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PostPosted: Thu Jan 15, 2015 1:22 pm 
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WHO has released a series of papers on the Ebola outbreak.

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PostPosted: Thu Jan 15, 2015 1:22 pm 
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Note to the Media /WHO1
15 January 2015


Ebola in West Africa: 12-months on


Geneva- One year after the first Ebola cases started to surface in Guinea, WHO is publishing this series of 14 papers that take an in-depth look at West Africa’s first epidemic of Ebola virus disease.

The papers explore reasons why the disease evaded detection for several months and the factors, many specific to West Africa, that fuelled its subsequent spread.

The most extensive papers trace events in each of the three most severely affected countries – Guinea, Liberia and Sierra Leone. These countries shared many common challenges, shaped by geography, culture, and poverty, but each also faced, addressed and sometimes solved some unique problems.

Key events are set out chronologically, starting with the child who is believed to be the index case of this epidemic through to the Director-General’s commitment to steadfastly support affected countries until they reach zero cases.

The report also looks back at WHO’s response over the past 12 months, including the 9 August declaration of an international health emergency. It documents the many challenges faced by countries and the international community in dealing with the largest, longest, most severe, and most complex Ebola outbreak in history.

Throughout the report, the contributions of national governments and their many partners weave in, as does the great human misery caused by a terrible and terrifying disease.

Other papers provide insight into:
how the fast-track development of Ebola vaccines, treatments and rapid diagnostic tests is progressing, with no compromise of safety and efficacy standards.
how Senegal, Nigeria and likely Mali managed to contain imported cases and bring their own outbreaks under control.
the state of worldwide vigilance and preparedness, especially in countries targeted by WHO as being at greatest risk of an imported case.

The report also looks ahead. Based on what was learned during the previous year, what critical strategies and interventions will give countries and their partners the best chance of bringing the outbreaks under control?

Read the report here.
http://www.who.int/csr/disease/ebola/on ... uction/en/
For more information, please contact:
Gregory Hartl, Telephone: +41 22 791 44 58; Mobile: +41 79 203 6715; e-mail: hartlg@who.int

Tarik Jasarevic, Telephone: +41 22 791 5099; Mobile: +41 79 367 6214; e-mail: jasarevict@who.int

All WHO information can be found at: www.who.int

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PostPosted: Thu Jan 15, 2015 6:23 pm 
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One year into the Ebola epidemic: a deadly, tenacious and unforgiving virus

One year into the Ebola epidemic. January 2015

One year after the first Ebola cases started to surface in Guinea, WHO is publishing this series of 14 papers that take an in-depth look at West Africa’s first epidemic of Ebola virus disease.

WHO Director-General Dr Chan shaking hands with Rebecca Johnson, nurse, Ebola survivor, Sierra Leone 2014
UNMEER/Martine Perret
INTRODUCTION - This assessment looks at how West Africa’s epidemic of Ebola virus disease has evolved over the past year, giving special attention to the situation in Guinea, Liberia, and Sierra Leone. The success stories in Senegal, Nigeria, and likely Mali are also described to show what has worked best to limit onward transmission of Ebola following an imported case and bring the outbreak to a rapid end. The fact that a densely populated city like Lagos was successful in containing Ebola offers encouragement that other developing countries can do the same.

An overview of how the outbreak in the Democratic Republic of Congo evolved and was brought under control underscores the many differences between the outbreaks in West Africa and in equatorial Africa, where all previous outbreaks since the first two in 1976 have occurred.

Key events in the WHO response are outlined to show how initial control efforts were eventually overwhelmed by the wide geographical dispersion of transmission, the unprecedented operational complexity of the outbreaks, and the many factors that undermined the power of traditional containment measures to disrupt transmission chains. These factors are also described.

In efforts coordinated by WHO, scientists and the pharmaceutical industry have geared up to develop, test, license, and introduce the first Ebola vaccines, therapies, and point-of-care diagnostic tests. As a strong expression of solidarity with the people of West Africa, these groups are attempting to compress work that normally takes two to four years into a matter of months.

Finally, the assessment takes a look at the potential future evolution of the Ebola epidemic. Based on what has been learned during this first year, what critical strategies and interventions will give countries and their partners the best chance of bringing the outbreaks under control?

http://www.who.int/csr/disease/ebola/on ... uction/en/

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PostPosted: Thu Jan 15, 2015 6:23 pm 
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Origins of the 2014 Ebola epidemic

One year into the Ebola epidemic. January 2015

A "mysterious" disease began silently spreading in a small village in Guinea on 26 December 2013 but was not identified as Ebola until 21 March 2014.

WHO mobile lab scientists at the crossing point between Guinea and Sierra Leone.
WHO/Saffea Gborie
CHAPTER 2 - Retrospective studies conducted by WHO staff and Guinean health officials identified the index case in West Africa’s Ebola epidemic as an 18-month-old boy who lived in Meliandou, Guinea. The boy developed an illness characterized by fever, black stools, and vomiting on 26 December 2013 and died two days later. The exact source of his infection has not been identified but likely involved contact with wild animals.

The remote and sparsely populated village of Meliandou, with only 31 households, is located in Gueckedou District in what is known as the Forest Region. Much of the surrounding forest area has, however, been destroyed by foreign mining and timber operations.

Some evidence suggests that the resulting forest loss, estimated at more than 80%, brought potentially infected wild animals, and the bat species thought to be the virus’ natural reservoir, into closer contact with human settlements. Prior to symptom onset, the child was seen playing in his backyard near a hollow tree heavily infested with bats.

"You have to know Ebola to fight Ebola. Mobilize your people."

Dr Clement, WHO, Liberia

By the second week of January 2014, several members of the boy’s immediate family had developed a similar illness followed by rapid death. The same was true for several midwives, traditional healers, and staff at a hospital in the city of Gueckedou who treated them.

During the following week, members of the boy’s extended family, who attended funerals or took care of ill relatives, also fell sick and died. By then, the virus had spread to four sub-districts via additional transmission chains. A pattern of unprotected exposure, more cases and deaths, more funerals, and further spread had been established.

The first investigations: cholera?

The first alert was raised on 24 January, when the head of the Meliandou health post informed district health officials of five cases of severe diarrhoea with a rapidly fatal outcome. That alert prompted an investigation the next day in Meliandou by a small team of local health officials. The reported symptoms, including diarrhoea, vomiting, and severe dehydration, appeared similar to those of cholera, one of the area’s many endemic infectious diseases. However, no firm conclusions could be reached.

A second larger team, including staff from Médecins Sans Frontières (MSF) travelled to Meliandou on 27 January. Microscopic examination of patient samples showed bacteria, again supporting the conclusion that the unknown disease was likely cholera. Following the team’s visit, other deaths occurred but were neither reported nor investigated.

On 1 February, the virus was carried into the capital, Conakry, by an infected member of the boy’s extended family. He died four days later at a hospital where, as doctors had no reason to suspect Ebola, no measures were taken to protect staff and other patients. As the month progressed, cases spread to the prefectures of Macenta, Baladou, Nzerekore, and Farako as well as to several villages and cities along the routes to these destinations.

Alert, investigation and identification of the Ebola virus

The Ministry of Health issued its first alert to the unidentified disease on 13 March 2014. On that same day, staff at WHO’s Regional Office for Africa (AFRO) formally opened an Emergency Management System event for a disease suspected to be Lassa fever.

A major investigation, involving staff from the Ministry of Health, WHO AFRO, and MSF, took place from 14 to 25 March, involving site visits to Kissidougou, Macenta, Gueckedou City and Nzerekore. That investigation found epidemiological links among outbreaks previously not known to be connected and identified Gueckedou City as the epicentre for transmission of a disease that still had no known cause.

On 21 March, the Institut Pasteur in Lyon, France, a WHO Collaborating Centre, confirmed that the causative agent was a filovirus, narrowing the diagnosis down to either Ebola virus disease or Marburg haemorrhagic fever.

The next day, the laboratory confirmed that the causative agent was the Zaire species, the most lethal virus in the Ebola family. That same day, the government alerted WHO to what was described as a “rapidly evolving” outbreak of Ebola virus disease. When WHO publicly announced the outbreak on its website on 23 March, 49 cases and 29 deaths were officially reported.

http://www.who.int/csr/disease/ebola/on ... origin/en/

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PostPosted: Thu Jan 15, 2015 6:27 pm 
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Factors that contributed to undetected spread of the Ebola virus and impeded rapid containment

One year into the Ebola epidemic. January 2015

Several factors, including some that are unique to West Africa, helped the virus stay hidden and elude containment measures.

Ebola survivors at the Survivors’ Conference in Kenema, Sierra Leone, 2014.
WHO/S. Gborie
CHAPTER 3 - In Guinea, it took nearly three months for health officials and their international partners to identify the Ebola virus as the causative agent. By that time, the virus was firmly entrenched and spread was primed to explode.

By 23 March 2014, a few scattered cases had already been imported from Guinea into Liberia and Sierra Leone, but these cases were not detected, investigated, or formally reported to WHO. The outbreaks in these two countries likewise smouldered for weeks, eventually becoming visible as chains of transmission multiplied, spilled into capital cities, and became so numerous they could no longer be traced.

Countries in equatorial Africa have experienced Ebola outbreaks for nearly four decades. Though they also have weak health systems, they know this disease well. All previous outbreaks, which remained largely confined to remote rural areas, were controlled, with support from WHO and other international partners, in periods ranging from three weeks to three months. In those outbreaks, geography aided containment.

Clinicians in equatorial Africa have good reasons to suspect Ebola when a “mysterious” disease occurs, and this favours early detection. Laboratory capacity is in place. Staff know where to send patient samples for rapid and reliable diagnosis. Health systems are familiar with Ebola and much better prepared. For example, hospitals in Kinshasa, the capital of the Democratic Republic of Congo, have isolation wards, and staff are trained in procedures for infection prevention and control. Governments know the importance of treating a confirmed Ebola case as a national emergency.

An old disease in a new context

In contrast, West African countries, which had never experienced an Ebola outbreak, were poorly prepared for this unfamiliar and unexpected disease at every level, from early detection of the first cases to orchestrating an appropriate response. Clinicians had never managed cases. No laboratory had ever diagnosed a patient specimen. No government had ever witnessed the social and economic upheaval that can accompany an outbreak of this disease. Populations could not understand what hit them or why.

Ebola was thus an old disease in a new context that favoured rapid and initially invisible spread. As a result of these and other factors, the Ebola virus has behaved differently in West Africa than in equatorial Africa, challenging a number of previous assumptions.

In past outbreaks, amplification of infections in health care facilities was the principal cause of initial explosive spread. Transmission within communities played a lesser role, with the notable exception of unsafe burials. In West Africa, entire villages have been abandoned after community-wide spread killed or infected many residents and fear caused others to flee.

Also in past outbreaks, Ebola was largely confined to remote rural areas, with just a few scattered cases detected in cities. In West Africa, cities – including the capitals of all three countries – have been epicentres of intense virus transmission. The West African outbreaks demonstrated how swiftly the virus could move once it reached urban settings and densely populated slums.


In past outbreaks, the primary aim of rapid patient isolation was to interrupt chains of transmission. Today, with so many people infected, the primary aim must also include aggressive supportive care, especially rehydration and correction of electrolyte imbalances, which improves the chances of survival. Life-saving supportive care is difficult to provide in a typical West African health care setting but is improving as more treatment facilities are built by MSF, the UK and US governments, WHO, and other partners.

