Since the Ebola outbreak in West Africa was officially declared on 22 March in Guinea, it has claimed 5,420 lives in the region. The outbreak is the largest ever, and is currently affecting four countries in West Africa: Guinea, Liberia, Sierra Leone and Mali. One person in Spain and three people in the USA have recovered; one person in the USA has died. Outbreaks in Nigeria and Senegal have been declared over. A separate outbreak in DRC has also ended.
Following announcements made in the last weeks, deployment of international aid is slowly rolling out in the three main countries affected: Sierra Leone, Liberia and Guinea. However, there is little indication that current efforts to increase capacity to isolate and take care of suspected and confirmed Ebola cases will address needs sufficiently.
Last week, MSF and three research institutions announced that clinical trials for three different treatments would be carried out at MSF sites in West Africa. The French National Institute of Health and Medical Research médicale (INSERM) will lead a trial for antiviral drug favipiravir at MSF’s facility in Guéckédou, Guinea; the Antwerp Institute of Tropical Medicine (ITM) will lead a trial of convalescent whole blood and plasma therapy at MSF’s Donka Ebola centre in Conakry, Guinea; and the University of Oxford will lead, on behalf of the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), a Wellcome Trust-funded trial of the antiviral drug brincidofovir at a site yet to be determined.
The United Nations Mission for Ebola Emergency Response (UNMEER) has been set up and will be based in Ghana to pursue five strategic priorities: stop the spread of the disease; treat the infected; ensure essential services; preserve stability; and prevent the spread of the disease to countries currently unaffected.
MSF teams in West Africa are still seeing critical gaps in all aspects of the response, including medical care, training of health staff, infection control, contact tracing, epidemiological surveillance, alert and referral systems, community education and mobilisation.
MSF has been responding to the outbreak since March, and currently has more than 3,400 staff working in Guinea, Liberia, Sierra Leone and Mali, treating an increasing number of patients. Since the response began, 24 MSF staff members have fallen ill with Ebola, 11 of whom have recovered. The vast majority of these infections were found to have occurred in the community.
MSF’s West Africa Ebola response started in March 2014 and counts activities in Guinea, Liberia, Mali and Sierra Leone. MSF currently employs 276 international and around 3,160 locally hired staff in the region. The organisation operates six Ebola case management centres (CMCs), providing approximately 600 beds in isolation, and two transit centres. Since the beginning of the outbreak, MSF has sent more than 700 international staff to the region and admitted more than 6,000 patients, among whom around 3,800 were confirmed as having Ebola. Nearly 1,600 patients have survived.
More than 1,200 tonnes of supplies have been shipped to the affected countries since March.
The provisional budget for 2014 and 2015 for MSF's Ebola response in West Africa is €113M. So far MSF has raised €21M in institutional funds and €52M in private funds.
The overall situation in Guinea remains concerning. Patient numbers remain high and the number of new cases continues to rise.
Last week there was a small increase in cases. Because the Donka case management centre (CMC) requires refurbishment – it was meant as a temporary structure when it was built in March 2014, seven months ago – MSF has identified a site for a new structure and is currently engaging with community to ensure acceptance.
Friday 14 November saw the official handover of the MSF-built CMC in Macenta to the French Red Cross, with high-level officials from both Guinea and France.
On two separate occasions in the last 14 days, the MSF transit facility in Macenta had to stop admissions because the clinic was full, and the safety of the staff would be compromised with more admissions.
The CMC in Guéckédou is currently full to capacity and the situation in surrounding prefectures, especially the eastern ones, is concerning. Patients often come from far away – sometimes travelling 12 hours in an ambulance – and they are often in a bad state when they arrive at the CMC.
The number of patients in ELWA3 has been dropping: as of 18 November, the total number of confirmed cases was only 18. There is a decrease in case numbers everywhere else in Monrovia and in some other parts of the country. This is a positive development but the epidemic is still far from over and we need to remain vigilant. MSF continues to admit new patients: there were 42 admissions last week.
MSF is still concerned about the poor ambulance and referral systems, community surveillance, safe body management practices, and contact tracing. However an ambulance service has been set up with a dedicated hotline and the first team became operational this week.
Recruitment and training of home visitors is ongoing.
Distribution of malaria treatment started in Monrovia on 25 October and was well received by the population. By the end of the first round, 100,000 households will have received medication. The second round of the distribution is due to start in late November.
On 19 November, MSF opened a 10-bed triage point at Redemption hospital in New Kru Town, Monrovia. Patients going to the government-run hospital can now be screened for Ebola and referred if needed to a CMC. Redemption hospital is one of the few hospitals providing care free-of-charge in Monrovia. Until recently it has been unable to run its normal operations as it was being used as a holding centre for Ebola patients.
