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West Africa: Ebola Down But Not Out

AfricaFocus Bulletin
May 11, 2015 (150511)
(Reposted from sources cited below)

Editor's Note

"The [Ebola] epidemic is at its lowest but not over yet. The recent weeks have seen an important decrease in new confirmed Ebola cases across West Africa. Liberia is now close to being declared Ebolafree on 9 May, while Sierra Leone and Guinea are finally getting close to zero. However, the outbreak is not over until it's over at the regional level." - Doctors without Borders, May 6 update

The welcome announcement that Liberia is now "Ebola-free," having passed 42 days without a case of Ebola, came with many caveats. The full picture includes the continuation of new cases in neighboring Guinea and Sierra Leone. It also includes the massive damage done to the preexisting inadequate health systems, jobs lost and education postponed, and, recently, the discovery that even Ebola survivors are likely to have ongoing after-effects.

Internationally, while there is much attention given to "lessons learned" and the need for ongoing improvement in health systems and preparedness for health emergencies still to come, the resources to implement the lessons learned are still largely missing from the budgets of international agencies. The burden still falls primarily on health workers in the countries themselves, who have already made heroic sacrifices.

For a short video (9 minutes) featuring Sierra Leoneans responsible for the difficult task of "getting to zero," see the latest Ebola on the Ground episode from OkayAfrica and Ebola Deeply, at http://tinyurl.com/lzmh47l

This AfricaFocus Bulletin contains a brief excerpt from the latest Ebola update from Doctors without Borders and longer excerpts from a feature article from Ebola Deeply on the difficulties of "getting to zero" in Sierra Leone.

Also recent and of related interest

Long-term impact of Ebola in Sierra Leone Guardian, May 8, 2015
http://tinyurl.com/m79heoh

Interview with Dan Edge, director of PBS documentary Outbreak, tracing path of Ebola & mistakes made in the response
http://tinyurl.com/ngsx9mc The 54-minute video is available at http://www.pbs.org/wgbh/pages/frontline/outbreak/

Perseverance in Life and Art: African Voices on Ebola
http://usanafricanvoicesebola.weebly.com/

For previous AfricaFocus Bulletins on Ebola and other health issues, visit http://www.africafocus.org/intro-health.php

++++++++++++++++++++++end editor's note+++++++++++++++++

Ebola crisis update - 6 May 2015

[Excerpt. Original at http://www.msf.org/article/ebola-crisis-update-6-may-2015]

Liberia: Zero cases since 20 March 2015
Guinea: 9 confirmed cases in the country on 4 May.
Sierra Leone: 21 confirmed cases in the country on 27 April: 6 new cases (3 in Kambia, 3 in Western Area) from 22-29 April

MSF Staff on ground (as of 21 April)

Total: 185 international and about 1,150 national Guinea: 83 international, around 500 national Sierra Leone: 61 international, around 310 national Liberia: 39 international, around 350 national

Overview

The epidemic is at its lowest but not over yet

The recent weeks have seen an important decrease in new confirmed Ebola cases across West Africa. Liberia is now close to being declared Ebola-free on 9 May, while Sierra Leone and Guinea are finally getting close to zero. However, the outbreak is not over until it's over at the regional level. No country can really be thought to be Ebola-free until all three countries in the outbreak have no recorded cases for 42 days.

Even after the end of this outbreak, West Africa will have to remain vigilant against a re-emergence of Ebola; there must be strengthened epidemiological surveillance and a rapid response alert system for when - rather than if, a new Ebola case occurs.

Key 'pillars' of the response are still missing

Regional cooperation: Given the high mobility of the population across the three most-affected countries, surveillance must be ensured across borders and coordinated on the regional level to avoid new cases to be 'imported' in Ebola-free zones.

Community awareness remains low in some areas, raising the risk of local people panicking, which can lead to violence against medical and aid workers. Community mobilization and sensitization efforts supported by national and local leaders must be reinforced rapidly.