Damaged public health infrastructures

Guinea, Liberia, and Sierra Leone, which are among the poorest countries in the world, had only recently emerged from years of civil war and unrest that left basic health infrastructures severely damaged or destroyed and created a cohort of young adults with little or no education.

Road systems, transportation services, and telecommunications are weak in all three countries, especially in rural settings. These weaknesses greatly delayed the transportation of patients to treatment centres and of samples to laboratories, the communication of alerts, reports, and calls for help, and public information campaigns.

High population mobility across porous borders

West Africa is characterized by a high degree of population movement across exceptionally porous borders. Recent studies estimate that population mobility in these countries is seven times higher than elsewhere in the world. To a large extent, poverty drives this mobility as people travel daily looking for work or food. Many extended West African families have relatives living in different countries.

Population mobility created two significant impediments to control. First, as noted early on, cross-border contact tracing is difficult. Populations readily cross porous borders but outbreak responders do not. Second, as the situation in one country began to improve, it attracted patients from neighbouring countries seeking unoccupied treatment beds, thus reigniting transmission chains. In other words, as long as one country experienced intense transmission other countries remained at risk, no matter how strong their own response measures had been.

The traditional custom of returning, often over long distances, to a native village to die and be buried near ancestors is another dimension of population movement that carries an especially high transmission risk.

Severe shortage of health care workers

Prior to the outbreaks, the three countries had a ratio of only one to two doctors per nearly 100,000 populatoin. That meagre workforce has now been further diminished by the unprecedented number of health care workers infected during the outbreaks. Nearly 700 were infected by year end and more than half of them had died.

Though the number of infected health care workers was highest at the start of the outbreaks, infections in doctors and nurses began to spike again in the last quarter of the year. The reasons for this spike are currently being investigated.

In Liberia, some evidence suggests that, as cases began to decline and the risk was perceived to be lower, stringent measures for personal protection lapsed. Protective measures in the community, such as frequent hand hygiene and keeping a safe distance from others, visibly declined. In Sierra Leone, which now has 5 times as many new cases per week when compared with Liberia, exhaustion among staff may help explain the increase.

As experience has shown, when a city experiences intense and widespread transmission, as happened first in Monrovia and then later in Freetown, the distinctions between “hot” and “low-risk” zones become blurred. Infections in at least some health care workers, who rigorously followed safe procedures while caring for Ebola patients in a hospital or clinic, are known to have acquired their infection in the community.

As of mid-December, MSF had more than 3,400 staff working in the affected countries. Of these staff, 27 became infected with Ebola and 13 of them died. Investigations by MSF found that the vast majority of these infections occurred in the community, and not in its treatment facilities, which have an outstanding reputation for safety.

Cultural beliefs and behavioural practices

High-risk behaviours in the three countries have been similar to what has been seen during previous Ebola outbreaks in equatorial Africa, with adherence to ancestral funeral and burial rites singled out as fuelling large explosions of new cases. Medical anthropologists have, however, noted that funeral and burial practices in West Africa are exceptionally high-risk.

Data available in August, as reported by Guinea’s Ministry of Health, indicated that 60% of cases in that country could be linked to traditional burial and funeral practices. In November, WHO staff in Sierra Leone estimated that 80% of cases in that country were linked to these practices.

In Liberia and Sierra Leone, where burial rites are reinforced by a number of secret societies, some mourners bathe in or anoint others with rinse water from the washing of corpses. Understudies of socially prominent members of these secret societies have been known to sleep near a highly infectious corpse for several nights, believing that doing so allows the transfer of powers.

Ebola has preyed on another deep-seated cultural trait: compassion. In West Africa, the virus spread through the networks that bind societies together in a culture that stresses compassionate care for the ill and ceremonial care for their bodies if they die. Some doctors are thought to have become infected when they rushed, unprotected, to aid patients who collapsed in waiting rooms or on the grounds outside a hospital.

As several experts have noted, when technical interventions cross purposes with entrenched cultural practices, culture always wins. Control efforts must work within the culture, not against it.

Reliance on traditional healers

Traditional medicine has a long history in Africa. Even prior to the outbreaks, poor access to government-run health facilities made care by traditional healers or self-medication through pharmacies the preferred health care option for many, especially the poor. Many surges in new cases have been traced to contact with a traditional healer or herbalist or attendance at their funerals.

After the outbreaks began, the high fatality rate encouraged the perception that hospitals were places of contagion and death, further reinforcing the lack of compliance with advice to seek early medical care. Moreover, many treatment facilities, hidden behind high fences and sometimes draped with barbed wire, looked more like prisons than places for health care and healing.

Community resistance, strikes by health care workers

Control efforts in all three countries have been disrupted by community resistance, which has multiple causes. Fear and misperceptions about an unfamiliar disease have been well documented by medical anthropologists, who have also addressed the reasons why many refused to believe that Ebola was real.

People and their ancestors had been living in the same ecological environment for centuries, hunting the same wild animals in the same forest areas, and had never before seen a disease like Ebola. Equally unfamiliar were the response measures, like disinfecting houses, setting up barriers and fever checks, and the invasion by foreigners dressed in what looked like spacesuits, who took people to hospitals or barricaded tent-like wards from which few returned.

A second source of community resistance arose from the inability of ambulance and burial teams to respond quickly to calls for help, with bodies sometimes left in the community for as long as 8 days. The communities will comply with official advice if it benefits them. They are far less likely to comply if the result, like uncollected bodies, causes visible harm.

Burials performed by military personnel have been safe and efficient but not always dignified, especially in a culture that observes ancestral mourning rites and is accustomed to touching bodies of loved ones before they are buried in their finest clothes, in graves that are marked.

Strikes by hospital staff and burial teams have further impeded control efforts. Most strikes occurred after staff were not paid for weeks or months, did not receive promised hazard pay, or were asked to work under unsafe conditions associated with the deaths of many colleagues.

Public health messages that fuelled hopelessness and despair

In the face of early and persistent denial that Ebola was real, health messages issued to the public repeatedly emphasized that the disease was extremely serious and deadly, and had no vaccine, treatment, or cure. While intended to promote protective behaviours, these messages had the opposite effect.

If hospitals and “Western” medicine offered no treatments, therapies, or cures, families preferred to care for their loved ones at home. In their view, if death is almost inevitable, let this happen as comfortably as possible at home, amid familiar and well-loved faces. Moreover, when patients were taken to treatment or transit centres, anxious families often received little information about the patient’s condition, outcome, or even the place of burial.

With time, and as entire households died of the disease, communities began to understand that keeping patients in homes carried a high risk for care-givers. However, the severe shortage of treatment beds, first in Monrovia and later in the western part of Sierra Leone, left families with few other options.

For unknown reasons that may include the stigma that surrounds this disease, the practice of hiding patients in homes continued in some areas, even after abundant treatment beds became available. The great stigma attached to Ebola explains why suspicious deaths are routinely tested for Ebola. Bodies that test negative can be buried in the traditional way, and families are freed from ostracism by the community.

Spread by international air travel

The importation of Ebola into Lagos, Nigeria on 20 July and Dallas, Texas on 30 September marked the first times that the virus entered a new country via air travellers. These events theoretically placed every city with an international airport at risk of an imported case.

The imported cases, which provoked intense media coverage and public anxiety, brought home the reality that all countries are at some degree of risk as long as intense virus transmission is occurring anywhere in the world – especially given the radically increased interdependence and interconnectedness that characterize this century.

Background noise from endemic infectious diseases

All previous Ebola outbreaks occurred in countries with a number of long-tenured infectious diseases that mimic the early symptoms of Ebola and help keep the disease hidden. The initial symptoms of malaria, for example, are indistinguishable from those of Ebola. Cholera is likewise endemic in the area and caused a large outbreak in Guinea and Sierra Leone in 2012 that lasted most of that year.

As a further complicating factor, the incidence of Lassa fever – which, like Ebola, is a viral haemorrhagic fever – is uniquely high in this West African region, with Sierra Leone recording the world’s highest incidence of cases.

A virus with different clinical and epidemiological features

Recent virological analyses have determined that the virus circulating in West Africa is genetically distinct from Zaire viruses seen in past outbreaks and in the 2014 outbreak in the Democratic Republic of Congo. As scientists have noted, the virus in West Africa takes a different clinical course with different epidemiological consequences, although these differences do not affect the infectious period, case fatality rate, or modes of transmission.

As noted in a major study and commentary published in Science Magazine on 29 August, the virus’ genome – its genetic “identity card” – is changing “fairly quickly” in fixed ways. As the authors of the report concluded, “continued progression of this epidemic could afford an opportunity for viral adaptation, underscoring the need for rapid containment.”

A fire in a peat bog

In past outbreaks of Ebola virus disease and the related Marburg haemorrhagic fever, cases were concentrated in a small number of geographical foci, which simplified logistical demands. Under such circumstances, the principal responders, WHO, MSF, and the US CDC, could flood affected areas with staff and materials, hunt the virus down, and uproot it within several weeks to three months.

The situation in West Africa has been far more challenging, with cases reported in all or most parts of the three countries, including their capital cities. The demands of addressing this broad geographical dispersion of cases outstripped international response capacity at nearly every level, ranging from worldwide supplies of personal protective equipment to the number of foreign medical teams able to staff newly built treatment centres.

During 2014, the outbreaks in West Africa behaved like a fire in a peat bog that flares up on the surface and is stamped out, but continues to smoulder underground, flaring up again in the same place or somewhere else. Unlike other humanitarian crises, like an earthquake or a flood, which are static, the Ebola virus was constantly – and often invisibly – on the move.

The long duration of the outbreaks

The Ebola outbreak demonstrated the lack of international capacity to respond to a severe, sustained, and geographically dispersed public health crisis. Governments and their partners, including WHO, were overwhelmed by unprecedented demands driven by culture and geography as well as logistical challenges. Together, these and other factors, including the behaviour of the virus, created a volatile situation that evaded conventional control measures and constantly delivered surprises.

Faced with so much suffering and so many unmet needs, many partners in the outbreak response courageously took on responsibilities that went beyond their traditional areas of work and expertise. Some, including MSF, the US CDC, the International Federation of Red Cross and Red Crescent Societies (IFRC), the World Food Programme, and UNICEF built upon their well-established roles during health and humanitarian crises to expand their areas of engagement.

MSF, which provided the bulk of clinical care since the beginning of the outbreaks, used its treatment centres to collaborate in clinical trials of experimental therapies and also provided funding. The World Food Programme extended its unparalleled logistical capacities to support response operations that went well beyond the delivery of food. Its helicopters were used to get rapid response teams to remote rural areas. Its engineering teams supported the rapid construction of treatment facilities by WHO and others and the clearing of ground for cemeteries.

Hundreds of CDC staff, including epidemiologists with extensive experience in outbreak containment, were deployed to support surveillance, contact tracing, data management, laboratory testing, and health education. UNICEF worked to promote child health and safe childbirth in addition to taking the lead on social mobilization.

IFRC used its vast network of volunteers to take on primary responsibility for safe and dignified burials. As WHO field staff observed, some operations encountered less community resistance when local staff were part of the response team, as is often the case with IFRC volunteers. However, given the cultural and religious sensitivities surrounding burials, the work of several teams was disrupted by violent community resistance, resulting in serious injuries to some team members.

