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2014 Ebola Outbreak – Security Review for Travellers and Companies in West Africa

Summary

The current Ebola virus outbreak in West Africa is the most severe in terms of the number of human cases and fatalities since the virus was discovered in 1976. Cases of the virus have been confirmed in Guinea, Liberia, Nigeria and Sierra Leone. On 25 August, the Democratic Republic of Congo confirmed two Ebola deaths however officials believe the cases are unrelated to the outbreak in West Africa.

On 8 August 2014, the World Health Organization (WHO) formally designated the outbreak as a Public Health Emergency of International Concern. This designation invokes legal measures pertaining to disease prevention, surveillance, control and response.

The WHO has announced that the current Ebola outbreak is likely to continue for another six months before it is completely contained.

Ebola Virus Disease (EVD)

Genus Ebolavirus is a virological taxon that is included in the Filoviridae family (filovirus), order Mononegavirales. Genus Ebola virus comprises of five distinct species in which four of these cause the EVD in humans: Bundibugyo ebolavirus (BDBV); Ebola virus, formerly known as Zaire virus (EBOV); Reston ebolavirus (RESTV); Sudan ebolavirus (SUDV); Taï Forest ebolavirus (TAFV).

The five known virus species are named for the region where they were originally identified. Although Bundibugyo, Reston, Zaire, and Sudan ebolavirus have been associated with the large Ebola virus outbreaks in Africa, Zaire ebolavirus is the virus with the highest mortality rate of the ebolaviruses and is responsible for the largest number of outbreaks of the five known members of the genus, including both the first documented outbreak in 1976 and the outbreak with the most deaths (2014).

Symptoms

EVD is a severe acute viral illness that is often characterized by the sudden onset of fever (greater than 38.6°C/101.5°F), intense weakness, muscle pain, severe headache, abdominal pain, lack of appetite and sore throat. This is then followed by vomiting, diarrhoea, rash, impaired liver and kidney function, and in some severe cases, both internal and external bleeding. The incubation period, which is the time interval between infection with the virus to the onset of symptoms, is 2 to 21 days however symptoms commonly appear between 8 – 10 days.

The virus is believed to originate in fruit bats, which carry and spread the virus without being affected. EVD is believed to occur after the ebolavirus is transmitted to an initial human by contact with an infected animal’s body fluids. Human-to-human transmission occurs via direct contact with bodily fluids, including blood, faeces and sweat. Transmission can also occur by touching an infected deceased person during embalming, or by contact with contaminated medical equipment, particularly needles and syringes. Spreading of the virus through air has not been documented. People are infectious as long as their blood and secretions contain the virus.

Laboratory tests must be carried out in order to confirm an Ebola virus diagnosis as the virus displays similar symptoms to malaria, typhoid fever, shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis and other viral haemorrhagic fevers. Samples taken from possibly infected patients pose an extreme biohazard risk; therefore testing should be conducted under maximum biological containment conditions.

Treatment

No specific treatment for EVD is available and the disease has a high risk of death, killing between 50% and 90% of those infected with the virus. Severely ill patients require intensive supportive care. ZMapp is an experimental biopharmaceutical drug that is currently under development as a treatment for EVD. It has been given to several patients infected with the virus however it is not widely available. 

2014 West Africa Ebola Virus Outbreak

Unlike previous Ebola outbreaks, which have occurred in isolated areas, the current West Africa epidemic erupted in places where there is more traffic, trade and freedom of movement, effectively making it easier for the disease to spread. Myths about the Ebola outbreak have also made combatting the disease more difficult.

Guinea

Guinea was the first nation to report cases of Ebola in the current outbreak. Researchers believe that the first Ebola case emerged in late 2013 however it was not reported, nor confirmed, to international authorities until March 2014. This lag period effectively enabled measures to not be enacted and resulted in the outbreak spreading throughout the country and then into Liberia and Sierra Leone.

