Since the Ebola outbreak in West Africa was officially declared on 22 March in Guinea, it has claimed 4,959 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 the United States of America (USA) is currently being treated for Ebola, and one has died. One person in Spain and two people in the USA have recovered. Outbreaks in Nigeria and Senegal have been declared over.
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.
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 a total of 3,340 staff working in Guinea, Liberia, Sierra Leone and Mali, treating an increasing number of patients. Since the response began, 24 MSF staff have been infected with Ebola, nine of whom have recovered. The vast majority of these infections were found to have occurred in the community.
Operational Highlights
MSF’s West Africa Ebola response started in March 2014 and counts activities in Guinea, Liberia, Mali and Sierra Leone. MSF currently employs 263 international and around 3,077 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 5,600 patients, among whom around 3,500 were confirmed as having Ebola. More than 1,400 patients have survived.
More than 1,107 tonnes of supplies have been shipped to the affected countries since March.
The provisional 2014 budget for MSF’s Ebola response in West Africa is €51 million. MSF will continue its operational response in 2015, and is currently estimating operational budgets beyond 2014. So far, MSF has approved institutional funding for a value of €20M and have raised about €28M in private funds.
Guinea
The overall situation in Guinea remains very concerning, as the number of patients remains high. In October it was 23% higher than in was in September (451 vs. 366 confirmed cases). The number of new cases seems to be on the rise again, despite a slight decrease last week.
Guinea has a new national plan of action to stop Ebola. It is planning eight new CMCs, and many more transit centres and community treatment centres as well. The ambitious plan aims to control the Ebola epidemic in Guinea by end of January 2015. MSF welcomes the new plan of action, however construction and running this infrastructure is not without challenges as the training of staff remains an important bottleneck.
MSF is still the only organisation running CMCs. The overall capacity of MSF is now at 225 beds. But there are some changes to come as the Ministry of Health (MOH) has recently opened a new transit centre in Forécariah, east of Conakry (with technical support from MSF) and, the French Red Cross (FRC) and the NGO Alima are planned to start running CMCs as well, with a combined capacity of about 120 beds. MSF is now training FRC and Alima staff to run the new CMCs.
Conakry
For the last three weeks, the situation in Conakry seems to be stable, with a limited number of cases per week. The CMC in Donka has about 20 new patients every week and it remains an important training facility for our staff and other organisations planning to run CMCs.
Macenta/Gueckedou
In the southeast of the country the situation is more problematic. In Guéckédou the CMC is still seeing a lot of patients, but very few of them are from Guéckédou itself. The origin of admitted patients demonstrates that there are significant hotspots in Macenta, Kérouane and N’Zérékoré (About 80% of cases come from these three districts). However, the good news is that the epidemic seems, at least temporarily, to be under control in Guéckédou (together with the neighbouring Lofa district in Liberia) where it seems the comprehensive approach is paying off.
In Macenta MSF is building a new CMC that will replace the current transit centre. The CMC will be handed over to the Red Cross before the end of the month. The NGO Alima is building a CMC in N’Zérékoré, to be opened in December.
Liberia
Monrovia The number of patients in our centre has decreased. One week ago we had 80 patients in the 250-bed capacity centre and as of 4 November we have 52 confirmed patients admitted. In the past seven days we have discharged 20 patients while another 20 passed away. The total number of new admissions in the last week is around 50.
It appears that this decrease in cases is happening elsewhere in Monrovia and also in some other parts of the country. While the situation seems to be improving, the epidemic is still far from over and we need to remain vigilant. Meanwhile, this dip in cases highlights the need for a flexible response, and there should be a renewed effort to fortify the basic elements of a response: contact tracing, safe burials, epidemiological surveillance, etc.
Distributions of household protection kits continue: more than 50,000 kits had been distributed as of 4 November. MSF is still concerned about the poor ambulance and referral systems in Monrovia, as well as community surveillance, safe body management practices, and the fact that there are no actors doing contact tracing.
A mass distribution of anti-malaria treatment began in Monrovia on 25 October. In a context of a collapsing health system, the objective is to eliminate malaria in the most impoverished and densely populated areas where there is very limited access to health care. The target population is 350,000 people. In the first six days, MSF distributed malaria tablets to all 120,000 people living in New Kru town, a township of Monrovia. MSF has also distributed malaria tablets to another 50,000 people living in West Point.