The International Medical Corps, International Rescue Committee, and International Organization for Migration played major roles in staffing and managing treatment facilities, in Liberia and Sierra Leone, designed to meet all isolation, care, safety, and waste management needs. Staff provided by the International Medical Corps included mental health and psychosocial specialists.

Doing unfamiliar work

Many organizations and agencies took on technical work normally handled by public health experts. UNFPA, for example, undertook contact tracing. The charity Save the Children assumed responsibility for managing a treatment centre built by the UK government in Kerry Town, Sierra Leone.

As the year drew to a close, several charities were struggling to care for Ebola orphans, estimated by some to number more than 30,000 in the three countries. Poverty, the heavy stigma attached to this disease, and the speed with which it can devastate a village made it difficult to find homes for orphaned children.

Manufacturers of essential supplies, like personal protective equipment, were also stretched to the limits of their production capacity, while WHO was left to ensure that donated supplies from existing stockpiles were of the right quality to protect staff during an outbreak caused by an especially contagious and lethal virus. Unfortunately, when the outbreak started, no gear specifically designed to protect against Ebola virus infection existed, and this problem raised some uncertainties throughout the year.

In a new role for WHO, the Organization supervised and funded the construction of treatment centres, as requested by ministries of health, and developed floor plans for safe facilities constructed by others.

Despite all this support from multiple sources, capacity was insufficient for most of the year or not available where it was needed most. The problem of insufficient capacity was greatest for foreign medical teams needed to run treatment centres. Many WHO staff sent to the field to serve as coordinators ended up donning protective gear and treating patients as well.

With response teams overwhelmed and resources stretched so thin, these laudable efforts to fill in the gaps raised some important questions. Who is responsible for coordinating all these efforts? Who is responsible for ensuring that unfamiliar jobs taken on by some are properly done?

http://www.who.int/csr/disease/ebola/on ... actors/en/

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PostPosted: Thu Jan 15, 2015 6:28 pm 
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Guinea: The Ebola virus shows its tenacity

One year into the Ebola epidemic. January 2015

As the first country affected, Guinea illustrates – sometimes to an extreme – some of the many problems that compromised control efforts elsewhere.

The district hospital staff attend training on Ebola infection prevention, Guinea, 2014
WHO/T. Jasarevic
CHAPTER 4 - Since the outbreak was officially declared in mid-March 2014, Guinea has experienced three cyclical patterns of intense transmission followed by an apparent decline in cases and then a return to intense transmission. The first dip in the number of probable and confirmed cases occurred in the week starting 28 April. Cases subsequently increased then dropped again in mid-June. A sudden flare-up occurred during the week starting 11 August, initiating a pattern of high-level transmission that continued for the rest of the year.

The first cycle led to early optimism that the outbreak was under control. As early as 15 April, the outbreak was being publicly described by staff in the Ministry of Health as “nearly under control”. By 25 April, the government had begun the countdown of passing through 21 days, the recognized incubation period, with no cases in the affected prefectures. At that time, Gueckedou was the epicentre of the outbreak, with Macenta also showing a slow rise in new cases.

Early optimism – and calls for caution

Guinea illustrates key issues that have compromised control efforts both within and beyond its borders.

On 1 May, the country’s President visited WHO headquarters in Geneva to discuss the outbreak with Director-General Dr Margaret Chan. He cited several signals that the outbreak had peaked and expressed his hope that WHO could soon declare an end to the event. Dr Chan argued for caution and continued high vigilance. As she stressed, the outbreak could be declared over only after 42 days (twice the incubation period) had passed with no new cases detected under conditions of intense surveillance.

Indications of an apparent decline in cases were noted by others, including Médecins Sans Frontières (MSF) and staff from the US Centers for Disease Control and Prevention (CDC). In early May, MSF put its team in Macenta on standby, while likewise calling for continued vigilance.

"When we got the results from Conakry confirming that Ebola had reached our place, we were scared. But we knew that we, health workers, have the responsibility to fight it.”

Dr Beuvogui, District Hospital, Telimele, Guinea

As events would prove, these early signals were false.

Other WHO staff, including its leading Ebola expert, also called for caution, arguing that the outbreak had most likely moved underground, as families hid their sick in homes and buried bodies in secret ceremonies after dark. In other words, the outbreak had moved underground, invisible in the statistics. That warning was supported by two phenomena never before observed during previous Ebola outbreaks.

First, as new treatment beds became available, they were filled – virtually overnight – by a hidden caseload largely made up of previously unidentified patients.

Second, zones of intense transmission were kept in the shadows by the refusal of communities to accept investigations by foreign medical staff, including WHO teams. In these “shadow zones”, WHO epidemiologists were often forced to use proxy indicators, such as the number of fresh graves, to produce crude maps of areas with intense transmission. Almost from the beginning, WHO epidemiologists working in Guinea recognized that the true scale of the outbreak was being underestimated by officially reported data, though the magnitude of underreporting could not be accurately measured.

With each cyclical rise in the number of cases, the outbreak demonstrated the virus’ remarkable tenacity, repeatedly returning in ways that were impossible to hide either intentionally or – more likely – because of gaps in the surveillance system and the difficulty of uncovering what was happening in the many shadow zones.

Community resistance to an extreme: mobs and murders

Community resistance has been a major barrier to control in all three countries but took on extreme dimensions in Guinea.

The first recorded incident occurred on 4 April, when an angry mob attacked an MSF treatment facility in Macenta, claiming that staff had introduced the disease into the community. Fear spread faster than the virus. In early June, when an MSF emergency coordinator reported a resurgence of Ebola in West Africa, she attributed the rise in cases to community resistance and the challenges of conducting cross-border contact tracing.

By mid-June, incidents of violence against response teams were being reported in communities across the country. In some incidents, response teams were forced to hide in the bush, fearing for their lives. Facilities, equipment, and vehicles were vandalized. Some riots followed disinfection campaigns, as communities believed that the spraying of chlorine was actually disseminating contagion, not stopping it. That impression was further enforced by the fact that spray teams wore equipment that protected themselves from head to toe. People in other communities believed that foreign teams were causing deaths in order to harvest organs.

In the worst incident of violence, an 8-member team of outbreak responders was found murdered in a village on 18 September. A second severe incident followed on 23 September, when Red Cross volunteers who had safely buried a body in the town of Forecariah were attacked by an armed mob. They seriously injured two volunteers, uncovered the grave, removed the highly infectious corpse from its body bag, and hid it somewhere in the village.

At that time, Forecariah, a mining town in western Guinea, had a case fatality rate among Ebola patients of at least 80% and had experienced a serious incident of spread among patients and staff in a large regional hospital. Moreover, cases in this hotspot had established two chains of transmission in Conakry and a third in Sierra Leone.

As the mob in Forecariah grew to more than 3,000 heavily armed youths, the focus of anger shifted to a WHO-led team of epidemiologists. They fled for their lives. Meanwhile, all equipment and vehicles at the treatment centre were either stolen or vandalized by the mob. Weeks of persistent and effective efforts to slow the outbreak down were undone on that day. As the event also underscored, working with patients infected by a deadly and highly contagious virus was not the only life-threatening risk faced by outbreak responders.

Why community resistance persists

Many analysts have attempted to explain why community resistance is persisting in parts of all three severely affected countries.

Traditional belief systems that attribute adverse events, including diseases, to non-medical causes having magical or mystical dimensions, such as a curse or a payback for past sins, have been important factors in some areas.

A December report from the Assessment Capacities Project, or ACAPS, which assesses humanitarian needs, cited ignorance among a cohort of young adults, including some former child soldiers, who received little or no education during the years of civil war and unrest that disrupted progress in all three countries.

Still others look to shortcomings in the response, including delays – sometimes for days – in answering calls for an ambulance or burial team, especially in remote areas in Guinea. In Liberia and Sierra Leone, bodies were left on city streets; some communities waited more than a week for burial teams to arrive. Such failures undermine community trust in the response effort.

Lack of logistical support further fed this community resistance and unwillingness to cooperate with response teams. In parts of Guinea, for example, bad road conditions, lack of properly maintained vehicles and fuel, and fear on the part of ambulance crews have meant that patients may need to undergo an ambulance ride of 8 to 10 hours, sometimes with no food or water, to reach a treatment centre. Many died along the way. Relatives were understandably reluctant to submit loved ones to such an ordeal.

Different challenges in urban and rural areas

The outbreak in Guinea also demonstrated the different challenges faced in rural and urban areas. Whereas health services are more accessible in cities, contact tracing is harder and requires more staff given the numerous opportunities for close contact to occur.

In rural areas, the two biggest problems have been community resistance to safe burials and refusal to cooperate with contact tracing teams. As anthropologists learned, contact tracing was impeded by public interpretations of contact lists as “death” lists indicating who would be next to die. Again, people were understandably reluctant to add the names of a spouse, child, or neighbour to such lists, fearing that doing so condemned them to die.

The outbreak in Guinea further revealed the consequences of both the area’s exceptionally high population mobility and the cyclical pattern of a decline in new cases, followed by a return to intense transmission. When cases in Guinea declined, ill people from neighbouring countries with no available treatment beds flocked to the country seeking treatment after hearing stories that the outbreak there was under control. In all three countries, cross-border movements, especially of patients seeking treatment beds, introduced new chains of transmission, sometimes re-infecting areas that had been coming under control.

Plans versus the realities on the ground

As in Liberia and Sierra Leone, efforts to bring Guinea’s outbreak under control faced multiple barriers, including logistical problems linked to the country’s weak public health infrastructures.

The construction and opening of badly needed Ebola treatment centres took longer than planned. At year end, only 5 of 10 planned treatment centres were operational, leaving far too many patients without a treatment option.

For a long time, the country had only two treatment centres, in Conakry and Gueckedou, both run by MSF. In mid-November, a treatment centre opened in Macenta, run by the French Red Cross. In December, another centre became operational in Nzerekore, run by Alima, a French aid agency. Construction of a fifth centre, in Kankan, to be run by MSF, is nearing completion.

Likewise, plans to construct 62 community transit centres, where suspected patients could be held pending the results of diagnostic tests, were delayed as funding was available to construct and run only 10 of these centres.

WHO’s 31 December situation report singled out community resistance to response measures and an exceptionally mobile population as two major barriers to outbreak containment. To counter resistance to control measures, the concept of village “watch committees” had been put forward as a way to engage community leaders and secure public cooperation in case detection, contact tracing, and safe burials. Again, at year end, only half of planned committees were established and functioning.

Case management in several prefectures was impaired by a shortage of vehicles, lack of fuel, and poor road conditions which slowed the transportation of samples to laboratories and of patients to treatment or transit centres. For example, in the Siguiri area near the border with Mali, only one ambulance was available to transport patients and samples to facilities in Gueckedou, a distance which takes a day-long drive over rough roads each way. WHO secured a second ambulance, but transportation capacity still fell well below the need. Every delay that leaves a potentially infectious person in the community feeds opportunities for further virus transmission.

Continuing infections in health care workers

The continuing high number of newly infected health care workers in West Africa’s outbreaks is unprecedented. In previous Ebola outbreaks in equatorial Africa, infections among health care workers rapidly diminished soon after the causative agent was identified and measures for infection prevention and control were introduced. In contrast, the concluding months of 2014 saw a surge of infections in doctors and nurses in all three countries.

Of the total of 153 infected health care workers in Guinea, of whom 90 died, 60 national staff became infected from the start of October to end-December, representing nearly 40% of the total.

