EBOLA Stop the Transmission!

EBOLA Stop the Transmission! REGIONAL OPERATIONS FRAMEWORK West Africa Ebola Virus Disease Response 27 October 2014 1 P a g e

INTRODUCTION West Africa is currently facing the first and worst epidemic of the Ebola Virus Disease 1 (EVD) ever. The outbreak first began in Guinea 2 in December 2013, but it took two months to identify the unfamiliar illness ravaging isolated communities, where there is one doctor per 10,000 inhabitants. In March 2014 the virus spread rapidly through porous Guinean borders into Liberia and Sierra Leone affecting and killing thousands of people. The spread of Ebola in West Africa has been fuelled by limited health infrastructure, poor hygiene practices, the inability to control and screen population movements across borders, the lack of adequate community involvement in the definition of communication and information and consequent suspicion and growing mistrust towards health and political authorities. As of 23 October 2014, the total number of cases is now over 10,141 with 4,922 confirmed deaths and the numbers continue to increase exponentially. It is estimated that each single confirmed case of EVD is responsible for infecting 1.5 to 2.0 additional individuals over a 10 to 20 day period and, therefore, the outbreak is in a phase of very rapid growth. The outbreak has now affected some neighbouring countries with a first case in Mali on 24 October, one confirmed case and no deaths in Senegal and 21 cases and 8 deaths in Nigeria. Both Senegal and have since been declared Ebola free on the 17 and 19 October 2014 respectively. A number of surrounding countries are considered at high risk, particularly Côte d Ivoire in areas close to the Liberian and Guinean borders. Qualified estimates are predicting a number of new cases reaching 10,000 per week in December (CDC/WHO). According to CDC the number of cases could swell dramatically to between 550,000 and 1.4 million in Liberia and Sierra Leone by January, 2015, without effective methods to contain it. Unless effective interventions are quickly implemented at large scale, it is estimated that the disease will continue to spread and that the epidemic will end naturally only when a very large proportion of the population, i.e. millions of people, has been infected and has either died or has recovered. The collective response in the respective countries by local actors with limited support of the international community at first, has not made the Ebola virus under control and it has now become a global priority to reduce the transmission of Ebola and stop the spread of the disease. This regional operational framework outlines the role and guides the work of the International IFRC of Red Cross and Red Crescent Societies (IFRC) in supporting African Red Cross Societies to respond to the current EVD outbreak, contributing to stop further spread and increase preparedness measures. In doing so it provides strategic direction, focus and coherence in supporting the country level emergency operations. It guides the collective EVD response and communication of Red Cross and Red Crescent Movement partners. 1 Ebola virus disease (EVD) first appeared in 1976 in 2 simultaneous outbreaks, one in Nzara, Sudan, and the other in Yambuku, Democratic Republic of Congo. The latter occurred in a village near the Ebola River, from which the disease takes its name. 2 http://www.theguardian.com/global-development/2014/oct/09/ebola-guinea-family-west-africa-crisis 2 P a g e

This Framework consists of two sections: - The situational analysis and current response provides an overview of the background to the crisis and an epidemiological analysis. It does not, however, replace continual situation assessment in the country level operations, which remain the key assessment information guiding the respective operations. In addition it provides an array of possible IFRC response mechanisms. It will be regularly updated to reflect the situation as it develops. In this section the current IFRC response is also outlined. - The regional operational response and preparedness strategy provides an overview of the IFRC strategy and approaches to prepare and respond to the crisis in the affected countries and the neighbouring at-risk countries. The situation continues to deteriorate rapidly and risks affecting the economies as well as the public order of the countries concerned. The Ebola outbreak also generates secondary humanitarian needs, such as food, clean water and sanitation and is a serious concern as the disease continues to spread. The comparative advantage of the IFRC approaches is outlined in the operations with the five key pillar approach common to all the affected countries. The different IFRC business units involved in the response and coordination in support of country offices and Red Cross national society operations further defines the role of the IFRC. The Framework is a guiding tool, constantly changing to adapt to the rapidly evolving situation and is aligned with existing IFRC policies and strategies in particular the IFRC Africa Disaster Management Framework 2013-2017, the IFRC Africa Zone Standard Operating Procedures (SOPs) and generally as a Red Cross and Red Crescent Disaster Response framework for Ebola. This document is a living document, and will be updated regularly to reflect the changes in the context, activities and partners involved. SITUATION ANALYSIS AND CURRENT RESPONSE On 21 March 2014, the Ministry of Health (MoH) of Guinea notified the World Health Organization (WHO) of a rapidly evolving outbreak of EVD. The cases of EVD were initially reported in Guéckédou, Macenta, and Kissidougou in the Forest Region and later in Conakry, the capital city. Blood samples collected from the initial cases tested positive for Ebola virus, Zaire Ebola virus (EBOV) species, by RT-PCR at Institut Pasteur in Lyon, France. Retrospective epidemiological investigation suggests that the first cases of EVD may have occurred as early as December 2013. The EVD subsequently spread to the neighbouring countries of Liberia, Sierra Leone, Nigeria and Senegal. The Ministry of Health and Social Welfare (MoHSW) of Liberia formally declared EVD outbreak on 30 March 2014, while the first case of EVD in Sierra Leone was reported on 25 May 2014 (WHO Accra report). In Nigeria, the first case was declared on 2 August 2014. In Senegal a case was confirmed on 29 August 2014 and both Nigeria and Senegal were dismissed as Ebola free later in October 2014. This can be contributed to a swift and robust crisis management system activated by the Governments to contain further transmission in the early phase. The latest case as of 25 October 2014 Guinea Liberia Mali Nigeria Senegal Sierra Leone Total Cumulative cases 1,553 4,665 1 21 1 3,896 10,141 Cumulative deaths 926 2,705 1 8 0 1,281 4,922 3 P a g e

