Ebola outbreak in West Africa: MSF updates
On 25 March 2014, Guinea’s Ministry of Health reported an Ebola outbreak in four southeastern districts. The virus then spread to neighbouring countries Sierra Leone and Liberia, eventually resulting in an unprecedented outbreak with over 10,000 people dead across West Africa.
From the very beginning of the epidemic, Doctors Without Borders (MSF) responded in the worst affected countries – Guinea, Liberia and Sierra Leone - from setting up Ebola treatment centres and isolation units to providing services such as psychological support, health promotion activities, surveillance and contact tracing. At the peak of the epidemic, MSF employed nearly 4000 local staff and over 325 international staff to combat the epidemic across the three countries. MSF admitted a total of 10,376 patients to its Ebola treatment centres, of which 5,226 turned out to be confirmed Ebola cases.
After first being declared free of Ebola transmission on 9 May, six new cases were confirmed in Liberia at the end of June following the death of a 17-year-old boy. Liberia was again declared free of Ebola virus transmission on 3 September 2015, and has now entered a period of heightened surveillance.
Three new confirmed cases in the country in the week ending 25 October. All three new cases are from the same household in the sub-prefecture of Kaliah, Forecariah, and are registered high-risk contacts linked to a case from the same area last week. The country also reported three cases the previous week. There are currently 364 contacts under follow-up in Guinea (an increase from 246 the previous week), 141 of whom are high-risk. An additional 233 contacts identified during the past 42 days remain untraced. Therefore there remains a near-term risk of further cases among both registered and untraced contacts.
The last case to receive treatment for Ebola in Sierra Leone was confirmed free of the virus after a second consecutive negative test on 25 September. The country will be declared free of EVD transmission on 7 November assuming that no further cases are reported and it will enter into a period of enhanced surveillance.
Update: 23 March 2016
Ebola Activity Update
Guinea was declared free of Ebola the 28th of December 2015. MSF is now running an Ebola clinic for survivors in Conakry. In February, there were 126 psychological consultations and 181 medical consultations at the clinic. In addition to this, the MSF team also carries out sensitization activities at the clinic and in the community.
On 17 March, the Guinean government announced two new confirmed deaths and three suspected cases, in the first re-emergence of the virus in the country since the outbreak was declared over in December 2015. MSF is not involved in case management but is ready to provide support if needed.
The last patient was tested negative and discharged on the 4th of December. Liberia was then declared Ebola free on 14th of January. According to WHO, the last cluster of cases is now understood to have been a result of the re-emergence of Ebola virus that had persisted in a previously infected person.
The Liberian national health system, which was already among the weakest in the world, has been decimated by the outbreak – close to 200 Liberian healthcare workers having died from Ebola according to official statistics, which represents 8% of all health workers in the country. MSF is now focusing activities on helping to restore offer of healthcare, notably through a MSF-managed paediatric hospital in Monrovia.
Before the epidemic, there were 220 inpatient pediatric beds in Monrovia, but in April 2015, when MSF opened its paediatric hospital, all paediatric wards had closed. At the end of 2015, 122 inpatient beds were available. But this is clearly not enough for a city of 1,4 million inhabitants, with an estimated 17% of them being children under 5 years-old.
Monrovia – Paediatric hospital and survivors clinic
In Monrovia, MSF is running a 91-bed pediatric hospital, the Barnesville Junction Hospital (BJH), including a 22-beds neonatal intensive care unit, aiming to contribute to restoring the provision of emergency and secondary healthcare for children in the aftermath of the Ebola outbreak. In 2015, more than 3,400 consultations took place in the emergency room of the hospital, and over 3 000 children were admitted in the inpatient ward. MSF also runs a clinic for Ebola survivors in the premises of the hospital.
Former patients have to face stigma and discrimination while accessing care, as well as social and economic problems (loss of work, loss of housing, etc.). MSF provides general outpatient consultations, and addresses mental health needs to a group of more than 500 identified former Ebola patients, which are estimated to be a third of all survivors in Montserrado County.
Teams have been providing consultations also to patients who are not identified as survivors, because of the lack of certificates of cure / discharge from ETCs. Compared to identified survivors, their access to medical and social assistance has therefore been even poorer. Common complaints are joint pains and ophthalmic issues.
