By Rob Verkerk PhD

Founder, scientific and executive director, ANH International

Last week we discussed dehydration as an underestimated and insufficiently prioritised contributory factor to the estimated 70% death toll from those infected by Ebola in West Africa.

This week, having returned on Sunday afternoon from my second trip to Sierra Leone, I bring you some fresh-from-the-field insights. I also take a closer look at the situation from the perspective of how nutrition could perhaps be better deployed to secure improved outcomes and survival rates among Sierra Leoneans in Ebola-stricken areas.

TOP FACTS

• Six British-built Ebola Treatment Units (ETUs) are coming online to help support patients in Ebola-ravaged Sierra Leone

• Clinical practice guidelines are beginning to look at the effects of dehydration loss, but as yet, there is no emphasis on how nutritional status might affect the body's viral load or survival chances
  

• Some community holding centres are still desperately under-supported despite £280 million of British donations flooding into the country

• Patients in community holding centres and quarantined homes are not getting even the minimum protein requirement to meet the adult requirement of protein, let alone the micronutrients or phytonutrients needed

• There is a dire need for more emphasis on nutritional support among suspected and confirmed Ebola patients, as well as those most at risk, namely health workers and members of quarantined households
  

• You can help by supporting our efforts

While we may have passed the peak of the West African outbreak, there is still lot at stake that will determine whether or not Ebola can be defeated altogether in Sierra Leone. If the present fight against Ebola is not won, West Africans, and potentially others further afield, will have to accept that the deadly Ebola Virus Disease will establish itself as yet another endemic disease, wreaking havoc on lives, along with malaria, cholera, tuberculosis, HIV/AIDs and others.

The British public, who have contributed millions towards the effort, have now something tangible to show for their generous donations in Sierra Leone: six Ebola Treatment Units, or ETUs. Not all are complete and functional at the time of writing. ‘Treatment Unit’ is of course an interesting term given the consensus among the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) that there are, as yet, no therapeutic treatments available for the deadly virus. Intravenous fluid replacement, balancing electrolytes, managing oxygen status and blood pressure, along with using broad spectrum antibiotics for any other infections that might arise, represent current clinical practice guidelines stipulated by the CDC.

While supporting some of the work being done by the Sierra Leone government in more remote communities, our team was invited to the opening of the new, 100-bed British-built treatment unit in Port Loko. It is called the Mataska ETU. The Kerry Town ETU, handed over to Save the Children, got off to a much-publicised rocky start. But the Mataska ETU, named after the little, nearby village of Mataska, was opened on 13 December 2014. Just on the outskirts of Port Loko town, it took just 11 weeks to build. The lab and a few other buildings are hardened, the rest being metal frame and white tarpaulin, with an estimated life span of around 5 years. The other four, British-built ETUs, will come online soon.

Construction of the Mataska ETU was managed by the humanitarian outfit Goal, whose logos are strategically placed adjacent to the UK Aid ones, that also carry beneath them the strap line “from the British people”.

Fence-line of the Mataska Ebola Treatment Unit, near Port Loko, northern Sierra Leone

At the time of writing, there are only a small number of measures known to be able to quell the devastation being caused by the Ebola virus. One that’s been at the core of the ‘national Ebola response’ in Sierra Leone is the process of breaking the transmission chain. Alongside this, is the ‘social mobilisation’ and education effort that has involved a multitude of approaches designed to change attitudes and behaviours to prevent transmission. That includes stopping traditional burial rituals that have been a major source of contagion. Everyone from community leaders like Paramount Chiefs, to Section Chiefs in individual chiefdoms, along with teams of trained educators, some in our own team, have been or are involved. President Ernest Bai Koroma and other Ministers, notably Alpha Kanu, Minister of Information and Comunications, tirelessly travel the country getting these messages across.

National Ebola response

Breaking the transmission chain essentially means isolating those who meet the ‘case definition’ of Ebola Virus Disease from their communities as quickly as possible, putting them in community holding or treatment centres, identifying whether or not those in holding centres are confirmed via a lab test as being infected with the virus, and then releasing those who are not and treating those who are. With the new ETUs, that means standards of treatment will in the main be improved, but it is truly remarkable what some of the local doctors and nurses are doing for their own people, often with incredibly limited resources.

Directors at the Mataska ETU claimed ambitiously to try to bring the fatality rate down to just 10%. That would really be something, in the absence of any therapeutic measure. Such a goal also demonstrates just how much faith may be placed in the innate defence mechanisms with which each one of us is blessed, to deal with a virus as potentially lethal as Ebola, given some additional support.