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, or exit, from the country. Expect to experience delays at land border crossings. Enhanced screening measures have been introduced for outbound passengers at Conakry airport.

Hospital response and isolation/treatment centres:

• Conakry: MSF is running the ETU in Donka Hospital
• Gueckedou: MSF treatment centre in Guinee forestiere
• Macenta: The WHO and MOH have set up a transit centre. Confirmed EVD patients are transferred to Conakry or Gueckedou for treatment.
• Telimele: The MSF treatment centre in Basse-Guinee was closed in July after no new cases were reported for twenty-one days.

Due to the Ebola outbreak, general medical facilities throughout the country are currently under strain and are unable to provide the same standard of healthcare as in Western countries. Dedicated healthcare facilities for Ebola are also under pressure.

Liberia

Liberia has experienced two Ebola outbreaks in 2014. The first was reported in late March in Foya district, Lofa county. The virus later spread to Monrovia and Margibi and by early April, cases were reported in Nimba and Bong counties. Although in mid-April, suspected or confirmed cases were reported in six counties: Bong, Grand Cape, Moount, Lofa, Margibi, Montserrado and Nimba, by mid-May there were no reports of new suspected or confirmed cases. The country at this time was on track to declare the outbreak over. Although 42 days passed with no new cases reported, at the beginning of June, suspected cases were again reported in Lofa county. This effectively launched a second outbreak of the deadly virus, with cases being reported in Foya and Monrovia.

The Liberian government has declared a state of emergency and since 20 August, security forces are enforcing a nationwide curfew. Between 9PM 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.

Hospital response and isolation/treatment centres:

• Foya, Lofa County: Borma Hospital Ebola Treatment unit is being run by MSF.   It has a capacity of 40 beds, with expansion to 80 beds currently underway. A mid-level isolation unit has been established in Telewowan Hospital, Voinjama. It is also managed by MSF. The centre will expand to 40 beds however no estimated date for completion has been set.
• Monrovia: ELWA Hospital Ebola Treatment Unit (ETU) is run by MSF. The new 120-bed facility was opened on 17 August. There are plans to expend it to 300 beds by 2 September. The facility in JFK hospital is functioning as a full ETU.
• Montserrado: West Point holding unit has been established.
• Nimba: Renovation of the holding facilities at G.W. Harley and Ganta Hospitals is underway as of 20 August.
• Bong: As of 22 August, a new ETU is being constructed however it has not been determined how the clinic services will be run.
• Bomi: Bomi county Health Team (CHT) opened three, two-room, quarantine units with a 12-bed capacity.

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.

Nigeria

Nigeria’s first Ebola case was an imported one. In July a Liberian man, Patrick Sawyer, flew from Monrovia, Liberia to Lagos, Nigeria, via Lome, Togo, despite displaying Ebola-like symptoms. He arrived in Nigeria on 20 July and died five days later while in quarantine. In response to his death, which was later confirmed to have been the result of Ebola, the Nigerian government placed all of those who had contact with the man under observation.  All confirmed Ebola cases have been linked to Mr Sawyer. On 28 August, Nigerian authorities confirmed that a doctor has died from Ebola in the south-eastern city of Port Harcourt. This is the first case of the deadly virus to be reported outside of Lagos.

On 8 August 2014 Nigerian President Goodluck Jonathan declared a national state of emergency. Since then, the Nigerian government has introduced measures for passengers departing from and arriving at all airports.

Hospital response and isolation/treatment centres:

• Lagos:   Infectious Disease Hospital, Yaba, has an isolation facility for Ebola cases.
• Delta State: Seven hospitals have been identified to be isolation centres for Ebola Cases. These include Warri Central Hospital; Ughelli Central Hospital; Sapele Central hospital; Agbor Central Hospital; Oleh Central Hospital; Eku Baptist Government Hospital and Delta State University Teach Hospital Oghara.
• Niger State: A quarantine centre is being established in Minna, with containment centres being established in the three Senatorial districts.

