1. Ebola outbreak in Africa: Impact in India and Response by Indian Armed Forces Medical Services Lt Col Vikram S Grewal MD (Community Medicine) Reader and Instructor Department of Community Medicine Armed Forces Medical College Pune, India

2. Ebola: Impact on the World Ebola Virus disease first surfaced in 1976 1976 – 2014: 23 Outbreaks 2388 Cases 1590 Deaths Precise onset of present outbreak Guinea Dec 2013 Involvement of Liberia, Sierra Leone Zaire strain

3. 22 million living in areas of active Ebola transmission

4. 08 August 2014 WHO declared the outbreak : PHIEC ‘Public Health Emergency of International Concern’ Ebola was expanding at an exponential rate: Cases were doubling every 3 weeks

5. Ebola: Hard Facts Sporadic Cases with intra and Trans- continental spread: Mali Nigeria Senegal Italy Spain UK USA

6. Timeline: September 2014

7. Why did India feel threatened ? Action initiated by Government in April 2014 Stock taking done for Indian residents in affected countries Accounting and Threat assessment done for Indian Troops deployed in African continent

8. Action by the Government of India Formulation of Joint Monitoring Group at the Ministry of Health 1 st meet 04 Aug 2014, subsequent meets every fortnight Stakeholders Ministries of Aviation, Defence, Ports, External Affairs, Home State Governments Apex Medical Institutions: NCDC, AIIMS, NIV International Organizations: WHO, CDC

9. JMG Recommendations Close watch on evolving situation Deliberately NO alert was raised nationally Action intensified at ports to implement surveillance at short notice Increased awareness in medical and paramedical staff Monitoring troops deployed in Africa to be done as deemed fit by DGAFMS Main Aim: Prevent entry of Ebola in country at all costs

10. JMG Actions Surveillance at Ports and airports established Passengers entering India screened based on WHO travel advisories with surveillance and contact tracing Isolation and treatment facilities created to handle Ebola Apex Diagnostic facilities augmented at Delhi and Mumbai Training of medical staff commenced Availability of PPE ensured Public assurance and control of media

11. Armed Forces Scenario: Dual Roles Part of JMG Augment National Effort to prevent entry of Ebola Reinforce own resources within country Concern for deployment in Africa Prevention Surveillance

12. Why concern for deployment in Africa? Approx 7000 Indian troops in UN Missions in Africa Present for 6 monthly rotation Deployment in Democratic Republic of Congo South Sudan Region of outbreak Indian Troops 2 nd Outbreak

13. Why concern for deployment in Africa? Outbreaks in Congo : Boende Muke Boende Lokolia 600 Km from Goma Reports of Suspected outbreak in Rwanda and Gabon Indian troops DRC Indian troops South Sudan Suspect Outbreak Confirmed outbreak

14. Action by AFMS

15. Sensitization of Environment All Medical and Paramedical staff sensitized. Advisories Issued on relevant topics Geared up for eventuality AFMS members told to keep abreast of National and International Guidelines through internet. Comprehensive DVD created by AFMC and NIV: Circulated to all

16. Sensitization of Environment Medical Officers deployed in UN Msn tasked to conduct aggressive IEC campaigns to Alleviate fear and misconceptions Promulgate correct preventive practices Increase awareness about situation Target: Commanders and troops separately

17. Deliberate decision to implement surveillance All Inbound troops from UN Missions in Africa were included for surveillance This was beyond the International Travel Advisory of WHO as DRC and South Sudan were not labeled as Ebola Affected Areas Was it an Overkill????

18. Reasons Situation was overwhelmingly unstable in African continent with spread at exponential rate of Ebola Chances of occurrence of Ebola infection to Indian troops (whichever strain) could not be ruled out Porous borders with Rwanda, Gabon, which had suspect cases Delicate geo-political situation Mandate of Peacekeeping soldier: Heavy patrolling and interaction with local population

19. Collaborative Action Govt of India, Army, Navy and Air Force Protocol for Surveillance was circulated on 08 Aug 2014 Point of Entry: Air- Only Delhi (Mumbai for Sea route only) Logistic, administrative and financial issues sorted out. PMO and National Security Council Informed Planning and implementation for Mass de-inductions done Ministry of Civil Aviation Ministry of Health

20. Screening Mechanism All troop de-inductions were screened at Delhi Airport Move Coordinator (MOVCON) identified 08 bays screened approx 250-300 troops at one time Doctors from AFMS, MoHFW and APHO Thermal imagers from MoHFW

21. Screening Mechanism Suspect cases were detained at local isolation facility Sample was sent to NCDC for test Troops who cleared screening kept separate from embarking troops Advised to report to nearest Govt / AFMS hospital in case symptomatic

22. Surveillance Mechanism Point of entry restricted: Delhi only Synchronization of de-induction schedules Creation of isolation and testing facilities Screening as per proforma Preflight (Africa), Post flight (Delhi) Method for Contact Tracing: Line-listing of de-induction troops Soft copy of manifest on excel format created Included leave address and contact number of each soldier List forwarded to IDSP, MoHFW Pinged across the country to all IDSP nodes (> 600)

23. Preparing AFMS Hospitals Apex facility for isolation at Base Hospital Delhi Isolation: 8 patients Treatment: 4 Patients Dedicated team of Critical Care specialist, Medical Specialist, Microbiologist, Public Health Specialist, 2 x Nursing Officers, paramedical and housekeeping staff identified Training to handle PPE and Ebola patients conducted at NCDC Apex hospitals at Mumbai (Navy), Bangalore (Air Force) were geared up Procurement of PPE was initiated

24. Feedback and Sitrep Immediate telephonic feedback for suspect case at Airport Immediate telephonic feedback of Lab test result. Consolidated Weekly feedback Feedback From Service Medical Directorates Telephonic Feedback from MoHFW regarding IDSP admissions

25. Numbers Country of deployment PeriodScreenedSuspect FromTo Congo MONUSCO 14 Sep 201411 Oct 20141927 08 13 Jan 201511 Feb 20151729 South Sudan UNMISS 02 Oct 201430 Oct 2014217901 Total (Incl Leave party) 12 Sep 201402 Jun 2015731313

26. Conclusion Ebola remains a worldwide threat in-spite of timely and aggressive action worldwide India responded well in time and put procedures in place Indian AFMS took deliberate actions to over ensure prevention of entry of Ebola in to country Timely preventive, screening and surveillance mechanisms were put in place for troops stationed in Africa Internal infrastructure and planning was put in place to match any eventuality

27. Thank You