On March 20, a patient tested positive for Ebola in Monrovia, which was the first confirmed case in Liberia in more than two weeks. A total of 150 new confirmed cases were reported across Guinea and Sierra Leone in the week ending March 15. The virus has now infected more than 24,700 people across the region since the outbreak was declared a year ago.
Key challenges include contract tracing and surveillance, regional cooperation to trace contacts across borders and raising awareness in areas where public understanding of Ebola remains low.
Case numbers continue to fluctuate in Sierra Leone, despite earlier optimism that they were on the decline. According to government figures, in the week ending March 15, there were 55 new cases of Ebola reported in Sierra Leone, concentrated in hot-spots in the Western Area (Freetown), Tonkolili, Kambia, Kono, and Port Loko districts.
According to the World Health Organization (WHO), more than two-thirds of confirmed Ebola cases arose among known contacts in the week ending March 8. Today about 5,000 quarantined contacts are being traced, but few unquarantined contacts are being followed.
At the end of February, Doctors Without Borders/Médecins Sans Frontières’s (MSF) Kailahun and Prince of Wales (Freetown) Ebola management centers were decommissioned and others will follow in the coming weeks and months. This does not signify a scaling down of MSF's Ebola response in Sierra Leone but instead an increased focus on epidemic surveillance, health promotion and other needs in the communities.
MSF’s teams are working in this capacity across Freetown, Bo, and Magburaka, as well as in Kambia, a district bordering Guinea, where about 10,000 people cross between the two countries each week. MSF will continue to focus on health care for Ebola survivors in Freetown, including mental health and ongoing conditions and complications caused by Ebola.
With a collapsed surveillance system and a health system strongly affected by the Ebola outbreak, other diseases are not being treated as needed. In the past few weeks more than 800 hundred cases of measles have been identified in six districts of Sierra Leone, including the highly populous Western Area, which includes Freetown. MSF is planning a pilot project for a measles vaccination campaign during Ebola epidemics.
Referral services for Ebola-positive women are still needed in Freetown. While the reopening of schools is an important priority for the government, a specific referral center for Ebola positive women is required until the end of the epidemic in Sierra Leone. MSF is currently providing maternity care and supportive Ebola treatment for pregnant women at its Kissy Ebola management center near Freetown.
Stigma and resistance remain significant challenges in Guinea. There have been violent attacks against aid workers involved in the Ebola response, caused by stigma and resistance within the population, since the beginning of the outbreak. Although good progress has been made in recent weeks in changing people’s behavior in many rural areas, such as Forecariah and Boffa, stigma and resistance are still strong in the capital, Conakry. Misinformation about Ebola continues to spread in the city, and the general level of knowledge about the disease is extremely low.
Given the history of unpredictability of the epidemic in Guinea, continued alert and active surveillance are key. Since the beginning of the outbreak, the number of cases in Guinea has been fluctuating. We have seen low numbers of cases later rise again. While the number amount of cases is now lower than during the late December peak, the outbreak is far from over. Due to the resistance there is fear of hidden cases, especially in Conakry. Reaching “zero cases” will be difficult unless significant improvements are made in active surveillance, alerting and tracing Ebola contacts, and in infection control protocols.
Infection control measures need to be implemented in all health facilities throughout the country. The level of knowledge about Ebola is still low, even among health workers. Infection control protocols are not in place and non-Ebola health facilities risk becoming pockets of infection. An example of this is the recent contamination of five health care workers at the Ignace Dean hospital in Conakry.
A new case was confirmed on March 20, and the country will remain at risk while active transmission continues in neighboring Guinea and Sierra Leone. It is important to remain vigilant and ready to react immediately and comprehensively to any new cases that may arise.
Non-Ebola health needs in Liberia are an urgent priority that must be addressed. Liberia’s already fragile public health system has weakened even further, with many hospitals shut, health workers fleeing and few places for people to access care. In Monrovia, pregnant women often have to visit several health facilities before finding one that will accept them. With some hospitals now reopening, strict infection control must be implemented in order to mitigate the risk of Ebola. MSF is currently providing infection prevention and control support to 13 primary health care facilities, supporting the maternity department at James Davies Junior Hospital in Monrovia and running a new medical pediatric structure at Barnersville Junction.