London School of Hygiene & Tropical Medicine

Outbreaks of filovirus haemorrhagic fevers (FHFs) such as those caused by the Ebola and Marburg viruses can only be controlled if agencies have the support and trust of local communities, according to two papers just published in the online edition of the Journal of Infectious Diseases as part of a special supplement on filovirusues.

Few records exist of the experiences of outbreak control teams, and the lessons learned from previous outbreaks were not easily accessible to the initial team at Uige, Angola, when an outbreak of the Marburg virus occurred in 2005. As a consequence, a number of initial mistakes were made and protocols and strategies had to be modified as the outbreak progressed.

Members of the Medecins sans Frontieres (MSF) Spain team which took part in the Uige response have written about the lessons they learned there, in the hope that those working to control future outbreaks will be able to benefit from their experiences. The two papers, produced jointly with the London School of Hygiene & Tropical Medicine (LSHTM), look at the lessons learned in the community, and in the local hospital, where an isolation ward was set up specifically for the treatment of patients with Marburg.

While the effectiveness of treatment for FHF is limited, and the case fatality is high (50-90%) outbreak control procedures are effective at controlling its spread. The difficulty lies in securing the trust and cooperation of communities, for whom these diseases, and the equipment that surrounds their control - white suits with the wearer's face obscured, disinfectant spraying devices in a part of Africa where fear of poisoning is widespread - are a source of great anxiety. In previous outbreaks in Gabon and Congo, community resistance had been so severe and violent that international teams had been prevented from completing their missions.

The MSF team learned the importance of incorporating local traditions into their approach, and addressing the psychological and spiritual needs of families in the burial and disinfection process. At first, bystanders were not always told why procedures were being carried out, which led to fear and mistrust. The process of disposing of corpses, which are a route of transmission for the infection, was initially handled by the hospital; preventing relatives from performing burial rites, or ascertaining where their loved ones were buried.

The MSF team realised that if the community was to be brought on board, burial rites would need to be adopted that, while safe, resembled traditional ones as far as possible, even though this was likely to be more time-consuming. They therefore adopted a modified version of the WHO protocol which involved the burial and disinfection team changed in and out of their protective clothing in front of household members, so they would understand that they were human beings, just like them. Burial rites now involved the use of coffins and allowed the family to identify the corpse before burial, which confirmed the death and allayed any rumours about what might have happened to their loved ones, and included songs and dancing, carrying and lowering of the coffin using gloves, and filling the grave with earth, as would normally occur.

The team also replaced or repaired items that had been damaged by the disinfection process, such as burned mattresses, which helped to make the families more accepting of the control measures.

If a filovirus outbreak is to be contained and terminated, then early detection and the subsequent isolation of patients is vital. In Uige, however, only 44 of the known cases were isolated and in the absence of obviously effective therapies for what is more often than not a fatal disease, it is difficult to persuade people to go to hospital for the purely altruistic reason of preventing transmission within their families and communities, particularly when traditional healers promise a cure.

The MSF team in Uige enlisted the support of the Sobas - traditional and official community leaders trusted by the people - in trying to persuade families to accept hospital treatment for their loved ones. The team also developed a more proactive treatment approach involving IV fluids and naso-gastric feeding, both commonly-used interventions in hospital wards in Africa, and had the impression that this approach helped some patients to survive. Furthermore, the idea was that if people perceived that if greater effort was being made, they would be more likely to accept isolation and, indeed, the reputation of the Marburg ward improved after the proactive approach had been put in place.

The team also realised the importance of improving psychological support for everyone involved in the outbreak. Initially, only MSF personnel had been offered stress and fear management sessions, but these were extended to patients and relatives, who reported finding these helpful in allaying fear and anger, reducing patient stigmatisation and quelling rumours and panic within the community.

Matthias Borchert, a clinical lecturer at LSHTM, is one of the report's authors, having been seconded to MSF by LSHTM to contribute to the evaluation of the intervention. He comments: 'The experience in Uige clearly shows that biosafety and epidemiological efficacy alone are not sufficient to make an FHF intervention effective. Involving local authorities and respected influential individuals is an established principle of public health interventions in the community. Yet this principle is easily forgotten in the heat of an FHF outbreak. When MSF involved such authorities, community relations improved promptly and significantly, ameliorating case finding and outbreak control'.

Co-author Paul Roddy, an epidemiologist based with MSF Spain, adds: 'Similar to previous outbreak response teams, the MSF team in Uige made errors, corrected them and underwent a learning process that improved intervention effectiveness. MSF hopes that sharing these experiences with other FHF outbreak response actors will strengthen future FHF responses'.