Over the past two months the number of infected and deaths have doubled every two weeks reaching another peak in October. While the outbreak remains concentrated with 80% of cases in 9 out of 42 districts, the majority of cases are now occurring outside the main epicenters (Gueckedou and Macenta in Guinea, Lofa in Liberia, and Kenema and Kailahun in Sierra Leone) and have soared in capital cities (Monrovia, Freetown). This outbreak is the largest in history, both in terms of case loads and geographical spread. The difficulty in controlling the initial outbreak is the proximity of the indexed cases in Guinea to the porous border areas of Sierra Leone and Liberia, with cross border movement and trades is a significant factor in the spread. The severity of the situation in West Africa is exacerbated by the scale and unique characteristics of the outbreak. Health systems in the Guinea, Sierra Leone and Liberia have buckled under the strain of the Ebola outbreak. Health workers have become infected during routine contact with patients in health facilities and public mistrust in the health care systems and Governments of affected countries is mounting. Treatment centers and clinics have closed as fear caused patients to keep away and medical staff to flee. There is a severe shortage of health personnel and adequate treatment facilities with an estimated 2,500 Ebola treatment centre beds needed today (existing gap). As the situation continues to deteriorate rapidly, the main challenges contributing to the size and scale are ongoing and include: General lack of understanding of EVD as communities face the first major epidemic outbreak reported in West Africa. Limited capacities of partner organisations to rapidly respond with the correct technical expertise within an already fragile health structures. High exposure to EVD within the community through home care and customary burial procedures, resulting in a high level of deaths in the communities and raising anxiety. Denial, mistrust and rejection of proposed public health interventions arising from misunderstanding of the cause of the new disease. 3 3 According to the latest KAP study in Sierra Leone, almost a third of population thinks one can get Ebola from Mosquitoes (30%), 30% also believes Ebola is airborne, 20% believe Ebola can be treated successfully by Spiritual Healers (in Western Area urban & rural -this misconception is especially high). 42% believe that bathing with salt and hot water can prevent Ebola. 4 P a g e

Violent attacks on Red Cross teams and other humanitarian workers by some communities have made sensitization and social mobilization impossible and has incapacitated tracing contact cases. Lack of experience and fear among health workers, with limited access to protective equipment. Close community ties and movement within and across borders are increasing the difficulties in tracing and the following up of contacts for the three countries. The magnitude and geographical spread of the outbreak poses serious challenges in terms of human capacity, financial, operational and logistics requirements, which threatens international health. Cases in densely populated urban areas, including all three capital cities of the mainly affected countries. Insufficient speed and scale of response by governments in acknowledging the extent of the outbreak. Reluctance from some Ministeries of Health (MoH) to share data and information in a transparent way. Weak leadership in coordination of the control of the outbreak in some of the affected countries. Closure of borders, airlines and movement restrictions leading to serious economic implications for the affected and surrounding countries. SUMMARY OF THE CURRENT RESPONSE The IFRC and its National Red Cross Societies are among the major operational partners in all the affected countries. The IFRC has been reinforcing the community outreach of the National Red Cross Societies with social mobilisation, community engagement, hygiene promotion and Ebola prevention measures, the tracing of contact cases, the safe and dignified burial (SDB) of the deceased and case management in Sierra Leone. In surrounding countries preparedness and prevention measures have been taken through the launch of several DREF Operations. Many Partner National Societies have bilateral long term commitments of support to NS and have expressed an interest in in getting involved in preparedness activities. An overview will become available shortly. 5 P a g e

