Active case finding as a key part of the Ebola response

Emergencies, Health

Duoi Ampilan, one of our public health promoters, talks about how our work on active case finding, whereby Oxfam went to communities to find cases of Ebola and other illnesses, became a key part of the overall response to Ebola in Liberia. 

When I was called to join the Ebola Response in Liberia, there were  many doubts in my mind. Firstly, we are not a medical organisation. Secondly, I am used to the standard Oxfam way of doing water, sanitation, hygiene and social mobilisation activities. I would normally know my role and what I could contribute to the team when I was on the ground.

We knew that awareness raising was not enough to break the transmission chain of the virus.

When I reached Liberia, our team was already engaging the communities with hundreds of volunteers on the frontline with the door-to-door awareness campaign to prevent Ebola. We knew that awareness raising was not enough to break the transmission chain of the virus. We had to contribute to the Ebola case finding, contract tracing, treatment and safe burial or reintegration of the survivors.

After a series of coordination and consultation meetings, analysis of the disease cycle and the referral chain, we came up with a proactive way of detecting individuals showing the classic symptoms of the disease at the earliest time and called it active case finding.

The active case finding work contributed to the whole system of breaking the transmission chain though it works dependently with other actions. It is most relevant in an urban context where people are in a congested environment where rejection, denial and mistrust to the whole system are common.

In consultation with my colleagues, I made a model called the EVD Control Process; a diagram showing the series of interconnected activities detailing what needs to be done in each of the five major steps:

  1. Active case finding
  2. Isolation (while waiting for help)
  3. Safe Transportation
  4. Treatment
  5. Safe and Dignified Burials

Many of the infections are occurring from unsafe practices along the way. This model was revised many times.

Utilising our expertise on social mobilisation, we engaged ourselves to popularise active case finding. I drafted a simple questionnaire and worked with 22 individuals to do a one-day trial. That one day was so precious because it helped us to improve the questionnaire and taught us lessons on how to effectively engage communities.

After integrating the comments, suggestions and the experiences of the first trial, we launched a community-wide piloting of the active case finding. We mobilised 125 volunteers targeting thousands of households in Clara Town, Monrovia in Liberia. After three days, we launched the activity in West Point and New Kru Town; mobilising more than 300 volunteers. This pilot activity ran for a week. Our team was overwhelmed with finding hundreds of individuals with different health complaints. There were a few however that were suspected to
be Ebola.

We again reinvented our strategy based on the week long pilot test. We revised the questionnaire, we added an EVD triage flowchart to filter the signs and symptoms, and reduced the number of individuals for referral. We developed a reporting and referral flow and we monitored waiting time for ambulances to improve the system. We also learnt how to talk to families and individuals who were in denial, angry and even rejecting us. We collaborated with the Ebola Task Force and community leaders including religious ones to
help influence the community to cooperate. We continued to build relationships with the communities, which started when we first did the Ebola awareness campaign.

Once there is an active case (probable or suspected based on the EVD Triage Flowchart), the team quickly collaborates with the Ebola Task Force and call the Case Investigation Team from the Ministry of Health. They investigate the case, then transport the patient safely with an ambulance to the Ebola Treatment Unit (ETU).

Once someone is confirmed as Ebola positive (+), the Contact Tracing Team identify the contact and do the surveillance. The blanket approach of active case finding ran for two months in the target areas until we concentrated on the hot spot areas with the help of GPS and based on the confirmed Ebola cases. We increased our visibility in the hot spot areas while also maintaining our presence in the void areas (no cases for two-three weeks). 

At the time of writing, Liberia has gone over 21 days without a case of Ebola. Through our continuous presence in the communities and our way of building relationships with the communities, the synergy between the EVD awareness and active case finding, we are winning the trust and confidence of the communities.

So far, we have reached more than 46,000 households and identified 1,179 households with sick members required for monitoring. A total of 239 suspected cases were referred and 203 individuals went to local health facilities for testing and were sent to ETUs for treatment. Patients would walk in to units and tell them that Oxfam encouraged them to seek medical attention.

We are winning the trust and confidence of the communities.

Some patients are directly going to the ETUs. It seems that we are winning the battle based on the game of statistics. But, we need not to be complacent. Though there are no more cases, we still maintain our active presence on the ground. From the door-to-door approach, we are levelling up to engage more the community structures and this time, aside from the township formal leadership and the Ebola Task Force, we are targeting religious, women and youth groups.

We are also extending our activities in schools. We have reached more than 400 schools in Monrovia, training school teachers on how to maintain a Safe School Environment, in partnership with the Ministry of Education to ensure that schools comply with the Ebola protocols set by the government. We’re also working on the facilities in 82 schools to ensure that children have access to clean water, decent sanitation and hand washing facilities.

Looking forward we are revising our strategies to ensure that we contribute to the long term development programme and the rehabilitation phase of the Ebola response in Liberia.

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Author: Abdullah Ampilan
Archive blog. Originally posted on Oxfam Policy & Practice.