Sierra Leone

Sierra Leone’s first Ebola case occurred in late May, in Kailahun district near the border of Guinea. The deadly virus later spread to Port Loko district and then to Kenema, Kono and the Western Area. Kenema and Kailahun have been the most affected areas. Ebola affects twelve out of thirteen districts in Sierra Leone however the epicentres of the deadly disease are in the Eastern Province, near the borders with Guinea and Liberia.

On 30 July, President Koroma declared a state of public emergency, which is expected to last between 60 – 90 days. This measure effectively enables the military to enforce quarantine zones, restrict public movements and limit public gatherings. There is currently a nationwide ban on public gatherings. Increased restrictions on movement of people and vehicles have been placedin the districts of Kailahun and Kenema. All land borders with Guinea and Liberia have been closed. Health screenings have been introduced at all border crossings and all travellers displaying a fever or EVD-like symptoms will be subject to quarantine and/or denied entry, or exit, from the country. Over the weekend of 25 – 27 July, reports emerged that demonstrations and local disturbances had occurred in Kenema and Freetown and were related to the Ebola outbreak. Further such demonstrations cannot be ruled out at this time.

Hospital response and isolation/treatment centres:

• Kenema: The isolation facility in Kenema Government Hospital is to be relocated outside the township of Kenema, a few miles from Hanga. All new cases will be treated at the centre in Kailahun until the new facility is open. The Red Cross is establishing a new facility, with officials reporting on 22 August that it is expected to be functional soon.
• Kailahun: There is an 80-bed facility that is operated by MSF. The villages of Koindu and Buedu have referral units, where patients displaying symptoms of Ebola are isolated and evaluated for the disease. If it is determined that they have Ebola, they are then transferred to the isolation facility.
• Freetown: An isolation unit has been established at Connaught Hospital.
• Bo: MSF is constructing a 35-bed isolation centre that is expected to be functional by 28 August. A transit centre in Gondama is run by MSF.
• Western Area: A holding facility is being established in Lakka and a facility is being constructed in Kerry Town. Monrovia: ELWA Hospital ETU is run by MSF. The new 120-bed facility was opened on 17 August. There are plans to expand it to 300 beds by 2 September

Democratic Republic of Congo

Authorities in the DRC have confirmed two deaths related to the Ebola virus. Officials have disclosed that two of eight samples from the northwest Equateur province have come back positive for the deadly disease, with officials believing that Ebola has killed 13 people in the region, including five health workers. An epidemic has been declared in the region of Djera, in the territory of Boende in the province of Equateur. Officials however believe that the infections are of a different strain to those in the outbreak in West Africa.   One of the two cases tested positive for the Sudanese strain of the disease, while the other tested positive for a mixture between the Sudanese and the Zaire strain. The outbreak in West Africa is due to the Zaire strain.

 Ebola Myths and Impact on Outbreak

A number of myths that have materialized over the past few months have greatly impacted the spread of the current outbreak. In turn, a lack of understanding about what causes Ebola and how it is passed on has effectively resulted in the region developing into a fertile ground for speculation and mistaken beliefs.

Officials at the WHO have confirmed that the already difficult conditions are made more difficult by public misunderstanding caused by “rumours on social media claiming that certain products or practices can prevent or cure Ebola Virus Disease.” In Nigeria, at least two people died as a result of drinking salt water after stories circulated that doing so would protect against the deadly disease. Other supposed cures for the virus include raw onions, coffee, condensed milk and holy water. Some civilians have opted to hide infected family members at home, or prefer to take them to local doctors instead of to an Ebola treatment centre. Health officials in Sierra Leone disclosed in August that the Ebola outbreak spread from Guinea after an herbalist in the remote eastern border village of Sokoma claimed to have powers to heal the deadly virus. Officials have confirmed that the virus spread in Sierra Leone after cases from Guinea crossed over the border, seeking treatment.

Fears over the deadly virus have also sparked riots and attacks on health workers. As the Ebola outbreak continues, such attacks may spark similar reactions to those carried out against polio workers.

