Q&A

JIMMY WHITWORTH: Thank you. I would like to welcome you all to the panel discussion for the outbreak preparedness MOOC. Thank you for joining us. My name is Jimmy Whitworth. I’m the lead educator here at the London School of Hygiene and Tropical Medicine for this course, and I’m very pleased to have four experts joining me on the panel. I have Rosamund Southgate, who’s an epidemiology public health intelligence team co-ordinator at the Manson unit Médecins Sans Frontiéres, based in London in the UK. We have Dr. Soka Moses, who is site physician for the PREVAIL Study in Monrovia in Liberia. We have Esther Ngdaya, principal research scientist at the National Institute for Medical Research, Dar Es Salaam in Tanzania.

And we have professor Dale Fisher, who’s head of the Division of Infectious Diseases at the National University Hospital in Singapore, and also is the chair of the GOARN Steering Committee at WHO. You’re all very welcome, and thank you very much for participating in this panel discussion. So let me start off with the first question that has been submitted from the participants, and this is, how do you know if a country is prepared for an outbreak? How can this be ascertained when there is no outbreak currently? And let me ask Dale, perhaps, to comment on this one first.

DALE FISHER: Thanks, Jimmy. I hope you can hear me well enough. And thanks to the person that submitted that question. It’s a good question and one that we often reflect upon in our activities. The main tool that we use is called the Joint External Evaluation, the JEEs, and this is run by a specific division within the WHO Emergencies Programme. And what JEE– the abbreviation is JEE– this is an assessment tool which can go to a country and really assess the core capacities for full compliance with the IHR. And the majority of countries have signed up to this. They end up with sort of a traffic light system of green is they’ve got that particular area well under control.

Red is a lot of work to do. Orange is sort of somewhere in between. So the JEEs, once completed, feed into the national action plans of that country, and then there’s an expectation of proceeding with those activities to move towards compliance and a subsequent JEE assessment. To do this, it requires at least six, maybe sometimes up to 10 or 12, international experts, which will go to the country and work with the ministry.

I don’t know the exact number, but it’s very common, and certainly at the World Health Assembly, countries that have done it described how rewarding it was and encouraged other countries to get involved. There certainly are other efforts from NGOs and donors, who use their own ways of assessing the needs of a country. Certainly, World Bank reports, things like that, how much money’s been invested in various aspects of the IHR, maybe other ways to do the assessment. So this all sounds very bureaucratic, and it is, and cynics could well sit back and say, there’s only one way to test whether a country is ready, and that’s to have the real thing. And of course, there’s a lot of truth to that.

It’s, in many ways, easy to tick boxes and say they’re all good and we’ve got good systems happening. But what happens in the chaos and the requirements for surges is often another thing, which I’d like to hear from some other members of the panel that have probably got plenty of experience in what happens when the real thing occurs. So that’s sort of a little bit of an overview for you, Jimmy.

JIMMY WHITWORTH: OK. Thanks very much, Dale. Rosamund, could I ask you for thoughts on this?

ROSAMUND SOUTHGATE: Yeah, thanks, and also, thanks for the question. I think it is a really important and interesting one. So in settings where MSF works, for us surveillance, what surveillance systems are in place, will be a key area we’re focusing on, particularly in my line of work with MSF. So can that country, can we detect an outbreak early? Have we got clear risk assessments of what diseases to put under surveillance? Do we have case definitions for those to be diseases, and robust reporting system to get alerts at the very local level right up to the national level? Are there teams and systems to then respond to those alerts? And are we linked up well to laboratories for testing and confirmation?

And then are we regularly reviewing that risk assessment, the diseases that we’re particularly looking out for? Another thing that MSF is thinking more and more about is about training and simulations. So it’s a question that refers to, how do you tell how good you’d be responding to an outbreak without an outbreak occurring? Training is really key in that, from your clinical staff, but also your coordinators, to a response. And simulation exercises, where you don’t have a real outbreak occuring, but you’re put into situations where it very much feels like an outbreak is occurring. And does your training, your systems, match up to that?

