Since December 2013, when the first Ebola Virus Disease (EVD) case is believed to have occurred in Guinea, the West African countries of Guinea, Liberia, and Sierra Leone have struggled with the region’s first known EVD outbreak. After identifying the outbreak in March 2014, the situation improved during April, when disease activity was contained in Liberia and transmission declined dramatically in Guinea. However, persistent transmission in rural southeast Guinea in May led to the first sustained transmission in Sierra Leone and a second outbreak in Liberia. Since that time, cases have steadily risen – particularly in Liberia – and have spread to two nearby nations – Nigeria and Senegal – despite attempted containment measures at international borders and points of entry. Traveler and consumer confidence has greatly diminished in West Africa. As affected governments and international health agencies struggle to contain the EVD outbreak, the continent faces the threat of a declining tourism industry and loss in its appeal as a rich venue of emerging markets.
Although the risk of actually contracting EVD remains extremely low for most travelers and expatriates, serious ancillary risks have created significant travel and business disruptions -particularly in Guinea, Liberia, and Sierra Leone – for which many nations now recommend against nonessential travel. Other concerned African countries have taken additional measures to attempt to prevent importation of the disease by refusing entry to any traveler who has been in countries experiencing EVD outbreak within the previous 21 days.
Specific concerns are two-fold. The first concern is the rapidly increasing number of cases, which appear to be undeterred by extensive attempts at control measures (e.g., intense world health response; quarantine and isolation of confirmed patients, suspected cases, and contacts of those confirmed and suspected cases; treatment of the infected; intense screening activity at borders and points of entry/exit; application of experimental treatments; etc.), coupled with the continued circulation of rumors among local populations that medical practitioners are actually seeking to harm those at risk or infected, causing the sick to hide, flee, or even riot in some cases, thereby spreading the disease – potentially across borders. The second concern is that the operational and travel threat matrix in West Africa has increased exponentially, as those operating in the region may encounter border closures, strict security and health screenings when attempting to cross borders, a lack of goods and services as personnel – especially healthcare professionals – vacate for what they believe are “safer” areas, and the potential for quarantine. Additionally, many global and regional commercial air carriers have begun to suspend travel to the most affected areas. Recent guidelines provided by global health authorities and international partners, as well as nations who have implemented internal EVD protocols, have eased medical evacuations some, but air carrier service for providers, as well as intensive permissions necessary for transporting patients, are still a hindrance in many areas.
SummaryWest Africa EVD Outbreak
As of Sept. 5, international authorities have reported at least 3,970 EVD cases and more than 2,030 EVD deaths in West Africa. These include 823 EVD cases and 522 deaths in Guinea, including 621 confirmed cases; 1,839 EVD cases and 1,051 EVD deaths in Liberia, including 606 confirmed cases; 1,292 EVD cases and 452 EVD deaths in Sierra Leone, including 1,174 confirmed cases; 21 EVD cases and seven deaths in Nigeria, including 16 confirmed cases; and one confirmed case in Dakar, Senegal. As these figures demonstrate, the focus of EVD activity has shifted to Liberia and Sierra Leone since May, and persistent disease activity has finally led to the international exportation of infections to additional countries.
Whereas disease activity during the first wave of the outbreak March-May was centered in rural areas of southeast Guinea and northwest Liberia – with a significant focus in the city of Conakry with epidemiological links to southeast Guinea – disease activity has now shifted to include significant urban centers such as Freetown, Sierra Leone and Monrovia, Liberia, where quarantine facilities and treatment centers have been erected to render management options to a growing number of cases. Additionally, the Nigerian foci in Lagos and Port Harcourt – both populous centers of business – via the travel of infected individuals highlight the enormous challenges to the tracing of all contacts of potentially infected individuals and the prolonged isolation of potentially exposed individuals to prevent further spread of disease. In some locations, armed military escorts have been called upon to accompany the transport of high-risk patients to quarantine centers and to ensure the safety of healthcare personnel at these locations.