For the latter, MSF provides care in collaboration with a Liberian eye clinic. About 400 survivors have been seen since April 2015, 168 are actively followed. 32 patients are under psychiatric treatment and 35 patients are currently followed for eye problems. MSF also offers supportive mental health services to frontline workers during the outbreak (ETU staff, burial teams, etc.), as well as members of the families of survivors.
Sierra Leone (OCA, OCBA, OCB)
The country was declared free of EVD transmission on 7 November but a new death was confirmed on 14 January, followed by an additional case on 20 January. Sierra Leone was once again declared free of EVD transmission on 17 March.
MSF played a key leading role in treating people who suffered from Ebola and continue to provide medical and psychosocial services to some of the country’s 4,000 Ebola survivors in Freetown and Tonkolili district.
New projects on maternal and child health opened in different towns of the country, as the already fragile health system has been further weakened by the burden of the Ebola epidemic. MSF is also maintaining an emergency response capacity through a small team.
Freetown – Survivor clinic (OCB)
The survivor clinic in Freetown has been running since February 2015, providing primary healthcare and mental health support, with currently around 140 consultations per month. MSF also runs community sensitisation and stigma reduction activities.
Magburaka (OCA) – Survivor clinic
By the end of February 2016, the MSF survivor care in Tonkolili has been integrated into the MoH primary healthcare system. We are still following a small number of survivors with mental health support, medical care and referral, but the majority of patients have been discharged from our program. While supporting survivors, we saw a reduction in medical complaints and improvement of the mental health status.
Tonkolili District (OCA) – Reproductive and Child Health
The project continues to support paediatrics and maternity in Magburaka hospital. 10 days after MSF started supporting the hospital in January, a new Ebola case was identified in Magburaka.
The team managed to continue medical care in the hospital throughout this new outbreak, which was rapidly contained. MSF is also supporting the screening and isolation facility at the hospital. In February, we admitted 152 children to the pediatric ward and 83 women to maternity.
Koinadugu District (OCBA)– Maternal and Child Health
In Kabala hospital, in Koinadugu district, MSF will open a new project with the aim to increase access to free maternal, neonatal and paediatric care while ensuring health care to Ebola survivors in the district and effective response to outbreaks and emergencies in the area.
MSF Ebola Accountability Report
The severity of the West Africa Ebola epidemic saw MSF launch one of the largest emergency operations in its 44-year history. Between March 2014 and December 2015, MSF responded in the three most affected countries - Guinea, Sierra Leone and Liberia – and also to the spread of cases to Nigeria, Senegal and Mali. At the peak of the epidemic, MSF employed nearly 4,000 national staff and more than 325 international staff who ran Ebola management centres as well as conducted surveillance, contact tracing, health promotion and provided psychological support.
MSF admitted 10,310 patients to its Ebola management centres of which 5,201 were confirmed Ebola cases, representing one-third of all WHO-confirmed cases. In total, the organisation spent nearly 104 million euros tackling the epidemic between March 2014 and December 2015. During the first five months of the epidemic, MSF handled more than 85% of all hospitalised cases in the affected countries.
Today MSF continues to support Guinea, Liberia and Sierra Leone by running Ebola survivor clinics that provide a comprehensive care package, including medical and psychosocial care and activities to counter stigma. Through this short report, MSF would like to provide transparency about its expenditure linked to the worst Ebola outbreak in history.
Update: 16 January 2016
The Sierra Leone Ministry of Health announced on Friday 15 January that a new case of Ebola has been confirmed. While disappointing - particularly only one day after West Africa was declared Ebola-free – occasional flare-ups of the virus were always a possibility.
MSF remains vigilant and is in discussion with the Sierra Leone health authorities about any support MSF can provide. Emergency teams are on standby and ready to deployed. Sierra Leone was declared free of Ebola on 7 November 2015.
MSF played a key role in treating people who suffered from the virus and continues to provide medical and psychosocial services to some of the country’s 4,051 Ebola survivors in Freetown and Tonkolili district. MSF also maintains an emergency response capacity in the country.