And finally, I guess I’d say to assess how good an outbreak response would be, I’d say, how good is your community engagement? So is a baseline of people educated about health, disease, and outbreaks at school or culturally? Are health services and public health agencies talking about outbreaks, about vaccines and the benefits of that.

JIMMY WHITWORTH: OK. Thank you very much, Rosamund. Esther, do you have any perspective on this from your position in Tanzania?

ESTHER NGADAYA: Thank you for the question and the response from Dale and Rosamund. To me, I’ll just talk using examples, and it is from the community perspective, from the local people perspective. We know that we have a goal, like say in Congo there’s Ebola. So Tanzania, there is risk, number one. So recently, do you remember like two weeks ago, it was just through the social media, like what’s app with– I mean, the messages started to go viral that there’s a case of Ebola. Then the Ministry of Health, I mean, they’re prepared for it, but at least they just came out just to respond to the social media.

So coming to your question, how the country is prepared, I mean, how can someone know if the country’s prepared, social media can also make the people who are responsible to come out, like for the case I was talking about Ebola.

JIMMY WHITWORTH: Yes, thank you. Rumour management is often an important part of both surveillance and preparedness for outbreaks there. But let’s move on then to the second question, which I think relates to that first one. And that was, are there guidelines and tools for selecting diseases for surveillance in a country? So I guess this is, about how do you determine what are the priorities for your surveillance system? And Rosamund, I think you were starting to talk a little bit about that previously. Could I ask you to enlarge upon that?

ROSAMUND SOUTHGATE: Sure. I can speak from an MSF perspective how we pick the diseases. A lot of the time, it’s down to what we’ve experienced in that country in the past, but we do have a couple of tools to help guide us there. So we’ve taken guidance from the World Health Organisation’s SAGE, the Strategic Advisory Group of Experts, I believe. Correct me if I’m wrong. We’ve developed our own tool for risk assessing vaccine preventable diseases, in particular. So it has three steps. So initially, we look at whatever data we can gather on recent cases and outbreaks in that setting, and what the population has been vaccinated against.

And then we have a tool, which helps us determine the risk of spread of vaccine-preventable diseases in the context. So we look at six environmental factors in that setting, so overcrowding, malnutrition, water and sanitation, access to health care, birth rate, and chronic disease. And by rating each of those, we essentially get a ranking of the likelihood of spread of 12 different vaccine-preventable diseases. So for instance, if we’re in a setting, a refugee camp setting, with overcrowding, malnutrition, measles will pop up very near the top. So we then, in step 3, combine those two things, what we’ve seen in the area recently, the vaccine coverage, what our tool is rated as should be on our radar.

And then we make a decision on what diseases we should put under surveillance, and then also what vaccines we should try and deliver to the population very quickly.

JIMMY WHITWORTH: OK, thank you very much. Dale, what about from the WHO perspective?

DALE FISHER: Well, that’s a terrible way to introduce a conversation. I don’t want to speak for the WHO. But yeah, pretty much as Rosamund said. It is based on the threats seen, the ones that you actually know about and can predict risk assessments for other things, particularly emerging diseases or imported diseases. There’s a lot of countries, for instance, that have got MERS surveillance happening, even though they don’t have any MERS. They appreciate it as a risk. There’s a couple of documents, since you mentioned WHO.

Certainly in AFRO perhaps Soka and Esther can comment on this, that there is a set of guidelines called the Integrated Disease Surveillance and Response, which really has taken this risk assessment and helps guide surveillance, I guess. And in my part of the world, over here in Singapore, there’s the Asia-Pacific Strategy for Emerging Diseases, which, again, helps guide, I guess, some of those surveillance activities.

Yeah, I think that’s about all I wanted to add.

JIMMY WHITWORTH: OK. Thank you very much. Esther?

