On March 10th 2014, hospitals and public health services
in Gueckedou and Macenta districts alerted the Guinea Ministry of Health (MoH)
and Medecins sans Frontieres in Guinea about a rapidly evolving outbreak of a
mysterious disease characterized by fever, sever diarrhea, vomiting and an
apparently high fatality rate. Eight
patients were hospitalized in Gueckedou of which three died. Additional deaths
were also reported among family members of the patients. In Macenta, deaths
were also observed among hospital staff members.
On March 13th, 2014 the Guinea Ministry of Health (MoH)
notified the World Health Organization (WHO) of the outbreak of a communicable
disease in the forested areas of South Eastern Guinea with cases reported in
Gueckedou, Macenta and Kissidougou districts.
A total of 86 suspected cases, including 59 deaths were reported (case
fatality ratio of 68.5%).
The Guinea Ministry of Health sent a team to the outbreak region on
March 14th, 2014. Medecins sans Frontieres in Europe were also notified
and a team was also sent which arrived in Guekedou on March 18th,
2014. Epidemiological investigation was initiated.
By March 27th 2014, the disease had spread to the capital
of Conakry with 4 confirmed cases and 1 suspected case.
Virologic investigation identified the Ebola virus as the causative
agent. This is the first Ebola virus disease outbreak (formerly called Ebola Haemorrhagic
Fever) in Guinea, thousands of miles away from Uganda and the Democratic
Republic of Congo where recent outbreaks have been observed.
From the investigation it was discovered that epidemiological links
between cases suggest a single introduction of the virus into the human
population. This introduction might have happened in December 2013 or earlier.
However the animal source of the outbreak is yet to be identified. It is
suspected that the virus might have been transmitted for months before the
outbreak became apparent as a result of clusters of cases in the hospitals
located in Gueckedou and Macenta (Sylvian Baize et al, 2014).
To determine the index case, Sylvian Baize et al, conducted an
epidemiological look-back. This was achieved by reviewing hospital
documentations and interviewing affected families as well as patients with the
suspected disease and inhabitants of villages where cases occurred. According
to there investigation, the first suspected case of the outbreak was a
two-year-old child who died in Meliandou village in Gueckedou prefecture on
December 6, 2013. His sister, mother and grandmother were later infected and
they too also died. Patient S14, health care worker with the suspected disease,
seems to have triggered the spread of the virus to Macenta, Nzerekore, and
Kissidougou in February 2014.
The epidemiological investigations by Sylvian Baize et al determined
the index case and transmission chain as detailed in figure 1.
Figure 1: Transmission chain of the outbreak of Ebola Virus Disease
in Guinea
Shown are the transmission
chains of the outbreak involving laboratory-confirmed cases. The solid arrows
indicate the presumed means of transmission as revealed by epidemiological
investigation. Dashed arrows indicate that the epidemiological links have not
been well established. Red circles indicate laboratory-confirmed (C) while
suspected cases (S) are indicated with the case number. (Sylvian Baize et al,
2014).
Figure 2: Map of Guinea showing initial
locations (highlighted in red) of outbreak of Ebola Virus Disease. (Courtesy: Sylvian Baize et al, 2014)
Since then the Ebola virus disease outbreak has reached the capital
city of Conakry following the trails as shown in the figure 2.
The outbreak area is highlighted in red and the main road between
the outbreak area and Conakry, the Capital of Guinea is also shown. (Sylvian
Baize et al, 2014). This main road
provides easy access for people, goods and services to move from one part of
the country to another, including crossing the porous borders with neighboring
countries with which they share a common language, cultural practices as well
as trade. It also provides an enabling
contact link across the country and as a matter of fact, puts across-border
countries at a high risk of the EVD outbreak. For instance, Sierra-Leone and
Liberia presently have recorded major outbreaks! Ivory Coast, Mali, Senegal and
Guinea Bissau should be on high alert too!!
Apart from the outbreak areas cases have also been observed and
confirmed in the following districts in Guinea: Dabola, Djingaraye, Telimele
Boffa, Boke, Dubreka and Kouroussa, making it the largest Ebola outbreak in
terms of geographical areas.
The figure below is a map of the Republic of Guinea showing the
geographical distribution of cases.
Figure 3: Geographical distribution of Ebola virus disease Cases in
Guinea. Map by me.