Initial investigations indicate that most of these recent infections occurred in non-Ebola health care facilities, both privately run and government funded. Insufficient supplies of personal protective equipment in these facilities may help explain the continuing high level of infections in health care workers. As long as case detection and contact tracing remain weak, the risk is high that patients receiving health services for other conditions, including such high-risk events as childbirth, may be infected with Ebola yet not diagnosed.

Finally, all three outbreaks have demonstrated the dangers of using growth in GDP as the sole measure of a nation’s socioeconomic progress as it conceals vast social inequalities and hides the vulnerability to national security created by large numbers of desperately poor populations. The economies in all three countries were on the upswing following years of civil war and unrest, yet crumbled under the severe shock delivered by Ebola.

Supportive care reduces case fatality

As the outbreak in Guinea evolved, evidence emerged that good supportive care saves lives. Following confirmation of the outbreak in March, WHO deployed clinicians to Conakry to treat the first patients there. A retrospective clinical study, coordinated by WHO, examined data on 37 laboratory-confirmed cases treated at a hospital during the first month of the outbreak. Fourteen of the patients were health care workers, and 12 of them acquired their infection in a health care setting. These figures demonstrate the role that hospitals can play in amplifying transmission once cases begin occurring in an urban setting.

Clinical presentation of patients with Ebola virus disease in Conakry, Guinea
N Engl J Med 2015; 372:40-47January 1, 2015
The study benefitted from careful and thorough daily data collection, laboratory records, and case histories compiled by clinicians from the Ministry of Health, MSF, and WHO. To replace fluids lost through severe diarrhoea, 36 patients (97%) received oral rehydration solution. Additional intravenous fluid resuscitation was given to 28 (76%) patients. The case fatality rate, at 43%, was lower than that recorded at other outbreak sites, also in Guinea, and in previous outbreaks caused by the Zaire species of the Ebola virus.

Good supportive care, especially to correct substantial fluid loss from copious diarrhoea, is thought to have contributed to the larger number of survivors. However, two limitations compromised the quality of bedside care: staff were too few in number, and the duration of time spent providing care at the bedside was too short, as heat exposure and dehydration in staff wearing personal protective equipment limited the amount of time they could spend on the ward.

Despite these encouraging results, the case fatality rate in all three countries has remained high, at around 71%. As experiences during 2014 revealed, communities will not seek early testing and treatment – even when laboratory results are rapid and sufficient treatment beds are available – if they have no trust in the outbreak response. In Guinea, a WHO staff member who spent several months in the Forest Zone in the last quarter of the year noted a strong sense of resignation among residents: having lived with this deadly and poorly understood disease for so long, they see no end in sight and little reason for hope.

An upsurge in cases

By late November, Guinea was reporting more new cases, over a broader geographical area, than ever before. Areas that had been reporting no new cases were once again affected. In December, Forecariah again experienced an upsurge in the number of cases, as did the capital, Conakry, and the Dubreka prefecture, north of the capital. Newly affected areas included villages near the borders with Mali and Cote d’Ivoire, increasing the risk that more cases would be exported across exceptionally porous borders. In early December, Telimele reported its first new cases since June.

These areas of resurgence point to the need to tailor responses to the situation in individual prefectures and sub-prefectures. They also call for the deployment of staff and the channelling of funds from the central to the local level.

Control efforts continued to face a high level of community resistance, especially to contact tracing and safe burials. In early December, the opening of a new 50-bed treatment centre in Conakry was initially delayed by a rioting mob. Geographical expansion of the outbreak continued as December progressed. WHO epidemiologists estimated that more cases in recognized hot spots likely meant more cases elsewhere, given the increase in population movements with the start of the dry season.

To date, Conakry has not witnessed, on a large scale, the horrific scenes that unfolded in Monrovia in September and in Freetown in November and December – of uncollected bodies on the streets, patients dying on the grounds of overflowing treatment facilities, and orphans shunned by the community and left to die. However, the country’s sheer geographical size, coupled with the persistence of extreme and often violent community resistance, continue to impede control efforts.

Whereas only 7 prefectures reported cases in October, that number had grown to 17 by mid-December. During the third week in December, Guinea reported 156 confirmed cases, the highest weekly case incidence recorded during the year-long outbreak.

On 31 December, WHO recorded 25 sub-prefectures where response efforts encountered community resistance. These sub-prefectures are located in prefectures adjacent to Conakry (Dubreka, Forecariah, Coyah and Kindia), in the Forest Region (Bela, Kissidougou, Gueckedou, Lola, Macenta, Nzerekore), in Upper Guinea (Dabola), and in Western Guinea (Telimele and Labe).

At year end, it looked like Guinea – where the outbreak started, simmered, and then resurged time and time again, nationwide and in individual areas – could present an especially hard challenge in bringing the Ebola epidemic under control.

http://www.who.int/csr/disease/ebola/on ... guinea/en/

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PostPosted: Thu Jan 15, 2015 6:30 pm 
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Liberia: a country – and its capital – are overwhelmed with Ebola cases

One year into the Ebola epidemic. January 2015

When the virus entered Monrovia, the outbreak’s calm start turned into an illusion.

Active case finder Tony B. Harrison asks community member Victor a number of questions to better understand if there are any sick persons in his house, Liberia
WHO/P. Desloovere
CHAPTER 5 - Liberia’s first two cases of Ebola, in the Foya district of Lofa county near the border with Guinea, were confirmed on 30 March 2014. On 2 April, an infected traveller from Lofa passed through Monrovia, the country’s capital, but was not known to have transmitted the virus to others.

On 7 April, the country reported 21 confirmed, probable, and suspected cases and 10 deaths. All five laboratory-confirmed cases died, including one in Monrovia. In a pattern that would become a striking feature of the outbreak, those numbers included three cases in health care workers, all fatal.

The situation in Liberia then stabilized throughout the rest of April and most of May, with cases still largely concentrated in Lofa county. For weeks on end, WHO’s Disease Outbreak News about the Ebola situation in West Africa reported “no new confirmed cases in Liberia” or described the situation as “stable”. By the end of May, Liberia had reported no new cases since 9 April.

Further cases were detected in early June, mainly in Lofa county, but the trend still looked calm, especially when compared with the situation elsewhere. At the end of June, Liberia reported 51 cases, compared with 390 in Guinea and 158 in Sierra Leone.

Monrovia turns a calm start into an illusion

"This morning, I went into my community, searched house to house and interviewed a few people. It is something I love to do because it will save my community."

Robbin George, student, an active Ebola case finder

That appearance of calm turned out to be an illusion. The first additional cases in Monrovia were reported in mid-June. The city was ill-prepared to cope with the onslaught of infections that rapidly followed.

Monrovia was home to the country’s only large referral hospital, the John F Kennedy Medical Center, but that facility had been heavily damaged during the civil war and never fully repaired. Frequent floods and electrical fires were hazards for patients and staff alike. Several prominent doctors working there became infected and died. By the end of September, Liberia would have the highest number of infections in health care workers – at nearly 200 – among the three countries.

No hospital anywhere in the country had an isolation ward. Few medical staff had been trained in the basic principles of infection prevention and control. Facilities had little or no personal protective equipment – not even gloves – and virtually no knowledge about how to use this equipment properly.

Under such conditions, treatment of the first hospitalized patients ignited multiple chains of transmission, among staff, patients, and visitors, in ambulance and taxi drivers who ferried the sick to care, in relatives, neighbours, and eventually entire neighbourhoods. Case numbers that had multiplied quickly began to grow exponentially.

On 6 August, President Sirleaf declared a three-month state of emergency and announced a string of new regulations, which included the closing of markets, curfews, and restrictions on the movement of patients and their contacts, to be enforced by the country’s military. In her view, such restrictions were justified as the disease threatened to undermine the nation’s “economic and social fabric”.

In August, Liberia made the cremation of people who died from Ebola mandatory in Monrovia. That decree followed the refusal of several Monrovian neighbourhoods to allow burials near their homes, leaving hundreds of highly infectious bodies unattended.

A WHO emergency team begins its investigation

In mid-August, a WHO team of emergency experts, working alongside staff from the Ministry of Health and other key partners, began a three-week long investigation of the situation in Liberia. That investigation revealed that an outbreak had been simmering in the country for at least several weeks before the first cases in Monrovia were detected, giving the virus a huge head-start on control measures.

All agreed that the demands of the Ebola outbreak had outstripped the government’s and partners’ capacity to respond. By that time, 14 of the country’s 15 counties had reported confirmed cases. Some 152 health care workers had been infected and 79 of them had died, representing a significant loss of talented and dedicated doctors and nurses at a time of immense need.

By 8 September, Liberia had the highest cumulative number of reported cases, reaching nearly two thousand cases and more than one thousand deaths.

In Monrovia, bed capacity could not keep up with the growing number of very ill Ebola patients. New treatment centres were opened by MSF and others, but were rapidly filled to overflowing. The WHO team estimated that 1000 beds were needed just for the treatment of currently infected patients. Only 240 beds were available. Although another 260 beds were planned, the shortage meant that only around half of patients could be admitted to treatment facilities over the next several weeks and months.

One treatment facility, quickly set up by WHO at the Ministry of Health’s request, was equipped and staffed to manage 30 patients but had 70 as soon as it opened.

At the end of August, the government quarantined the city’s West Point slum, home to at least 75,000 people crowded together under unsanitary conditions, as part of efforts to slow the explosive spread. Violence broke out and one teenager was killed as armed forces struggled to contain the event.

Overwhelmed by a runaway virus

As the first week of September ended, data indicated that that exponential growth of cases had overwhelmed response capacity in the capital city. Taxis filled with entire families, of whom some members were almost certainly infected with Ebola, constantly crisscrossed and circled the city, searching for a treatment bed. They found none. MSF announced that its facilities were overstretched and began to turn patients away.

WHO sent one of its most experienced emergency responders to Monrovia to head its office there. More logisticians arrived from Geneva to address urgent material needs, while field epidemiologists were deployed to undertake case finding and contact tracing. Nonetheless, the outbreak still ran ahead of all these stepped-up efforts.

The lack of adequate numbers of treatment beds provided the most dramatic evidence of a runaway virus. It also jeopardized key control measures, such as the isolation of confirmed and suspected cases, and ensured that the virus would continue to race through families and neighbourhoods. The country’s President pushed partners hard to build more treatment centres.

In September, WHO began construction of a new treatment centre in Monrovia, using teams of 100 construction workers labouring in round-the-clock shifts. On 21 September, the Island Clinic was formally handed over by WHO to Liberia’s Ministry of Health. The clinic added 150 Ebola treatment beds to the city’s existing 240 beds. However, within 24 hours after opening, the clinic was overflowing with patients, again demonstrating the desperate need for more treatment beds.

Epidemiological trends were difficult to assess. Accurate monitoring of the situation suffered from the weak surveillance and reporting systems in place prior to the start of the outbreak. The onslaught of cases strained those mechanisms further. At times, the overwhelmed systems were unable to confirm or discard probable and suspected cases, as laboratory backlogs delayed testing and confirmation of positive cases – sometimes for weeks.

The first drop in cases: a model of success

The first encouraging trend was detected during the last days of September, when reports of new cases in Lofa County, the initial epicentre of intense transmission, began showing an apparent decline. WHO watched that encouraging trend with hope but also caution, given the well-known problems with under-reporting.

By the end of October, WHO could conclude that the decline of cases in Lofa was persistent, consistent, and likely real. The trickle of cases then dried up in November, with no new cases reported for four consecutive weeks. Confidence that Lofa had indeed beaten back the virus increased throughout December. No new cases were reported.