ESTHER NGADAYA: Thank you, Jimmy. Actually, I concur with the rest of the responses, but I think we can use, also, Assessment of Communicable Disease Risk and from research data. I remember, it was like nine years ago, we did several studies in Tanzania, so that NCDs, non-communicable diseases, were on the rise. And then we just reported to the Ministry and they shared the information. Then they decided to include its priority NCDs in the IDSR and that is reported on a monthly basis. So even research data is also country specific research data in that if they see a major public health threat, then yeah, it can be used to improve the WHO development.

JIMMY WHITWORTH: OK, thank you. And Soka Moses, what about in the Liberian context?

SOKA MOSES: Thank you very much. The IDSR is very, very important in the Liberian context. But in addition to the IDSR and what everyone has said, the routine reporting system from local clinics, primary clinics, within rural areas and other communities within urban settings play a very big role. Sometimes these routine systems, the challenges with them is the delay in which the data comes. But that is changing now, as local clinics are using mobile phones and using different electronic equipment to be able to send information directly to the Ministry of Health and the electronic tools in place to be able to analyse and give information directly to the Public Health Institute. So that’s also playing a very big role.

JIMMY WHITWORTH: OK well, thank you all very much for those. Let’s move on to a third question. And this gives the context of when there is an outbreak of a disease in a particular geographical location, the population in that affected location plays an important role in reporting vital information about that disease. Now, the questioner asks, what can be done in a situation whereby the affected population fails in their responsibility to provide timely information necessary for action? And I want to start with Esther in this particular one.

ESTHER NGADAYA: Thank you, Jimmy, and thank you for the question. I think the most important thing first is to learn why they fail.

Sometimes they don’t have a mechanism and resources to report it to, or if they don’t have the technical know how about the presence of the disease, their risk of acquiring the disease and the importance in controlling the disease. So probably, if there are cultural taboos associated with it. So you need to learn all this, and probably the mechanism approach we use to involve them was not culturally acceptable. So I think we need to be certain that it’s developed to tackle the problem and to make the communities to get involved, because you need the community in combating the disease. It should be tailored to the main reason of what made them to not reporting.

Nevertheless, I think we can strengthen our civic surveillance and do contact tracing, although it can be not enough, especially when the community is not with you. So I think the important thing is to start with why they’re not with you. Is it from you to them or is it from the community perspective to– I mean, to the Ministry something like that.

JIMMY WHITWORTH: Thank you. Thank you. And Soka, what are your thoughts on that in Liberia?

SOKA MOSES: Yeah, so just to follow up on Esther’s points very, very important. Sometimes communities and nations look at the incentives and disincentives around reporting. Some of the disincentives of reporting, if you go back to the Ebola outbreak in West Africa, you see there are good examples. You report a very big outbreak, the economy goes slow. I mean, big airlines are all grounded, and then a lot of things happen. So many times communities sometimes are afraid of the repercussions from reporting what really happened, how negative reporting an outbreak is going to affect the economy. It’s going to affect everyday life.

It’s going to affect many, many aspects of the health care, drawing resources away from the routine health systems, to other problems, and consider as big to the outbreak. And also, the resources involved in pulling all these resources. Now, we need to emphasise more around the incentives of reporting, that once countries report early, I mean, your neighbours need to be reassured that they don’t have to ground their flights and they’re going to get adequate global support, rapid support to be able to manage and operate, but also to strengthen what the weaknesses are locally so that next time, you’re able to report it.

So once you have these kinds of mechanisms in place, now communities and countries are now very motivated to report on time, because they know that negative effects are taken away and they are going to get adequate capacity to be able to respond on time. In terms of going back to the question, what are the consequences of not reporting? There are actually no legal mechanisms in place to be able to punish countries for not reporting. So that’s why I’m emphasising in increasing the incentives.