Other partners MSF. MSF has been managing the large majority of the clinical treatment in all three countries. MSF has provided high quality training and standards that the IFRC has used in both clinical treatment Ebola Treatment Centres (ETC) of Kenema and SDB and are guiding Red Cross volunteers in its implementation work. WHO. WHO is supporting governments of the affected countries in the coordination of the response. A regional coordination mechanism SEOCC/CNLEB was established in Conakry to manage the outbreak as a whole. After UNMEER s establishment in Accra, this regional coordination body has been transferred to Accra as well and integrated within UNMEER. United Nations Mission for Ebola Emergency Response (UNMEER). UNMEER is appointed by the UN SG to provide crisis management for the Ebola outbreak. The objective is to install robust incidence control mechanisms at country level to stop the outbreak. UNMEER will establish 40-45 crisis management centres in the three affected countries, has appointed Ebola Crisis Managers in Guinea, Sierra Leone and Liberia, and established a coordination and crisis management centre in Accra, Ghana. The recent Planning Conference for Ebola Response organised by United Nations Mission for Ebola Emergency Response (UNMEER) in Accra (15 to 18 October) had as objective to produce a comprehensive Ebola emergency response operational plan 4 based on the Ebola response strategy developed by the UN Special Envoy. The strategic objective is to identify a response strategy in support of the national efforts and plans. In this pursuit and in order to ensure adequate, coherent and coordinated international support to national plans that will identify all the necessary lines of action; assign responsibility to an actor or actors for the lines of action, and ensure there are no gaps; identify resource requirements (human, material and financial) for each line of action; set deadlines to achieve specific results within each line of action; identify metrics to measure performance across various indicators within each line of action, and associated reporting. The detailed finalised plan has not been officialised yet but for safe and dignified burials, UNMEER is expecting the IFRC to take the lead in supporting the Red Cross in dead body management and SDB across the three affected countries. Others: Centre for Disease Control (CDC), USAID/OFDA, Institut Pasteur, Canadian Public Health, academic institutions and NGOs have been involved in a wide range of ongoing response, including lab support, social mobilisation and support to Ministry of Health. Military: The British and US government have deployed troops in Sierra Leone and Liberia and together with German and French Governments have made bilateral commitments to the Governments of Sierra Leone, Liberia and Guinea respectively, and are providing large contingents of medical and logistics army personnel. 4 Not yet officialised to date add reference when out. 6 P a g e

RED CROSS RESPONSE TO DATE 7 P a g e

The main goal of our collective efforts is to ensure massive scaling up in order to get ahead of the curve of exponential increase in EVD caseload. The response to date has resulted in six emergency appeals in affected countries (Guinea, Liberia, Sierra Leone, Nigeria and Senegal and the regional coordination and preparedness appeal). Funding from Disaster Relief Emergency Fund (DREFs) have supported as well as re supporting preparedness activities in 11 countries (Kenya, Benin, Burkina Faso, Cameroon, Central Africa Republic, Côte d Ivoire, Democratic Republic of Congo, Gambia, Ghana, Guinea Bissau, Mali and Togo) sharing direct or indirect borders with the affected countries. The new case in Mali on 23 October 2014, indicates the urgency of having measures and trained Red Cross volunteers in place to react immediately, if cases are detected in new countries. A full overview will be incorporated in the next updated Regional Framework. The emergency appeals are being revised to scale up activities, plans and budgets to match the growing needs. This will require more discussion on the gaps and future plans, including the recovery phase and the resource mobilization implications. Overall the Movement partners response is extremely positive with all acknowledging the key role the National Societies and the IFRC have been playing in the most difficult areas of intervention. At times Red Cross volunteers have been the only people allowed to enter communities and they have been crucial in combating fear and reducing stigma while ensuring safe access for response teams. This grassroots involvement is essential in stopping the spread of EVD. Furthermore, partners also recognise that the Red Cross is a major player in social mobilisation, contact tracing and safe and dignified burials. This has been reflected in the amount and consistency of media coverage relating to the Red Cross response (4000 media hits and 1 billion people reached since March 2014), which has been significant and global. At this stage of the emergency response it is urgent to beef up the operations with more human resources with a defined schedule specific to each country as well as for the reinforcement of the regional coordination team s staffing needs. 8 P a g e

OPERATIONAL RESPONSE STRATEGY 1. The five pillars of intervention The standard recommended public health actions implemented, using WHO standards, for stopping the Ebola outbreak include the early identification of cases, isolating and treating all patients in Ebola Treatment Centres (ETCs) under the guidance of MSF; establishing rigorous contact tracing, and safe and dignified burial practices (SDB) supported by coherent social mobilization and sound risk communication practices. These key public health activities have been characterised as the five pillars of the IFRC Ebola response known as: - Community engagement, beneficiary communication and social mobilisation - Psychosocial Support - Surveillance and contact tracing - Safe and dignified Burials and disinfection, formerly called Dead Body Management - Case Management and treatment. The five pillars were established as a coordination mechanism to technically design and roll out coordinated activities at scale. The grouping of the activities into coordination hubs or pillars ensures a harmonised approach and collaboration across key interventions. Each pillar is equally important and intrinsically interconnected, with each reliant on the others to be effective. One of the objectives of social mobilisation and community engagement is to encourage and educate people to identify possible symptoms early, and present themselves in case of close contact with a contaminated person or deceased and facilitate case management. With no case 9 P a g e