In one of the most encouraging investigations in all three countries during 2014, WHO was able to find a direct link between implementation of the full package of control interventions, including community engagement, acceptance, and ownership of the response, and the decline and then end of new cases. Those findings were all the more impressive given Lofa’s proximity to Guinea, where transmission was still ongoing and intense.

The situation in Lofa underscored the value of stratifying the response to this extremely complex and challenging outbreak to meet the unique context and challenges at the district level in all affected countries. This was not an epidemic with three different national patterns, but likely hundreds of distinct patterns, with their own transmission dynamics, playing out within individual districts and sub-districts.

Fortunately, that observation coincided with better reporting at the district level as WHO deployed more experienced epidemiologists to the field. The US CDC likewise sent more staff to help correct deficiencies in the surveillance and reporting systems.

Support escalates in Monrovia

At the start of October, WHO estimated that 1,500 treatment beds were needed in addition to those already in place or planned. Support escalated, as commitments, made by the US government and others following the September emergency meeting of the UN Security Council on Ebola, began to materialize. Two US Navy mobile laboratories arrived and began processing samples in Bong and Monrovia on 5 October.

More treatment facilities were built by US military personnel. They used WHO master plans for a treatment centre that strictly separated “hot” and “safe” zones, allowed no contaminated wastes to leave the patient ward, and provided space for safe triage. Safe triage reduced the risk that people suffering from another illness or entirely healthy contacts would be placed near confirmed cases, increasing the risk of infection.

The number of trained and supervised staff conducting case finding and contact tracing, and the daily monitoring of contacts increased considerably in Monrovia, but was still insufficient elsewhere in the country. Laboratory capacity improved, but WHO concerns about the quality of data and the under-reporting of cases continued.

The first signals that the situation in Monrovia had stabilized began in late October, with a slow decline detected in the early weeks of November. As a precaution, WHO staff conducted a study of data collected from funeral homes, crematoria, and coffin makers to assess the likelihood that hidden burials might account for the decline in reported mortality. The results of that study supported the conclusion that the decline in cases and deaths in Monrovia was real and robust. In mid-November, the government set a target of no new Ebola cases by 25 December.

As the year concluded, the main risks in Liberia were two-fold: complacency as a traumatized population began to feel safe and vigilance relaxed, and the move of the virus from cities to remote rural areas.

Exchanging one set of problems for another?

During the second week of December, only 6 of the country’s 15 counties reported new cases. That situation contrasted sharply with the one reported by WHO on 22 October, when all counties had recorded at least one case and Monrovia was reporting more than 300 new cases each week.

During late November and early December, rural outbreaks were seeded as people who had been working in the cities returned to their rural homes, sometimes to die. By mid-December, the virus had largely moved from cities to remote rural areas that lie well beyond the places where the road system ends.

Apart from continuing – though declining – cases in Monrovia, the districts of greatest concern included Grand Bassa, Bong, Grand Cape Mount, and Margibi. In a Ping-Pong effect, the genuine successes recorded in Monrovia and Lofa risked coming unravelled: travellers from affected rural areas could re-ignite infections in the cities. Based on available evidence, WHO viewed that risk as greater than the risk that new cases would be imported, especially from Sierra Leone.

Given the very different challenges seen in urban and rural areas, the virus’ retreat from the cities might turn out to mean that one set of problems has been exchanged for another. As experience has shown, especially in Guinea, areas that come under control remain at risk of re-infection as long as virus circulation continues anywhere in the country or its neighbours.

In Grand Bassa and Grand Cape Mount, health officials struggled to cope with almost no staff properly trained in case detection, patient management, contact tracing, and the safe collection of patient samples. Personal protective equipment was in short supply, as were essential medicines. Almost no villages had ambulances or trained ambulance crews and burial teams. The few vehicles available were poorly maintained and fuel was scarce.

These problems were vastly amplified by the absence of transportation and telecommunications networks. Some villages can be reached only after an eight-hour hike across rough terrain. Prompt reporting of cases and responses to calls for help have been further impaired by patchy and sporadic telecommunication services. Health staff in these remote counties were lucky to have brief internet access once or twice per week.

In yet another complication, patients in rural areas did not want to be sent for treatment to Monrovia, where abundant beds were available, as they knew that bodies in the capital city would be cremated, in line with the President’s August decree. In Liberia, “Decoration Days” – holidays when the graves of relatives are cleaned and decorated – are a deep-seated cultural tradition.

At year-end, Liberia had 10 beds available for each Ebola patient in Monrovia, but faced an urgent need to shift this capacity to rural areas. As experience has shown, moving testing and treatment facilities closer to where cases are occurring is a far better strategy than moving patients, often over long distances, to treatment facilities. Such movements are hard on patients, poorly accepted by families, and fraught with risks of further transmission en route.

WHO has shifted its strategy to the use of rapid response teams sent to rural areas. In the best-case scenario, these teams will catch flare-ups early enough to stamp them out – before entire villages are paralyzed by illness and deaths and the virus inevitably spreads to new areas. However, the difficulty of reaching these remote areas and the absence of so many essential services, personnel, vehicles, and other material support work against the kind of speed that is so badly needed.

Getting an upper hand on the virus?

As the year concluded, four important lessons could be drawn from Liberia’s experiences with the Ebola virus.

First, Lofa county, which reported no new cases since early November, demonstrated the feasibility of “bending the curve” and defeating the virus – even in heavily affected areas with intense transmission.

Second, intensification of technical interventions, like increased laboratory capacity, more treatment beds, and a larger number of contact tracing and burial teams, will not bend the curve in the absence of community engagement and ownership.

Third, with the right support, a country can permanently improve its capacity to collect and report health-related data, even under the demanding pressures of a severe outbreak. At year-end, laboratory capacity had improved, in less than three months, to the point where all probable and suspected cases were being tested, with the results promptly reported.

Finally, strong, hands-on, and frequently courageous support from the country’s President helped match the severity of the disease with forceful – though sometimes controversial – control measures. President Sirleaf also undertook numerous field visits to severely affected areas to show citizens the level of her engagement and concern.

This leadership helped coordinate the activities of a large number of partners, including US government agencies and military personnel, supporting the response effort.

A Presidential Task Force on the Ebola response, which brought partners and donors together with senior government officials and civil society leaders, was established on 26 July and functioned through the end of September, when it was replaced by a Presidential Advisory Committee on Ebola, or PACE, again chaired by the President. Additional task forces operated in each county to tailor the response to local needs and keep partners working in tandem.

In a worrisome trend, six health care workers were infected nationwide during the first week of December, of whom three died. An investigation was launched to determine how staff were getting infected and what additional protective measures were needed.

At year-end, despite imperfections in the surveillance and reporting systems, evidence indicated that Liberia – which long showed the most explosive transmission – was getting an upper hand on the virus.

http://www.who.int/csr/disease/ebola/on ... iberia/en/

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PostPosted: Thu Jan 15, 2015 6:40 pm 
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Sierra Leone: A slow start to an outbreak that eventually outpaced all others

One year into the Ebola epidemic. January 2015

The funeral of a faith healer ignited an outbreak characterized by innovative response measures, including the Western Area Surge that began in mid-December 2014.

Ibrahim Suri Kamara, himself suffering fever, joint and muscle pain and fever tries to cool his feverish 6 year old twin daughters, Sinna and Sento.
WHO/C: Black
CHAPTER 6 - In Sierra Leone, the outbreak began slowly and silently, gradually building up to a burst of cases in late May and early June. Cases then increased exponentially in the last quarter of the year, with November seeing the most dramatic jump.

A retrospective investigation by WHO revealed that the country’s first case was a woman who was a guest at the home of the index case in Meliandou, Guinea. When the host family became ill, she travelled back to her home in Sierra Leone and died there shortly after her return in early January. However, that death was neither investigated nor reported at the time.

On 1 April the country stepped up vigilance for imported cases when two members of the same family who had died from Ebola virus disease in Guinea were repatriated to Sierra Leone for burial.Though heightened vigilance yielded a number of suspected cases, all tested negative.

Death of a faith healer: the first two hot spots in Kailahun and Kenema

The burst of new cases seen in early June has been traced to the 10 May funeral of a respected traditional healer held in Sokoma, a remote village in Kailahun district, near the border with Guinea. The healer became infected while treating Ebola patients who crossed the border from Guinea, seeking her healing powers.

"This is a medical war my country is fighting and I believe that the only way to stop this disease is for us, health practitioners, to come on board. We need to identify all sick people and take them out of the community as soon as possible."

Stephen Kamara, medical student

That funeral sparked a chain reaction of more cases, more deaths, more funerals, and more cases in multiple transmission chains. Local epidemiologists eventually traced 365 Ebola-related deaths to that single funeral, which also seeded cases reported in Liberia.

On 12 June, a state of emergency was declared in Kailahun, calling for the closing of schools, cinemas, and places for night-time gatherings and the screening of vehicles at checkpoints along the borders with Guinea and Liberia.

Kailahun and, to its south, the larger city of Kenema, formed the early epicentre of the outbreak. WHO and other partners concentrated their response teams in that area.

Kenema benefitted from a laboratory and ageing isolation ward set up to manage cases of Lassa fever. That laboratory diagnosed the city’s first Ebola cases, but the poorly-maintained isolation ward was soon overwhelmed with Ebola patients and services collapsed.

At Kenema’s government-run hospital, two wards were converted to serve as an Ebola-designated treatment facility. Unfortunately, eight nurses working there became infected in July, adding to the problem of finding sufficient staff willing to work under life-threatening conditions. As the year progressed, that number grew to more than 40 deaths among doctors and nurses at the single district hospital, dealing a huge blow to the country’s already overstretched health system.

On 24 June, MSF opened an Ebola treatment centre in Kailahun. As an emergency coordinator with the charity noted, “We came too late when villages already had dozens of cases. We don’t know where all chains of transmission are taking place.” By mid-July, so many people were dying of the disease that teams trained by WHO buried more than 50 bodies over a 12-day period.

The MSF 50-bed treatment centre in Kailahun managed more than 90 confirmed cases in the first four weeks after it opened. To meet diagnostic needs, WHO helped establish a mobile laboratory provided by Public Health Canada. However, the number of new cases continued to outstrip both treatment and laboratory capacity.

In both Kailahun and Kenema, the greatest need was for more treatment facilities backed by greater and faster laboratory support. Pending the availability of those facilities, WHO worked, in collaboration with UNFPA, to reduce the number of new cases by training and equipping hundreds of local volunteers to search for cases, use mobile phones to send alerts to health authorities, and conduct contact tracing.

However, a shortage of experienced staff meant that much of this work was not supervised. In particular, the quality of contact tracing suffered. Too many people with a history of high-risk exposure were missed, cases were not detected and managed early, and chains of transmission continued to multiply.

In July, partners working in Kenema and Kailahun agreed that containment would require an enormous and robust scaling up of response capacity. Much stronger basic health infrastructures had to be quickly put in place and made to function well. As the WHO emergency coordinator in Kailahun noted at that time, “We need to step up the response and we need to do it fast.” Partners further recognized the need for far greater engagement of community leaders, especially paramount chiefs and religious leaders, to promote local acceptance of control interventions.