Once you can increase incentives and motivate communities and countries to report on time and remove the disincentive from reporting, you can actually leverage a lot of people reporting on time, and you have a mechanism that can respond quickly.

JIMMY WHITWORTH: Dale, I think you’ve got a comment on this one. Do you want to come in?

DALE FISHER: Yeah. Thanks, Jimmy. Yeah, I absolutely agree with Esther and Soka. But just to go back to the original question, you know, it is the population? I would ask is it the population’s responsibility? I think the questioner said, if they fail in their responsibility to provide the information, and I think that’s probably one step too far. I would ask, have we failed in our community engagement if the community is really not delivering that? As we know with some of these outbreaks, the first step is to actually convince the population that it’s an infectious agent and it’s not a conspiracy, for instance.

So we’ve got a huge job, and that’s the role of everyone in the field, actually, to get that. And in fact, I’d go another step and say if an outbreak response is suboptimal, I guess, in how we would hope it goes, usually the reason for this failure is community engagement. And that can be good reasons and bad. It can be the risk– the communication is they’re trying very hard, but it’s still not working. So you can do all the surveillance and epidemiology and case management and IPC around a place, but if the community doesn’t accept what you’re doing then you’re doomed for a fairly prolonged outbreak.

When our activities appear to be penalties, as Soka said, there might be something brought in, but you’re holding patients who may have Ebola, for instance. But then they’re just in one place for two days with no one communicating with them, and someone eventually says, you didn’t have Ebola afterwards. They say, well, why did I present in the first case? This system didn’t work for me. Yeah, thanks.

JIMMY WHITWORTH: Yeah. Thank you, Dale. I think that’s an important point, and I want to bring Rosamund in in a minute. But there’s actually a need for communication to be going all the way along the line. It’s not simply from the community to, perhaps, local health authorities. It still needs to get from those local authorities through to national authorities and, potentially, to international agents as well. So it’s not simply down to the community. But Rosamund.

ROSAMUND SOUTHGATE: Jimmy, I agree with you there, and this is why I think this is a great question, because you can look at it, are we talking about from the national level to the international or from the very local community level into their local and higher system? I’m afraid to say, I just wanted to always kind of second what Dale has just said because he almost took the words out of my mouth about the community engagement aspect of things. Yeah, I think, rather think, that the population failed in its responsibility. Actually, those preparing for responding to the outbreak failed in their responsibilities to engage the community.

And the community are not communicating, usually, out of mistrust and fear, differences in, we mentioned, Ebola a lot in the West Africa Ebola outbreak. And I heard about rumours, when I was there, of people not coming to management centres because they truly believe if they came that we would take away their blood or their organs or kill them. So I don’t blame them for cases not coming forward and not sharing information about those cases. So very much, the question is, what can be done? So yeah, engaging with communities, understanding where their knowledge is and where the gaps are, because those gaps get filled with rumour and speculation instantly.

Understand their concerns, and then try to not only allay fears, but change the response so it’s more acceptable and understandable. So again, going back to Ebola, invite the communities to come have a tour around new Ebola management centres before they open so they can see what they look like and what happens, ensuring that the relatives and friends can take part in the, say, burials, rather than just have their departed loved one taken away, with no rituals and rights.

JIMMY WHITWORTH: Yeah, excellent. So I think we have a lot there about the vital importance of community engagement and community involvement, and that is something, I hope, that you’re starting to get out of this course and realise just how important and how central that is to outbreak preparedness, surveillance, and response. Now, let’s move on then to the fourth question, which is about prevention of dengue, and asking, apart from vector control, what else can be done to prevent dengue and other vector-borne diseases from entering a country? And Esther, let me start with you.

ESTHER NGADAYA: Thank you, Jimmy, once again. I think the first thing, we need to understand the nature of the outbreak itself, what we fight against into the country. And then a country probably need to have a well-established national surveillance and epidemic preparedness plan.

