track Eric’s movements before he died. They discover that some 40 gang associates are at risk. Tracers head to the neighborhood where the gang hangs out and make initial contact. Using a community engagement approach that worked elsewhere with sensitive communities, the team immediately provides food to the suspected contacts. They work with the gang members to emphasize the risk they face and convince them to agree to quarantine.
Thursday, 3:30 p.m.: Balser meets with the larger Montserrado response team and updates them on containment progress.
Thursday, 7:45 p.m.: The team checks in with the sector coordinators and confirms to meet the next morning to debrief.

The Sector 4 team mapped contacts and interaction of positive cases to track possible infections.
Friday, 8:40 a.m.: The team meets again and follows up on yesterday’s action points. Two homes were disinfected, and the 40 gang members remain compliant with quarantine. They continue to be provided with food. Contact tracers report that they also visited the clinics where Eric went after the fight to seek treatment for facial lacerations. The man who beat Eric is identified but is still at large.
The team continues to build the story. They learned that Steve, who is still alive at the ETU, has more potential contacts. He attended church before he was admitted, and a team is assigned to meet with the pastor to assess risk. Steve may be able to talk, and a case investigator will see if the ETU staff can get more information from him.
Friday, 10:14 a.m.: The team disbands. A group will ensure that Steve’s church is disinfected, and another team will line list contacts from clinics where Eric sought treatment. The quarantined gang members are requesting mattresses and other provisions, so a sector representative will negotiate with them to make sure they remain quarantined and have what they need. A psychosocial support supervisor will visit resistant contacts. Later in the afternoon, the sector coordinators will brief the Paynesville mayor.
“Some people might see new cases as a failure in the fight against Ebola,” said Balser to the sector team of nearly two dozen government, NGO and health-sector representatives as the meeting concluded. “But this is also an opportunity for success in our response to containing this cluster outbreak in our sector. Let’s keep yesterday’s momentum going and stop this from spreading.”
*The names of the men have been changed to protect their privacy.