1. 4th – 5th August, 2016, La Palm Beach Hotel – Accra, Ghana
Enhancing Laboratory capacity during Ebola Virus Disease heightened surveillance in Liberia Lessons Learnt & Recommendations
Katawera V, Kohar HT, Mahmoud N, Raftery P, Sahar PK, Nyenswa T, Condell O, Durski NK, Hardy P, Gahimbare L, Kateh FN, Naidoo D, Nsubuga P, Formenty P & Gasasira AN.
3rd SAA Symposium
Africa’s preparedness for emerging viral infections: Lessons from HIV/Ebola and the outlook for Zika & Lassa
4th – 5th August, 2016, La Palm Beach Hotel – Accra, Ghana

2. Outline
Introduction
Lab capacity
Heightened surveillance
Enhancing laboratory capacity
Lessons learnt
Recommendations

3. !!!Confirmation of EVD is by laboratory testing!!!
Introduction
Ebola Virus Disease (EVD)
Severe, often fatal haemorrhagic fever
Caused by Ebola Virus
5 species identified, 4 known to cause disease in humans
Zaire, Bundibugyo, Sudan, Taï Forest and Reston (CDC, 2015)
Zaire, Bundibugyo, Sudan associated with large outbreaks
Highly infectious
Risk of infection upon contact ~ 8-83% (Bower et al, 2016)
Average CFR is 50% (WHO, 2016)
2014 EVD outbreak in West Africa (WHO, 2016)
Affected 3 countries mainly
Liberia, Guinea and Sierra Leone
!!!Confirmation of EVD is by laboratory testing!!!

4. 2014 EVD outbreak in Liberia
Impact
Started March, 2014
Affected >10,000 people
Lasted more than a year
First interruption of transmission
Declaration - 9th May, 2015
Several flare ups post first declaration
June, 2015
November 2015
March 2016
Prior to declaration
Number of cases & alerts significantly dropped
Lab confirmation of EVD – Molecular diagnostics, qRT-PCR

5. Laboratory capacity in Liberia
Prior to 2014 EVD outbreak
Limited capacity for viral infection diagnostics
HIV, Hepatitis, Yellow fever
Mainly serological techniques
Molecular diagnostics for HIV were under development
No capacity for EVD diagnosis (or VHFs)
During the 2014 EVD outbreak
Initial support for EVD diagnosis
Neighbouring countries – Guinea and SL
Later, with support of Partners
Molecular diagnostics introduced
Upto 11 testing sites or laboratories
Of these, 8 were mobile labs

7. Upon declaration… Number of EVD alerts declined significantly
Started prior to the declaration
Significant reduction in the demand for lab testing
Much fewer specimens received in labs
Some labs received zero specimen for days
Closure of 8 labs – all mobile labs
Predominantly supported and operated by international partners
Only 3 operational labs left

8. But…
There continued to be a risk of new importations of EVD into Liberia
Guinea and SL still had active transmission
Also, the consequences of a new emergence from a possible animal reservoir could not be ignored
And the possibility of sexual transmission or a missed transmission chain could not be ignored either
This led Liberia to enter a period of EVD heightened surveillance post the WHO declaration

9. Heightened surveillance
Entailed use of a broad EVD case definition
“Any person who has fever and two or more other symptoms (headaches; vomiting; runny stomach; weak in the body); or who died after serious sickness with fever and bleeding”
Continuity with EVD outbreak definition post the outbreak
Significant increase in the number of alerts
Also facilitated by the June 2015 EVD flare
Significant increase in the number of specimen
Average ~200 specimen /day
Remember, there were only 3 EVD labs at this time!

10. Remember… 11
Post declaration 3

11. Limited laboratory capacity to test all specimens!
Unfortunately…
Limited laboratory capacity to test all specimens!
3 testing labs – all using qRT-PCR
3 out of 15 counties
2 out of 5 regions
10 local lab techs competent in EVD diagnostics
+ ~4 expatriates
Testing capacity
Daily ~82 samples
Surge ~301 samples
Specimen backlog
~ 900 specimen
Turn around time
~ 2 weeks

12. Enhancing laboratory capacity
Increased testing sites
Added 2 – total 5
ELWA lab – Sept, 2015
Redemption hsp – Nov, 2015
Recruitment & training of local lab personnel
16 personnel – Aug, 2015
15 competent – Oct, 2015
Recruitment of international technical personnel
3 expatriates – Nov, 2015
Institution of working ‘shifts’
Staggered approach

13. Enhancing lab capacity…
Implementation of new diagnostic techniques
GeneXpert machines (TAT~2 hours)
Sept – November, 2016
Several partners (WHO, FIND, ACCEL, NIH)
EVD Laboratory
County
Date opened
Facility type
Operator
Technology used
No. of staff
Median
Range
LIBR-NRL
Margibi
7-Aug-14
Renovation
Partner
qRT-PCR
GeneXpert 4
4,7
Phebe Hospital
Bong
3-Oct-14
MoH
4,6
Tappita
Nimba
2-Mar-15
2,6
ELWA III
Montserrado
28-Sep-15
Mobile*
4,4
Redemption Hospital
3-Nov-15 2
2,2

14. Impact of enhancing lab capacity

15. ‘Unrealized’ attempts
Challenges
‘Unrealized’ attempts
Supplies’ stock-out
Reagents
Consumables
Other supplies
Departure of technical personnel
For greener pastures
Operational challenges
Utilities
Training duration
No previous training on molecular diagnostics for the trainees
Establishment of a testing site in South Eastern B
Plans still in progress
Recruitment of more international personnel
Complexities with identifying and relocating personnel
Implementation of Ebola RDT (Oraquick/OraSure)
Succeeded in 2016
5 out of 15 counties
>50% of the population
Institution of working shifts in other labs
NRL, Bong

16. Lessons learnt Capacity building Multi-target approach
Needs to be established prior
Prepare for the known and the unknown…
Very complicated during an outbreak/ emergency
Much more complicated during heightened surveillance
Build & maintain local capacity – even during outbreaks
Multi-target approach
Initiation at the beginning
Importance of central coordination
Both international and local partners
For all support
Modern diagnostics techniques
Priceless

17. Recommendations Coordination of partners and all support
At central level – MoH
Prioritize laboratory capacity building
In preparation for the known and unknown
Invest in People, Places and Panels (Tests)
Investment in more robust diagnostic techniques
Shorter turn around time
Multiplex
Many panels in one
Encourage development of innovative diagnostics
Context specific
Easy to modify

18. Conclusion
In preparation for management and containment of emerging viral infections
Africa urgently needs to invest in quality laboratory diagnostics
Build capacity with respect to:
People
Places
Panels

19. References
WHO. (2016). Ebola virus disease [Online]. Available: [Accessed 20/07/2016]
Bower H, Sembia J, Bangura MS, Kamara AJ, Kamara O, Mansaray SH, Sesay D, Turay C, Checchi F and Glynn JR. (2016). Exposure-Specific and Age-Specific Attack Rates for Ebola Virus Disease in Ebola-Affected Households, Sierra Leone [Online]. Available: [Accessed 30/07/2016]
CDC. (2015). Review of Human-to-Human Transmission of Ebola Virus [Online]. Available at: [Accessed 31/07/2016]

20. Partners

21. THANK YOU