Non-Ebola needs are a persisting concern

Already weak public health systems have been seriously damaged by the epidemic. The long period of interrupted health services has caused significant gaps in preventive activities, such as routine immunization of children, and in retention in care for people on long-term treatments such as HIV and other chronic diseases. There is a need to catch up and mitigate the consequences of the treatment interruption.

...


Why Sierra Leone Can't Get Rid of Ebola

April 23rd, 2015 by Mark Honigsbaum

http://www.eboladeeply.org

[Excerpts: for full report visit http://tinyurl.com/occ3vxs]

Dr. Ernest Bai Koroma, the president of the Republic of Sierra Leone, was having trouble "getting to zero," and his underlings were getting antsy. "We need one more push," said Major Palo Conteh, the commander of Sierra Leone's National Ebola Response Centre (NERC) and a former Olympic quarter miler. "It's like in the 400 meters when you're 20 meters from the finish line, that's the time to kick hard."

Brigadier General David Taluva, a jovial officer with the physique of a shot putter, had other ideas. "Perhaps we should quarantine Port Loko," he mused to a group of officers gathered outside a Portakabin by the Special Court building in Freetown, now transformed into an Ebola situation room. "No, wait, then we would have to quarantine the whole country."

The officers shuffled their feet awkwardly, then parted to make way for an official who was late for that evening's briefing.

Taluva was joking, but of course Ebola is no laughing matter. Port Loko is one of the most populous districts in Sierra Leone and the site of Lungi International Airport. Quarantine Port Loko and you effectively cut the flow of international health workers and aid to President Koroma's beleaguered administration. The problem is that Port Loko, or to be more precise, Lokomasama - the district to the north of Freetown - is scored with shallow swamps and twisting rivers perfect for evading the Ebola control measures. And, since February, that is exactly what fishermen and recalcitrant villagers in Lokomasama have been doing. The result has been new clusters of infection up and down the country, frustrating the effort to "get to zero," as the World Health Organization (WHO) calls the elimination of Ebola transmissions (getting to zero requires no new cases to be reported in a country for 42 days, double the maximum incubation period of the virus).

"I fear that people have grown complacent," sighed Professor Monty Jones, the president's special adviser, when I caught up with him in early March at the State House, an imposing stone building with uninterrupted views over Freetown to Susan's Bay and Destruction Bay. "The epidemic has been going on too long. They just want life to return to normal."

***

It was a refrain I was to hear again and again during an 11-day tour of the country that took me from the sun-kissed beaches of Aberdeen - where during daylight hours fishermen reel in glistening barracudas and pots stuffed with outsized lobsters - to a surreal meeting of tribal chiefs and frustrated British officials at Port Loko, to an overgrown graveyard in Kenema, the district in the far east of the country where Ebola first erupted in Sierra Leone in May 2014. On the way I met traumatized survivors, inspiring community activists, and stressed-out scientists doing their best to launch trials of experimental vaccines and drugs in difficult conditions.

...

Zero transmission of Ebola is theoretically achievable. Indeed, it is argued nothing less will do, and that unless and until the last case is found and safely isolated, there will always be a threat of Ebola rebounding. That is surely right. The question is, at what cost will containment be achieved?

***

A major exporter of diamonds and iron ore, Sierra Leone is rich in natural resources and, until Ebola, had one of the fastest growing economies in the world. Now mechanical diggers lie idle beside the red, African earth, and investment from China and other foreign sources has stalled. ... Sierra Leone was once a popular tourist destination: the airport is just meters from a gorgeous sandy beach ...

That image was all but erased by the country's brutal 11-year civil war, which only ended in 2002 when British troops helped expel rebel forces from the outskirts of Freetown. Then came a second blow: Ebola.