management, the impact of social mobilisation is limited, but the same can be said for the effectiveness of case management if no one is willing to present themselves to the health centre. Social mobilization cut across all areas and aims at engaging communities in a meaningful dialogue, building trust and creating the space for their feedback. Establishing processes on established communication networks and in communities that allow the population to clearly voice their understanding of the issues and provide feedback will build stronger trust and a more community led solution. This is particularly important in the current environment where Rumours, myths, lack of trust, and misinformation about Ebola are fuelling anxiety and confusion at all levels, hindering an effective response. Deep rooted traditions (i.e washing the body of the deceases as part of the burial practices) are also fuelling the epidemic and require sustain interaction with communities to be addressed. The operational response strategy seeks to set out guidance for the programmes in the affected countries, building on lessons learned, ensure common standards articulated around the country wide approaches, specific to the environment and what common standards can ultimately assure a harmonize approaches across the board. Through the application of this Framework the IFRC aims to: Support National Societies to effectively contribute to the reduction of risk in the current Ebola outbreak. Strengthen National Society capacities to respond to epidemics and other crises in future. Facilitate cross-border learning, support and cooperation. Ensure a Federation-wide coordinated and harmonized approach with standard operating procedures in place and established guidelines. Facilitate Movement cooperation across the region Provide leadership within Safe and Dignified Burials, in standardisation, information management and coordination as guided by UNMEER in Guinea, Liberia and Sierra Leone. 2. Approaches and methodology in key areas of interventions From the start of the Ebola outbreak it has been agreed that there needs to be a unified response to the EVD outbreak and that the IFRC has the lead. The IFRC applies a harmonized strategy of intervention in all affected countries through the five pillars of intervention. Each country has its own characteristics; however, to the extent possible harmonized approaches apply across the region. Common standards are being developed for equipment, trainings, dead body management and protocols. The five pillars response strategy is built on common activities and indicators. Each country will, however, plan and implement to different degrees in the five pillars, with emphasis on different pillars and implementation at varying paces and timing schedules across the region. The Red Cross Societies, are one of the only local organisations with a national outreach, a network of volunteers and the capacity to implement: the Red Cross Societies are under pressure to engage with a wide range of partners outside the Movement. The framework aims to support and guide the Societies to ensure that they stay focused on priority actions, avoid being tasked with activities outside the strategic framework and their respective plan of action. 10 P a g e

Community Engagement: Social mobilization, two-way beneficiary communication Community engagement is a core activity and encompasses the way in which we work with communities to implement all pillars. Community engagement entails beneficiary communication and social mobilisation activities and comprises behaviour change communication and health education, utilizing a PSS approach. It ensures participation that extends beyond acceptance and knowledge and guaranties that this knowledge is turned into action and acceptance. It is targeted on risk factors and focuses on two-way communication with those most affected, be it through a sick person in the family, the death of a family or community member, the admission to an ETC or the notification of being a contact. This component focuses on establishing systems that allow communities to voice their needs to assist in reducing fear and rumours and raise awareness. Efforts are directed towards effective and sustained two-way communication and engagement with beneficiaries, as the most effective mean to tackle the disease and build collective trust, confidence and a lasting community understanding of how to prevent and control Ebola. The strategy entails a mix of communication channels, which includes radio programming, SMS messages, distribution of posters and leaflets and door-to-door visits in communities. Safe and Dignified Burial (SDB) and Disinfection (formerly Dead Body Management - DBM) Safe and dignified burial and disinfection is an expansion of the key activity of dead body management, reflecting what teams are delivering in practice. The terminology indicates that the Red Cross teams do more than manage bodies. They care for families and their loved ones ensuring that the burial is conducted in a dignified and safe way, limiting further spread in making them understand the need for precautions whilst understanding and respecting their loss. Highly trained burial teams, in conjunction with community engagement volunteers educate the communities about the need for safe burials; explain the process and the equipment used. They open a dialogue with the community to find contacts; they explain and sensitize on the risks of transmission and prevention messages encouraging the adoption of safe behaviours, participation in contact tracing and early presentation if symptoms are present. 11 P a g e

The same approach is utilised for disinfection teams, ensuring communities understand the need and process before commencing. The respect of the deceased and care of their families at this time is a key interaction with the community that can affect their willingness to continue to engage and change behaviour to break the cycle of transmission. This care with dignity extends before the practicalities, including the reporting and recording of deaths, their names, age, gender and the locations of burials to ensure accountability at the end of the epidemic and assist in restoring family links when needed. Safe tools have been designed, developed and rolled-out for dead body management with two types of kits to support the SBD teams: 1. Dead Body Management Starter kit and 2. Dead Body Management Kit and also a Social Mobilization Kit. Psychosocial Support (PSS): Re-entry and Social Re-integration into Society Currently these activities consist of PSS support and the provision of a solidarity kit with key items to families that have lost material goods through disinfection or who are unable to manage their normal lives because of isolation schemes or other measures related to having an Ebola patient in the family, or being a contact. The kits are offered to families with a sick person who are experiencing social exclusion and stigma or after the safe burial and disinfection team has completed their task or on discharge of a survivor from the ETC with the possible stigma and further safety measures that needs to be respected with precaution for male cured patients during 90 days. Red Cross volunteers, within their own communities, are conducting door-to-door visits, working with elders, community and religious leaders to engage people and families in a meaningful dialogue to address stigma, dispel rumours or cultural misperceptions about the disease. Door-to-door visits are a key community interaction that should be used to provide support, information and improve engagement with the community and individuals affected. Surveillance and Contact Tracing approach. Alert and Surveillance is a key activity that focuses on the follow up of potential contacts to ensure early presentation to the ETC. Contact tracing is a key interaction with potential new cases and is an important engagement in trying to limit the next generation of cases. Engagement with the individual and the family is extremely important to ensure adaptation of behaviours to protect the family and community. Contacts require a large amount of information but also reassurance and support. Contact tracing is conducted utilising community engagement and PSS 12 P a g e

