Monday, September 08, 2014

WHO: Liberia, Ebola Cases Increasing `Exponentially’


# 9055

On top of the news that a WHO doctor in Sierra Leone has contracted the virus , we’ve a somber assessment in today’s Situation Report from the World Health Organization , one that warns that `thousands’ of new cases are expected in Liberia alone over the next three weeks.

Ebola situation in Liberia: non-conventional interventions needed

Situation assessment - 8 September 2014

During the past weeks, a WHO team of emergency experts worked together with President Ellen Johnson Sirleaf and members of her government to assess the Ebola situation in Liberia.

Transmission of the Ebola virus in Liberia is already intense and the number of new cases is increasing exponentially.

The investigative team worked alongside staff from the Ministry of Health, local health officials, and other key partners working in the country.

All agreed that the demands of the Ebola outbreak have completely outstripped the government’s and partners’ capacity to respond. Fourteen of Liberia’s 15 counties have now reported confirmed cases.

Some 152 health care workers have been infected and 79 have died. When the outbreak began, Liberia had only 1 doctor to treat nearly 100,000 people in a total population of 4.4 million people. Every infection or death of a doctor or nurse depletes response capacity significantly.

Liberia, together with the other hard-hit countries, namely Guinea and Sierra Leone, is experiencing a phenomenon never before seen in any previous Ebola outbreak. As soon as a new Ebola treatment facility is opened, it immediately fills to overflowing with patients, pointing to a large but previously invisible caseload.

Of all Ebola-affected countries, Liberia has the highest cumulative number of reported cases and deaths, amounting, on 8 September, to nearly two thousand cases and more than one thousand deaths. The case-fatality rate, at 58%, is also among the highest.

Situation in Montserrado county

The WHO investigation concentrated on Montserrado county, which includes Liberia’s capital, Monrovia. The county is home to more than one million people. The teeming West Point slum, which has no sanitation, little running water, and virtually no electrical supplies, is also located in Monrovia, and is adjacent to the city’s major market district.

In Montserrado county, the team estimated that 1000 beds are urgently needed for the treatment of currently infected Ebola patients. At present only 240 beds are available, with an additional 260 beds either planned or in the process of being put in place. These estimates mean that only half of the urgent and immediate capacity needs could be met within the next few weeks and months.

The number of new cases is moving far faster than the capacity to manage them in Ebola-specific treatment centres.

For example, an Ebola treatment facility, hastily improvised by WHO for the Ministry of Health, was recently set up to manage 30 patients but had more than 70 patients as soon as it opened.

WHO estimates that 200 to 250 medical staff are needed to safely manage an Ebola treatment facility with 70 beds.

The investigation team viewed conditions in general-purpose health facilities as well as Ebola-specific transit and treatment facilities.

The John F Kennedy Medical Center in Monrovia, which was largely destroyed during Liberia’s civil war, remains the country’s only academic referral hospital. The hospital is plagued by electrical fires and floods, and several medical staff were infected there and died, depleting the hospital’s limited workforce further.

The fact that early symptoms of Ebola virus disease mimic those of many other common infectious diseases increases the likelihood that Ebola patients will be treated in the same ward as patients suffering from other infections, putting cases and medical staff alike at very high risk of exposure.

In Monrovia, taxis filled with entire families, of whom some members are thought to be infected with the Ebola virus, crisscross the city, searching for a treatment bed. There are none. As WHO staff in Liberia confirm, no free beds for Ebola treatment exist anywhere in the country.

According to a WHO staff member who has been in Liberia for the past several weeks, motorbike-taxis and regular taxis are a hot source of potential Ebola virus transmission, as these vehicles are not disinfected at all, much less before new passengers are taken on board.

When patients are turned away at Ebola treatment centres, they have no choice but to return to their communities and homes, where they inevitably infect others, perpetuating constantly higher flare-ups in the number of cases.

Other urgent needs include finding shelters for orphans and helping recovered patients who have been rejected by their families or neighbours.

Last week, WHO sent 1 of its most experienced emergency managers to head the WHO office in Monrovia. Coordination among key partners is rapidly improving, aiming for a better match between resources and rapidly escalating needs.

Implications of the investigation

The investigation in Liberia yields 3 important conclusions that need to shape the Ebola response in high-transmission countries.

