Ebola virus epidemic in Liberia

Ebola virus epidemic in Liberia

A map of Liberia
Cases contracted in Liberia 9,555 (as of 17 March 2015)[1]
Deaths 4,283 (as of 17 March 2015)

The West African nation of Liberia is experiencing an epidemic of Ebola virus disease (commonly known as "Ebola"), as are the neighbouring countries of Guinea and Sierra Leone. The outbreak was discovered in late March 2014.[2] The Ebola virus, a biosafety level four pathogen, is an RNA virus discovered in 1976.[3]

Before the Ebola epidemic, Liberia had 50 doctors for its population of 4.3 million, weakened from a civil war that ended in 2003.[4]

History of Ebola in Liberia

Early events

On March 30, 2014 Liberia confirmed its first two cases of Ebola virus disease.[5] By 23 April 2014 there were 34 cases and six deaths from Ebola in Liberia.[6] By June 17, 2014 sixteen people had died from Ebola in Liberia.[7] Doctors would get infected early on, because they would think the patient had malaria.[8] Malaria is extremely common in Liberia; for example in 2010 there were nearly 1.3 million cases of malaria in a country of about 4 million.[9][10]

The first deaths from Ebola in Monrovia occurred by 17 June 2014 when seven died from Ebola.[11] The dead included a nurse along with some from her household.[11] The nurse was treated at Redemption Hospital located west of Monrovia.[11] At the time there were about 16 cases reported in Liberia overall.[12] Redemption Hospital is a health care facility in New Kru Town somewhat west of Monrovia in Liberia.[13] It is a state-run institution that offers free health care in New Kru Town.[14]

By 2 July 2014 a doctor at the hospital, the head surgeon, died from Ebola.[13] Redemption Hospital was shut down and its patients distributed to other facilities in the area.[13] The Redemption Hospital doctor who died was being treated at the JFK Medical Center (also in Monrovia).[13]

On 21 July 2014, four nurses at Phebe Hospital in Bong Country contracted Ebola.[15] On July 27 Samuel Brisbane, one of Liberia's top doctors, died from Ebola. By this time a doctor from Uganda also died, and two U.S. doctors became infected.[16]

By July 28, most border crossings had been closed, with medical checkpoints set up at the remaining ports and quarantines in some areas; Arik Air suspended all flights between Nigeria and Liberia.[17]

On July 30, Liberia shut down its schools as the Ebola outbreak spread.[18]

August

On the weekend of 2–3 August 2014, locals fought a burial team trying to bury 22 bodies, and the police were called in to restore order.[19]

On 4 August, the Liberian government ordered corpses of those that died from Ebola virus disease to be cremated.[19] Ebola corpses are highly contagious immediately after death.[20] At this time there were 156 recorded deaths from the disease in Liberia.[19]

On 11 August, the Ivorian government had announced the suspension of all flights coming from countries affected by Ebola. Ten days later, it decided to close its borders as well with Guinea and Liberia, the two countries most affected by Ebola, in view of the reactivation of old cases.[21]

On 27 August, there was a problem with dogs eating the corpses that had not been picked up, and packs of dogs were observed digging up bodies and eating them in Liberia.[22] One study pointed out pet dogs may eat at Ebola-infected carcasses.[22]

West Point quarantine (Aug 19-30)

A view of the West Point area of Monrovia

On 18 August, a mob of residents from West Point, an impoverished area of Monrovia, descended upon a local Ebola clinic to protest its presence. The protesters turned violent, threatening the caretakers, removing the infected patients, and looting the clinic of its supplies, including blood-stained bed sheets and mattresses. Police and aid workers expressed fear that this would lead to mass infections of Ebola in West Point.[23][24]

On 19 August, the Liberian government quarantined the entirety of West Point and issued a curfew statewide.[25][26] Violence again broke out on 22 August after the military fired on protesting crowds.[27] An inquiry into the incident found the security forces at fault, stating they "fired with complete disregard for human life”.[28] The quarantine blockade of the West Point area was lifted on 30 August. The Information Minister, Lewis Brown, said that this step was taken to ease efforts to screen, test, and treat residents.[29]

September

On 1 September, Ivory Coast announced the opening of humanitarian corridors with its two affected neighboring countries.[21]