We need to have an establishment of sentinel surveillance sites. And fortunately, like for the case of Tanzania, we have several sentinel surveillance sites, like this single diseases specific, and we are thinking of having a sentinel surveillance sites, which is a much more disease-specific site. And then we need to formulate a standby response team to be in place, just in case the epidemic occurs. We need to have a private public engagement to obtain access to public information. Normally, during the outbreak, normally we forget about the private engagement in the fight against the outbreak. We also need to set up public, health, and maintenance plan. And standard operating procedures should be in place, actually.

Like for the case of a port of entry, we need to speak to people. In Tanzania when you come, you need to have your yellow fever vaccination card especially if you’re coming from a country which is endemic to yellow fever diseases. And we need to strengthen our laboratories to deal with the national and regional, as well as global public efforts. And unfortunately, in most of the developing country, laboratories are the weakest link in the health system.

We need to have a laboratory that can effectively be able to network, which is essential in their provision of public health services. And the networking is very critical in this sense, because without network, you cannot have a timely sharing of information across countries, because most of these diseases, they are cross-border. They don’t obey the borders. Networking also contributes to the joint investigation of diseases, rumours, and outbreaks, just in case. And then it ensures laboratory capacity to diagnose diseases, just in case the country doesn’t have a capacity to do it. And networking was effective platform for learning and actually knowledge sharing. We need to have laboratories with regional coordinated approach.

And we also need to have collective action at the regional level. That’s at the centre to build on country capacity to make sure countries adhere to set of norms and standards. And we also need to demonstrate the operational feasibility of regional approaches.

We need to have one to combat– I mean, at least for the language and communication, we also need to strengthen information and communication technologies, vaccination for the cases, say, of yellow fever. We need to vaccinate your people before they go to yellow fever endemic areas. The country needs to set up policies so it educates the citizens to use prophylaxis drugs before they travel to endemic areas. Also, the country needs to have a clinic that polices the system. I mean, to take prophylaxis, they need to be vaccinated. They need to make sure they get treatment promptly, just in case they travel to countries where there’s outbreak, and they got to outbreak.

Before coming back to their original country, then they need to be treated well. And in case they feel any symptoms while they’re in their country, they need to be treated as well. I think we need also to strengthen community engagement. And in most cases, we need to build capacities of different ministries and actors to be able to use surveillance data and research data and translation of data. Because in most cases, especially in our countries, you have the Ministry of Health. They have their own data. Metropolitans they have their own data. The Ministry responsible for the animal health they have their own data. So when the outbreak is occur there is no coordination, actually.

So we need to settle this, and then we need to be able to use data to predict the future. Thank you.

JIMMY WHITWORTH: OK, thank you. Thank you, Esther. Dale, do you have any comments on this?

DALE FISHER: Yeah. Again, I think the answer is almost in the question with the vector control, obviously, if you’re trying to prevent it entering a country. I think if a country, or an area of a country has Aedes mosquitoes, it’s very difficult to eradicate Aedes mosquitoes, of course. So the countries are a continuous target. I think it’s worth just the audience bearing in mind the work that’s being done with Wolbachia, which is current trials undergone to see if you can reduce Aedes populations by releasing Aedes mosquitoes infected with Wolbachia. So I won’t go through that work now, but it certainly shows a lot of promise as a future control mechanism.

I think it was only about entering a country, rather than preventing dengue in people, which is obviously a different conversation, so I won’t get through that.

JIMMY WHITWORTH: Yeah. Thank you. We’ve now got a question about public awareness campaigns. This says, how can we assess if the public has received messages through public awareness campaigns? And how often should messages be sent during an outbreak? And Rosamund, over to you.

ROSAMUND SOUTHGATE: I love this question, being a public health person. So yeah, so the second part of that question, how often should messages be sent out? I suppose as regularly as possible would be the very brief answer, but also, importantly, in as many formats or channels as possible. And for me and for MSF, the most important one’s along with dialogue. So radio messages, posters, loudspeaker announcements are all important, and you’ll notice these are all ones that MSF employs in settings that we work that are quite different than the UK. But speaking with communities and actually hearing about their beliefs and their fears, and addressing those specifically for what makes a difference, in terms of raising awareness and positive response.