Mataska Ebola Treatment Unit (ETU), near Port Loko town, northern Sierra Leone, on the day of its inauguration by the Hon Alpha Kanu, Minister for Information and Communications (13 December 2014), prior to receiving patients 

Another key process quelling the fury of the virus in Sierra Leone involves burying the dead within 24 hours of death to avoid any further human contact. This is one of several tasks being stage-managed by ‘command and control’ centres run by the British forces, with a tight collaboration with Sierra Leonean forces. Here you’ll find more unsung heroes, alongside the Sierra Leonean health workers who are in the front lines and doing incredible work against the odds, often with precious little in the way of resources.

The attitudinal and behavioural shifts are being managed via a ‘social mobilisation’ and ‘sensitisation’ strategy, which has been unleashed as part of the natonal Ebola response. Further pillars to the Sierra Leonean government-led assault on Ebola include community surveillance, contact tracing and case management. Put together, the best estimates suggest that if the national Ebola response can maintain its present form and level of acceptance by communities, by the end of January, the situation might look considerably more rosy than it does now.

At the crux of the community outreach has been ongoing efforts to change behaviours and attitudes to help communities better understand early symptoms of Ebola, avoid body contact (yes, 'ABC'), stopping social gatherings and festivities, reducing unnecessary travel – and critically – warning against superstition, traditional burials and other practices that have been major factors in continued transmission.

Damned to eternity?

A former British police officer managing one of the ‘command and control’ centres admitted to us that he felt community outreach would probably never stamp out practices that aided the virus' transmission altogether. As he said, if faced with the option of being lambasted by your community's Paramount Chief or even being imprisoned for breaking the law, that would surely be preferable to having your soul damned to eternity for not ensuring traditional burial rites.

Community action

Thousands have been trained as members of surveillance teams to patrol communities and identify those meeting the Ebola ‘case definition’, to call free-of-charge ‘117’ on their mobile phone and have them plucked from their community by ambulance and deposited in the nearest holding, or treatment, centre. Nearly two hundred centres are now up and running, with a bed capacity approaching 700. The majority of these are holding, not treatment, centres, largely make-shift structures using wooden frames made of un-milled branches of trees and blue tarpaulin, based around local schools or community centres that have been closed since the outbreak took hold.

A patient preparing to receive IV fluids at the Sumbuya holding centre, Port Loko district

A typical centre might have a 30-bed capacity, although some have twice or more this number and others less than half. Not many Westerners would feel comfortable having their nearest and dearest brought to one of these. Some international aid workers ahve labelled them as 'death camps', but really, manged with due care, they save lives, both inside and outside. Classrooms have been turned into wards. Some have no partitions between beds. The beds are either old hospital beds or cobbled-together wooden ones sporting a thin mattress, generally without a sheet. Once inside the ‘red zone’, reserved for suspected or confirmed Ebola patients, you will find health workers adorned head-to-toe in ‘personal protective equipment’ – PPE – including masks and face shields. Of the literally hundreds of millions of pounds of aid that have poured into Sierra Leone, only a smattering has trickled down to some of these community holding centres. Some of them, including two with which we’ve been involved, have received almost no external support. They are funded by the cash-strapped Sierra Leone government, local chiefs and local foundations. The majority of the staff, comprised of nurses, disinfection sprayers, cleaners and security personnel, are volunteers. Even the construction of some of the centres has been a community effort—and largely a voluntary one.

Staff and project team at the Sumbuya holding centre, Port Loko district, northern Sierra Leone 

Another measure that is known to protect against death from Ebola is the viral load in the body. This may be affected both by the extent of the transmission exposure, such as the surface area of contact with infected body fluids, but also the ability of the virus to replicate once within the body. To give you some idea, an earlier study showed that the amount of Ebola virus RNA in the blood of patients who died from Ebola was around 200 times greater in those who died, compared with the survivors.

Food as medicine

The science of immunology tells us that the quality and amount of food and water available to any patient facing immune challenge by a pathogenic agent are major factors affecting the competence of the immune response. While it is emerging that a common reason for death by Ebola is dehydration, we also must consider the role of nutritional inadequacy or, what we might call in the case of an Ebola outbreak, ‘conditional malnutrition’. These are among the key factors that determine whether or not someone will survive infection by the deadly virus. Managing nutritional status has soi far received very little attention in the West African Ebola crisis.