Update: 14 January 2016
Today is a day of celebration and relief as Liberia celebrates its 42nd day without any new Ebola cases, effectively marking the end of the epidemic in West Africa. Sierra Leone and Guinea have already been declared Ebola-free. We call on the global health community to draw on lessons learnt in order to be better prepared for future similar outbreaks. Although the epidemic is over, our teams are continuing with Ebola activities in Liberia, Sierra Leone and Guinea through running support clinics for Ebola survivors.
Ebola is one of the world’s most deadly diseases. It is a highly infectious virus that can kill up to 90 percent of the people who catch it and is so infectious that patients need to be treated in isolation by staff wearing protective clothing.
Since developing in March 2014 in Guinea, this outbreak spread to Sierra Leone and Liberia, where according to the World Health Organization (WHO), there were 11,315 deaths. MSF has over 4,475 staff on the ground helping to treat those infected and contain the Ebola outbreak.
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MSF’s Ebola response started in March 2014 and had included activities in the three most affected countries of Guinea, Liberia, and Sierra Leone as well as Nigeria, Mali and DRC.
Since the beginning of the epidemic:
- 10,376 patients were admitted to MSF Ebola management centres
- 5,226 patients were confirmed with Ebola
- 2,478 patients recovered from Ebola in our centres
The lessons learnt:
We have learned a lot from the past outbreak, which should allow us to provide an improved response during a future outbreak. Below are a few key points:
- There is now a new, promising vaccine, that can help us slow the expansion of an epidemic, and also protect medical staff working with Ebola patients.
- We now have an independent way of testing for Ebola, which organisations like MSF can operate ourselves.
- We are now able to do better medical follow up of the patients, which enables better supportive care.
But there is still a lot of room for progress. Most importantly, there still is no treatment for this deadly disease, and a lot remains unknown about the virus and the disease.
Highlights per country
Guinea was declared free of Ebola the 28th December. The Nongo Ebola Treatment Center has been passed to the authorities but an MSF structure for Ebola survivors remains within the same compound.
Since March 2014 (start of the epidemic), MSF teams treated 10,288 patients in West Africa including 3,804 patients in Guinea. The authorities reported that 110 health workers died from the virus in the country.
According to WHO, the last cluster of cases is now understood to have been a result of the re-emergence of Ebola virus that had persisted in a previously infected individual. But the outbreak should be over the 14th January.
Liberian national health system, which was already among the weakest in the world, has been decimated by the outbreak –near to 200 Liberian healthcare workers having dead from Ebola according to official statistics, which represents 8% of all health workers in the country. MSF is focusing activities on supporting the recovery of health facilities. For instance before the epidemic, there were 220 inpatient pediatric beds in Monrovia. In April 2015, when MSF opened its paediatric hospital, all paediatric wards had closed.
End of 2015, 122 inpatient beds are available, including 40 in the MSF hospital. But this is clearly not enough for a city of 1,4 million inhabitants, with an estimated 17% of them being children under 5-years-old.
Monrovia – paediatric hospital and survivors clinic
In Monrovia, MSF is running a 74-bed pediatric hospital, the Bardnsesville Junction Hospital (BJH), including a 10-beds neonatal intensive care unit, aiming to contribute to restoring the provision of emergency and secondary healthcare for children in the aftermath of the Ebola outbreak. From January to end of November 2015, more than 3,100 consultations took place in the emergency room of the hospital, and 1,900 children were admitted in the inpatient ward. One third of these admissions were due to malaria.
MSF also runs a clinic for Ebola survivors in the premises of the hospital. Former patients have to face stigma and discrimination while accessing care, as well as social and economic problems (loss of work, loss of housing, etc.). MSF provides general outpatient consultations, and addresses mental health needs to a group of more than 500 identified former Ebola patients, which are estimated to be half of all survivors in Montserrado county.
Teams have been providing consultations also to patients who are not identified as survivors, because of the lack of certificates of cure / discharge from ETCs. Compared to identified survivors, their access to medical and social assistance has therefore been even poorer. Common complaints are joint pains and ophthalmic issues. For the latter, MSF guarantees referral to external specialists. About 400 survivors have been seen since April 2015, 168 are actively followed. 23 patients are under psychiatric treatment and 35 patients are currently followed for eye problems.