Death of a national hero: safety issues raised

Tragedy struck on 29 July, when Sheik Humarr Khan, the country’s only expert on viral haemorrhagic fevers, who had been leading the Ebola response in Kenema, died of the disease at the treatment facility in Kailahun. The death of Dr Khan, who was regarded as a national hero, and surrounding publicity removed many public doubts about whether Ebola was “real”, but it also introduced questions about the safety of the area’s treatment facilities.

In August, WHO urged governments and the international community to make available, in all three Ebola affected countries, incentives, protection, and treatment for health personnel to improve their safety and provide the motivation needed to ensure uninterrupted health care services.

Confidence in the safety of medical staff was further eroded in the last week of August when a WHO-deployed epidemiologist working in Kailahun became infected. Just a few days later, three staff at a hotel where foreign medical teams were staying became infected.

Following those events, most foreign medical staff, included those deployed by WHO, suspended operations in Kailahun. A team of logisticians and experts in infection prevention and control was deployed by WHO to investigate exactly how health care workers were being infected and to ensure working conditions were safe. Confidence was gradually restored and operations resumed in early September.

In Kenema, more evidence that capacities were overwhelmed came on 30 August, when health care workers at the government-run hospital went on strike over unpaid salaries and poor and dangerous working conditions. Nurses and burial teams complained that they had not been paid for several weeks, had insufficient personal protective equipment, and were forced to use a single broken stretcher to transport bodies as well as patients. WHO made arrangements to pay their back salaries, but not enough could be immediately done to improve the safety of working conditions.

As the number of patients, doctors, and nurses dying at the Kenema government hospital continued to escalate, rumours grew that something other than a disease was responsible for the deaths. More deaths began occurring in the community as patients fled or avoided the hospital, again undermining the effectiveness of treatment in isolation as a control measure.

The "Kenema tent": isolation in reverse

Residents of villages near Kenema witnessed how quickly the virus could sweep through crowded households, but saw few alternatives to home care. Weak response capacity meant that people with suspected Ebola were often not moved to a treatment centre until positive test results became available, which could take up to four days. By that time, many more in the household would be infected. Spread within households, where five to six children might share the same mattress, was ruthlessly swift.

In discussions with village leaders, the WHO field coordinator in Kenema learned that what people wanted was a place where uninfected members of a household could go to “self-isolate”. They wanted a low-risk environment to stay in while waiting for the results of diagnostic tests. They had observed the high risk of being infected when people were trapped in a quarantined and crowded household with at least one confirmed Ebola case. The idea of providing a tent, offering sufficient space to keep a safe distance from others, was born.

The WHO office in Freetown provided the first tent. The International Federation of Red Cross and Red Crescent Societies supplied others, while UNICEF took care of sleeping mats, bednets, and cooking equipment.

This community-initiated innovation proved popular and effective. In the village of Mondema, for example, household contacts of confirmed cases able to self-isolate in the tents experienced no new cases. Though the impact on the overall outbreak was small, that innovation demonstrated one of the most important lessons to emerge during the first year: listen to the community. Communities know what they need. If that need is met in an acceptable way, it will be used.

Freetown: the new epicentre

The first confirmed case in Freetown was reported to WHO on 23 June. Cases in Freetown and the adjacent district of Port Loko initially rose slowly, with patients transferred to Kenema for treatment. Throughout July and August, Kailahun and Kenema remained the districts with the most intense virus transmission, and cases there continued to occur at an alarming rate.

On 6 August, the President declared a national state of emergency, with quarantines, enforced by the military, imposed on the areas and households hardest hit. Also in August, the government passed a law imposing a jail sentence of up to two years on anyone found to be hiding a patient. At the end of that month, the country reported a cumulative total of 1,026 cases, compared with 648 in Guinea and 1,378 in Liberia.

But the real surge in cases began in September as the virus gained a foothold in Freetown. Teams were soon struggling to bury as many as 30 bodies per day. As the situation rapidly worsened, South Africa deployed a mobile laboratory to Freetown and work began to construct Ebola treatment centres, as Kenema’s treatment capacity was quickly overwhelmed.

By the third week of September, the situation had begun to stabilize in Kailahun and Kenema, but Freetown, Port Loko, Bombali, and Tonkolili districts showed a sharp and alarming spike in a situation described by WHO as “continuing to deteriorate”. Nationwide, WHO estimated that more than 530 additional treatment beds were needed.

The biggest challenges in the densely populated capital were limited treatment and diagnostic facilities and the difficulty of undertaking contact tracing. In parts of Freetown, as many as three families occupied the same household in shifts, increasing even further the risks of disease spread within these families.

In early October in Port Loko, no treatment beds were available in any health care facilities. At one health facility, nurses had no personal protective equipment, no food, and no rehydration fluid. WHO organized the transportation of suspected cases to treatment facilities and provided a supply of essential medicines and equipment, but these did not last long as cases continued to mount and the demand continued to overwhelm existing capacities.

By mid-October, WHO described virus transmission in Freetown and the western districts as “rampant”, with more than 400 new suspected cases being reported each week. All administrative districts nationwide had reported at least one case. The impression of stability in Kailahun and Kenema was temporarily lost as cases once again began to rise.

In Freetown, the government and its partners recognized an increasingly urgent, almost desperate situation. On 21 October, the World Food Programme used its unparalleled logistical capacities, supported by funding from the World Bank, to airlift 20 ambulances and 10 mortuary pickup trucks to Freetown to support the government’s efforts to shorten response times. An additional 44 vehicles followed a few weeks later by sea. This support was in addition to the delivery, by that date, of food to more than 300,000 Ebola-affected people nationwide.

Community care centres: invention born of necessity

Although the UK government and other partners were rapidly building new treatment centres, especially in Freetown and the adjacent western districts, inadequate bed capacity remained the outstanding problem for patients and their families. It was also a major problem for outbreak responders, as case detection and contact tracing have little impact in the absence of facilities where infectious patients can be removed from the community and safely treated. As field coordinators in all three countries noted, the different control measures were closely interlinked; the failure of one jeopardized the success of others.

Staff from the WHO country office worked closely with government officials, community leaders, and multiple partners active in the country to find immediate solutions that matched the emergency situation. Although a telephone hotline had been set up, those answering the calls had little to offer – not enough ambulances to collect suspected cases, too few treatment beds, and insufficient burial teams to collect all bodies promptly. People needed at least some form of treatment and care close to their families and homes.

As a first step, WHO staff worked with four communities to construct safe isolation units with eight to twelve beds. These were not hospitals, but community care centres – facilities that could be quickly and flexibly set up in areas with the greatest unmet needs. Strong support from UNICEF and from the UK’s Department for International Development made an immediate large-scale difference in the country’s capacity to care for many more patients close to their homes. In this way, Sierra Leone became the pathfinder in establishing these centres and making them work.

WHO consulted experts in infection prevention and control to establish floor plans that provided space for patient triage and separated high-risk from low-risk areas. To staff them, also safely, WHO trained village volunteers and teams of local nurses in the basics of infection prevention and control and patient care. WHO was assisted in these tasks by medics from the country’s armed forces. WHO also brought in ten experienced health care workers from Kenema, where cases had again declined to almost zero, to take on coordination and supervisory roles.

Though the level of care was not the same as in specialized treatment facilities, patients did receive essential first-line treatments delivered by trained staff – care that was far safer than that provided by family members in a home. The community care centres also responded to the reality of logistical constraints, including poor road systems and a shortage of ambulances to transport patients to distant facilities. Equally important, the centres allowed patients to stay near their homes. For families, low fences let them interact with patients from a safe distance, thus increasing the transparency of care and removing much anxiety about the fate of loved ones.

The Western Area Surge: listen to the community

In the first week of December, Sierra Leone surpassed Liberia as the country reporting the largest cumulative number of cases. The number of new cases reported that week, at nearly 400, was three times as many as in Guinea and Liberia combined. Though cases in Kailahun and Kenema had dwindled to only one or two each month, the country was still reporting new cases from 10 of its 14 districts.

As in Guinea and Liberia, the outbreak in Sierra Leone showed how quickly the dynamics of an outbreak could worsen once cases reached the capital cities. Freetown consistently accounted for around a third of the country’s cases. Other areas experiencing intense transmission were the neighbouring districts of Port Loko and Western Rural and, in the eastern part of the country, Kono district on the border with Guinea.

Against this backdrop, the government responded with a massive Operation Western Area Surge initiative, which was launched in mid-December and ran through the end of the year. As the government explained to populations in and around Freetown, the strategy aimed at correcting past deficiencies in the response and regaining the public’s confidence and cooperation, especially in the early reporting of cases.

Planning was meticulous. A malaria campaign, supported by the Bill and Melinda Gates Foundation, the UK government, MSF, and WHO, was conducted in targeted areas prior to launch of the surge. It involved distribution of antimalarial medicines, for preventive purposes, to tens of thousands of households in areas where fear of Ebola was causing people to avoid all contact with health services. Among infectious diseases, malaria is one of the biggest killers in Sierra Leone, especially of young children, and the campaign was well-received by the public.

On the technical side, preparations urgently increased bed and laboratory capacities, stepped-up the number of staff trained by WHO and CDC to undertake contact tracing, and made on-site assessments of treatment facilities to improve their safety for staff and patients alike. To support the anticipated surge in requests for testing, WHO added three strategically placed laboratories.

Considerable groundwork also reflected the lesson learned earlier: listen to the community. Well-known religious and traditional leaders were consulted to get a sense of community concerns and expectations. Well-known entertainment personalities were recruited to communicate messages, emphasizing how early detection and treatment greatly improved the prospects of survival.

Thousands of community volunteers came forward for training. This time the government made sure that calls to the Ebola hotline would be answered, with callers referred to local people, local services, local help, and local success stories.

The results of the campaign will be analyzed in January 2015. In a 19 December report, the Ministry of Health and Sanitation could already record a surge in the number of suspected cases being tested in the Western Area. As WHO staff present in Freetown and Port Loko observed, the fundamental systems and capacities for a stepped up response were now in place. Full community cooperation, however, remained a problem and contact tracing suffered as a result.

At year end, that view was shared by the country’s health officials, who noted that denial, traditional burials, and fear were still driving spread of the disease in Freetown and adjacent districts, where transmission remained intense.

The persistence of fear and denial was easy to understand. At the end of December, Sierra Leone – with its population of only 6.2 million – had recorded more than 9,000 cases of what all will agree is a terrible and terrifying disease.

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PostPosted: Thu Jan 15, 2015 6:41 pm 
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Key events in the WHO response to the Ebola outbreak

One year into the Ebola epidemic. January 2015

This account of the WHO response gives a timeline and explanation of actions taken, including why the outbreaks were declared an international public health emergency in August 2014.

WHO-led training on Ebola infection control, Sierra Leone
WHO/N. Alexander
CHAPTER 7 - The first report on the Ebola outbreak in Guinea was published on 23 March on the website of WHO’s Regional Office for Africa (AFRO). It described measures taken by the Ministry of Health, together with WHO and other partners, to control the outbreak and prevent further spread. Those measures included multidisciplinary teams deployed to the field to detect and manage cases and trace their contacts. As the report noted, “WHO and other partners are mobilizing and deploying additional experts to provide support to the Ministry.”

WHO immediately mobilized its collaborating laboratory in Lyon, France, together with West African laboratories located in Donka, Guinea, Dakar, Senegal, and Kenema, Sierra Leone, to prepare for the diagnosis of more cases. MSF, which had a well-established presence in the region, rapidly set up isolation facilities.