The WHO reported on 26 September 2014 that Liberia had informed, as of 23 September 2014, there had been 3,458 total cases, 1,830 deaths, and 914 lab confirmed cases.[30] For comparison, Lassa fever is estimated to kill about 5000 people a year in West Africa,[31] and in Western countries, medical mistakes kill between 44,000 to 400,000 people a year.[32]

On 20 September, Liberia opened a new 150-bed treatment unit clinic in Monrovia. At the opening ceremony of the Old Island Clinic on Bushrod Island six ambulances were already waiting with potential patients. More patients were waiting by the clinic after making their way on foot with the help of relatives.[33] Two days later 112 beds were already filled with 46 patients testing positive for Ebola, while the rest were admitted for observation.[34] This expanded the number of beds in the city beyond 240.[35] 100 construction workers worked multiple shift for three weeks to get the clinic open, but its capacity was exceeded in 24 hours.[35] The term bed here is not just a bed, but implies the staff and logistics to take care of a patient with right precautions.[35] One source says it opened on 21 September 2014 with a 100-bed capacity.[36]

By late September there were three clinics in Monrovia, but it was an increasingly common occurrence to have patients waiting and even dying outside because the clinics had run out of space.[37] If patients cannot get a bed in the clinic they sometimes wait in holding centers until a bed opens up.[38] There are additional cases in Monrovia where the bodies are dumped into the river.[39]

One woman used trash bags to protect herself as she cared for four other family members ill with Ebola.[40] Her father became ill in late July 2014, but they could not find a place of treatment for him and ended up doing home-care.[40]

On 25 September Liberia's chief medical official went on a self-enforced quarantine after her assistant died from the illness, having potentially exposed her to the Ebola virus.[41] By the 29th of September 2014, it was announced she tested negative for Ebola, but government officials praised her for following the self quarantine rules.[42]

On 28 September 2014, Ivory Coast resumed flights to Liberia which had been suspended since 11 August 2014, after WHO's critique for tending to economically strangle the affected nations.[21] From the beginning of the crisis, WHO has discouraged closing the borders with afflicted countries.

On 30 September 2014 a cameraman was diagnosed in a Texas hospital of having contracted Ebola before traveling back to the United States from Liberia, where he covered the Ebola outbreak for NBC News[43][44] (see 2014 Ebola virus cases in the United States). Also that day, Liberian's government also enacted restrictions on journalistic coverage aimed at protecting patients' privacy.[45]

October

The 25-bed Monrovia Medical Unit was constructed for health care workers supporting Operation United Assistance.

In early October, the president continued to ask for more aid to fight against Ebola.[46]

On 2 October 2014, a new 60-bed clinic was opened in Kenema.[47] However, the outbreak was described as being out of control and an exponential growth in cases was expected, with a focus on slowing the outbreak down.[48] One problem is that the health care establishments are overwhelmed, so even when those infected come to a hospital they are often turned away and go on to infect others.[48]

By 3 October 2014 at least 8 Liberian soldiers died after a woman infected with Ebola visited them.[49]

On 3 October 2014 medical supplies arrived from Germany, which cared for two evacuated Ebola cases in Germany by that date.[50] On that same day GERLIB opened up an Ebola isolation ward at its 48-bed facility in Paynesville (Monrovia).[51]

On 10 October 2014, journalists were banned from Ebola clinics.[52]

In October the WHO pushed for its 70-70-60 plan to control the outbreak.[53] By October 19, it was reported that 223 health care workers had cases of Ebola, and 103 of them had died in Liberia.[54]

On 14 October, 100 U.S. troops arrived, bringing the total to 565 to aid in the fight against the disease.[55] On 16 October, U.S. President Obama authorized, via executive order, the use of National Guard and reservists to Liberia.[56] A report of 15 October indicates that Liberia needs 80,000 more body bags and about 1 million protective suits for the next six months.[57]

On 19 October 2014, the President of Liberia apologized to the Mayor of Dallas for the Liberian national that brought the disease to the United States.[58]

By 19 October only one area in Liberia, Grand Gedeh, has yet to report an Ebola case. 14 out of the 15 districts have reported cases.[54]

The disease has been noted to be spreading in Monrovia, the nation's capital.[59] There are about 1 million people in the city.[60] Monrovia is particularly affected with 305 new cases reported in the week ending 19 October.[54]

