Ebola a reality of modern Public Health; need for Surveillance, Preparedness and Response Training for Health Workers and other multidisciplinary teams: a case for Uganda

Introduction West Africa is experiencing the largest ever reported Ebola outbreak. Over 20,000 people have been infected of which about 9000 have died. It is possible that lack of community understanding of the epidemic and lack of institutional memory and inexperienced health workers could have led to the rapid spread of the disease. In this paper, we share Uganda's experiences on how the capacity of health workers and other multidisciplinary teams can be improved in preparing and responding to Ebola outbreaks. Methods Makerere University School of Public Health in collaboration with the Ministry of Health and the African Field Epidemiology Network (AFENET), trained health care workers and other multidisciplinary teams from six border districts of Uganda so as to increase their alertness and response capabilities towards Ebola. We used participatory training methods to impart knowledge and skills and guided participants to develop district epidemic response plans. Communities were sensitized about Ebola through mass media, IEC materials, and infection control and prevention materials were distributed in districts. Results We trained 210 health workers and 120 other multidisciplinary team members on Ebola surveillance, preparedness and response. Evaluation results demonstrated a gain in knowledge and skills. Communities were sensitized about Ebola and Districts received person protective equipments and items for infection prevention. Epidemic Preparedness and Response plans were also developed. Conclusion Training of multidisciplinary teams improves the country's preparedness, alertness and response capabilities in controlling Ebola. West African countries experiencing Ebola outbreaks could draw lessons from the Uganda experience to contain the outbreak.


Introduction
Since 1976 when the Ebola virus was first identified, no Ebola Virus Disease (EVD) outbreak has been as large or geographically widespread or persistent as the current epidemic in West Africa.
Worse still, this is the first time that EVD is affecting West Africa; the disease was previously limited to East and Central Africa [1,2] With each passing day, news of the ongoing Ebola outbreak becomes more dire [3]. EVD is spreading across Guinea, Sierra Leone and Liberia at an unprecedented and exponential rate, with global health agencies predicting 10,000 new cases a week by the end of 2014 culminating in hundreds of thousands of affected people if response efforts are not rapidly strengthened [4,5]. As of 29 October , there were 13,567 confirmed, probable, and suspected cases of EVD reported in eight affected countries-Guinea, Liberia, Mali, Sierra Leone, Spain, Nigeria, Senegal and the United States with 4,951 deaths [6] . The reported number of EVD cases exceeds that from all previous outbreaks combined [5,7] According to the United Nations Mission for Ebola Emergency Response (UNMEER) 4,199 cases and 1,023 deaths have occurred in Sierra Leone (24% Case fatality rate). However, the case fatality rate among healthcare workers (HCWs) in Sierra Leone is very high at 80% with 101 deaths out of 127 infected HCWs (as of 26 October 2014). This is worrying given the limited number of health care workers; there were only 100 doctors serving 6 million citizens prior to the EVD outbreak, translating into two doctors per 100,000 people [8,9]. Weak health institutions, marred by the county's 11year civil war coupled with low numbers of trained local HCWs have contributed to the country's inability to properly recognize, isolate and treat patients, bury their dead or contain the disease's spread [3,7,10]. The ongoing EVD outbreak has weakened the entire health system of the three most affected countries of Sierra Leone, Liberia and Guinea given that its fragile state prior to the onset of the outbreak [4,11] noted that Sierra Leone's non-Ebola health system has collapsed at the height of the epidemic, and the university medical and health programs have been shuttered for months.
The International Health Regulations 2005 (IHR) require every country to develop its capacity to detect and respond to public health events of potential international concern. There is an immediate need to train health care professionals to provide critical care in Ebola Treatment Centres (ETCs), district and community level health centers, as well as provide training and education for local health care students who are unable to graduate due to the closure of schools in order to strengthen the resilience of the local health care system in Sierra Leone as well as the other EVD affected and high risk countries [10,12]. Uganda has experienced six EVD outbreaks in 14 years, three of which appeared in 2011 and 2012 [13]. The first Ebola outbreak occurred in 2000 in Uganda's Northern District of Gulu and led to a total of 425 cases and 224 fatalities, making it the largest Ebola outbreak globally until the West African epidemic of 2014 [13][14][15]. Uganda has standing multisectoral and multidisciplinary task force committees on epidemics that include partners and NGOs at the national and district level [13]. The national task force is composed of experts Over the years, the county's surveillance system has been strengthened. There are designated surveillance focal points at health sub-district, district, and regional levels, have been trained and facilitated to ensure timely detection, reporting, and investigation of priority diseases ( including VHFs). These coupled

