Ebola Outbreak November Review

As of the end of 27 October 2014, a total of 13,703 confirmed, probable and suspected cases of EVD have been reported in six countries: Guinea, Liberia, Mali, Sierra Leone, Spain and the United States of America. The figure of confirmed, probable and suspected EVD cases includes cases in previously affected countries: Nigeria and Senegal. A total of 4,922 deaths have been reported. The death rate in the current outbreak has risen to 70 percent from the previously estimated mortality rate of 50 percent.

EVD transmission remains persistent and widespread in Guinea, Liberia and Sierra Leone, with World Health Organization (WHO) officials particularly concerned about the spread of the disease in the capital cities – Conakry, Monrovia and Freetown – where people are able to freely move across borders. All administrative districts in Liberia and Sierra Leone have now reported at least one confirmed or probable case of EVD since the outbreak began. According to WHO officials, “new cases continue to explode in areas that looked like they were coming under control,” noting “an unusual characteristic of this epidemic is a persistent cyclical pattern of gradual dips in the number of new cases, followed by sudden flare-ups.” While some regions in these countries have seen the number of EVD cases either stabilize or decrease, this does not mean that the regions are Ebola-free.

Countries with localized transmission, including Mali, Spain and the United States, are currently continuing to monitor potential contacts. On 23 October, Mali confirmed its first EVD case, a 2-year-old girl who died on 24 October.

On 21 October, the single patient with EVD in Spain tested negative for the disease for a second time. Unless a new case of EVD arises during this period, Spain will be declared Ebola-free 42 days after the date of the second negative test. In the United States, two health-care workers have tested negative for Ebola for the second time. They have both been discharged from hospital. Another health-care worker remains in isolation and is receiving treatment. WHO officials declared Senegal and Nigeria Ebola-free on 17 October and 20 October respectively.

The BBC has launched an Ebola public health information service on WhatsApp. The service will provide audio, text message alerts and images in order to help people living in West Africa get the latest public information on how to combat the spread of Ebola in the region. Content will be limited to three times per day and the service will be available in both French and English. To subscribe to this service, add +44 7702 348 651 to your contacts then send ‘JOIN’ to the number via WhatsApp. To unsubscribe, send ‘STOP’ via WhatsApp to the same number. Due to the large volume of requests, the BBC has warned that it may take a little time to be added or removed from the service.

Affected countries currently fall into three categories:

1. Those with widespread and intense transmission: Guinea, Liberia and Sierra Leone;
2. Those with either an initial case or cases, or with localized transmission: Mali, Nigeria, Senegal, Spain and the United States
3. Those countries that either neighbour or have strong trade ties with areas of active transmission: Benin, Burkina Faso, Cameroon, Central African Republic, Democratic Republic of Congo, Gambia, Ghana, Guinea Bissau, Ivory Coast, Mali, Mauritania, Nigeria, Senegal, South Sudan and Togo.

The World Health Organization (WHO) has identified three patterns of transmission:

1. In rural communities, which is facilitated by strong cultural practices and traditional beliefs;
2. In densely populated urban communities;
3. Cross-border transmission

1. Countries with Widespread and Intense Transmission

 Guinea

Guinea currently has 1,906 confirmed, probable and suspected cases of EVD and 997 deaths.  While cases of EVD transmission are the lowest in Guinea, transmission across the country continues to be of concern and is being driven by transmission in four key areas:

• The capital city Conakry – Over the past week, there have been six new confirmed cases of Ebola reported in Conakry. The capital city remains a key area of concern with the nearby district of Coyah reporting 8 new confirmed cases.
• N’Zerekore – Located south-east of Macenta, the district of N’Zerekore reported 10 new confirmed cases over the past week.
• Keouane – Transmission remains strong in this district, with 22 new confirmed cases in the last week, effectively continuing a rapid three-week growth in new cases.
• District of Macenta – The most intense transmission in Guinea is occurring in and around Macenta, which is located in the south-west region of Guinea, near the border with Liberia. Over the past week, the district reported 15 new confirmed cases. Transmission in this district has remained intense for the past 10 weeks.