One of the tragedies of the outbreak in Sierra Leone is that it might have been avoided had WHO acted more decisively at the beginning of the epidemic. The first official acknowledgment of Ebola came on March 23, 2014 when WHO was notified of 49 cases and 29 deaths in Guéckédou, a small village bordering a forested area of southern Guinea inhabited by wild bats, the presumed reservoir of the virus. Within a week Médecins Sans Frontières (MSF) was reporting an epidemic of "unprecedented" magnitude and the spread of infections to Liberia. Kailahun, Sierra Leone's most easterly province, which shares a border with both Guinea and Liberia, was the obvious next port of call for the virus. Indeed, in April, Dr. Sheik Humarr Khan, the chief physician on the Lassa fever ward at Kenema Hospital, who at the time had the only laboratory in the country capable of testing for Ebola, began warning nurses that Ebola was 'coming' and they had better be ready. But by the time Dr. Khan confirmed the first positive blood sample on May 24, from a nurse who had attended the funeral of a traditional healer in Koindu in northern Kailahun, it was too late: staff had already admitted a pregnant woman infected with Ebola to the maternity ward. Within days the ward was overrun with Ebola cases, the majority of them other funeral goers or their contacts. In all, ten staff would die battling the virus between May and August, including Dr. Khan and the hospital's chief nurse, Mbalu Fonnie.

Kailahun was Sierra Leone's "shark in the water" moment. Knowing that a deadly predator had strayed into its territory, the Ministry of Health should have closed the road between Koindu and Kenema and flooded Kailahun with health workers and contact tracers - epidemiological teams equipped to rapidly trace and isolate infectious patients and their contacts. But at the time Sierra Leone had just 1,000 nurses and midwives for the whole country. Besides, at this stage few of the so-called experts, including WHO, seemed to think there was a danger of Ebola reaching a major town or city - and those WHO officials in Geneva who did see the danger thought an international health alert would be counterproductive, stoking needless fear and hysteria at a time ...

But, of course, everything was not fine. To date there have been 12,265 Ebola cases in Sierra Leone - more than any other country in West Africa - and though Liberia has suffered more fatalities (4,486 to Sierra Leone's 3,877), in Liberia the epidemic peaked in midSeptember, whereas in Sierra Leone infections climbed steadily throughout the autumn before peaking at a much higher level in early December. As new Ebola treatment centers came online and burial squads - backed by an army of international contact tracers and outreach workers - descended on rural communities to promote safe hygiene messages, cases declined - but at the end of January that decline stalled. Since then the Ebola reduction effort has plateaued, with the weekly case totals stuck in the mid-70s for most of February and the mid-50s in March.

...

To get a measure of the challenges facing President Koroma on what many officials are calling the "bumpy road to zero," I headed to Port Loko, where the coordinator of the local District Ebola Response Center, Raymond Kabia, had called a meeting of the district's 12 political leaders, known as paramount chiefs, in order to address the continued flouting of quarantine measures and restrictions on 'unsafe' burials. The idea was to get the chiefs to take ownership of Ebola control, but as we sped through unattended checkpoints and past banners scrawled with fading Krio messages ("Ebola nor touch am" - "Ebola don't touch"), the auguries were not good. A few weeks earlier, a fisherman from Lokomasama infected with the virus had ignored the official requirement to report to an Ebola assessment unit, and instead had persuaded three friends to ferry him to a remote island in the Rhombe swamps. There he consulted a traditional healer before continuing along Port Loko's mosquitoinfested coast to Freetown, where he alighted at a wharf in Aberdeen, a stone's throw from the Radisson Blu Mammy Yoko, the city's premier hotel, then host to more than 50 staff from the US Centers for Disease Control and Prevention (CDC).

By now the fisherman was a walking virus bomb, and on disembarking made straight for an Oxfam-built toilet block, where he vomited hemorrhagic fluids. As a result, 20 villagers in the Tamba Kula district of Aberdeen were also infected with Ebola, prompting the quarantining of the community for 21 days. In theory that should have been the end of the transmission chain, but despite the best efforts of contact tracers, one of the contacts got away - hitching a ride on the back of a motorcycle to Makeni, three hours from Freetown, where he infected three more people, including a traditional healer. All four were now being 'offered' life-saving treatment at an Ebola treatment center in Makeni operated by the International Rescue Committee (IRC), the relief agency headed by David Miliband. I say offered because, according to the nurse from Public Health England I spoke to, several patients were refusing treatment, fearing IRC medical staff were trying to murder them with what the healer, who has been keeping up a running commentary on the ward, calls their 'Ebola guns' - the hand-held electronic thermometers that nurses use to record patients' temperatures.