That’s not easy and it’s time-consuming and it needs to be done repeatedly. And messaging, whatever the format, also needs to be changed as the outbreak evolves, rumours unfold, and understanding of beliefs adapt during the outbreak. So then in terms of the first part of the question, assessing your message that’s gotten across. So one way to look at this is you can look at people’s knowledge, attitudes, and practises. So what they know and what they think and what they do, and how that changes over the course of your awareness campaign. And in terms of knowledge and attitudes, we can survey people.

We go to their houses often, but you can do that online to ask them questions about what they know about the disease, its spreads, management, what they think of the information they get. Do they believe it? Do they think that the vaccines or medicine that’s being proposed actually work, or is it a big conspiracy theory? And where have they heard? Where have they got their knowledge from? Was it from your campaign or from mates or from googling or from Facebook? And then practises, I think, is a really interesting one. So we continue to observe what people do. So are they coming forward when they get sick?

For instance, in the current Ebola outbreak, we have to look at the proportion of– it’s a bit morbid– but the proportion of fatalities, deaths from the disease occurring in health facilities or in the community. Because often, those that have passed away in the community have not known enough about the disease to come forward with the treatment, or they might be hiding. What else can we look at? The proportion of people accepting or refusing a vaccine or medications. And just overall, how were the response activities accepted in the community?

So again, at the moment, we’re seeing a lot of the attacks on health facilities and health workers on the Ebola outbreak in DRC, which is a fairly strong sign that public health campaigns, information campaigns, are not being accepted, even if they’re being heard. And two last things on this– I know I have a lot to say. Big data is being used more and more, and that’s the number of clicks or online searches about diseases, about treatments, or about conspiracy theories, again. And then what’s really core in growing an MSF disease is the qualitative or anthropological research, to really sit with people and understand, if they heard the messages but didn’t accept them, why not?

And how did the messages they heard in your campaign chime with the cultural beliefs, maybe their spiritual beliefs, their other health knowledge? So lots of ways to assess the impact of your campaign.

JIMMY WHITWORTH: OK. Thank you. Thank you, Rosamund. That was really comprehensive. Very good. I mean, just one thing I’d add in there is I think it’s important with your messages to tell people what to do and what they can do to protect themselves. Very often, you will see health messages will tell you what you shouldn’t do, but don’t actually tell you what, practically, you can do instead. I think it’s important to empower people by telling them what they can do. Now, time is moving on, but there are two, I think, very important questions that we still need to cover.

The first one is about how you might provide some surge capacity, in terms of laboratory capacity and supplies and microbiology expertise during an outbreak? And how do you provide diagnostic capacity nearer to the site of the outbreak itself? And Soka, I’d like to start with you for this one.

SOKA MOSES: Thank you very much, Jimmy. I mean, that was a real, real big issue, particularly going back to 2013, 2014 to 2016 Ebola outbreak in West Africa. Locally, in many of these countries, there is no capacity to be able to diagnose emerging pathogens, especially, in this case, Ebola, what’s been seen for the first time within West Africa. And there’s also no HR capacity, laboratory technicians, with the actual training. There’s no infrastructure in place, especially in rural areas where these outbreaks started. One strategy that’s always been used for a long time has been mobile laboratory.

Being able to establish mobile labs quickly closer to regions where you have cases of the disease happening, and then closer to isolation units, so that first you have access, and then you’re able to improve the turnaround time, from reducing that time from several days down to like two to four hours. Now, there are many challenges with mobile laboratory capacities. First, many of the time, you don’t have time during an outbreak situation to procure replacement parts. Sometimes there is no capacity in country for repair and maintenance of laboratory equipment. But then there’s also issue around ensuring system of staff, making sure that you’re able to train local staff each time to be able to use mobile labs.

