Settin Up the Biological Ebola Bank Facility, Including Training of African Technicians at the Ebola Diagnostic & Research Laboratory of the Holy Spirit Hospital, Diocese of Makeni, Sierra Leone

Project location: SIERRA LEONE, Makeni
Project start date: June 2015 - Project end date: November 2015
Project number: 2015-011
Beneficiary: Società Geografica Italiana - ONLUS


On May 5, 2014 the first case of Ebola Virus Disease (EVD) disease spread in Sierra Leone was reported: a young pregnant woman, admitted at the government hospital in Kenema (in the Eastern Province) following a miscarriage, showed some symptoms of Ebola. The source of her infection pointed to an earlier event. A well-known and widely respected traditional healer, who lived at the border of Guinea where the outbreak continued to swell, died allegedly of Ebola. Mourners came by the hundreds, also from other nearby towns, to honor her memory by participating in the traditional funeral and burial ceremony. The participation in that funeral could be linked to as many as 365 Ebola deaths.
On July 29, the head of country's Lassa Fever Programme, Dr. Sheik Humarr Kahn, a virologist and world-renowned expert on viral hemorrhagic fevers, died of Ebola virus disease (cf. WHO, 23 September 2014). Since then to the end of the year 2014, the confirmed cases skyrocketed to 9,832, particularly in the major districts of Kailahun (631), Bombali (718), Port Loko (658), Kenema (5931), Tonkolili (234), Bo (74) plus another 6 districts. The total confirmed deaths rose to 2.835. (as reported in December).
At present, the situation continues to deteriorate with a sharp increase in the number of newly reported cases. Five of Sierra Leone's 15 districts are on lockdown, more than a third of the population of six million is no longer able to move freely.
Sierra Leone is still among the worst country in the world in terms of health status where infant and maternal mortality is among the highest in the world. The average life expectancy is at 57. One out of eight women risks dying during pregnancy or childbirth.
The country has a weak health care system: it suffers from outbreaks of epidemic diseases such as cholera, lassa fever, and meningitis. These fragile health services couldn't avoid the spread of Ebola in Sierra Leone and its heinous impact on the population. Although Guinea, a neighboring country, has succumbed already to the EVD, information about how to prevent the spread of Ebola and care for its victim was disseminated, the national response wasn't able to contain and to cope with the disease and its complications.
In particular, Bombali District, the primary target of this project, is the third district of Sierra Leone with high number of confirmed cases (718). The Ebola Treatment Center (ETC) and 5 Holding Centers (HCs) in such district, with a total of 100 beds, cannot accommodate all suspected cases on a daily basis and cannot ensure the match with demand in each area. There are only 845 beds available out of 2.050 needed.
In the villages, a total of 140 families (1.864 individuals) are put under quarantine for 21 days or more due to suspected case/s among the family members. (as of November 2014). Suspected cases particularly in remote villages are not easily attended and put into the HC immediately because the surveillance and medical teams are overwhelmed by the daily episodes. When a suspected (symptomatic) case is not isolated, the patient can easily contaminate the rest of the family because of their living conditions.
To help containing the current outbreak, the surveillance remains key: it helps confirm diagnoses of Ebola, and aids decisions to quarantine patients and begin tracing their contacts. Unfortunately the surveillance team lacks mobility (transportation), communication (technology) and support (food and allowance).
Furthermore, medical and technical personnel are at high risk. Several of them died at the early onset of Ebola. The presence of personal protective equipments (PPE) and more strict procedures provided by the international cooperation help decreasing the risk of contagion. Providing the capacity to isolate and treat patients with EVD is central to the EVD response, but the breach of medical security protocols, the lapses of screening of persons before entering the hospital premises, the lack of adequate preparation and lapses in hospital infectious disease protocols cannot help to stop the spread of the disease, to treat infected patients, to ensure essential services, to preserve stability, and to prevent the spread of EVD to unaffected countries. On the other hand, with the closure of most of hospitals, many of workers are on leave and some without payments. Fear of contracting the virus and high levels of mistrust led both health workers and service users to abandon health facilities. Those who remained working in the hospital (in particular Holy Spirit Hospital of Makeni) see their colleagues succumbing to the disease, and so they are understandably fearful of going to work.
The outbreak has heightened the lack of trust between service users and health service providers. People in remote areas of the country initially turned to traditional healers rather than health facilities, because of rumours that spread of the virus was taking place in the Hospital.

Taking into consideration the overall situation, in September 2014 the Italian Geography Society and the UNESCO Chair of Interdisciplinary Biotechnology of the University of Rome Tor Vergata replied to an urgent formal request arrived from the Government of Sierra Leone in order to help the country under attack of Ebola virus. The Bombali District has been identified as a top priority, and Hon. Thomas Turay, a member of the Parliament elected in the Bomboli District, and President of the NGO Partners in Relief and Development (PaRD) is the main contact person for the UNESCO Chair.