However alert and surveillance goes beyond contact tracing and includes the notification of potential cases for transfer and potential Ebola deaths. The information from alert and surveillance should be utilised by all teams to inform programming and resource allocation. Case management and Treatment The names and descriptions of case management options are changing slightly from country to country, between partners and over time, but in essence consist of 5 levels of care options. It may be necessary to update the concepts as they evolve. (A description of the options are listed below, box 1). All options, including large scale ETCs (more than 60 beds) are being piloted and evidence of their effectiveness and levels of safety is limited. All options are under constant review and when evidence for each approach has been collected; final technical recommendations will be published. Ebola Transit Centre is a facility for testing, triage and referral of suspected and probable cases. Ebola Treatment Centre is the provision of clinical care in a unit utilising full biosecurity measures. Patients are cared for by nursing, medical and allied health professionals. Household Protection, formerly known as Home Based Care - is a temporary intervention under cases management, to prevent transmission at the household level when isolation in an Ebola treatment centre is not available. Referral of the case remains the primary objective, however. The branch health officers provide training to the family and supports key community members to help safely isolate and care for potential Ebola cases until transfer is available. Basic PPE such as raincoats and gloves are provided in addition to soap, chlorine, buckets and training. Ebola Community Care - is understood to be the care of Ebola positive patients by community members in a designated area supported by minimal supervision and provision of basic PPE and materials. The risk of transmission is high, and the use of ECC should be limited to a measure of last resort. 13 P a g e Ebola Treatment Centres (50-200 beds) Staffed by health workers (clinicians), WATSAN experts, logistics support and unit manager Patient care; rehydration; nutrition; standardized SOPs Full Infection Prevention and Control, dead body management Transit Centres (10-40 beds) Staffed by smaller team of health workers Patient care; rehydration; nutrition; standardized SOPs Full Infection Prevention and Control, dead body management Isolation Areas (2-10 beds) Established at all health facilities (April 2014 directive from MOHSW) to isolate suspected or probable cases following triage Cases to be referred to ETU ( or transit centre) as soon as feasible Community (5-15 beds) based Ebola Care Units, Community Care Centres (CCC) Staffed by trained community volunteers (single designated family member) Supportive care for patients i.e. food, oral rehydration, clothing, hygiene, malaria treatment, pain and fever relief Household Protection patient care Home based hygiene kits and training of a care giver

THE REPONSE BY COUNTRY Guinea Red Cross Society/IFRC Operation: MDRGN007 In Guinea, the Red Cross is focusing on four of the five pillars: Safe and dignified burials (SDB) and transportation of sick patients, community engagement and contact tracing and psychosocial support. Currently the Red Cross is the sole provider of SDB and is also transporting sick patients from villages to the transitional or treatment centres which has placed a huge burden on its capacities to reach all the affected areas. The Red Cross community volunteers are the ones with access to communities all over the country, especially in the most remote villages where other actors are often not present. In order to scale up its capacities with greater outreach, the Red Cross Society of Guinea (RCSG) have increased their teams with additional 35 newly trained SDB teams by the end of October, bringing the number of SDB teams to a total of 72. For rapid scale up, RCSG is currently conducting trainings of more teams through the Training of Trainers methodology and planning systematic refresher trainings. Liberia National Red Cross Society/IFRC Operation: MDRLR001 In Liberia the Red Cross focus is on all five pillars with the main emphasis on SDB. Liberia is planning to scale up the number of SDB teams to 34, under the supervision of an overall SDB manager. There are an insufficient number of beds for treatment and while this is being addressed and established by foreign teams, US Army and others, the challenge remains on exploring other means to provide temporary care until treatment and isolation can be provided. Household protection is one of the modalities under consideration. The IFRC discourages the use of Community Care Centres (CCC), as the risk of the virus transmission is too high. Sierra Leone Red Cross Society/IFRC Operation: MDRSL005 In Sierra Leone one of the main activities of the Red Cross response is an Ebola Treatment Centre in the seriously affected area of Kenema. It will have 60 beds once scaled up to full capacity. Furthermore, Red Cross interventions are concentrated to varying degrees on the other four pillars, with the main emphasis on SDB and community engagement. The Red Cross expects to expand to 49 SDB teams by 2 November 2014. Beneficiary communication in the Ebola response has helped engage people and families in a meaningful dialogue to address stigma, dispel rumours or misperceptions of the disease, bury bodies safely and respectfully and highlight the importance of seeking early treatment and provide opportunities for communities to voice their say and ask questions using different communication mediums. The use of mobile phones by volunteers for data collection will ensure improved, quality, complete and reliable data is collected for effective reporting and monitoring. Nigeria Red Cross/IFRC: MDRNG017 Nigeria was declared Ebola free on 19 October 2014. Activities in Nigeria in support of the NS will focus on preparedness and social mobilization in the event of new Ebola transmission to the country. Senegal Red Cross/IFRC: MDRSN010 Senegal was declared Ebola free on 17 October 2014. Activities in Senegal in support of the NS will also focus on preparedness and social mobilization in the event of new Ebola transmission to the country. Federation Regional EVD Coordination & Preparedness: MDR60002 Beyond operational coordination between the three most affected countries, the preparedness aspect is addressing the surrounding countries at risk of transmission, supporting with interventions to strengthen National Society preparedness, including sound dissemination of information about EVD, social engagement with local communities, pre-positioning of basic items to provide immediate response, training of Red Cross staff and volunteers in the Ebola response interventions and prevention and how to use Personal Protective Equipment (PPE) etc. Training of volunteers will be standardized across all countries and manuals and materials will be translated into both English and 14 P a g e