The community holding centres are reliant on food donations from the World Food Programme (WFP). These amount to little more than rice, palm oil, bean powder and salt. Sometimes, a little more will be available to quarantined households, including sugar, tinned fish, luncheon meat, sugar and Ovaltine.

The price of vegetables, and in particular protein sources like meat and Omega3-rich fish, have skyrocketed since the Ebola crisis brought the country to a standstill in May. These provisions are too costly to use, other than perhaps for a little flavouring or texture. Estimating the protein intake among patients and health workers at one of the centres last week, I was hard pushed to find a protein intake greater than 10 g/day. The Food and Agriculture Organization (FAO) suggests about five times this amount as a minimum intake for adults, 0.75g/kg body weight/day, which equates to over 50 g for a 70 kg adult. And that’s not one infected with Ebola. Micronutrient and phytonutrient intakes across dozens of categories would be well below the amounts required for essential, and particularly, optimal, physiological and metabolic function.

Water shortage

Clean drinking water is expensive too. And given the central symptoms of Ebola, often including bouts of uncontrollable fits of diarrhoea and vomiting, fluid loss is a huge problem. If you’re a health worker, not only do you risk your life daily—often voluntarily—you have to accept that patients get priority over you for water. I have seen health workers almost collapse from dehydration after working in full PPE for several hours work in temperatures exceeding 30 degrees centigrade. It’s not worth thinking how much less efficiently their bodies would cope with the onslaught of Ebola should they become infected compared with a body fully hydrated. Tragically, I heard yesterday that one of the disinfection sprayers I had met in one of the centres had just died of Ebola.

Food being delivered to the Sumbuya holding centre, Port Loko district

But it’s not just the patients and health workers in community holding centres that are suffering dehydration and malnutrition. It’s also quarantined homes. When surveillance teams remove one or more infected individuals from a home, the home is quarantined. That means the remaining household members, irrespective of their ability to cook or prepare food, can’t get to the local market to buy their food. They too are reliant on the WFP-donated rice, palm oil, bean flour, salt and any other ancillaries. Some may go on to develop Ebola may be later plucked from their houses.

We were witness to an impassioned plea about nutrition by the Hon Alpha Kanu, who has been a champion of community-level action in the Port Loko district for which he is also Member of Parliament. The plea, in which the Minister proclaimed that “food is 50% of the medicine,” was delivered outside the Lokomasama holding centre, which Mr Kanu’s foundation, the AlphaKha Foundation had been largely responsible for constructing, last Saturday, 13 December.

Minister for Information and Communications, Hon Alpha Kanu, making an impassioned plea for improved nutrition for patients and health workers in the Lokomasama holding centre in the Port Loko district and in quarantined homes

It’s a travesty that with all the money pouring in to Sierra Leone, that such key areas of the overall programme are being largely ignored. It was reassuring to recently find the French NGO, Action Contre le Faim (ACF), advertising a position for a nutrition and health coordinator in Sierra Leone. Any takers?

For some families, losing a loved one to the handful of ‘flashy’, and more importantly, distant, treatment centres, is not as attractive an option as one might imagine. Visiting would be nigh on impossible for some, as many communities are many tens of kilometres from an ETU. No problem for the few with cars or motorcycles, but impossible distances for those without.

The relative lack of attention to community holding centres and to quarantined homes is to my mind a disgrace to the international aid effort, that now appears to await the arrival of vaccines, that may or may not work. One vaccine trial has already been suspended owing to untoward side effects.

Food and water are vital to life, and particular nutrients, over and above the requirements for an uninfected individual, are required to establish a competent immune response to one of the world’s most deadly viruses. It is astonishing given the scale of the Ebola relief effort, that these factors, along with adequate support for the hundreds of voluntary Sierra Leonean health workers, are being so overlooked.  Let an equilibrium be found—and urgently. Special emphasis should also be given to local, nutrient-rich foods along with other concentrated sources of nutrients.

If such approaches help communities with residual infection, or if they were to help infected individuals emerge from hiding within their communities, this would be one step further towards stopping Ebola becoming endemic in the region. But, among the many scientists, doctors and health workers on the ground in Sierra Leone that I talked to, I found very few who thought eradication any longer a likely outcome.  The saving grace is, at least, that the multi-lateral approach to dealing with this most deadly disease is increasingly becoming better established, while it is still being refined and improved.

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