Consequently in the months of September and October the Director of UNESCO Chair of the University of Tor Vergata, Prof. Vittorio Colizzi, has carried out the following actions:

1. Preparation of the "Action Plan for Ebola Emergency in Sierra Leone" submitted to the Italian Ministry of Foreign Affairs and International Cooperation. A Verbal Note, including a formal communication of the visit of Prof. Colizzi in Bombali district, had been sent to the Ministry of Foreign Affairs of Sierra Leone by the Italian Embassy in Abidjan;
2. Involving in this Action Plan also other Italian universities and the Italian Society for Infectious and Tropical Diseases in order to recruit a sufficient numbers of experts in supporting the realization of the Action Plan;
3. Cooperation with Caritas Italia and Camillian Task Force (both already present at the Holy Spirit Hospital in Makeni) to identify the most urgent actions to be put in place at the level of Makeni. A general agreement has been reached to equip a Laboratory for Ebola virus into the Holy Spirit Hospital, Diocese of Makeni.
4. Integrating the proposed Action Plan with the on-going projects realized by two Italian NGOs (ENGIM and DOKITA) to be financed by the Italian Ministry of Foreign Affaires and International Cooperation.
5. Acquisition of the equipment for the setting up of a Laboratory in Holy Spirit Hospital, with the help of the Caritas Italia and with additional financial support by CEI, Makeni Catholic Diocese and MAGIS (Jesuit NGO). In this way the health workers will be able to handle, to make diagnosis and to quantify the Ebola virus according to the WHO standards. The necessary materials are the following: Biosafety Cabinet BSL3, the RT-PCR machine, centrifuge, and all other small equipment and reagents.
6. Involving the Pharmaceutical Company Merck (Capacity Advancement Program for Africa) and UNESCO in a short-time course Teaching Emergency for Ebola for students at the universities in Sierra Leone (Freetown and Makeni).
7. Organization of a on field visit of Prof. Colizzi and Dr. Gianluca Russo in the second week of November in Freetown and Makeni (Bombali District). The main objective has been to assess the Holy Spirit Hospital for setting up the Laboratory, and to evaluate the Medical/Nurse/Technician Training/Motivation needs. Although P. Arias Miranda Diez (Camillian Task Force) has already carried out an assessment visit in the Holy Spirit Hospital, this mission has been focused on the Laboratory and Medical technical aspects to both hospitals.
8. Restructuration of Laboratory's space and the other structures (Triage, Holding Center) in order to ensure the containment of Ebola virus isolated at the Holy Spirit Hospital.
9. Delivering and gathering of all equipment, materials, and procedures for the setting up of the Ebola Diagnostic & Research Laboratory at the Holy Spirit Hospital, in order to start hospital activity as soon as possible.

The laboratory staff has been selected considering the skills, the personal availabilities, the high profile of the participants in order to implement successfully the project working plan. The staff members are partly Italian and partly Cameroonian, all of them trained in Italy. They will receive a specific training before departure at the University of Rome Tor Vergata. Therefore the staff consists of:

1. A project technical-scientific Head: Prof. Vittorio Colizzi (Senior Clinical Infectious Diseases and Senior Laboratory Scientist). He is coordinating activities both in Italy and in Sierra Leone and oversee the laboratory-working plan. Prof. Colizzi is already at the Holy Spirit Hospital to set up the Ebola Laboraotry.
2. A laboratory Director (Biomed expert) of the University of Rome Tor Vergata (Prof. Carla Montesano & Prof. Domenico Frezza) in rotation with Prof. Colizzi.
3. Highly specialized laboratory technicians (two Cameroonian experts and four Italian ones) in a total number of six, who will run the laboratory daily activities for 12 weeks in rotation.

The main aim of the project submitted by the Società Geografica Italiana which received a grant from the Nando Peretti Foundation is to strengthen and improve the local health system in Sierra Leone with the introduction of new technologies in the field of Ebola epidemiology and scientific research. So the project will realize vocational training in medical laboratory techniques while putting advanced instruments, knowledge and methodologies at the service of health workers who will be able in the future to effectively track outbreaks, not only of Ebola Virus Disease, but also of other microbial diseases, using limited resources and diagnostic technologies.

In Sierra Leone, there are only 4 diagnostic facilities and the nearest one is more than a 300 km away from Makeni, so the realization of a new center allows to accelerate the releasing of patients in the holding centers (HCs), to screen and examine the waitlisted suspected cases and to identify quickly the virus thereby avoiding its spread. In order to fight the Ebola Disease Virus and to meet the need of a closer diagnostic center in Makeni (Bombali District), the Italian Geographical Society proposes to set up the Biological Ebola Bank Facility inside the Ebola Diagnostic & Research Laboratory, to store all biological samples that will be an important resource in the further scientific and epidemiological research while training the staff who will be strictly supervised by international experts. The Laboratory is under construction with the fund of Caritas International and the support of the DOKITA, Italian NGO based in Sierra Leone that has received financial resource by the Italian Ministry of Foreign Affairs for the realization of such Laboratory.