Media have reported significant numbers of healthcare workers abandoning their posts due to EVD concerns. For example, nurses at JFK Hospital in Monrovia called a strike Sept. 3 over lack of appropriate personal protective equipment (PPE). Although the Nigerian Ministry of Health was able to end the long-standing physician strike in Nigeria in an effort to address staffing needs in the wake of hundreds of isolated patient contacts and other clinical requirements, Guinea, Liberia, and Sierra Leone have not been as fortunate. The infection of several prominent physicians volunteering with aid organizations in the course of this crisis – as well as multiple local national doctors, nurses, and ancillary staff – has led to several violent incidents targeting local government offices and hospitals treating EVD patients. Increased security has been provided to facilities and towns to discourage protests and mass gatherings, which can also facilitate disease spread, and governmental and non-governmental officials have promised increased protection through more personal protective equipment (PPE) and cleansing materials. However, after a UN staff member contracted EVD and necessitated medical evacuation to Germany, the WHO removed more than 60 staff members from Sierra Leone, which has hampered efforts there to accurately diagnose and adequately treat the disease. Many aid organizations are calling for global assistance from any provider with expertise in infectious disease processes and handling special virus samples, as fatigued crews and staff shortages not only underserve the afflicted but create room for error while working and may be partially a cause of the heightened rate of healthcare worker infections, despite careful protocols.
The shortages are not only affecting healthcare workers. Shortages of food and clean water are increasing dangerously due to a number of secondary economic effects: businesses closing due to the outbreak or the repatriation of expatriate workers, farmers being unable to tend to their crops, and cargo vessels refusing to dock at ports where the virus may be present. Disease control efforts at international borders further restrict the delivery of food and other products. Economic recovery in Guinea, Liberia, and Sierra Leone may be slow, even when EVD is finally controlled – which experts have projected to take at least six to nine months.
These infections have also prompted several foreign missions, including the US Peace Corps, to suspend operations in Guinea, Liberia, and Sierra Leone and to repatriate personnel operating in the region. Other organizations, such as mining, extraction, and financial organizations, have reduced staff to essential personnel or have vacated entirely. Nigeria may be able to cope better due to its more fully established infrastructure and more coordinated response efforts, but international authorities have expressed concern that the cluster of EVD cases in Port Harcourt could surge following that index patient’s many contacts with coworkers, friends, and family members. So far, few nations have recommended against travel to Nigeria. However, media have reported that some hospitals in Lagos are rejecting patients with non-EVD-related complaints due to fears that healthcare personnel may be unknowingly exposed to EVD.
Analysis
In both scope and scale, this outbreak has become the largest recorded EVD outbreak in history. Previous EVD outbreaks largely occurred in extremely remote areas that prevented the geographic spread of disease activity. However, this outbreak has affected nearly the entirety of three neighboring countries, including significant areas of urban and peri-urban transmission. Prior to this outbreak, the largest known Ebola epidemic occurred in Uganda in 2000, when officials reported 425 confirmed, probable, or suspected cases. In this epidemic, though, officials have identified nearly 4,000 suspected, probable, and confirmed EVD cases, and some experts anticipate up to 20,000 cases before the end of the outbreak.
One of the primary explanations for the severity of EVD activity in Guinea, Liberia, and Sierra Leone relates to widespread community resistance to disease control measures. This outbreak is the first known incidence of EVD activity in West Africa, and – unlike populations living in countries such as Uganda or the DRC – communities in Guinea, Sierra Leone, and Liberia were largely unfamiliar with the measures necessary to control this disease. Even after more than six months of disease activity and response efforts, local populations remain suspicious of authorities. In at least one instance, a community rioted when officials sprayed disinfectant, because local residents believed that they were being sprayed with the disease and intentionally infected. Although many teams are making headway with cultural relations and communications, it is generally accepted that more connection is needed for wider messaging. Recently, the government of Uganda and the African Union had both pledged assistance in durable goods, personnel, and financing to aid in control measures. As Uganda has vast experience in EVD outbreaks, this may assist quite a bit in cultural sensitivity and processing.