The outbreak’s epicentre Gueckedou has reported few new cases over the past 7 weeks, with 3 confirmed new cases in the past week, however transmission persists. In contrast to the situation in Liberia and Sierra Leone, several areas in Guinea have not reported a single case of Ebola while seven areas have not reported any new cases over 21 days after reporting an initial case/cases.

Two new districts in Guinea reported a case or cases of Ebola for the first time in October. In the eastern region of the country, on the border with the Ivory Coast and on a major trade route with Mali, the previously unaffected district of Kankan reported 1 new confirmed case. In the central region of the country, the previously unaffected district of Faranah reported 1 confirmed case of Ebola. Faranah borders the newly affected Sierra Leonean district of Koinadugu to the southwest.   The central district of Mamou is currently classified as unaffected.

Land borders with Liberia, Senegal and Sierra Leone have been closed. Health screenings at all border crossings have been set up and all travellers displaying a fever, or EVD-like symptoms, will be subject to quarantine and/or denied entry/exit, from the country. Expect to experience delays at land border crossings. Enhanced screening measures have been introduced for outbound passengers at Conakry airport.

Liberia

Liberia has 6,535 confirmed, probable and suspected cases of EVD and remains the worst affected country in the current outbreak. The country has reported 2,413 deaths.  All administrative districts in Liberia have now reported at least one confirmed or probable case of EVD since the outbreak began.

The most intense transmission continues to occur in the Montserrado area, where in the past week, 30 new probable cases were reported. This area includes the capital city, Monrovia. While the weekly increase in new cases in this area appears to have halted since mid-September, underreporting of cases remains to be an issue across the country, especially in Monrovia, and therefore it is difficult to capture an accurate picture of the current situation. Beyond the capital city, most new reported cases have occurred in the districts of Bong, Margibi and Bomi, which over the past week have each reported 12 probable cases. The district of Grand Gadeh, which previously was considered the only unaffected area in Liberia, now has 2 confirmed and 2 suspected cases of EVD. It must be noted that these new cases may have not occurred in the past week and that reporting of these cases was delayed.

Since 20 August, a state of emergency has been in place, with security forces enforcing a nationwide curfew. Between 11PM and 6AM every night no movement is allowed anywhere in the entire country. Liberian authorities have set up road blocks in a bid to restrict movement around the country while security forces have been deployed in order to enforce quarantine for certain areas, including Lofa county. In Monrovia, the army and police have sealed off the neighbourhood of West Point with the area being placed under quarantine. There have been a number of outbreaks of violence, with civilians rioting at hospitals and attacking health workers.

All borders of Liberia have been closed, with the exception of major entry points, including the Roberts International Airport and James Spriggs Payne Airport. The Bo Waterside Crossing to Sierra Leone remains closed along with the Foya Crossing to Guinea. Any remaining border crossings may be closed with minimal notice. The Liberia Airport Authority has introduced enhanced screening measures for both inbound and outbound travellers at airport facilities.

The Ministry of Health and Social Welfare has established hotlines for the public to get basic information on Ebola: Call 0770198517 or 0777549805 or 0886530260 or 0886549805.

General medical facilities throughout the country are currently under severe strain as a result of the Ebola outbreak. Dedicated healthcare facilities for Ebola are overwhelmed and may not accept further cases.

Sierra Leone

EVD transmission remains intense across Sierra Leone, with 5,235 confirmed, probable and suspected cases and 1,500 deaths. All districts in Sierra Leone have now reported at least one case of EVD.

Over the past week, the capital city Freetown reported 63 new confirmed cases and remains one of the country’s worst affected areas. The western rural region of the country reported 81 new cases over the past week, effectively making it the sixth consecutive weekly rise in the number of new cases in the area. The western districts of Bombali, which confirmed 56 new cases in the past week, and Port Loko, with 47 confirmed new cases, continue to be seriously affected by the outbreak. EVD cases in the district of Tonkolili are of increasing concern as over the past week the area reported 36 confirmed new cases. The neighbouring regions of Kenema and Kailahun reported 13 and 5 new confirmed cases respectively over the last week and remain amongst the worst affected areas of the country.

2. Countries with Initial Case/Cases or Localized Transmission

Five countries – Mali, Nigeria, Senegal, Spain and the United States – have reported a case or cases of EVD imported from a country with widespread and intense transmission.