The first team drawn from institutional partners in the WHO Global Outbreak Alert and Response Network, or GOARN, travelled to Guinea on 28 March. The team was headed by a senior WHO field epidemiologist. As a reporter covering early events in Guinea for Vanity Fair later noted, the international response was “rapid and comprehensive – exactly what you would hope.”

Findings from the investigation were reported on 8 April during a Geneva press conference, where WHO officials alerted reporters to “one of the most challenging Ebola outbreaks that we have ever faced”. The challenges observed included the wide geographical dispersion of cases in both Guinea and Liberia, cases in the capital city, Conakry, and a high level of public fear, anxiety, rumours, and misperceptions.

By mid-April, the cumulative totals in Guinea had risen to 168 cases and 108 deaths in six prefectures. More cases were being reported in Liberia, largely concentrated in Lofa county.

At a meeting jointly convened by the African Union and WHO on 16 April in Angola, WHO Regional Director for Africa, Dr Luis Sambo, summarized the situation as follows: “WHO has issued an alert on the importance of epidemiological surveillance, public information and biosafety measures including strengthening of the quality of support to laboratories. Although the epidemic is still rife, we are hopeful that it will be contained and overcome shortly and that we will be able to mitigate its adverse impact on human lives, travel, economies and international trade.”

Dr Sambo encouraged all health ministers “to strengthen their alert systems and implement the relevant provisions of the International Health Regulations.”

During the third week of April, WHO, in collaboration with GOARN partners, mobilized a new medical team of physicians with expertise in infection prevention and control and in intensive care to support clinicians at Donka Hospital, Guinea’s principal hospital, located in Conakry.


In that same week, Guinea reported 218 clinically compatible cases and 141 deaths. Liberia reported 35 clinically compatible cases. Symptom onset of Liberia’s first confirmed case was retrospectively dated back to 13 March. Sierra Leone was investigating 3 cases that might be either Ebola virus disease or Lassa fever, a disease endemic in large parts of West Africa.

By 5 May, WHO had deployed 112 experts to West Africa to assist in the response, including 68 experts deployed through its global surge mechanism, 10 external experts, and 33 international experts from GOARN partner institutions. Of these, 87 went to Guinea, 20 to Liberia, and 4 to AFRO. Although Sierra Leone had not yet reported a confirmed case, vigilance was high and one expert was sent to support surveillance efforts there.

The expertise among deployed staff had been broadened beyond the traditional areas of epidemiology, laboratory services, infection prevention and control, clinical case management, and logistics to include expertise in medical anthropology, risk communication, and social mobilization. The reason was clear: community resistance had joined inadequate treatment facilities and insufficient human resources as a major barrier to control.

WHO again expressed its heightened level of concern on 6 May, when it convened a high-level meeting in Conakry, attended by governmental health officials and staff from WHO headquarters and AFRO. The purpose of the meeting was twofold: to identify the most important weaknesses standing in the way of a stronger strategic response, and to define the precise support needed from WHO and other partners.

Very encouraging results

On 19 May, Guinea’s Minister of Health briefed the World Health Assembly on the Ebola situation in his country. He referred to field investigations that were “yielding very encouraging results”. As he reported, five of the country’s six foci of intense transmission were coming under control, with Gueckedou remaining the epicentre of transmission.

He credited much of this success to the permanent field presence of more than 70 WHO staff and the rapid deployment by WHO of two mobile laboratories. He also noted the need to combine efforts to control the outbreak with efforts to strengthen the country’s health system.

Later in May, Sierra Leone reported its first 16 cases and 5 deaths, all concentrated in Kailahun district. Within days, that number more than doubled.

By early June, it was clear that large and fluid population movements over exceptionally porous borders were interfering with control measures, most notably contact tracing and monitoring during the 21-day incubation period. To address this problem, WHO introduced a system of cross-border surveillance in the designated “hot zone”, a triangle-shaped forested area where the borders of the three countries converged. Additional epidemiologists were sent to support that effort.

The sense of urgency increased on 23 June, when a second high-level meeting was held in Conakry. Participants included Guinea’s President, a special representative of AFRO’s Regional Director, the head of the WHO country office, the US Ambassador in Guinea, and staff from the US Centers for Disease Control and Prevention (CDC).

A call for WHO leadership

On that same day, a turning point occurred when the GOARN steering committee, which included several MSF staff, held a session to discuss the Ebola situation. Its members expressed a desire for WHO to lead the response more strongly as the only agency with the experience, seasoned senior staff, constitutional mandate, and country presence to do so. A message and report conveying the need for more forceful leadership were sent to Dr Chan on 27 June. She immediately took personal responsibility for the WHO response.

Among her first steps, she declared a level 3 emergency – the highest level –and set in motion plans to hold an urgent high-level ministerial meeting with senior health officials from African countries, partners, Ebola survivors, representatives of airline and mining companies and financial donors, including executives from the African Development Bank.

The broadened range of participants reflected yet another set of problems: the political dimensions of the outbreaks, the impact of restrictions on air travel and trade, fears that companies critically important to national economies might leave, and widespread public perceptions that Ebola virus disease was invariably fatal.

That meeting was held in Ghana from 2 to 3 July and resulted in both significant commitments of financial support and new strategies to accelerate the operational response. Key priorities identified included mobilizing community and religious leaders to improve Ebola awareness and understanding, as well as strengthening surveillance, case finding and contact tracing.

By that time, the areas of intense virus transmission were well known. Participants agreed to deploy additional staff to these areas and to commit additional country funding to the response. The meeting further recommended the establishment of a WHO sub-regional Ebola outbreak coordination centre in Conakry, which became operational on 25 July.

Also in early July, WHO issued the results of an analysis of the situation in the three countries and risk factors for the continuing spread of the disease. The main risk factors amplifying the outbreaks were identified as high-risk cultural practices and traditional beliefs, extensive population movements within countries and across borders, and inadequate coverage with effective containment measures. The magnitude of the task ahead was also recognized: the unprecedented expansion of the outbreaks demanded “enormous and robust response capacity and structures in terms of human capital, financial, operational and logistical requirements.”

Overwhelming demands

Some of these “enormous” needs were addressed in the third week of July, when WHO organized a conference with potential donors of financial and in-kind support. Dr Chan described the overwhelming demands created by the outbreaks and clearly stated that WHO, acting alone, could not meet all response needs for a disease of this scale and complexity.

In reviewing the situation, she noted that all three outbreaks were experiencing a second major wave of transmission, with a third wave of even more intense transmission expected to emerge soon. That wave arrived in September.

On 1 August, Dr Chan attended a meeting in Conakry where the presidents of the three countries had gathered to discuss what they increasingly believed was a public health emergency of unusual severity. In hours of face-to-face discussions with these leaders, she explained why WHO was so deeply concerned and stressed the need for them to take high-level responsibility for the response.

As she argued, WHO could provide technical guidance and scale up its material support but these measures could never substitute for decisive government action. She also spelled out the consequences of allowing the outbreaks to continue, including more bans on travel and trade, isolation from the international community, and severe shocks to their struggling economies.

The meeting resulted in a Joint Declaration of Heads of State and Government of the Mano River Union, which included Cote d’Ivoire as well as the three countries. Commitments set out in the Joint Declaration included the isolation of areas in the cross-border region by police and military forces, with material support provided to citizens in these areas.

The Declaration further recognized the need for international support to build capacity for surveillance, contact tracing, case management, and laboratory services. In parallel, WHO launched an appeal to donors for $100 million needed to support its own plan for stepped up action in the three countries.

The emergency committee meets

On 20 July, an airline passenger from Liberia introduced the virus into Lagos, Nigeria, marking the first time that Ebola entered a new country via international air travel. His Ebola infection was confirmed on 23 July. That event rocked public health communities around the world, leading some to anticipate an “apocalyptic” urban outbreak. It also triggered urgent plans to organize an Emergency Committee to assess the Ebola situation under the provisions in the International Health Regulations. The committee met on 8 August.

The use of emergency committees was introduced in 2005 when the IHR were revised. The committee’s job was to make a recommendation as to whether the event constituted a public health emergency of international concern and what “temporary recommendations” (a special term for official IHR advice) should be issued by Dr Chan to limit further spread of the disease.

The Emergency Committee was chaired by Dr Sam Zaramba, former Director-General of Health Services at Uganda’s Ministry of Health, who played a leading role in responding to that country’s large Ebola outbreak in 2000. He noted several serious challenges confronting the three countries: fragile health systems, lack of experience in dealing with Ebola virus disease, highly mobile populations, and wide-ranging public misperceptions about the disease and its modes of transmission. The experts further assessed the implications for control of active transmission in the three capital cities, the large number of infections and deaths among health care workers, and the likelihood that more cases would be exported.

The Committee reached unanimous agreement that the Ebola outbreaks constituted a public health emergency of international concern and transmitted that decision, together with its temporary recommendations, to the WHO Director-General. WHO declared the outbreaks a public health emergency of international concern on 9 August.

Such declarations, which are rare at WHO, are intended to alert all countries to the likelihood of further international spread. Given West Africa’s mobile populations and porous borders, the outbreaks in Guinea, Liberia, and Sierra Leone behaved like a single epidemiological geography, with little indication of a potential to spread internationally beyond the area. That view changed when the air traveller from Liberia imported the virus into Lagos.

The IHR emergency committee mechanism was set up in 2005 for a second purpose: to ensure that a system of checks and balances was in place to protect against recommended measures, issued solely by the Director-General, that can have severe economic consequences for affected countries, as happened during the SARS outbreak of 2003. The emergency committee on Ebola that met in August recommended exit screening of people travelling from the affected countries, but took a strong position against trade and travel bans, which have no evidence of effectiveness in preventing further international spread. That recommendation was important given the number of travel bans and restrictions in place that were crippling the response and increasing the hardship faced by populations.

The declaration that the Ebola outbreaks constituted a public health emergency of international concern served these purposes, but it was neither the start of the WHO response nor the first warning by WHO to the international community about the severity of the situation, both of which had started months before. As noted previously, the first WHO-deployed GOARN team travelled to Guinea on 28 March. The team’s findings led to stern warnings about the severity of the situation communicated on 8 April. From those early days on, WHO carried the lion’s share of the burden for providing logistical as well as technical support.

The "Roadmap" is issued

On 27 August, WHO launched its “Roadmap” for responding to the epidemic, setting out strategies, categories of risk levels in countries, and time-bound objectives. Since then, the presence of WHO staff in the field has been considerably strengthened, with staff staying to work in areas of high transmission for two to three months to ensure that efforts, also among the many nongovernmental agencies contributing to the response, were coordinated and focused on the most urgent needs.

These staff worked shoulder-to-shoulder with national staff and community leaders in tasks ranging from the treatment of patients to the construction of facilities.

Growing international concern

On 2 September, Dr Chan travelled to Washington, DC and New York City to warn government agencies and health officials that cases were increasing exponentially as the unprecedented scale and complexity of the outbreak continued to escalate.

WHO Assistant Director-General for Global Health Security, Keiji Fukuda, who had just returned from West Africa, warned reporters at a 3 September briefing in Washington that WHO did not have “enough health workers, doctors, nurses, drivers, and contact tracers” to handle the increasing number of cases. As he added, “Most of the infections are happening in the community, and many people are unwilling to identify themselves as ill. And if they do, we don’t have enough ambulances to transport them or beds to treat them yet,” he said.

On 8 September, the US and UK governments announced plans to construct treatment centres in Liberia and Sierra Leone.