First, conventional Ebola control interventions are not having an adequate impact in Liberia, though they appear to be working elsewhere in areas of limited transmission, most notably in Nigeria, Senegal, and the Democratic Republic of Congo.

Second, far greater community engagement is the cornerstone of a more effective response. Where communities take charge, especially in rural areas, and put in place their own solutions and protective measures, Ebola transmission has slowed considerably.

Third, key development partners who are supporting the response in Liberia and elsewhere need to prepare to scale up their current efforts by three- to four-fold.

As WHO Director-General Dr Margaret Chan told agencies and officials last week in New York City and Washington, DC, development partners need to prepare for an “exponential increase” in Ebola cases in countries currently experiencing intense virus transmission.

Many thousands of new cases are expected in Liberia over the coming 3 weeks.

WHO and its Director-General will continue to advocate for more Ebola treatment beds in Liberia and elsewhere, and will hold the world accountable for responding to this dire emergency with its unprecedented dimensions of human suffering.


Don said...

"Many thousands of new cases are expected in Liberia over the coming 3 weeks." This alarming statement was buried at the end of the article but it sounds almost apocalyptic. At this rate of accelerating spread, won't this mean hundreds of thousands of new cases appearing by the end of the year? And what does this mean for the rest of the world?

Michael Coston said...


I've seen estimates of anywhere between 20K and 100K Ebola cases by the end of year.

Since we don't know how many people are infected now, it is hard to know what the situation will look like in 4 months time.

But either outcome would represent a terrible human tragedy.

The math is pretty simple.

The more cases in Africa, the greater the chances we have of seeing the virus exported to other countries. Many far less able to deal with cases than the US, Canada, or Europe.

And while it is hard to predict the global public health and economic impacts of that, it is to our collective advantage to stop this virus before that happens.

Don said...

And since Ebola can be carried and transmitted by those not yet showing symptoms, it will be difficult if not impossible to contain it through airport surveillance measures, for example. It seems almost inevitable that with ever increasing numbers of people becoming infected, that it will make its way to megalopolises like Mumbai, Hong Kong, Mexico City, and Sao Paulo with disastrous effects.

It is not clear, to me at least, how this can be prevented. Stop it? I certainly hope so but that ship may have already sailed.

Michael Coston said...


It can certainly be carried asymptomatically, but the CDC & WHO both state you must be symptomatic in order to transmit the virus.

Don said...

I was basing my statement on an article in the New York Times that was reporting on an article in Lancet. From the NYT article,

"Scientists have known that Ebola usually spreads from an infected person to another individual and through contamination in clinics or hospitals. The new finding suggests that some cases may result from healthy carriers. How often is unknown. The finding could help scientists in their long-term quest to develop effective therapies to treat the virus or perhaps even a vaccine to prevent infection.

"But an immediate effect is to raise the need to reassess health policy about one of the most virulent viruses known and to determine how often healthy carriers transmit it, said the scientific team headed by Dr. E. M. Leroy of Franceville, Gabon.

"One concern is transmitting Ebola through blood transfusions. Dr. Thomas G. Ksiazek, an expert in Ebola at the Centers for Disease Control and Prevention, a federal agency in Atlanta, said that such concern would be much greater in Africa than in the United States, where blood banks usually ask people who have been in Africa in recent months not to donate because of the threat of transmitting malaria.

"Dr. Leroy's team said another public health concern was transmission of Ebola virus from healthy carriers through sex. Other scientists have detected Ebola in semen."

But also, asymptomatic carriers pose a huge threat, as they can escape detection at airports and borders only to become symptomatic once they arrive at their destinations. And as the number of cases in a place like Liberia fans the flames of panic, the motivation to flee the country will be very strong. Is containment a realistic expectation in the scenario where there are a hundred thousand sick and dying people and almost no hospital beds or medical personnel to care for them?

I know that this sounds like fear-mongering but I don't think my concerns are unrealistic and if the general public is not made aware of the urgency and seriousness of the world-wide nature of this threat, how else will we get the money and public support needed to stop the spread of this disease - if that is even possible at this point?

Don said...

Question for you: To the best of your knowledge, has the virus ever been isolated in the sweat of an asymptomatic individual?

Michael Coston said...


Not to my knowledge.

The best overview of the detection of Ebola in bodily fluids I know of was by Dr. Ian Mackay in his VDU blog Ebola: Blood, Sweat & Tears