At the start of the outbreak, a team from MSF had to stop working at an isolation ward in Guinea after local residents mistakenly believed that they had brought the virus with them. Groups of health workers from MSF, the Red Cross and from the ministry of health have been pelted with rocks as they attempted to reach Ebola-hit areas. In Liberia, a number of Ebola patients escaped a healthcare facility after it was attacked by rioters.

Due to the region’s recent history of bloody civil war, some believe that the army’s deployment to control the affected areas is a sign that the government is deliberately infecting people in a bid to have an excuse to enforce martial law.

Economic Impact

While the Ebola epidemic has been an urgent health crisis, it has also had a devastating impact on the economies of Guinea, Liberia and Sierra Leone.

Due to travel restrictions, and a growing fear of human contact, markets and shops throughout Guinea, Liberia and Sierra Leone have been forced to close, leading to the loss of income for producers and traders. The Ebola crisis has also resulted in many people moving away from the affected areas, which in turn has disturbed agricultural activities.  Road blocks and quarantines manned by police and military have prevented the movement of farmers and labourers as well as the supply of goods, resulting in the cost of farm produce doubling in a matter of weeks. Officials at the UN are now warning of a looming food crisis in eastern Sierra Leone because of the acute shortage in farm labour.

Tourism within the affected countries and regionally has also been directly impacted. Despite WHO officials advising against suspending flights to the affected region, several airlines have temporarily suspended flights to Guinea, Liberia and Sierra Leone while a number of airlines have opted to suspend flights to regional countries where no Ebola cases have been reported. In early August, Korean Airlines chose to suspend flights to and from Kenya in a measure aimed at preventing the spread of the Ebola virus. The closure of borders and the suspension of flights have had a detrimental effect on trade as the move has severely limited the ability of countries to export and import goods. A number of foreign companies have chosen to withdraw non-essential personnel.  Some mining companies in the region have imposed travel restrictions on their workers, deferred new investments and cut back their operations.

The Ebola epidemic has had a severe impact on the three West African nations, especially Liberia and Sierra Leone, which are still in the process of emerging from civil wars and are attempting to rebuild their economies.

Forecasts of economic growth in the region have been reduced as the outbreak has strained the finances of a number of governments. An initial World Bank-IMF assessment for Guinea projected a full percentage point fall in GDP growth from 4.5 percent to 3.5 percent. While Liberia’s economy had initially been expected to grow by 5.9% this year, the country’s Finance Minister has disclosed that this was no longer realistic as the Ebola crisis has slowed down the transport and service sectors and has resulted in the departure of a number of foreign workers. Sierra Leone’s Agriculture Minister has also disclosed that the country’s economy has deflated by 30% because of the Ebola outbreak, noting that the agricultural sector was the most impacted as 66% of the country’s population are farmers.  On 26 August, the African Development Bank disclosed that the worst-ever Ebola epidemic could cut the economic output of Guinea, Liberia, Sierra Leone and the Ivory Coast by between 1 percent and 1.5 percent of gross economic product.

 Advice for Companies/Employees in Affected Regions

MS Risk currently advises all to reconsider their need to travel to Guinea, Liberia and Sierra Leone. This is due to the current Ebola outbreak, the challenges in containing it, the limited emergency care options that are available and the increasing travel restrictions, which have significantly reduced the freedom of movement throughout the region. MS Risk advises all those in the affected countries to consider leaving while limited commercial flights continue to operate.

MS Risk advises all travellers and those working in the affected countries to closely monitor the advice provided by local health officials and the WHO. MS Risk advises all to maintain strict standards of hygiene, including following strict hand washing routines; avoiding contact with symptomatic patients and their bodily fluids; avoiding contact with corpses and/or bodily fluids from deceased patients; avoiding contact with any objects that may have been contaminated with bodily fluids. Travellers should also avoid close contact with live or dead animals and should not eat or handle raw or undercooked animal products, such as blood and meat. Travellers should avoid consumption of bush meat. All companies should be aware of the symptoms of Ebola and should brief all workers. Whenever possible, companies should implement screenings for workers, especially in highly affected areas. These include enforcement of regular hand washing routines and the measuring of temperature. If an employee develops symptoms, he/she must be quarantined immediately and a healthcare provider must be contacted.