French and possibly Portuguese as well. A regional preparedness delegate will ensure guidance, support and supervision to the National Societies in neighbouring at-risk countries. The Ebola preparedness delegate will be part of the Regional Coordination team. MOVEMENT PARTNERS In each of the most affected countries there is a IFRC country team working with members of the Movement. In each country the National Societies have developed long-term partners with Participating National Societies (PNS) which since the EVD break out, have scaled up and either continued work in a bilateral manner or have combined multi-lateral and bilateral support. Discussions will need to take place with all Movement partners on the longer term support in livelihoods and recovery activities. A significant number of Partner National Societies have contributed with delegates, Emergency Response Units, In Kind and cash donations. Reference is made to operations update and the respective appeal documents for a full overview. Direction for bilateral engagement in Ebola Treatment Centres Several Red Cross National Societies have, as auxiliaries to their Governments, been tasked with establishing and running ETCs in the affected countries. The IFRC welcomes these contributions of Movement partners in the EVD response. There is a strong need for more beds and treatment capacity. The criteria for the PNS are the following: The intervention must be agreed with the National Society in country. The partner national society must assume the full cost for the ETC for the full period of the epidemics. The partner national society must ensure the management and the staffing of the ETC for the full period. The partner national society must train a new set of RC volunteers to be involved in the ETC and not take the existing trained volunteers engaged in other activities. Since the IFRC is responsible for leading the Movement coordination in the Ebola response, the partner national society must apply IFRC standards in the ETC. An induction with the IFRC ETC in Kenema is recommended. Danish Red Cross DRC has a long-standing collaboration in Liberia and in Guinea with the Red Cross in both countries. In Liberia it is providing support to Ebola affected and at-risk Communities in Lofa, Bong and Nimba counties. This includes increasing community awareness, improvement of response behaviour and coping mechanisms for 80,000 EVD affected or at-risk community members. EVD awareness and PSS training to all 28 chapter staff in the 3 counties. Other components include household protection training and distribution of household protection kits, currently under discussion, distribution of cash grants or in-kind support to EVD affected and survivors and smallscale emergency WATSAN rehabilitation to priority communities. All is being closely coordinated with LNRCS and the IFRC. Netherlands Red Cross NLRC has a long-standing collaboration with the Côte d Ivoire Red Cross and Benin Red Cross. As a bilateral contribution coordinated through the IFRC, NLRC will conduct social mobilization and EVD preparedness activities in Ivory Coast, to be replicated to Benin at a later stage. Due to its highly vulnerable borders with Liberia and Guinea, Ivory Coast is one of the most at-risk countries for EVD transmission, and a massive preparedness intervention is needed, especially in the border areas. The intervention includes prepositioning of preparedness stock, training of the key methodologies within community engagement, SDB, contact tracing and PSS, including of the PPE protocols. 15 P a g e