On 18 September, an emergency session of the United Nations Security Council was convened to assess the implications of the epidemic as a threat to international peace and security. The event marked the first time that a disease provoked an emergency session of the Security Council.

On that same day, the UN Secretary-General announced the first-ever UN public health mission, with the formation of the UN Mission for Emergency Ebola Response, or UNMEER. The objective was to greatly increase the scale and coordination of the international response and to facilitate its logistics. WHO welcomed the move, especially in view of the heavy logistical burdens that were impeding the response.

UNMEER quickly established an air bridge to facilitate the flow of staff and materials, including badly needed vehicles as well as essential medicines. In some areas, though, demand continued to outstrip supply, especially for kits of personal protective equipment. Even a small treatment centre needed hundreds of these kits per day. Heightened international concern was accompanied by heightened preparedness measures in a large number of countries, especially after cases occurred in the US and Spain. That, too, placed a strain on limited supplies of critically important material support.

UNMEER also devised response plans for each of the three countries, modelled on the WHO Roadmap. Projections of precise needs, such as for treatment beds, foreign medical teams, and burial teams, helped channel the high-level of international concern into equally precise support, especially for the construction of new treatment centres.

However, the staffing of those centres with either national or foreign medical teams lagged behind. Given the unprecedented number of doctors and nurses infected during the outbreaks, many governments were reluctant to send their nationals into such high-risk environments, especially as state-of-the-art treatment for those who fell ill could not be guaranteed. Getting well-maintained vehicles and adequate fuel into remote areas of intense transmission also remained a pressing need.

A year-end commitment

Looking back at WHO’s response, its Director-General said in Washington, DC on 17 December, “We will continue to work with the governments affected by the Ebola outbreak and with development partners in the international community, and international responders to get cases down to zero.”

As she noted, sectors well beyond health had been affected in what had become a humanitarian, social, economic, and security crisis. She issued an urgent call for more field epidemiologists on the ground to undertake aggressive case identification and contact tracing. Above all, she stressed the need for all responders to recognize the importance of community engagement. Without community engagement and cooperation, she noted, technical interventions were doomed to fail.

As the year ended, WHO had already started to work with the three most affected countries to support the rebuilding of resilient health systems based on primary health care. In the view of WHO, such systems needed built-in – not separate – capacity to do disease surveillance, to be able to detect early and respond early to outbreaks caused by any pathogen.

At the same time, countries needed systems designed to provide a suite of essential services, including maternal and child health care, immunizations, the prevention and treatment of endemic infectious diseases, like HIV, TB, and malaria, and management of the rising problem of chronic noncommunicable diseases.

If vulnerable countries were supported in doing both – that is, strengthening primary health care together with essential capacities to detect and respond to health emergencies – they would gain greater social stability and resilience to withstand shocks, also from a changing climate, as well as better health. As she had stated before, “Universal health coverage is one of the most powerful social equalizers among all policy options.”

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PostPosted: Thu Jan 15, 2015 8:01 pm 
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WHO technical support – a lasting impact?

One year into the Ebola epidemic. January 2015

WHO diagnostic guidance, advice on personal protective equipment, and a protocol for safe and dignified burials illustrate some unique challenges of the outbreaks, while other areas of support, for laboratory and blood services, could jump-start the provision of essential health care, at a higher level of quality.

CHAPTER 8 - Shortly after confirmation of Guinea’s outbreak, WHO updated and revised its technical guidance in the full range of areas needed for a multi-pronged response. By the end of April, some 26 guidelines for field staff had been issued on topics ranging from correct laboratory procedures for testing and confirming cases, to steps to follow to ensure safe burials, to measures to prevent and control infections in households and health care facilities.

Diagnostic guidance: not always followed


Not all of this advice has been followed. For example, WHO recommends repeat testing, after a negative initial result, at least 48 hours later. Many patients initially test negative, especially when samples are taken early in the course of infection. Test results can also vary according to how the samples were collected. Two negative tests, taken at least 48 hours apart, are needed before a suspected case can be safely discarded or a patient can be released with confidence from a treatment facility.

Laboratory diagnosis is challenging, as it requires specialized facilities and equipment, a high level of biosafety, and trained and experienced staff. When a country diagnoses its first case, WHO recommends that samples be sent to a WHO-approved laboratory for confirmatory tests.

WHO is aware of several instances where a suspected case, clinically compatible with Ebola, was detected in a new country, and then discarded by health officials within hours following “negative test results”, with no alternative diagnosis confirmed. Several such instances have occurred in countries with inadequate diagnostic capacity, calling into question the validity of test results. Moreover, no laboratory in the world can reliably exclude a suspected Ebola case in a matter of hours.

Personal protective equipment: the most visible form of protection

On 31 October, WHO updated its guidance on the use of personal protective equipment in the Ebola response. The guidelines were developed using an accelerated yet scientifically rigorous methodology that drew on both available scientific evidence and field experience. This was done in collaboration with a large group of experts, including staff from the US CDC, MSF, and the Infection Control Africa Network.

"If you think you may have been exposed to Ebola, minimize close contact with others.

Ebola messages for the general public, WHO

The objective was to introduce standardized and effective options for protecting health care workers and patients from a lethal and highly contagious virus. The guidelines were strongly driven by concern about the many infections in health care workers among national staff and foreign medical teams in affected countries, and hospital staff who became infected in the US and Spain.

The experts agreed that it was most important to have equipment that protects the mouth, nose, and eyes from contaminated droplets and fluids, for example, through face masks and eye protection. Given that hands are known to transmit pathogens to other parts of the body, as well as to other people, hand hygiene and gloves were judged essential. Gowns or coveralls with apron, protective foot wear, and head cover were also considered essential to reduce the risk of transmission.

The guidelines stress that personal protective equipment, though the most visible of all measures for infection prevention and control, is the least effective. More important are administrative controls, such as those that provide for barrier nursing and guide the organization of work, and environmental controls that ensure the safety of water, sanitation, and waste management.

A fundamental principle guiding the selection of different options was the need to balance the best possible protection against infection with the best possible patient care, allowing staff to work with maximum ease, dexterity, and comfort and minimal heat-associated stress. Because of this heat-associated stress, which can reduce concentration when care is delivered and lead to mistakes, MSF and WHO recommend that personal protective equipment be worn for no more than 45 minutes at a time.

Equally important is supervised training in putting on and taking off equipment according to rigorous standardized procedures, properly decontaminating equipment after use, and safely disposing of equipment that cannot be reused.

In preparing the guidelines, the experts had to contend with a lack of solid evidence about what works best on a sustainable basis. Lack of evidence is a problem confronting many other dimensions of the Ebola response. Although the disease has been known for nearly four decades, the comparatively short duration of past outbreaks and their location in largely remote rural areas worked to discourage the degree of scientific research that is now so urgently needed.

A protocol for safe and dignified burial

"You cannot get infected with Ebola by talking to people, walking in the street, or shopping in the market."

Ebola messages for the general public, WHO

During the first week of November, WHO issued a new protocol for the safe and dignified burial of people who died from Ebola. Ancestral rites performed during funerals and burials have long been recognized as a major driver of Ebola virus transmission, and technical guidance on safe burials had been available from WHO for decades.

What was new in the protocol was the emphasis on dignified burials that respect religious rituals in both Christian and Muslim funerals. That emphasis, in turn, responded to mounting evidence that a failure to respect these traditions was a major reason why patients continued to be cared for in homes and bodies continued to be buried unsafely and in secret, even when sufficient treatment beds and burial teams were available.

The protocol takes burial teams through 12 critical steps needed to ensure that burials are dignified, respectful, and safe for families and mourners as well as team members. Illustrations are used to demonstrate the equipment and other supplies needed and their proper use, also for the management of hazardous wastes.

In line with advice from religious leaders, the 12 steps include opportunities for engaging families in the digging of graves and the performance of dry ablution and shrouding rituals. Families and local clergy are also given opportunities to plan the burial in line with cultural traditions and personal wishes. Advice ranges from the use of white body bags for Muslim funerals, to the need for burial teams to listen to the family’s concerns – face-to-face, before donning protective gear – to the importance of letting relatives decide on how they want the grave to be marked.

The protocol was developed by an interdisciplinary team at WHO, in collaboration with medical anthropologists and in partnership with the International Federation of Red Cross and Red Crescent Societies and faith-based organizations, including the World Council of Churches, Islamic Relief, Caritas Internationalis, and World Vision.

A lasting impact?

Some of the direct technical support provided by WHO and GOARN is likely to have a lasting impact on the capacity of the three countries to deliver stronger health services for multiple other diseases and conditions. Two examples illustrate this potential.

First, as the year evolved, more laboratories were added and their services gradually got better and faster, reducing some of the delays that fuelled community transmission and caused considerable anxiety among patients and their families, who were forced to wait days for test results. In providing this support, WHO drew on another network of partners, the Emerging and Dangerous Pathogens Laboratory Network.

Mobile laboratories, generously donated by several governments and economic consortiums worldwide, proved to be the fastest and most flexible solution, as these can be transported as smaller component parts and then set up and functioning within 48 hours.

A review of the evolution of laboratory services in Sierra Leone is particularly instructive – and encouraging. By year end, the country had 11 functioning laboratories equipped and staffed to safely process patient samples and diagnose Ebola virus disease. Many were strategically placed to support the government’s Western Area Surge that began in mid-December. Together, these laboratories were able to process 700 samples per day, with a surge capacity of up to 1,100 samples per day.

Three of the laboratories were also staffed and equipped to perform haematology investigations and biochemistry testing, thus upgrading the quality of support available to guide clinical decisions and improve patient care and survival rates.

Waiting times for test results shrank considerably, reaching times that compare well with diagnostic services in countries with advanced health systems. In Sierra Leone, if a patient arrives for testing in the morning, results will be ready that same evening.

Having international laboratory experts, deployed by WHO, in the country proved important for a second reason. In Kono district, staff discovered that a diagnostic test that had not been evaluated for safety and performance and had not been approved by WHO was nonetheless being used, with likely risks to both patients and laboratory technicians alike.

The next steps for early 2015 include introduction of a web-based platform for real-time analysis of laboratory results and feedback to laboratories on their performance as a contribution to quality control, and improvements in the ability to perform differential diagnosis. The latter is needed to assure safety during routine services, such as surgery and childbirth, where medical staff risk managing a patient with undiagnosed Ebola virus disease. Improvements in these areas can help restore public and professional confidence in general health services.

WHO further plans to integrate services, such as those needed to support its global malaria program, into the laboratory structures and procedures set up for the emergency response to Ebola. Yet another immediate objective is to increase the number of laboratories able to perform additional tests that help clinicians fine-tune their management strategies, ideally bringing down case fatality rates closer to those seen when foreign medical staff are evacuated and treated in advanced hospital settings.

A similar story has been unfolding since clinical trials of convalescent therapies, involving the transfusion of whole blood or blood plasma from Ebola survivors, began in December in Guinea and Liberia. The training, equipment, and facilities needed to conduct these trials have already upgraded the safety, quality, and range of modern blood services that can be offered. The list of common and severe health problems that benefit from safe and well-functioning blood services is long. It ranges from the treatment of malaria, dengue, Lassa fever, yellow fever, and many other diseases to the management of complications of childbirth and injuries following accidents and traffic crashes.

Both of these initiatives can jump-start the provision of essential health services, which had nearly ceased to function, and get them back into operation – at a higher level of quality.

http://www.who.int/csr/disease/ebola/on ... upport/en/

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