A year after: Revisiting 2014 Ebola outbreak in West Africa

By Sam Agona

In March 2014, Ebola grew from a scarcely known virus to the subject of daily news reports. The epidemic in West Africa quickly surpassed all previous outbreaks in impact; this outbreak is the 25th known since 1976.

Previous plagues where contained more efficiently, this particular one is nothing short of an unprecedented humanitarian crisis. With more than 23,825 (WHO, February 2015) reported cases and 9,675 deaths to date the Ebola epidemic is still a great concern. Vaccines are still not ready for testing in the field, and treatment trials are just in process.

March, 2015 marks one year since Ebola Virus Disease was reported in West Africa much as the index case occurred in December 2013. The outbreak severely affected Guinea, Sierra Leone and Liberia with only two cases in Mali and a single case in Nigeria and Senegal each. The virus exposed the weak health systems, lacking human and infrastructural resources of the countries that had just emerged from long periods of conflict.

Transmission and West African Social Construct;
According to a Professor of Emerging Infectious Disease at the London School of Hygiene and Tropical Medicine, Martin Hibberd, Ebola is a member of a family of viruses known as Filoviridae, and is related to Marburg virus and the recently discovered Cueva virus. One thing is that the strains are closely related (ranging from EBOV, BDVB, SUDV strains in DRC, Uganda, Sudan, Gabon and Guinea), much as the new outbreaks are not from the previous outbreaks but from a reservoir believed to be fruit bats; the question is what made the outbreak in West Africa so different, highly transmissible and far reached as it happened.

Ebola is transmitted through person to person contact (skin, mucosa, body fluids, vertical transmission - mother to child, short distance proximity (<1m) and fomites in shared spaces, but in West Africa, refusal to accept the problem meant the population defied regulations that could have lowered such contacts. This precipitated infections.

Prior to the 2014 Ebola outbreak, cumulatively there had been only 1500 recorded deaths from Ebola in 40 years. The social construct of the terribly hit West African countries made it more challenging to curb the spread, a thought supported by WHO statistics that shows the first 4,507 reported cases in 2014 were between 15 and 44, where half were female; an active age group that either lacked forehand information (health system fragility) or simply ignored information availed to them. 

Prior to the outbreak, health systems in Guinea, Sierra Leone and Liberia were already weak. The challenges were numerous, despite the decentralized service delivery systems that were in place. These included and not limited to insufficient qualified staff in the few health facilities that were in existence at the time; weak disease surveillance systems in place (none of these countries had attained the International Health Regulations(2005) core capacity requirements by 2012); inadequate number of laboratories and laboratory services, especially in the rural areas; inefficient reporting systems in all the three countries; and low level of expenditures directed to health services mainly focusing on HIV/AIDS, Tuberculosis, Malaria and maternal health.  

What was different in West Africa? 
The deeply entrenched mistrust of governments by local people, health systems collapsed due to civil war, hospitals void of professionals (Liberia had 51 physicians by 2010, some in administration thus not directly helpful in clinical work) therefore there was a physician for about every 100,000 people. Further, living in denial was a big factor; it was after 3 months that the first diagnosis was accepted as Ebola. Beliefs around disease causations such as witchcraft and suspicion precipitated Ebola and lack of effective response led to the crisis.

According to Regina Bash-Taqi a Sierra Leonean Health Worker, some even highly educated people in West Africa believed Ebola was government propaganda to keep the populace on its tenterhooks. People did not believe in the national health care systems, people believed in being treated from home and believed this time they could equally be attended to from home. 

Further Liberia, Sierra Leone and Guinea are extremely lowly ranked countries as of the 2012 human development index, at number 174, 177 and 178 respectively, out of 185 thus evidence of how brittle they are.  Basic systems were not in place and not ready for response, till months later, there were no mechanisms for patient isolation, contact tracing and community understanding. In Ebola, the incubation period is shorter than the latent period meaning the symptoms start showing before a victim becomes infectious, therefore with contact tracing and community understanding at its best, the virus can be contained.

Dead bodies of Ebola victims are infectious, but several months down the road, communities attended burials prior to March, 2014, in Guinea 60% of cases were linked with traditional burial practices, women wash bodies of dead women and men do the same for dead men, bodies are exposed for viewing thus exposing a whole community to risk. Even recovered victims are infectious since Ebola virus can survive in semen (sperms) for up to 3 months.

Way forward;
Research revealed the first case of this epidemic to have been a two year old toddler in Guinea who died in December 2013. Revealing that Ebola Virus Disease continued undetected for a period of about 3 months, it was only confirmed and reported on 21st March, 2014. It had already spread out far out of Dawa village to Guéckédou Baladou and Farako District to various districts within Guinea. This could probably be attributed to the poor diagnosis and reporting mechanisms that were present at the time, given there were records of prior diagnosis of cholera and suspicions of Lassa fever among some of the cases.

Key actions being taken by the affected countries in a bid to control the epidemic; 
There are community engagements and mobilization using faith based groups as an interface between the community and the national authorities.

Progressive strengthening health facilities especially the rural ones by providing them with qualified staff; 

The government of Liberia is beginning to use Performance Based Financing at county levels which will hopefully, improve the delivery of quality services thereof. A health equity fund has also been established by the government of Liberia to increase coverage and track the use of Ebola related funds.

In Sierra Leone, regional hubs are being developed with the provision of professionals who can act as stop gaps in service delivery and who can help improve quality in health care through onsite training and supervision.

Health System Strengthens measures to avoid a repeat of such an epidemic include; 

In addition to the actions being taken to control this epidemic, measures should be put in place to prevent history from repeating itself. Strategies should be geared towards; 

• Strengthening the disease surveillance systems in all the three affected countries in order to meet the IHR(2005) core capacity requirements;

• Establishing a sufficient number of well-equipped and staffed laboratories especially in the rural areas with core competencies in performing the required laboratory tests;

• Strengthening the reporting systems right from the lowest level of care through VHTs and general community in order to promote accurate and timely reporting to the relevant authorities;

• Harnessing all the financial support presently available through strict and reliable financial management systems in order to strengthen the health system that will go a long way in efficiently detecting and controlling future such outbreaks 

Importantly, there is a need for a holistic behavioral change, championed through trusted based government initiatives to campaign for affirmative response to announcements made by government and not look with suspicion as it was in Sierra Leone. It is also important to study how countries like Uganda, DRC and Nigeria handled their outbreaks and take the best practices. 

Excerpts from Ebola in Context, London School of Hygiene and Tropical Medicine

Sam Agona is a Global Health Fellow 2014 – 2015

Follow him on Twitter @samagona