French Red Cross FRC is planning to establish and manage, with funding and support from the French Government, an ETC in Macenta in Guinea, and will sign a MOU with the RCSG. German Red Cross GRC is planning to establish and run an ETC in Liberia, with the full funding and support of the German Government, and will sign a MOU with LRNCS. ICRC ICRC is supporting the Red Cross Societies in Guinea and Liberia during the outbreak through the donation of equipment and additional financial support. This has enabled the Red Cross Society of Guinea to hold public awareness session on communicable diseases and train over 280 volunteers in disease prevention, disinfection of homes and proper management of human remains. Prison authorities in the country have taken measures to prevent the spread of the disease with ICRC support. In Liberia the ICRC made available to Liberia's health and justice ministries its technical expertise in handling suspected or confirmed cases of Ebola among detainees by taking preventive hygiene measures. ICRC will also help Red Cross volunteers and state workers to manage the remains of those who have died from Ebola in a proper, safe and dignified manner; install a crematorium, conduct health worker training, upgrade water and power infrastructure at two health centres, draw up a nutritional protocol for patients to contribute to their recovery; provide household essentials to families of Ebola victims whose belongings were lost when disinfection procedures were carried out. PREPAREDNESS IN SURROUNDING COUNTRIES EVD infections mostly occur in adults working in health facilities, caregivers in the home and those managing funerals. The role that women and adolescent girls play in caregiving and the increased burden of care placed upon them due to the loss of their caregivers may put them at increased risk. It is estimated that women account for up to 60% of the deceased in the current outbreak, and 75% of the cases are women. In addition, pregnant women who have EVD are at increased risk of haemorrhage and miscarriage. Furthermore, women and girls may also not receive urgent information that they need about Ebola due to reliance on getting new information form men or from lack of access to information networks due to their caregiving and household roles. The two-fold aim of the Ebola response is to prevent transmission and provide care to the sick when a case occurs. Before a human outbreak: epidemic control is done mainly through: - Working with communities on communication campaigns to provide accurate information on Ebola, its preventive measures and steps to take if suspicion of exposure or case; encourage - early care seeking for fever; re-enforce messages around hygiene; strengthening hospital safety practices - Surveillance of imported cases from high transmission countries at the ports of entry - Surveillance of sick animals to prevent the initial infection to human (i.e., practicing safe meat preparation practices and avoiding contact with sick or dead animals in the forest). In the surrounding countries of the three mainly affected countries, preparedness has taken place and the key elements of preparedness are: contingency planning with the National Society, playing an active role in coordinating bodies within the respective countries. Preparedness activities are closely linked with activities within community engagement. They are focused on EVD awareness raising, dissemination of information about the EVD, the transmission, the measures to take to avoid infection and what to do if a person or family member starts developing symptoms. Furthermore, they include prepositioning of a starter kit and training of volunteers in the use of equipment and protocols. 16 P a g e

COORDINATION, ROLES AND RESPONSIBILITIES The IFRC operations management structure must allow the primary support functions of the Secretariat to be realized effectively. Therefore it is designed to support country-led operations, including providing operational and technical support as close to the operation as possible. The IFRC strives to have physical presence in all emergency operations. Operation managers and technical operations support teams will be deployed in all response operations to support the implementation of all Ebola response operations. The EVD outbreak currently affects countries in two of the five regions of Africa Zone and thus does not fall under the operations coordination function of a single regional representation. While project management responsibilities for the three operations lies with the respective operations managers (maintaining management reporting line to country/regional representatives), operational technical lead of the response operations lie with the IFRC Africa Zone Disaster Management Unit. The IFRC Regional Ebola Coordination hub To provide coordination and technical support as close to the field as possible, a IFRC coordination hub has been established in Conakry, Guinea. The coordination hub provides operational planning and implementation guidance to the operations and represents the IFRC in regional coordination mechanisms. The regional coordination hub has technical experts who will provide technical guidance for all the programmes across the region. The IFRC Ebola coordination hub is managed by a Head of Regional Ebola Emergency Operations and includes technical adviser functions such as resource mobilization/grant management, regional logistics, regional finance, technical Ebola, PSS and health advisers, regional communications, regional reporting, regional HR, communications and beneficiary communications, regional preparedness in order to ensure capacity to support the response and preparedness operations. Furthermore, there will be a regional SDB coordinator to oversee the IFRC s leading role in SDB in the three Ebola affected countries. The IFRC Regional Ebola Coordination hub reports directly to the Director of the Africa Zone. Discussions are taking place whether to move part or all of the regional hub to Accra, Ghana, to ensure close coordination with UNMEER and other external partners. The IFRC s Status Agreement in Ghana is being reactivated for that purpose. Frequent travel to the programmes and National Societies will be needed to ensure continued support and connectedness with the operational reality on the ground. The IFRC s Lead Coordination Role in Safe and Dignified Burials (SDB) In order to stop the transmission of EVD, UNMEER has emphasized 3 main strategies at scale: - Early isolation (ETU, CCCs, self-isolation if services are not available) - Safe and dignified burials - Community engagement The main components of the response are: 1. Safe and dignified burials 2. Community engagement. 3. Surveillance, active case finding and tracing contacts 4. Case management. Overarching challenges include: - Improve quality of burials - massive ramp-up of staff - functional supply - accommodation for staff - secure operating environment - Medevac and 21 days quarantine 17 P a g e