A number of airlines have changed or suspended flights to West Africa as a result of the Ebola outbreak. These include:

• Arik Air and Gambia Bird – Suspended services to Liberia and Sierra Leone
• Asky Airlines – Suspended flights to and from Guinea, Liberia and Sierra Leone.
• Air France – Suspension of flights to Freetown, Sierra Leone beginning 28 August.
• British Airways – Suspended flights to Liberia and Sierra Leone until the end of this year.
• Ceiba Intercontinental – Suspended flights to West African countries
• Emirates Airlines – Suspended flights to Guinea
• Kenyan Airways – Temporarily suspended flights from Liberia and Sierra Leone into Nairobi
• Korean Airlines – Suspended flights to and from Kenya
• Royal Air Maroc and Brussels Airlines are still operating however on modified routes and schedules
• Delta continues to operate as normal however the airline is due to cease flying to Monrovia, Liberia at the end of August.

ICC Court Announces Verdict for Congolese Ex-Militia Boss

On Friday, the International Criminal Court (ICC) found Germain Katanga guilty of war crimes but has acquitted him of sexual offences.  He has been found guilty of complicity in a 2003 massacre and becomes just the second person to be convicted by the court since it was set up in The Hague in 2002.  If he had been convicted of sexual offences, he would have been the first to be convicted of sexual crimes.

On Friday, the ICC was due to deliver its verdict in the trial of Congolese ex-militia boss Germain Katanga, who has been accused of using child soldiers in a 2003 attack on a village in the central region of the African country, killing 200 people.  Judge Bruno Cotte read out the verdict at 0830 GMT in the case against Katanga, the one-time commander of the ethnic-based Patriotic Resistance Forces in Ituri (FRPI), operating in the DR Congo’s mineral-rich north-eastern region.

Katanga, 35, went on trial more than four years ago, facing seven counts of war crimes and three of crimes against humanity, including murder, sexual slavery and rape, for his alleged role in the attack on the small village of Bogoro on 24 April 2003.  During the trial, prosecutors alleged that the man and his forces of the Ngiti and Lendu tribes attacked villagers of the Hema ethnic group with machine guns, rocket-propelled grenades and machetes, murdering around 200 people.  According to the prosecution, “the attack was intended to ‘wipe out’ or ‘raze’ Bogoro village…”  Child soldiers were used while women and girls were abducted afterwards and used as sex slaves, forced to cook and obey orders from FRPI soldiers.  In 2004, as part of a policy to end the civil strife, Katanga was made a general in President Joseph Kabila’s army, a post he held until he was arrested in 2005.  In October 2007, he was transferred to The Hague while his trial, together with that of his co-accused Mathieu Ngudjolo Chui, began two years later.  In November 2012, judges split the trials and a month later, Ngudjolo was acquitted after judges in that case indicated that the prosecution had failed to prove that he had played a commanding role in the Bogoro attack.  This was the first time that the ICCC had acquitted a suspect.  Katanga, who has pleaded not guilty to the charges, has consistently maintained that he had no direct command or control over the FRPI fighters at the time.  He also denied ever being present at the time of the attack on Bogoro, which is located 25 kilometres (15 miles) south of Ituri province’s administrative capital Bunia, near Lake Albert.  The Hague-based ICC has so far only convicted one other suspect, former Congolese rebel fighter Thomas Lubanga, who was sentenced in 2012 to 14 years for recruiting and enlisting child soldiers.

Tagged as: Democratic Republic of the Congo, DR Congo, DRC, FRPI, Germain Katanga, ICC, International Criminal Court, The Hague