Now, there’s also issue with transport. In Western, in African regions particularly, most of the road network are not really good against torrential rains. So during rainy seasons, when you have to transport, move samples in between labs, from a mobile satellite lab within outbreak regions or central labs to do additional testing, you have difficulty because roads are not in good conditions to be able to transport. So the response teams use other strategies, like using motorcycles, using bicycles, and using other people who are transporting their goods to be able to transport laboratory samples that can get them to areas that they have to get in time.

There are also other problems around having communication, adequate communication, to be able to share information quickly from areas where you have outbreaks happening to central sites, where you have epidemiologists who would be able to analyse information and send information back to the field. The type of laboratory diagnostics that are needed during outbreaks can vary. Most of, in the case of Ebola, real time PCR requiring huge equipment are not possible. But what’s possible is to be able to use adaptations. There are a lot of adaptations that were used during the Ebola outbreak. Taking these laboratory capacities close to ETUs.

But sometimes you also need to do sequencing beyond making diagnosis, as the outbreak stays longer, and then you have mutations in pathogens. If you’re using real time PCR and your assays are not adapted, you may not be able to make diagnostics and diagnosis correctly. There are other times serology was applied as also another form of diagnosis. But if you’re going to use serology to make diagnosis, for example, in dead bodies– I mean, people that died before the cases were identified– and they died too early, and then you’re not able to without humoral response to the disease, then serology, like in Lassa, would not be able to pick up these cases. This is where sequencing comes in.

And that has been possible with now mobile labs mounted on vehicles that can be pulled to rural areas, equipped with power source, water facility, and staff on ground to be able to maintain to have maintenance and be able to transport in time, has been a very, very good strategy in enhancing surge capacity. Usually, outbreaks happen in strategic areas. So these labs must be taken very close to areas where you have hot zones or there’s some high potential outbreaks happening. For example, in the case of the ongoing Ebola outbreak in the DRC, having these capacities within outbreak regions, but also around bordering areas, where there’s a huge area, thousands of people crossing every day.

It’s more important way of taking capacity closer to potential areas where you can have outbreaks of diseases coming up.

JIMMY WHITWORTH: Excellent. OK. Thank you very much, Soka. Let’s move on then to the final question now, and this is about IPC, so infection, prevention, and control. And there’s a question from one of the participants about not really understanding their role. Why do we need IPC specialists in addition to clinicians? Don’t the measures that they will be undertaking fit under the role of clinicians or infectious disease physicians? Aren’t they part of the team in other ways? And then a specific question around how are IPC specialists involved in the West Africa and Congo Ebola virus disease outbreaks? Dale, can I turn that one over to you?

DALE FISHER: Yeah. Thanks, Jimmy. I guess some conflict of interest. I’m an ID physician and also an IPC specialist. So I kind of understand where the question’s coming from. But they are separate bodies of knowledge, if you like. In fact, most ID physicians would not regard themselves as IPC experts. They could be HIV experts, or any number of other things with specialty interests. I think what makes an IPC specialist in the field particularly different is their ability to adapt the interventions. So I can’t do what I do in the National University Hospital in Singapore, I cannot do in Liberia. So it’s quite a different setting, quite a different set of soft skills needed.

You can’t walk in there and suddenly be given the same sort of, I guess, respect and imprimatur that you have at home. You’ve got to go there. You’ve got to earn your stripes, respect the relationships, and respect the setting and the context. So I think it is quite different. An ID physician in the field, if they’re deployed through GOARN, they’re not going to be seeing patients. These are ID experts that they’re not registered in the country. They don’t work in the hospital or ETU, or whatever. We would expect people looking after patients to be more through MSF, or even through the emergency medical team process, which is part of WHO.

