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Fear and ignorance aid spread of Ebola

Doctor Yab Boun disinfecting colleagues before they investigate suspected Ebola cases at a new isolation centre at Mbarara Referral Hospital, south of the affected Kibaale district in western Uganda Courtesy Dr. Yab Boun
An Ebola outbreak in West Africa that appeared to be winding down has flared up again, with officials blaming the resurgence on ignorance and a lack of experience in handling the virus.

Pierre Formenty, a technical officer at World Health Organization (WHO), who specialises in Ebola, used a recent news conference in Geneva to explain the fresh outbreaks. Pormenty warned that Ebola was turning up in West African countries that had never witnessed Ebola before and did not have established mechanisms for dealing with it.

The view amongst experts in recent weeks had been that the outbreak in West Africa, which likely began in December but was first identified in March, was beginning to slow. There had not been a new confirmed case in Liberia since early April, for instance.

Hopes fade for an early end to outbreak

But that optimism faded in late May. The virus began to spread to new areas of Guinea, where over 200 Ebola-related deaths have now been confirmed. Nine deaths have been reported in Liberia and 12 in Sierra Leone, with health officials warning of the worst problems being concentrated in the eastern region of Kailahun. The majority of the 430 plus suspected or confirmed cases have been in the forest-covered regions of south-eastern Guinea, where the outbreak was first registered.

The Ebola Virus Disease (EVD), previously known as Ebola Haemorrhagic Fever (EHF) Ebola has typically struck at east or central African countries. The most serious outbreaks have been in Uganda, the Republic of Congo and the Democratic Republic of Congo, with South Sudan and Gabon also affected. According to WHO statistics, between 1976 and 2012, EVD caused around 1,600 deaths in sub-Saharan Africa.

West Africa gets to know Ebola

The one recorded instance of an EVD-like condition occurring in West Africa was in Côte d’Ivoire when a female ethologist was infected while conducting a necropsy on a wild chimpanzee. The ethologist developed Ebola-like symptoms and was evacuated to Switzerland, but recovered.

Formenty said there have probably been other outbreaks of Ebola in West Africa before, but the disease was never identified as such. He says the lack of experience is telling. “I think the fact it's the first time that this is happening in West Africa works against us because the people don't really understand how this epidemic can continue for a long time if everyone doesn't pitch in.”

Deficiencies in response

Antoine Gauge, the deputy director of emergencies for Médecins Sans Frontières (MSF) in Geneva, said the lack of familiarity with Ebola in West Africa led to a substantial delay in alerting the international community to a possible outbreak. That gave the disease time to spread undetected for months, making stopping its transmission much more difficult.

MSF is helping authorities in all three countries to combat the Ebola outbreak. The organization has about 200 people working on Ebola and has sent around 60 tons of equipment to the region.

But Gauge warns that health workers are still playing catch-up, trying to make up ground after this late start.

Gauge contrasts this with Congo, where health authorities have known about Ebola for over 30 years.

Lessons from Congo

“A suspected case in Congo at a health centre, or a death where the deceased had the symptoms, particularly bleeding, etc, in those cases there is immediately an alert,” Gauge explained.

“The health centre contacts the Health Ministry on the regional level and we're also informed. That happens in a couple of days. In West Africa, there isn't that knowledge”.

“I think the fact it's the first time that this is happening in West Africa works against us because the people don't really understand how this epidemic can continue for a long time if everyone doesn't pitch in”
Instead, the virus circulated for months without anyone testing for Ebola, which has similar symptoms to other haemorrhagic fevers that are common in West Africa.

Ebola is highly contagious and up to 90 percent fatal. There is no vaccine and, while treatment can improve the chances of survival of those infected, there is no cure.

There are, however, recommendations on how to improve prevention. For example, the WHO’s own guidelines stress the need to avoid unprotected physical contact with Ebola patients and the need for those with symptoms of infection to seek medical attention at the first sign of illness.

Problems in accepting treatment

But Formenty said the current outbreak was flaring again at least partially because families were not reporting infections to authorities or were refusing care.

Formenty cited the example of relatives of sick people in Sierra Leone removing their family members from an isolation unit and taking them home, rather than seeing them moved to a hospital 90 miles away.

Medical teams need to tread carefully

But Fomenty also said that local authorities and international health workers should be more sensitive to the difficult decisions confronting relatives and more ready to explain why isolation might be necessary. Formenty called for more straightforward communication, urging medical teams engaged in contact-tracing, looking for potential transmission of Ebola, to be more accessible, greeting villagers and explaining their activities before embarking on the work, avoiding misperceptions in the community that can generate mistrust.

Finding a West African solution

Daniel Bausch, director of the Emerging Infections Department at the U.S. Naval Medical Research in Peru, pointed out that resistance to treatment encountered in West Africa was common, and understandable, in all Ebola outbreaks.

He stressed the terrifying impact on people knowing that that they or their family members may have a deadly disease. Bausch also pointed out that since the survival rate from EVD was so low, many people mistakenly believed the treatment, not the disease, was to blame for deaths.

For Bausch, these were problems familiar from other major epidemics. But he acknowledged that there were other complicating factors in West Africa. For example, the wide geographic spread makes the response more difficult, and more expensive. Each village that the disease is linked to requires not only a medical team, but an additional team to trace contacts. Effective tracing means keeping track of people’s cross border movements in a region where the nationals of Guinea, Liberia and Sierra Leone move easily from country to country. But researchers doing contact-tracing can’t necessarily do the same, sometimes having to hand over to a team on the other side of the border.

Despite these challenges, Formenty of the WHO said those fighting the diseases would prevail. “We all want to control this outbreak,” he said. “We will control this outbreak, but it will take longer than expected.”


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