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Rural Health Services, Regional Ministry of Health, Juba, Sudan

The epidemic of viral haemorrhagic fever now known to be due to a Marburglike virus to which the name Ebola has been given, occurred in three districts - Nzara, Maridi and Tambura of Western Equatoria Province, Sudan. The affected province borders Zaire and the Central African Empire. It has thickly forested and fertile land inhabited by about 200.000 people who mainly belong to a Bantu tribe called Azande, some of whom reside across the border in Zaire and the Central African Empire.

The official news of the epidemic was received by the Regional Ministry of Health and Social Welfare on September 15, 1976 through a telegram sent by the Medical Officer of Maridi Hospital. Before this date rumours of the epidemic had dominated the town of Juba, where two suspected cases (both school masters) had been flown in from Maridi and admitted to hospital. It was later discovered from records that the first case had occurred in Nzara about the end of June 1976. Between this date and the time medical intervention was initiated on October 23, 1976, the epidemic had spread to Maridi and then to Tambura killing the majority of those affected.

Three medical investigatory teams visited the affected towns between 14 September and 4 October 1976. Each of them reported similar impressions as to the possible causative agent: they suspected a viral cause with yellow fever and smallpox being highly probable but also typhoid fever.

Except for spraying with DDT in Maridi, Yambio and Nzara and limited vaccination against yellow fever, none of the recommended control and preventive measures were carried out because nobody was made to stay and implement the measures in the affected areas.

I arrived in Maridi October 23, 1976. Apart from Maridi, the situation had improved in Nzara and in other parts of the Yambio and Tambura districts. The shortage of medical and public health personnel in the area was a big constraint and this was aggravated by lack of facilities such as transport and protective clothing. The telegram service was out of order and road communication closed to and from the Western Equatoria Province. Communication between Juba and Maridi was maintained by a radio-telephone set belonging to ACROSS, a voluntary agency.

Two landrovers were functioning but the hospital had no fuel. The town had a poor and small water pump, often out of work for lack of fuel and had no electricity supply.

There was one Medical Officer in charge of the hospital and two sanitary overseers responsible for the public health services of the town. The majority of hospital nurses had fled to hide from the disease. On this very day there were only three nurses at work during the afternoon shift and none during the night. There were seven in-patients suspected of the disease with two runaways. The hospital had closed down as far as normal routine work was concerned. Only patients suspected of the epidemic disease were admitted to wards which were used disorderly, that is without specific quarantine regulations being applied. Relatives of in-patients moved freely in and out of the hospital and the dead were handed to them to bury. Cases outside hospital were cared for by traditional healers.

In Maridi the administration had formed a Committee to assist in the control of the epidemic. Through this Committee communication with the public was maintained and the construction of a quarantine area some 20 yards away from the hospital premises was ordered. However, this building could not be finished because the workers became scared and could not be persuaded to complete the construction. There was great fear among the public which deserted the town.

I brought from Juba a limited supply of cotton gowns, masks, caps, bedsheets, blankets, some antibiotics, gamma globulin, infusions and disposable syringes. Hospital supplies by this time were exhausted.


The following measures were taken.

1. Creation of an office from which all control activities would be directed. This was quickly established with the help of the local administration and the Voluntary Agencies (ACROSS, German Caritas and Kock's Road Company). This office was referred to as the Epidemic Control Centre for the Western Equatoria Province.

2. Establishment of contact and communications with the various categories of people I was to work with and education of the public on how to behave during the epidemic period.

Many of the Health Personnel were demoralized and had deserted their work following the death of some of their colleagues. I tried to console them and promised to solve most of their professional difficulties through the provision of better working facilities (protective clothing, shoes, gloves, masks, caps, disinfectants, etc.) and support to their families by providing free food and medical care. Most regained their morale and courage and were able to cooperate with me until the end of the epidemic.

I had good cooperation with the local authorities through which I managed to meet and talk to the traditional rulers chiefs and elders of the people. I was provided with interpreters from English into the local dialects and a hand microphone to announce to the public rules and regulations for the control of the epidemic.


On completion of the two quarantine blocks, with nurses duty shed and a fence with locked gate, patients were moved from the hospital wards and the hospital closed, except for the Medical Officer's office, out-patient clinic, stores and kitchen. Non-medical personnel of the hospital were instructed to remain at home and the number of nurses and cleaners on duty was reduced to 8-10 per shift.