...

The further you go from Freetown, the fewer Ebola patients you encounter. On the outskirts of Bo we passed a huge MSF Ebola management center, deserted save for a few orderlies and a skeleton medical staff, and in Kenema it was the same. Except for the triage tents at the entrance to the hospital, you would never know Ebola had once cut a swathe through the maternity ward here, bringing misery to a place of life. But while Ebola has now returned to the forest, Dr. Khan's Lassa fever unit remains open for business. Kenema's diamond mines are a breeding ground for rats, the carriers of Lassa, and technicians have been processing and storing Lassa blood samples here for several years. Those stores are proving to be a serological goldmine: retrospective studies by Tulane University researchers using Ebola reagents have revealed antibodies in the blood of several "Lassa" patients. The first of these seropositive Ebola samples dates back to 2006. In other words, Ebola may have visited Kenema before but no one noticed. "The scientific question for us now is why that didn't turn into an outbreak," said Dr. Joseph Fair, a Lassa expert and US Army researcher from USAMRIID who helped set up Kenema's diagnostics platform.

Answering that question will require not only a better understanding of the ecology and the biology of the virus and its interaction with the immune system, but also what Dubos would have called "social and environmental factors." As Dr. Fair recalled: "When I first came to Kenema in 2006 there was no Chinese highway, just a dirt road, and the journey from Freetown took eight hours. Now, it takes three, and instead of jungle all you see are cassava fields. That's got to have had an effect."

One of the reasons Ebola has proved so difficult to eradicate in Sierra Leone is the attachment to traditional burial customs. These dictate that the families of the deceased should be able to kiss and wash the bodies of their loved ones before laying them to the rest. But, of course, such customs also risk spreading the virus further, and in an effort to get to zero the NERC has mandated that the bodies of victims be disposed of within 24 hours - an edict that, in the case of the Western Area, usually means interment in a hastily dug grave in Freetown's King Tom cemetery. At Kenema's Dama Road cemetery, however, perhaps because it is further from the center, the rules were not applied so strictly, and people had time to place markers on the last resting place of the nurses and technicians who were among Ebola's first victims. On a broiling hot afternoon in March I asked Mohamed Sow, a driver with the Tulane Lassa fever program, to take me there. Sow did not need to ask directions: when Ebola struck it was all hands to the pumps, and instead of ferrying Lassa patients to the hospital he found himself transporting victims of Ebola, many of them former colleagues, to the cemetery.

Unlike at King Tom, there was no one guarding the gates at Dama Road and no one insisting we submit to a temperature check. We simply parked by the entrance and walked in. Although it had been scarcely nine months since Ebola swept through Kenema, the graves were already overgrown with tropical vegetation. As we picked our way gingerly between the plots, at first it was hard to distinguish one from another. Then we came across a marker commemorating the death of a local pastor. According to Sow, the pastor had contracted Ebola after visiting Kenema's maternity ward to read the last rites to a patient. He was just 34. "He was a Christian, a man of God, so it was his duty," Sow told me matter-of-factly. "He could not refuse."

Soon, we realized, we were standing in a thicket of Ebola graves. The majority had crosses like the pastor's, but in some cases the names were Muslim and the epitaphs were in Arabic. All seem to have died in a three-month period between July and September 2014. Sow wanted to show us other graves, but by now both my driver and I had seen enough. The earth may have been dry and cracked, but the fear was still palpable: it was the closest we had come to the virus in 11 days.

On the drive back to Freetown neither of us said very much for the first half hour. The highway was empty and, even though we were now speeding toward the epicenter of the epidemic rather than away from it, we were both relieved to be leaving Kenema. Eventually, however, we reached a checkpoint and had to stop to show our credentials and submit to the obligatory temperature check.

"People are sick and tired of Ebola," said my driver as we pulled away. "Do you think these vaccines will really make a difference?" I replied that I didn't know, but that scientists had a duty to try, if not for now then for the next time. He paused, considering my words. Then, smiling, he pointed to a phrase painted on the bumper of the bus in front of us. It read: "No condition is permanent."

...


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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