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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
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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
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