Barrier nursing techniques were demonstrated to nurses and public health personnel using the limited supply of protective clothing and other facilities available. The WHO team that came to Maridi to investigate the epidemic, helped in these demonstrations. Nurses were instructed not to remain unnecessarily long with patients and never to eat food in the quarantine block or to drink water from cups used by the patients. All disposable materials including patients' mattresses and bedsheets were destroyed following the death or discharge of patients. The non-disposable items were disinfected in formalin solution and the staff were instructed not to take home any items such as masks, gloves and caps.

Relatives of patients were not allowed to enter the quarantine area. The quarantine gate remained locked except to allow the health personnel on duty to go in and out. The dead were not handed to relatives but buried by public health staff. For some time this was resented by the relatives. The public health staff including ambulance drivers wore protective clothing while on duty. This team was responsible for collecting sick people from their homes and taking them to hospital and for collecting dead bodies from the quarantine block for burial.

Quarantine measures. There was no known measure to protect the public. There was a greater chance of infection from close and long contact with patients as evidenced by the high rate of Infection among nurses and family contacts. Therefore, the only way to save the public was to remove the source of infection, the infected and sick people, from the community as quickly as possible.

Chiefs were to report to the control office any of their subjects falling ill, their whereabouts and any deaths. Social gatherings were suspended and the market regulated to avoid crowding. Funeral rituals were forbidden. Notices and circular letters were written in the majority of the local dialects and distributed to all towns and road stations. The public was advised to remain calm, to restrict their movements only to vital activities, to report to health authorities or chiefs when any of them fell sick and never to run away or hide from health personnel.

We knew that there were more cases hidden in homes than those brought to hospital. Because very few in-patients survived the disease, and because health staff were also affected and killed by the disease, panic had arisen resulting in the running away of some hospital patients, and hiding of those who should have been brought to the hospital.

At the beginning, I employed volunteers - most of them school boys, to secretly spot homes where cases were hiding or where deaths had occurred. This method yielded good results, more cases were discovered which we were able, with some difficulty, to remove to quarantine. Two weeks later we decided to increase the number of detectors and to work openly. At little cost more students were employed, funds were provided by WHO. They were to search a larger area, the town and its immediate surroundings. The detection teams were put under the supervision of three public health officers who had been sent from Yambio, Juba and Khartoum, and two sanitary overseers from Maridi. The town was divided into blocks to be allocated to team members. By then a rule had been passed by us through the local administration giving team members the right of access to every house. They were required to check the health of every family member and register sick people or deaths and their close contacts. Literally every house was checked, and the Epidemic Control Office sent an ambulance to collect patients and take them to the hospital.

Case detectors roamed the town on foot, on bicycles or by car. Case detection and collection were not always easy. Some patients or their relatives resisted orders for removal to the hospital. In a few instances patients were moved from one house to another and police assistance had to be called for.

The result of the intensive search for cases was dramatic. In two weeks, Maridi town was almost depleted of cases. During the next three weeks few cases appeared among family or close contacts of cases who were in our registers for follow-up.

Surveillance Activities. During our search for cases and recent suspicious deaths in homes, all family or close contacts of such cases were registered and instructed not to leave their residence until two weeks after the date of last contact with a case or a dead body. They were visited and checked at home twice a week for a fortnight.

For distant towns, stations and other rural settlements, instructions were sent to the responsible people in those places, to report to the Epidemic Control Office any persons falling sick or dying in their areas. Surveillance teams under public health officers covered those areas in cars or on bicycles. Actually by the time the incidence of disease was highest in Maridi, the epidemic had subsided in the rest of the province (Nzara, Tambura, etc.) but nevertheless, we had to cover those areas during surveillance visits. Movement of people, vehicles and aircraft in, out and within the province remained forbidden.

The most distant place to which the epidemic spread from Maridi was Manikakara 20 miles west, but there the disease remained localized to five cases of whom two died; and from Nzara the furthest point was Tambura 130 miles away, where a lady patient exported the disease to her family out of whom three were affected and all died with no further spread. These two distant spots were checked twice during the time of our work in the epidemic area.

Before the Epidemic Control team withdrew on December 7, 1976, the public health personnel of the province were instructed to continue surveillance activities for six months after the disease was declared eradicated on December 15, 1976. I myself visited the province again twice, in March and May 1977, no cases were reported since November 22, 1976.

There were some difficulties in carrying out surveillance. The area to be covered was very large. The province is 225 miles long and 50-100 miles wide. Parts of it are mountains and some of the feeder roads had bridges broken or overgrown with shrubs and grass. Rural settlements are very scattered. Azande live in small clans whose homes are often 1-3 miles apart. Shortage of fuel also restricted our movements.

If this Ebola virus infection had the epidemiological features of smallpox infection, I do not think we would have contained the epidemic in view of the acute shortage of manpower and supplies and insufficient logistic support.

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