But our case management experts are more likely to get in and maybe help with protocols, treatment guidelines, triage protocols, different SOPs. Procurement, things like that sort of might be more what an ID physician there might do. An IPC specialist can be anything from your senior professor, potentially through to a junior nurse who’s qualified in IPC. But they’re going to offer different things. There are things that practicing IPC nurses will know, in terms of processes and day-to-day activities that someone more senior may not be as familiar with. Relationships are certainly going to be very different. The senior professor is going to be the one that can talk to the minister.

But he or she may well go into a remote facility and be completely ignored or scare people off or something. And I’ve been in this very situation, travelling with colleagues, and I can see that sometimes people are connecting with me and sometimes they’re connecting with a colleague. And that’s when you let it go. You just go, OK well, I’m going to let that happen.

And when it comes to IPC, if we talk about what happens in the field, it’s a whole spectrum of things. It can be right at the top level. For instance, we worked with ministry and MSF and CDC to standardise guidelines, which could go across the country. When– this is Liberia, September 2014 now– helped establish a national task force, write the guidelines, then it would be write a training package, deliver a training of trainers package, for instance, and then probably go and also provide that sort of input at an institutional level. So it is kind of all levels. We’re not going to be doing the IPC.

I can’t walk into the John Kennedy, I think it is, hospital in Monrovia and start practicing IPC because I don’t work there. But I can work with the people that work there and discuss what processes might be useful. So they are different bodies of knowledge, ID and IPC. I accept there is a lot of overlap, and some people can possibly do both. But you certainly couldn’t live without sort of the IPC– and I’ll say “nurses” in inverted commas because, actually, in the field, there is no difference. We’re all IPC experts, just with bringing a different set of skills. I hope that answers the question.

JIMMY WHITWORTH: Great. Thank you very much, Dale. We’re almost out of time, but just in the last few moments, I’d like to ask Soka to comment on this from the Liberian perspective, and how you distinguish between the different roles, where you’ve got national experts who are involved in the outbreak.

SOKA MOSES: Thank you very much, Jimmy. This is some real big discussion, but it all comes down to differences in rules, particularly during outbreaks. The outbreak setting can be very challenging with a lot going on. Clinicians, of course, some of the work involved, ensuring that IPCs in place to provide care for patients in a very safe and quality way. But a lot of the processes are involved that, obviously, measures are in place outside the realm of the clinicians. I mean, everything from ensuring that there are protocols for waste management, for management of dead bodies, that whatever disinfection solutions you have are the proper concentrations, are the correct ones, that you’re using Clorox solutions.

Concentrations reduce over time, so the IPC specialists, they’re making sure there are proper concentrations to the solutions out there all of the time. And ensuring that the other equipment, I mean, your gloves, your other personal protective equipment, are the right one. So it’s huge. I mean, it really goes far, far, far, far, far beyond patient care. And the processes involved, making sure the guidelines are there, people have training. They are following the protocols all the time. It’s very, very big, and that clinicians are really able to do that within the context of an ongoing outbreak. So you need IPC specialists working. You have adequate water. You have waste management protocols in place.

And also, simple things like having flow pathways, the correct flow pathways, for patients, for staff, for visitors, for guests, for resources, and then for waste. The pathways that ensure that there’s no contaminations along the way are very different, and that falls within the region of what the IPC specialist will be ensuring when an outbreak is happening within communities, and also within treatment units and health facilities.

JIMMY WHITWORTH: Excellent. OK, thank you. So I hope that gives the questioner there an idea about how these are distinct roles. Yes, there is some overlap. And you might find people coming from the same training pathway who enter both of these roles, but they are specific, separate items in a response. So we’re out of time now. I’d like to thank all of the course participants for listening to this and for sending in questions for us. I’d also like to thank our four panellists, Rosamund, Soka, Esther, and Dale, for your contributions and your energy and your insights into this. This has all been extremely valuable.

And I hope for all those of you who have been listening into this, you’ve found this valuable. Thank you very much.