In Lofa county, CMC in Foya has not recorded any admissions for the past 10 days and since 30 October there have been no confirmed Ebola cases. The teams are now reducing the capacity of the CMC from 25 to 10 beds and will close it by the end of the month. MSF continues health promotion work and outreach activities in the area.
In Voinjama, the transit unit, outreach and hygiene promotion activities and health worker training have been handed over to partners.
The comprehensive package of medical care, outreach activities, psychosocial support, health promotion, contact tracing and other measures has led to a steep decrease in cases in Lofa. There has been a strong acceptance of MSF within the community, and people have significantly changed their behaviours and daily routines to help stop the epidemic.
The fight against Ebola is far from over and people must remain vigilant. Complacency is a real issue and cases are on the rise again in neighbouring counties.
A team has arrived in Cess River to respond to positive cases coming from this rural area. Activities have already started and include contact tracing with the Center for Disease Control (CDC), safe burials, distribution of protection kits and preparation of a transit centre.
The overall effort to combat Ebola in Sierra Leone is being outpaced. Despite efforts from authorities and support from international actors, including MSF, the situation is not under control.
The NERC (National Ebola Response Committee) has initiated new coordination centres to improve communication and collaboration of country-wide and district-level responses. Despite an increased number of coordination structures, a wealth of technical expertise and substantial material support, the overall output of the response is struggling to face the needs.
Governments (including the UK and China) and various NGOs have sent teams to construct new centres in different locations around the country, including Port Loco and Freetown. While many centres are scheduled to open soon, they will not be running at full capacity until well into the New Year. Meanwhile, because of the overwhelming pressure, many localities, hospitals, transit centres, health units and communities are initiating responses with varying degrees of support from international actors.
Bed capacity remains a critical issue. Moreover, MSF is concerned that transit facilities, holding facilities, functioning healthcare facilities, and ambulances can all act as points of transmission.
For months, MSF teams in Bo and Kailahun have offered knowledge-transfer opportunities through “shadowing” and other engagements. MSF has recently launched a new project to offer more specific, structured, and targeted training opportunities for other organisations needing support in operating case management centres (CMCs) safely.
The MSF CMC continues to receive patients from outside of Kailahun as there are not enough CMCs in the country. Patients are transported from the heavily affected districts of Bombali and Tonkolili, travelling over eight hours by car. Conditions inside the ambulances can create cross-contamination as people are often very sick.
Social mobilisation and sensitisation activities have increased as the Health Promotion team and the medical team are reaching out to public health units, community stakeholders and the community at large to raise awareness.
In Bo the MSF CMC is gradually being scaled up to 64 beds. At the moment, its capacity is 60 beds. The CMC is receiving confirmed cases mostly from Moyamba, Port Loko and Freetown, but has recently received patients from the Koinadugu district.
In Freetown MSF is planning two rounds of house-to-house distributions of antimalarial medication. This initiative aims to reach about 1.4 million people and will start 5 December. The second round will be a month later.
A recent assessment by an MSF team in Freetown and the area identified beds for Ebola patients as the greatest need. Discussions with health authorities on a possible MSF intervention are in the advanced stages. A team of five is already on the ground and will be reinforced by another fifteen people by next week.
WHO declared 20 October as the official end of the epidemic after 42 days without a case. The MSF intervention has been closed.
WHO declared 17 October as the official end of the epidemic after 42 days without a case. The MSF intervention has been closed. MSF’s West African Unit (Dakar) will keep in contact with the government for follow up as part of their routine activities.
Democratic Republic of Congo (DRC)
The outbreak in DRC’s Equateur province, which was unrelated to the one in West Africa, was declared over this week. Around 60 MSF staff worked on this outbreak and two case management centres were established. The MSF teams have activated an exit plan.
On September 29, a case of Marburg fever was declared in Uganda. MSF has helped reinforce local capacities for treating confirmed cases and for infection control. No new cases of the disease have been declared since.
Mali confirmed its first case of Ebola on 23 October. So far there have been seven reported deaths in the country (including the first case): five confirmed with Ebola and two suspected cases. To date, 360 contacts have been identified and nearly all have been placed under surveillance.
In Bamako, MSF is running a case management centre (CMC) in collaboration with CNAM, Mali’s national disease centre. The only confirmed Ebola patient admitted to this facility recently died. The case was detected on 11 November and the patient was immediately admitted to the facility. There is one more suspected case currently at the CMC.
MSF has reinforced its team and expanded its activities to help stop the disease spreading further. MSF is training Malian staff from CNAM to manage Ebola cases, and is overseeing the organisation of an ambulance system and safe burials.