Selection of the training sites
Six boarder districts were considered and these were Kisoro, Kasese, Kabale, Busia, Tororo and Arua. Sites with border posts that are used by many people from neighbouring countries were selected. These are in the districts of Arua, Kasese, Kisoro, Kabale, Tororo, Busia. The Democratic Republic of Congo has had numerous outbreaks and even the outbreaks that occurred in Uganda in Bundibugyo and Kibaale were in districts close to the border. There are also many refugees that have crossed from Congo into Uganda.
There is therefore reason to include the districts of Kisoro, Kabale, Kasese and Arua in the border surveillance. Busia and Tororo are entry points for the main traffic from Kenya has an airport through which many passengers to Kenya and Uganda pass, entry points need to be put along this way to identify and support the efforts on this transit way.

Trainee selection
The

Training methodologies
The training was participatory using: group discussions, brainstorming; small group work, demonstrations, visual aids, role plays, case studies; and practical exercises. This tried to build on the experiences of these different professionals who were enhancing their expertise over and above their long experience in health care and surveillance. It also augured well with the adult training techniques for trainees of different disciplines. The training was done with mixed groups and sometimes with more specific groups aligned to the different disciplines [16]. The training lasted a week (five days) in each district to allow full commitment from the participants. A training of longer period would either not be attended by many people or some of the people would be off for some time and this would endanger the team spirit that the training was intended to achieve.

Training Content
Because not much is known comprehensively on Ebola and what is known is not universal, careful preparations were done and the

Training results/outcomes
Community engagement Radio talk show Three facilitators, and the district health educator were hosted on live call-in Health talked shows in both Tororo District In Kabale, the talk show was held at Radio West (FM 94.3) from 7PM to 9PM these being the pick time for the communities to be attending or listening to news and local informative programs. In Kisoro and Kasese districts.radio the talk shows were held at voice of Muhabura 88.9 FM and Radio Messiah 97.5 FM respectively. These radio talk shows have in the past shown to be effective in mobilising the communities for a common goal [16]. The facilitators were given an opportunity talk about Ebola facts. Thereafter, the lines was then a live question and answer session with the listeners (Figure 2).

Knowledge and skills gained
The participants in all the districts gained knowledge and skills that  Table 2 . 4) All the six district received logical support in terms of PPE and other assorted item as part of the preparedness and response efforts as shown in Table 3 below.

5) District Epidemic Preparedness and Response plans were
developed in all the six districts. The following key thematic areas were planned for: health worker training, laboratory strengthening, stockpiling of required material (PPE), seed funds, surveillance coordination and social mobilization. These will guide response actions in case of an outbreak in these districts: the capacity of screening at points of entry in all the district increased following the training. Currently plans are underway to create more screening points especially in Kasese district (Figure 6).

Discussion
Previous outbreaks have largely been contained without multiple transmission to other parts of the world and often only affected a few hundred people. The current outbreak with such a world wide spread mandates that all countries including the U.S. medical and public health systems were called upon to prepare adequately for Surveillance, Preparedness and Response by training the health workers and many other multidisciplinary teams [1]. The use of personal protective equipment (PPE) and adoption personal protective behaviours that can be used to prevent its spread and reduce exposure are key to the global preparedness and response efforts [17].There is a lot of research that has been done in laboratory setting but more work will be needed in or collected from real world settings (e.g., outside the laboratory) to inform the world how best to respond [18,19] . This need should take into account

Competing interests
The authors declare that there were no competing interest.

Acknowledgments
We acknowledge the financial support we received from AFENET and support from the Local Leaders and Health care workers we met in the different districts.          Medical cover overalls /Gowns 50 6 300

Tables and figures
Page number not for citation purposes 10