Mali

On 23 October, Mali confirmed its first EVD case. The patient was a 2-year-old girl who had travelled from the Guinean district of Kissidougou with her grandmother to the city of Kayes, located 600 kilometres (375 miles) from the Malian capital, near the border with Senegal. She had travelled by bus via the capital city Bamako, where she stayed for ten days in the Bagadadji neighbourhood. The patient was symptomatic for much of the journey. On 22 October, the patient was taken to Fousseyni Daou hospital in Kayes, where she died on 24 October.

Currently 82 contacts – 57 in Kayes and 27 in Bamako – are being monitored by officials and efforts to trace additional contacts are on-going. At the time of the confirmation of the first EVD case in Mali, a WHO preparedness team was deployed in the country to assess Mali’s state of readiness for an initial Ebola case. The team was immediately redirected to provide support and expertise to Malian health authorities and to help with contact tracing and the training of healthcare workers.

In the wake of the first confirmed case of Ebola in Mali, neighbouring Mauritania has implemented some border controls. 

Nigeria

On 20 October 2014, the WHO declared Nigeria Ebola-free after six weeks of no new reported cases. For officials to declare the country Ebola-free, Nigeria had to make it 42 days with no new cases, which is double the incubation period, verify that it actively sought out all possible contacts, and show negative test results for any remaining suspected cases.

Nigeria had a total of twenty cases after a Liberian-American man flew into Lagos International Airport on July 20 and collapsed shortly afterwards. The disease later spread to Port Harcourt.

While Nigeria has been declared Ebola-free, Nigerian authorities are preparing for any additional outbreaks as the current Ebola epidemic in West Africa is far from over and spread to additional countries, including to Nigeria, remains possible.

Senegal

On 17 October 2014, the WHO declared Senegal Ebola-free. The assessment was made after the West African country went forty-two days without reporting any new cases. In late August, Senegal confirmed one case of Ebola, an imported one from Guinea, which prompted officials to monitor seventy-four contacts of the patient and increase surveillance at the country’s entry ports.

Spain

A single case in Spain tested negative for EVD on 19 October. A second negative test was obtained on 21 October. A total of 83 contacts are currently being monitored. If no new cases are reported, Spain will be declared Ebola-free 42 days after the date of the second negative test. 

United States

There have been four confirmed EVD cases and one death in the US. Two health-care workers have now tested negative for Ebola twice and have been released from hospital. Another health-care worker has been placed in isolation in New York and is receiving treatment. Of 176 possible contacts, 92 are being monitored and 84 have completed the 21-day monitoring period.

3. Preparedness of Countries to Rapidly Detect and Respond to an Ebola Exposure

The WHO has identified fifteen countries that neighbour countries that either are experiencing widespread and intense EVD transmission or have strong trade and travel ties with countries with current widespread and intense transmission. These countries are: Benin, Burkina Faso, Cameroon, Central African Republic, Democratic Republic of Congo, Gambia, Ghana, Guinea Bissau, Ivory Coast, Mali, Mauritania, Nigeria, Senegal, South Sudan and Togo. The WHO has assessed that Mali and the Ivory Coast are currently at the highest risk of importing the disease.

The WHO and its partners are currently working with these countries in order to help increase their level of preparedness in the event of exposure to EVD. Teams have already been deployed to the Ivory Coast and Mali, where they have been working with health authorities, and over the next week a mission will be deployed to Guinea Bissau. In the remaining countries, WHO teams and partners are working with local authorities to help identify any gaps in their capacity to identify and respond to an initial EVD case.

Ebola Outbreak in Democratic Republic of Congo (DRC)

As of 26 October 2014, there have been 67 cases (38 confirmed, 28 probable, 1 suspected) of Ebola in the Democratic Republic of Congo. The test results for the one suspected case are not yet known. This includes eight cases amongst healthcare workers. In total, there have been 49 deaths reported, including eight healthcare workers. All suspected cases have now been either laboratory confirmed or discarded.

Of a total of 1,121 total contacs, 1,116 have now completed a 21-day follow-up. On 10 October, the last reported cases tested negative for the second time and was discharged. The DRC will thefore be declared Ebola-free 42 days after the date of the second negative test if no new cases are reported. The current outbreak in the DRC is unrelated to that affecting West Africa.