(*From information reported
as of 22nd June 2014)
The district of Guekedou has the largest number of cases (221 cases)
while Boke, Dubreka, Djingaraye and Kouroussa (each with 1 case) have the
lowest number of cases since the onset of the outbreak. The figure below shows
the geographical distribution of Ebola virus disease related deaths.
Figure 4: Geographical distribution of Ebola virus disease related
deaths in Guinea. Map by me
(*From information reported
as of 22nd June 2014)
A total of 485 cases (340 confirmed, 133 probable and 12 suspected)
and 358 deaths from the outbreak have been reported in Guinea.
As of 4th August 2014, 13 new cases and 12 deaths were
reported in Guinea.
Figure 5:Weekly trend of new cases (confirmed, probable and
suspected cases) and deaths in Guinea from March to July 2014.
(*Using data reported by
W.H.O as of 4th August 2014)
The figure above shows the progression of the Ebola Virus Disease in
Guinea over time. The number of new cases reported declined after the peak in
April but then a surge in new infections was observed in the month of June. This
was followed by weeks of relatively low viral activity with another surge
occurring in the last week of the month of July.
This surge indicates that undetected chains of transmission still
exist in the community.
Figure 6: Cumulative number cases and deaths of the Ebola Virus
Disease in Guinea from March to July 2014.
(*Using data reported by
W.H.O as of 4th August 2014)
Control of this strain of the Zaire Ebola virus subtype is proving
difficult resulting in this peak and trough of new cases. The main factor has
been the geographical spread of cases (as shown in figure 3) and movement of
people not only within the country Guinea but also with its neighbors where
cases have also been reported (figure 7) -in Liberia 468 cases and 255 deaths,
Sierra Leone 646 cases and 273 deaths. Travel-linked cases have also been
reported in Nigeria (5 cases and 2 deaths) and Morocco as well as Saudi Arabia. The Ebola virus disease
outbreak is currently in its fifth month with a cumulative total of 1603 cases
and 887 deaths (case fatality ratio of 55.3%) reported in four countries. Thus
making this outbreak the largest in the history of the disease. These movements make contact tracing (those
who might be infected) very difficult. As epidemiologist Michel Van Herp from
Medecins Sans Frontieres told The Lancet, “even the dead are moving”. As a result person-to-person transmission is
made possible.
Figure 7: Map showing main
roads connecting Guinea, Sierra Leone and Liberia. W.H.O Image
Unlike Central Africa where the disease is more common and health
workers better equipped to handle Ebola, the West Africa region’s health
workers have never dealt with this virus before and are therefore in dire need
of training in infection-control measures to protect themselves and provide
adequate care for their patients. To
date more than 60 health care workers have died. Dr. Kahn, a virologist, who has played a key
role fighting the disease in Sierra Leone, died from the Ebola virus disease infection
on Tuesday 29th July 2014 (which is so sad). He is credited with
having treated more than 100 Ebola virus disease patients.
Families do not co-operate with medical teams. Community members
have been known to throw stones at health workers as well as hide their sick
relatives for fear of stigmatization. MSF was forced to suspend activities in one of
its treatment center after it came under attack by protesters in April.
Relatives forcefully discharge Ebola virus disease patients from treatment center
as they doubt the existence of the disease as well as view the isolation units
as a “death sentence”. Also reported was
the corpse of a suspected Ebola patient, which was abandoned in Louisiana, in
Montserrade Liberia on Friday 18th July 2014. When health workers
arrived to get the body, the son of the deceased started throwing stones and
refused for the body to be removed. This is a major concern as direct contact
with the corpse could lead to transmission of the virus. Infected corpse needs
to be handled with care.
Figure 8: Staff of Doctors without Borders carrying the body of a
person killed by the disease. AFP/Getty Images
Apart from all these challenges, there are also Ebola-like diseases
all over the place such as Lassa fever, Malaria, and Typhoid fever etc., which
are endemic in West Africa, making early detection difficult.
Ebola is introduced into the human population through close contact
with the blood, secretions, organs or other bodily fluids of infected animals
such as fruit bats, monkeys, antelope, gorillas, chimpanzees and porcupines. It
then spreads in the human population with infection resulting from direct
contact with (through broken skin or mucous membrane) blood, secretions (such
as sweat, saliva, breast milk), organs or other bodily fluids of infected
people, and indirect contact with environments contaminated with the victim’s
fluids such as contaminated medical equipment. Men who have recovered from the
disease can still transmit the virus through their semen for up to 7 weeks
after recovery from illness.
