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The ongoing Ebola virus disease (Ebola) outbreak in West Africa is the largest and most sustained Ebola epidemic recorded, with 6,574 cases (1). A clearly defined chain of command and organizational structure, effective resource management, and advanced planning are important aspects of an emergency response. The national response system that was initially established by MOHSW employed several IMS elements. Regarding command and control, on August 10, 2014, the Minister of Health and Social Welfare appointed an incident manager (IM) responsible for only the Ebola response, chairing a 9:00 am incident management meeting, and establishing, following-up, and adjusting the response priorities and objectives. The revised IMS structure did not replace the national task force, which consists of a higher-level interministerial coordination group and key external partners. MOHSW has readily adopted the concept of IMS during the early months of this response to align their national response structure with well-recognized emergency management principles. The ongoing Ebola virus disease (Ebola) outbreak in West Africa is the largest recorded outbreak in history, and the response to the outbreak involves numerous domestic and international partners.
During July and August 2014, the Liberian Ministry of Health and Social Welfare (MOHSW), in consultation with CDC, refined their response to the Ebola outbreak through the institution of an IMS. IMS provides an organized response framework, which will allow MOHSW to more rapidly and effectively address the burgeoning Ebola outbreak. Alternate Text: The figure above is an organizational chart showing the Ministry of Health and Social Welfare (MOHSW) Ebola response framework in Liberia during July 2014. Alternate Text: The figure above is an organizational chart showing the Ministry of Health and Social Welfare (MOHSW) Ebola response incident management system (IMS) in Liberia during August 2014.
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An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Among the five affected countries of West Africa (Liberia, Sierra Leone, Guinea, Nigeria, and Senegal), Liberia has had the highest number cases (3,458) (1).
An IMS is a standard structure based on these principles that is used in large and small-scale incidents throughout the United States at the federal, state, and local level (3). The initial response structure implemented by MOHSW represented what would be recognized as the scientific response section of a public health response (4).
Where possible, efforts were made to work within the existing MOHSW framework to facilitate implementation of the changes (Figure 2).
Thus, ongoing work is need to integrate the MOHSW response structure into this overarching national Ebola response framework.


MOHSW colleagues, with technical assistance from CDC, will continue refining the IMS during the next 6–9 months. Clearly, the institution of an IMS in Liberia for the management of the Ebola response will be an evolutionary process, not only because the concepts are new to MOHSW, but because these concepts are also new to the other ministries with which MOHSW coordinates and to the political structure to which MOHSW reports. From SARS to 2009 H1N1 influenza: the evolution of a public health incident management system at CDC. A clearly defined chain-of-command and organizational structure, effective resource management, and advanced planning are important aspects of an emergency response.
Additionally, the findings in this report might also be useful in other settings where IMS has not been used previously and is being considered for the first time for the management of public health emergencies. MOHSW leadership recognized the organizational structure and overall response could be further optimized and sought to implement improvements with technical support from CDC.
This epidemic has severely strained the public health and health care infrastructure of Liberia, has resulted in restrictions in civil liberties, and has disrupted international travel (2).
In terms of organizational structure, a deputy IM, operations chief, and planning chief were identified. During this period, there are several anticipated objectives, the first of which is to ensure the IM designates all priorities for the subsequent 24–48-hour operational periods.
It is hoped that by instituting an organized response framework, which IMS provides, MOHSW will be able to more rapidly and effectively deal with the burgeoning Ebola outbreak in Liberia.
An incident management system (IMS) is a standard tool based on these principles, and CDC has adapted IMS principles in managing numerous public health emergency responses. Where possible, efforts were made to work within the existing MOHSW framework to facilitate implementation of the changes.
As part of the initial response, the Liberian Ministry of Health and Social Welfare (MOHSW) developed a national task force and technical expert committee to oversee the management of the Ebola-related activities. The deputy IM had the authority to step in and function as the IM, to ensure the response continued to have command and control when the IM was in higher level coordination meetings related to the response.
Continued development of a planning section in the IMS, to look beyond this limited timeframe, is required to anticipate potential problems and develop contingency plans.
Development of a robust planning section to look beyond this 24–48-hour timeframe also will occur.
The findings in this report might also be useful in other settings where IMS has not been used previously and is being considered for the first time. Hunter, DrPH4,5, Almea Matanock, MD4, Patrick Ayscue, DVM4, Benjamin Monroe, MPH6, Ilana J. During the third week of July 2014, CDC deployed a team of epidemiologists, data management specialists, emergency management specialists, and health communicators to assist MOHSW in its response to the growing Ebola epidemic.


MOHSW leadership recognized that this organizational structure (Figure 1) and the overall response could be further optimized and sought to implement improvements with technical support from CDC. The deputy IM also convened and guided a regular logistics meeting attended by MOHSW and partners with logistical interests or resources and chaired a subcommittee to address county level issues.
Because much of the operational component of the response (case identification and contact tracing) resides at the county level, there needs to be ongoing information exchange with the counties and MOHSW through the subcommittee chaired by the deputy IM. One aspect of CDC's response was to work with MOHSW in instituting incident management system (IMS) principles to enhance the organization of the response. Regarding meetings, each morning the national coordinator presided over a national task force meeting, during which presentations were made by technical committee heads.
This county-specific subcommittee served as the forum where technical, administrative, and logistical needs for the county responses could be raised.
This information exchange will need to focus on ensuring sufficient logistical support for these county-level operations.
This report describes MOHSW's Ebola response structure as of mid-July, the plans made during the initial assessment of the response structure, the implementation of interventions aimed at improving the system, and plans for further development of the response structure for the Ebola epidemic in Liberia. Finally, a permanent emergency operations center at MOHSW is planned to serve as a location to receive calls and reports, to replace the current model of direct reporting of information to the scientific response section chairs and IM leadership. The numerous comments and input from this large group made it difficult to develop clearly articulated action items.
With respect to IM meetings, each key Ebola response committee was instructed to have the chair (or an alternate with decision-making authority) attend.
An agenda was implemented that focused meeting discussions on the key actions completed during the previous 24 hours, actions to be completed during the next 24 hours, and major challenges being faced. The meetings also included a representative from the logistics and finance section (responsible for keeping track of the financial resources available to MOHSW for the managing the response). These changes allowed for more regular reporting of key logistical items to the IM, such as availability of personal protective equipment and regular budget status reports.
A task listing was implemented assigning responsibility and due dates for action items as they were identified, and more detailed meeting minutes were prepared and issued the same day as the meeting. To facilitate the ability of MOHSW to reach out to external partners, the IMS included liaisons with key external stakeholders involved in the coordination of international partners and provision of essential supplies and technical expertise, such as WHO, CDC, Medecins Sans Frontieres, UNICEF, and the U.S.



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