Other important issues such as PSS and recovery are also on the agenda, and will be dealt with during the roll out of the UNMEER strategy. Lead Agency responsibilities The IFRC has been recognized as the main actor in this component and has been tasked by UNMEER and partners in the UNMEER Planning Conference in Accra from 15-18 October 2014 to take up a leading role for SDB. The plan indicates the need for 154 burial teams by December 1 st performing Safe and Dignified Burials (5 cases per day). This component will have to be strictly interlinked with community engagement. The IFRC understands the role as being: In order to maintain independence and neutrality, the IFRC acts as a facilitator, convening agencies working on SDB to map the response, identify gaps, agree on common protocols and good practice, provide guidance, carry out advocacy, define what constitutes appropriate response and develop a common strategy. It will ensure that information management is well-coordinated as well as response at country level and an overview of who-does-what-where-and-when. Agencies involved in SDB are not subordinate to the IFRC, as it will act merely as convener or facilitator of consensusbased processes amongst all those responding. The IFRC may consider deploying SDB coordination teams, which include team members from other agencies. More concretely, the IFRC SDB coordination teams will: Ensure a firewall between the IFRC SDB operations and the IFRC SDB leadership/coordination role: in other words, the IFRC deploys SDB coordination team members that are delinked from the operation, fully dedicated to the task of coordination, and have no responsibility over IFRC SDB operations. This is to prevent a conflict of interest between the SDB lead role, which is carried out on behalf of all agencies involved in SDB, and IFRC/National Society SDB operations. It also recognizes that coordination of response is a full time job requiring full time dedication. Not accept accountability obligations to the UN system: In order to preserve its independence, the IFRC does not accept accountability obligations beyond those established in its constitution and policies. SDB coordinators do not have a formal reporting line to incountry UNMEER Crisis Managers or the UNMEER Coordinator in Accra. They report to the IFRC operations managers for security, administrative reasons, and have a technical reporting line to the IFRC regional Ebola technical adviser. They of course communicate and coordinate closely with UNMEER, but there is no formal reporting line. Not be a provider of last resort: the IFRC will advocate for an adequate and appropriate response, subject to the capacities and resources of the humanitarian community, rather than acting as a provider of last resort. Implications for the IFRC Develop an internal structure and implementation plan to fulfill our commitments by December 1 2014. The IFRC will ensure a structure in the three main affected countries to fulfill this role, consisting of a SDB coordinator and an information manager. These will report to the operations manager in the country, but will be outside the NS/IFRC operational set up. Country Level Ebola Response set up The IFRC has operations managers in the three affected countries with an operational set up to ensure technical support, logistics, management, reporting and supervision of the Red Cross EVD operations. Country Representatives ensure the long term relationship and dialogue with the National Societies senior management and coherence between the National Societies priorities and long term programmes. Movement Coordination A close collaboration amongst Movement partners is pursued in all countries of intervention. Movement coordination meetings are held on a regular basis in Guinea, Liberia and Sierra Leone to 18 P a g e

ensure joint understanding of the strategies and coordinated approaches. Besides that partner national society conference calls are held and consultations with key PNS are taking place. The IFRC West Africa Ebola task force The IFRC West Africa Ebola task force consists of relevant personnel at country, regional, Zone and Geneva secretariat level involved in the Ebola response. The task force meets through weekly teleconferences to highlight urgent challenges or issues that require action at any level. The IFRC Secretariat Advisory Cell The size, complexity and level of risk of the IFRC response to the West Africa Ebola Crisis (IASC Level 3 Emergency equivalent) requires a global or corporate level response structure to be put in place within the IFRC to ensure timely and efficient decision making. This goes in line with the structure established in the Africa Zone, with the deployment of a HEOps in the Ebola Regional Coordination hub office in Guinea Conakry reporting to the Director of Zone. In accordance with the recommendations of several recent operational real time evaluations (RTE s) and the substantive work completed to develop global disaster response SOPs, it is important to clarify responsibilities and streamline reporting lines for the global Ebola Advisory Cell. As such it is a small temporary advisory body structure, reporting directly through the USG PSD to the SG with a technical link to DCM. The Ebola Coordination Cell in Geneva will have a technical line relationship with the Regional Ebola Coordination unit currently in Guinea Conakry. Logistics Solid logistics support for the region will be established, and a logistics plan will be developed and implemented. In order to benefit from procurement of scale, a major tender will ensure an uninterrupted supply of up-to-standard essential items. Robust logistics capacity will be established with a regional logistics coordination overseeing the logistics coordinators in the three affected countries, fleet managers and a number of logistics delegates, logistics officers and warehouse managers to ensure the pipeline of essential goods needed for the Ebola response. The logistics set-up includes a large fleet of vehicles for Red Cross teams, motorcycles, ambulances for transport of the sick, and warehouses in central locations. The logistics set up will be supported from Dakar and possibly Accra. Communication Communication is essential in raising awareness, addressing stigma, changing behaviour and advocating for increased and decisive efforts to scale-up international mobilization to stop the unprecedented Ebola outbreak in West Africa As part of this framework, communication under the response will: - Raise awareness about the humanitarian impact of Ebola in a humanitarian context and advocate regionally and globally for more massive engagement of the international community in providing more on-the-ground people, more fund and sustained commitment to support regional preventative measures and recovery process. - Position the Red Cross Red Crescent as first responder to the outbreak at community level through Movement partners and unparalleled network of volunteers, and advocate for the protection of volunteers and safe access to communities. - Engage in awareness raising and social mobilization, locally, regionally and globally to reduce to address fears, misperceptions and stigmatization at nationally and globally. A Communication Strategy to guide the collective Movement communication is under elaboration. Beneficiary communications and social mobilization The IFRC will support National Societies in implementing and carrying out the following activities: 19 P a g e