The healthcare system has been severely affected by the Ebola outbreak and people lack regular access to free healthcare. MSF is establishing a ‘triage point’ where patients going to the government-run Redemption Hospital can be screened for Ebola and referred, if necessary, to an Ebola case management facility. Redemption Hospital is one of only a few hospitals in Monrovia that does not charge user fees. Until very recently, it was being used as a holding centre for Ebola patients, and therefore could not operate normally. The ’triage point’ will enable the hospital to close their Ebola holding facility and reopen safely.
Lofa
The number of admissions in Foya has been low for more than eight weeks. Last week there were three days with no patients in the centre at all and as of 6 November, there was one patient receiving treatment in the facility.
The decrease in the number of cases in Lofa has occurred as a result of a comprehensive package of medical care, outreach activities, psychosocial support, health promotion and contact tracing. 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 spread of the epidemic.
However, this does not mean that Ebola is over in Lofa County. With transmission happening nearby, MSF is remaining vigilant, and is reinforcing health promotion messages and activities. In Foya and Voinjama MSF has expanded health promotion activities, including to villages where outbreaks have not yet occurred. MSF arranged a visit to the Ebola CMC for community leaders in Voinjama and surrounding areas to demystify how the centre operates.
The MSF transit centre in Voinjama opens to accept patients this week. The transit centre will accommodate any patients identified late in the day, give them a safe place to stay overnight and then transfer them the next morning to the centre in Foya.
MSF continues to provide training for key partners in the Foya CMC and in its outreach activities.
Sierra Leone
Every district in Sierra Leone is now affected by the epidemic. Hotspots for the disease include the capital, Freetown, and the areas of Bombali and Moyamba. Forty per cent of admissions to MSF’s centres are coming from Western District (Freetown).
The government’s response is hampered by a lack of resources and coordination at both national and district levels. There is no strong surveillance system in place, while up to 85 percent of calls to the national telephone helpline get no response. Transit centres are full and management is really an issue, creating the risk of cross-contamination. As a result of overcrowding, delays in lab testing, and too few ambulances, staff in transit centres are obliged to send people untested to treatment centres, risking that positive cases infect those who are negative. As there are few treatment centres, and as these are often far away, people often die on the long ambulance journey there. Dead bodies have the highest viral load possible, putting other passengers at risk.
With so many deaths from Ebola, we are seeing an increasing number of orphaned children in our centres, and a lack of caregivers.
The international response is beginning to get underway, but it is slow and uncoordinated. Governments (including the UK and China) and various NGOs have sent teams to construct new centres at different locations around the country, including Port Loco and Freetown. Getting these new centres up and running is a matter of urgency. The need for more resources on the ground continues to exist. Community sensitisation is an area of increasing concern.
MSF has been conducting training for organisations interested in joining the response. So far three international organisations have been trained within MSF centres in Bo and Kailahun with more trainings planned in the coming weeks.
Kailahun
Our treatment centre continues to receive patients from outside of Kailahun as there are not enough treatment centres in the country. The patients are being transported from the heavily affected districts of Bombali and Tonkolili, travelling over eight hours by car which is a big medical concern as the conditions inside the ambulances can create cross-contamination and people are very sick. Sometimes people travel for hours with a dead body next to them. Almost all the admissions this week were from Tonkolili and Bombali districts.
Social mobilisation and sensitisation activities have increased as the Health Promotion team together with the medical team are reaching out to public health units, community stakeholders and the community at large to raise awareness.
Bo
In Bo our 40-bed Ebola case management centre (CMC) is being scaled up to 64 beds with an increase of five beds per week. There has been an increase in the number of confirmed patients referred from the Western Area (Freetown) holding centres. Trainings for other organisations and capacity building of national staff are ongoing.
Nigeria
WHO declared 20 October as the official end of the epidemic after 42 days without a case. The MSF intervention has been closed.
Senegal
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 current outbreak in DRC’s Equateur province is unrelated to the one in West Africa. Around 60 MSF staff have been working on this outbreak and two case management centres have been established: one in Lokolia (24 beds) and one in Boende (10 beds). With no reported new cases since early October, the MSF teams in Lokolia and Boende have activated exit plans for the coming weeks.
Uganda
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
Mali confirmed its first case of Ebola on 23 October 2014. The patient came from Guinea and died on 24 October, having been hospitalised since 22 October. No more cases have been confirmed and 108 contacts have been identified up to the present. An MSF team arrived in Mali last week to reinforce the regular mission and to provide technical support to the MOH.