November

On 5 November Liberia has 6,525 cases (including 1,627 probable, 2,447 suspected cases) and 2,697 deaths.[61] The 5th November WHO situation report noted that "There appears to be some evidence of a decline at the national level in Liberia, although new case numbers remain high in parts of the country."[62] A report by CDC released on 14 November, based on data collected from Lofa county, indicates that there has been a genuine reduction in new infections. This is credited to an integrated strategy combining isolation and treatment with community behaviour change including safe burial practices, case finding and contract tracing - this strategy might serve as a model to implement in other affected areas to accelerate control of Ebola.[63] On 13 November the Liberian President announced the lifting of the state of emergency in the country following the decrease in the number of new cases in the country.[64] The decline in Liberia cases is contradicted in the latest reports from WHO with 439 new cases reported between 23 and 28 November.[65][66]

December

On December 4, it was reported that President Ellen Johnson Sirleaf banned all rallies and gatherings in Monrovia before the senatorial election, indicating that it risked worsening the spread of the Ebola virus.[67]

2015

On 13 January 2015, the Liberian government announced that new cases of Ebola in Liberia were now restricted to only two of its counties: Grand Cape Mount County and Montserrado County.[68] On 28 January, the ELWA-3 Ebola treatment center in Monrovia was partially dismantled. When the center opened in August it had been swamped with patients, even needing to turn some away, but according to staff it was now down to only two patients. The MSF field coordinator said that as of that date Liberia was down to only five confirmed cases in all of Liberia.[69] On 30 January, Liberia extended school reopenings by two weeks.[70] On 10 February the U.S. military indicated it would end its relief mission.[71] On 20 February, Liberia opened its land borders.[72]

In the first week of March 2015, the World Health Organization announced that Liberia had released its last Ebola patient after going a week without any new cases of the virus. If the country has no new cases for 42 days, it will be declared Ebola-free.[73]

On 5 March 2015 Tolbert Nyeswah, the assistant health minister of Liberia, reported that the country have released their last confirmed case of Ebola from a Chinese staffed treatment center. Beatrice Yardoldo was the last confirmed case and has been treated since 18 February 2015.[74]

On 20 March 2015 after two weeks of not reporting any new cases Dr. Moses Massaquoi, leader of the Clinton Health Access Initiative in Liberia, reported a new confirmed case in the country. The patient developed symptoms on 15 March 2015, and was tested positive on 20 March 2015.[75] The patient subsequently passed away on 27 March 2015.[76] Two more cases have been reported since then in Liberia. An 18-year-old woman taking care of the first new case tested positive for the disease on 25 March 2015. A young man from the New Kru Town area was also diagnosed with Ebola on the same day. It is still unclear as to how he contracted the disease.[77]

Healthcare capacity

Doctors from Médecins Sans Frontières and the American CDC put on protective gear before entering an Ebola treatment ward in Liberia, August 2014.

Clinics

One of the other clinics in Monrovia is a 160-bed facility by Médecins Sans Frontières.[78]

JFK (John F. Kennedy Medical Center (Liberia)) is another treatment center, and could hold 35 beds but expanded to 75 because of the demand.[79]

On 10 November, the U.S. opened the first of 17 Ebola treatment facilities it is building for Liberia, in Tubmanburg.[80]

Confounding factors

A CDC official consulting with a Liberian District representative about Ebola

Sanitation

Sanitation is a struggle in some parts of the city, with estimates that there are four public toilets in West Point, Monrovia.[81] The beach surrounding West Point is often used as a lavatory, but it is also a source for drinking water, and the fish from the water are taken for food.[81]

Corruption

Further information: Corruption in Liberia

In Liberia, some body-collection teams dispatched to collect the Ebola dead have collected bribes to issue falsified death certificates to family members, stating that their dead relative did not die from Ebola. The body of the Ebola victim would also be left with relatives. Ebola carries a stigma in Liberia, and some families do not want to admit that their relative died of Ebola. Another factor is that families wish to give their relative a traditional burial.[82]

During the 10-day Liberian government quarantine of the West Point slum in Monrovia, residents were able to leave the blockaded area by paying bribes to soldiers and police officers.[83] A journalist inside West Point told a local radio station that Liberian soldiers and police were seen "daily soliciting monies from those being quarantined in the area to escape". The journalist reported that "many of those even suspected of having the disease were given free passage to leave West Point for Monrovia city center."[84]