Figure 9: Life cycle of Ebola Virus. CDC.
Ebola virus disease is characterized by sudden onset of fever, intense
weakness, muscle pain, headache and sore throat. This is often accompanied by
vomiting, diarrhea, rash, impaired kidney and liver function and in some
extreme cases internal and external bleeding.
The incubation period (i.e. the time from infection to the onset of
symptoms) of the disease is 2- 21 days. It has a high fatality rate of 63-90%
in identified cases.
At the moment there is no licensed vaccine or specific treatment
available, only palliative care.
Despite all this, the medical charity MSF reports that three
quarters of those suffering from the Ebola virus disease who entered their
treatment center in Telimele a small town, in northern Guinea have recovered
compared to only 20-40% of patients in Gueckedou. An unusually high proportion
that is puzzling to scientist and aid workers.
The observed difference in the survival rate might be due to mutation
of the original virus, increased immunity in the population or false positive
lab results (i.e. diagnosing a suspected Ebola case as having the disease when
in fact he/she does not).
This ongoing Ebola outbreak should serve as a wake up call to all
West African governments to:
- Improve and provide access to the much needed health care facilities (such as facilities for isolation and supportive therapy, this need to be built, equipped and adequately staffed) and diagnostic technologies. Only a few laboratories in the region have the capacity to safely test a biosafety level 4 pathogen. Early in epidemic blood samples were sent to France, Germany and Senegal. In Sierra Leone there is only one laboratory capable of testing for Ebola.
- Support for clinical care providers should be expanded. Presently Liberia has just 0.014 doctors per 1,000 people while Bo, a city in Sierra Leone, has less than 15 doctors for a population of more than 150,000 people. Training and constant access to reliable personal protective equipment should also be provided for health care workers for they are the first port of call for any one who is sick.
- Improve regional and global surveillance and data sharing. Such surveillance can help in early warnings, outbreak response and communication between health-care providers, wildlife and veterinary professionals, local and national health authorities, as well as regional and international agencies. Adopting new data-sharing technologies can do this. Digitalized maps can be created using available satellite images with distinction been made between residential and unoccupied buildings, so as to improve disease mapping, this can be done using open source geographical information system.
- Accurate information about the disease needs to be rapidly and widely spread across the infected countries so to curtail superstitious beliefs and improve compliance with prevention and control measures that have proven to be effective.
- Also the government should stop threatening to prosecute individuals who knowingly harbor an Ebola patient. These threats have raised anxiety, fuelled rumors that led to counter-productive behaviors as well as increased the animosity between the government and the people.
Individuals also have a role to play in other to curb this
epidemic. These can be done by:
- Attend the treatment center at the first onset of symptoms. Evidence exist that early detection of the disease and implementation of supportive therapy increases ones chances of survival.
- Close contact with Ebola patients should be avoided as much as possible. Gloves and appropriate protective equipment should be worn when taking care of ill patients as contact with ALL body fluid are contagious even vomits and diarrhoea.
- Do not travel if you suspect you might be infected, thereby reducing contact with susceptible people. Be your brother’s keeper.
- Dignified burial helps in gaining the public’s trust and eases grieving. However burial of infected relatives should be done promptly and with the upmost care using personal protective equipment so to minimize transmission, as the virus remains present in the body of the deceased. Traditional burial practices ignite further spread of the virus.
- Practice good hygiene. Wash your hands with sodium hypochlorite water after visiting patients in the hospital, as well as after taking care of patients at home. Knowing this is difficult in a region that barely has clean water for drinking. The owner of a restaurant in Sierra Leone, had a bottle of chlorinated water placed at the entrance, and everyone who entered was asked to wash their hands.
- Sick animals should be handled with gloves and other protective clothing and also when slaughtering animals. Animal products should be thoroughly cooked before consumption.
Ebola can be contained and chains of transmission broken.
Notice: If you suspect a case of Ebola in Nigeria call/text the Nigerian Ministry Of
Health Helpline: 08023169485, 08033086660, 08033065303, 08055281442, and
08055329229.
References:
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