As a result, the project includes the implementation of the following activities carried out by the specific partners:
- Training of health personnel in the Holy Spirit Hospital for the containment of Ebola virus and for the treatment and identification of EVD patients.
The training course will be promoted by the experts of the University of Rome "Sapienza", who will help to train 30 health care workers to identify and treat patients. It is providing medical supplies, equipment for staff at the Holy Spirit Hospital.
The course provides lectures on Ebola transmission, epidemiology, and prevention; small-group exercises on patient triage and working safely and practical hands-on exercise. It provides the basic principles of clinical care and management of the Ebola infected patient and describes patient and community assessment and intervention strategies for Ebola treatment and control.
- Specific training of local workers called "Molecular Biological & Immunology of Microbial Infections" in the field of the molecular diagnosis of Ebola virus for keeping the Biological Ebola Bank Facility update in Ebola Diagnostic & Research Laboratory in the Holy Spirit Hospital.
The training will be carried out by 2 experts from the International Reference Centre "Chantal Biya", and by 4 experts from the University of Rome Tor Vergata and thanks to the financial support of the Nando Peretti Foundation. The technical staff that includes such international experts is divided in three teams. Considering the training of 6 local technicians, two training runs will be organized. A period of 7 weeks is required for theoretical training (divided in 99 hours in 33 days) followed by a working period of 9 weeks. During the first 5 weeks, there will be laboratory practical activities, divided in 60 hours in 20 days. The last 4 weeks of the working period, the 6 local technicians will work by themselves in team of 2, with a regular monitoring in the respect of the procedures and reliability in the quality of the result generated by the technicians. After this period of practice and the training assessment, they will receive a certificate that recognizes their qualification and they will be entitled to work in the Laboratory. This local technical staff will be provided with a financial motivation, based on training results.
- Creation of a Biological Ebola Bank Facility in the Ebola Diagnostic & Research Laboratory in the Holy Spirit Hospital.
The Holy Spirit Hospital has received the financial support (130.000 Euro) by the Italian Bishop Conference (CEI) through the Caritas International, for the provision the Ebola Diagnostic & Research Laboratory with all equipment and reagents for diagnostic activity. Considering the importance to store all the biological materials for subsequent scientific research from patients, survivals and contacts, the main objective of the present request is to set up a Biological Bank. The Biological Bank is composed of one -80 Freezer, one computer and server for data storage, and an automatic Station to carry out serological analysis. The Biological Bank will store demographic and epidemiological data, viral and serological materials that can be used for epidemiological analysis, clinical trials, viral evolutionary analysis, and immunopathology studies in the post Ebola period of time. The Italian Geographical Society, funded by the Nando Peretti Foundation, will supply the Ebola Diagnostic & Research Laboratory with the necessary equipment, reagent and personnel (see detailed budget) dedicated to the Ebola Biological Bank, training of personnel and setting up of software and procedure for epidemiological studies.
- Other activities:
Other activities will put into practice by the PARD that will help the partners accomplish their tasks, offer the cover of travelling expenses at local level. PARD will commit in local activities, such as the tracing of Ebola survivors and victims and the collection of the information in a specific database. PARD will do this by recruiting local volunteers with the financial support of Nando Peretti (in order to have a better financial management, the SGI and PARD is going to sign a Partnership Agreement). The local volunteers will provide support to the people, give the necessary logistics for the promotion of the Ebola sensitization campaign, the identification of survivals cases and their familiar contacts to provide biological materials to the Biological Bank.
The role of SGI:
The SGI integrates with and support the local planning, management and coordination of the project's activities; it keeps track of how the project is progressing in terms of expenditure, resource use, and implementation of activities and delivery of results. Moreover it will undertake the administrative provisions for the implementation of the project and it will provide administrative support. Finally the Society will ensure dissemination activities (conferences and /or seminars) and establish the institutional and international relationships.

To summarize, this project's main goals are:

• Education and training of local technicians in handling Ebola contaminated biological and hospital materials.
• Banking biological materials both from the residual samples after the molecular diagnosis, and from specific campaign to trace survivals and their contacts.
• Providing the biological materials to collaborative research institutions on the ground of specific research projects authorized by the Government of Sierra Leone.
• Provision of technology and knowledge on how to develop prototypes of devise for the realization of rapid and low-cost tests.

The overall project has several multiplier effects on the target group, i.e. patients with suspect Ebola infection, which need hospitalization, but also on the way of life of local population. It is also going to improve the local health system because it will address the increasing demand for information and technical training from health and technical personnel in the field of Ebola Virus Disease.
The collection and banking of biological materials from Ebola patients will contribute in the near future for developing new medical devises for diagnostics, and better epidemiological information at the population and viral levels. The Biological Bank will remain active and available for future to all scientific and medical international institutions, including pharmaceutical companies, which aim to develop specific drugs against Ebola virus.

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