Public hiding of Ebola infected and dead

In October it was noted that many of the Ebola dead and dying are not being reported to health authorities in Liberia. While the epidemic has been accelerating, the number of bodies being collected is falling. “Very, very few of those dying in the community are being brought forward,” said Cokie van der Velde, who organises body collections with Médecins Sans Frontières.[85]

Van der Velde said that in late September the main crematorium in Monrovia was running at full capacity - burning 80 bodies at a time on its mass pyre. In early October, the number of bodies has dropped to 30 or 40 a day. Van der Velde said “That means they’re being kept hidden and buried in secret”. Traditional funerals have been a risk factor in the spread of Ebola.[85]

In late October it was reported that many beds in Liberian Ebola treatment centres were empty due to people no longer self-reporting suspected Ebola symptoms to health authorities. The assistant Liberian health minister said at the time that an assessment of Ebola treatment units found that out of 742 spaces, 351 were occupied by patients.[86]

The non-reporting by the public is believed to be due to an August policy decision to cremate all bodies of suspected Ebola victims in Monrovia, with cremation being against local sensibilities and preference for a traditional burial. The cremation order came after people in Monrovia's neighbourhoods resisted the burial of hundreds of Ebola victims near their homes.[86]

Issues within government

On August 6, Liberian President Ellen Johnson Sirleaf told absent government ministers and civil service leaders to return to Liberia as part of an emergency announcement.[87] In late August, Sirleaf dismissed 10 government officials, including deputy ministers in the central government who refused to return to Liberia, and froze the benefits and pay for nearly twenty other high-ranking officials who would not return.[88]

In mid-November President Sirleaf reshuffled the country's cabinet in response to widespread criticism of the government's heavy-handed yet ineffective response to the Ebola crisis. George Warner, previously the head of civil service, would replace Walter Gwenigale as health minister. Sirleaf commented Gwenigale had her "full confidence" and will continue on as an adviser.[89]

Transfusions of blood from Ebola survivors

A black market in the blood of Ebola survivors for has been reported in Liberia. Buyers of the blood hope to gain immunity or recovery via a blood transfusion.[90] These transfusions have been noted as posing a risk for the transmission of HIV/AIDS, malaria and other blood-borne diseases, which "has the potential to divert time and resources originally allocated to control Ebola", stated a US military report.[91]

Local conspiracy theories

Effects

A sign in a Monrovia radio station advising people not to shake hands, as Ebola can be spread through physical contact via body fluids.

Cultural effects

City inhabitants have tried to spread knowledge about Ebola, especially the importance of not touching those that are sick or dead from Ebola.[37]

Evacuations

On 5 August 2014, the Brothers Hospitallers of St. John of God confirmed that Brother Miguel Pajares had been infected after volunteering in Liberia. The Spanish military helped with his transfer on 6 August 2014.[98] Authorities stated he would be treated in the 'Carlos III' hospital in Madrid. This attracted controversy, amid questions as to the authorities' ability to guarantee no risk of transmission.[99] Brother Pajares died from the virus on 12 August.[100]

Kent Brantly, a physician and medical director in Liberia for the aid group Samaritan’s Purse, and co-worker Nancy Writebol were infected while working in Monrovia.[101][102][103] Both were flown to the United States at the beginning of August for further treatment.[104] On 21 August, Brantly and Writebol recovered and were discharged.[105]

A French volunteer health worker working for MSF in Liberia contracted Ebola there and was flown to France on 18 September 2014. French Health Minister Marisol Touraine stated the nurse would receive the experimental drug favipiravir.[106] By 4 October 2014 she had recovered and was released from the hospital.[107]

After a news-network's cameraman came down with Ebola, he was evacuated to the U.S. and the rest of the crew also returned and went into quarantine.[108]

Local works derived from the Ebola crisis

See also

References

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  83. ↑ NORIMITSU ONISHI. "Quarantine for Ebola Lifted in Liberia Slum". The New York Times. Retrieved 11 February 2015.
  84. ↑ ""LIBERIA: Soldiers Deployed At West Point To quarantine Suspected Ebola Affected Persons Accused Receiving Money To Allow Them ‘Go’", GNN Liberia, Cholo Brooks, August 25, 2014.".
  85. ↑ 85.0 85.1 "Some people would rather die of Ebola than stop hugging sick loved ones". GlobalPost. Retrieved 1 February 2015.
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