The outbreak has been declared over on 7 November. MSF is now focusing activities on survivor health care and surveillance in Western Area (Freetown) and Tonkolili (Magburaka). There are also plans to begin non-Ebola health activities in several districts of the country as many components of the health system need to be strengthened.
Magburaka (OCA) – Survivor clinic
MSF is running a survivor health clinic in Magburaka town as well as a mobile clinic in the surrounding villages in Tonkolili and Bombali districts. By the end of December the team had provided support to 146 survivors for medical and mental health needs. The team as well did a two week mobile clinic to Kailahun facilitating eye exams and providing medical screening, 153 survivors were seen.
Freetown (OCB) – Survivor clinic
MSF is running a survivor clinic in Freetown since February 2015 with around 150 patients attending up to now, providing primary healthcare and mental health support.
Koinadugu (OCBA) and Tonkolili (OCA) Districts – Maternal and Child Health
MSF is currently working to incorporate survivor health care in the national facilities in Tonkolili District. Since January 4th, the team has started clinical care in the maternity and pedicatric wards of Magburaka Government Hospital. The program will expand to provide basic emergency obstetrics and newborn care to primary level of care.
In Kabala hospital, in Koinadugu district, MSF is preparing to open a new project with the aim to increase access to free secondary level maternal, neonatal and paediatric care while ensuring free health care to Ebola survivors in the district and effective response to outbreaks and emergencies in the area.
The Ebola virus was first associated with an outbreak in Zaire (now the Democratic Republic of Congo) in 1976. Of the 318 cases, 280 died. That same year, 284 people in Sudan also became infected with the virus, killing 156.
There are five strains of the Ebola virus: Bundibugyo, Ivory Coast, Reston, Sudan and Zaire, all named after their places of origin. Four of these five have caused disease in humans. While the Reston virus can infect humans, no illnesses or deaths have been reported.
Before this outbreak, MSF has treated hundreds of people affected in Uganda, Republic of Congo, the Democratic Republic of Congo (DRC), Sudan, Gabon and Guinea. In 2007, MSF entirely contained an epidemic of Ebola in Uganda.
Ebola can be caught from both humans and animals. It is transmitted through close contact with blood, secretions, or other bodily fluids. Infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found dead or ill in the rainforest.
Burials, where mourners have direct contact with the deceased, can also transmit the virus, whereas transmission through infected semen can occur up to seven weeks after clinical recovery. Healthcare workers have frequently been infected while treating Ebola patients. This has occurred through close contact without the use of gloves, masks or protective goggles.
Early on, symptoms are non-specific, making it difficult to diagnose. The disease is often characterised by the sudden onset of fever, feeling weak, muscle pain, headaches and a sore throat. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function and, in some cases, internal and external bleeding.
Symptoms can appear from two to 21 days after exposure. Some patients may go on to experience rashes, red eyes, hiccups, chest pains, difficulty breathing and swallowing.
Diagnosing Ebola is difficult because the early symptoms are common. Ebola infections can only be diagnosed definitively in the laboratory by five different tests. Such tests are an extreme biohazard risk and should be conducted under maximum biological containment conditions. A number of human-to-human transmissions have occurred due to a lack of protective clothing.
“Health workers are particularly susceptible to catching it so, along with treating patients, one of our main priorities is training health staff to reduce the risk of them catching the disease whilst caring for patients,” said Henry Gray, MSF’s emergency coordinator, during an outbreak of Ebola in Uganda in 2012.
Standard treatment is limited to supportive therapy consisting of hydrating the patient, maintaining their oxygen status and blood pressure and treating them for any complicating infections. Despite the difficulty of diagnosing Ebola in its early stages, those who display its symptoms should be isolated and public health professionals notified.
Supportive therapy can continue with proper protective clothing until samples from the patient are tested to confirm infection. Once a patient recovers from Ebola, they are immune to the strain of the virus they contracted.
An Ebola outbreak is officially considered at an end once 42 days have elapsed without any new confirmed cases.