Many communities are also deeply distrusting of international medical teams. In some cases, local communities blame these teams for bringing the disease into their country; at other times, communities merely believe that infected individuals will receive better care at home. In either case, media have reported many instances in which community members have forcibly removed confirmed or probable EVD patients from isolation, or patients have eloped quarantine to return home. For example, the EVD cluster in Lagos, Nigeria was caused by an EVD-infected traveler, who may have been seeking more advanced medical care outside Liberia, according to his wife. Furthermore, the EVD cluster in Port Harcourt, Nigeria was caused by a companion of that traveler, who fled quarantine in Lagos to seek care elsewhere.
Unrelated to the cases in West Africa, the Democratic Republic of the Congo (DRC) notified the WHO of a confirmed case of EVD on Aug. 26. In the midst of a hemorrhagic gastroenteritis outbreak not caused by EVD in or near the Equateur Province, the Ministry of Health was able to delineate that a separate strain of EVD had, in fact, occurred in a woman from Ikanamongo Village near Boende and spread to family members and healthcare workers who were caring for her. In total, 58 suspected and confirmed cases and 31 deaths from EVD have been reported as of Sept. 4. Experts from the DRC and WHO have isolated the area, and other expert aid partners have been called to manage the outbreak, which so far appears confined to that specific area.
With disease projections continuing to increase in Guinea, Liberia, and Sierra Leone, the risk profile for most travelers and expatriates remains unchanged: individuals should strongly consider deferring nonessential travel to these areas. The risk of EVD is highest for healthcare workers, family members caring for ill patients, those attending traditional funerals or burials, and the consumption or proximity to processing primate or bat bushmeat, which has since been ruled illegal in the affected areas. However, even individuals not involved in such activities – for whom EVD risk is low – are at risk of increasingly severe healthcare shortages and increasing potential for civil unrest in disease-affected areas. Furthermore, individuals requiring medical evacuation, even for non-EVD-related issues, face extreme challenges when leaving outbreak zones.
Disease response efforts continue in Lagos and River State, Nigeria. Impacts to travelers or expatriates in these areas should be nominal, and the risk of spread outside of these areas is generally low to moderate given the current climate. The one case identified in Dakar, Senegal, with multiple contacts under surveillance, should not pose any significant risk to travelers or expatriates. However, the general reaction of other countries to nations having had EVD has so far been significant. The WHO has still not instituted any travel or trade restrictions on any of the affected countries, but many countries have implemented enhanced health screenings at borders or international airports and restricted flights or border crossings from affected countries. Individuals and organizations should review risk tolerance levels in anticipation of sudden changes in security and travel impact. Furthermore, individuals in or near EVD-affected areas should practice diligent personal health precautions, keeping in mind the following EVD-specific information:
| Although EVD is considered “highly contagious,” it is not highly transmissible. The risk of transmission among people not involved in healthcare or funeral settings is small.Local hospitals in the three most affected areas are at overcapacity, and personnel operating in the area and requiring nonemergency care may consider soliciting provider care at a hotel in lieu of a clinic. Many times, intravenous fluids, respiratory therapy, and other types of care can be administered by healthcare professionals in quality hotels. However, durable medical equipment, fluids, and medications are in short supply. Healthcare workers currently operating in the area are most at risk, since EVD is passed through blood, organs, tissues, bodily fluids, and close personal contact with infected individuals. Occupations with personnel at risk of trauma need to consider their proximity to appropriate care facilities and the possibility of exposure to EVD or other diseases while being treated. Managers charged with site safety and health should be able to recognize the signs of EVD and other hemorrhagic fevers: headache behind the eyes, flu-like symptoms, high fevers, diarrhea, and petechiae – a red or purple “rash” that may appear under areas with pressure. Bleeding, which may only be a late symptom in EVD and also appears in a number of other infections, cannot be relied upon for identification. Frequent and thorough hand-washing with soap and water may reduce the incidence of disease. If soap and water is unavailable, use of a hand sanitizer with at least 60-percent alcohol is an adequate substitution.Do not consume “bushmeat” or the meat from any primate, rodent, dog, or bat in the affected areas. Social distancing and avoidance of crowded venues may reduce risk of disease transmission, and in some areas, it is now mandated. Be aware of increasing travel disruptions related to this outbreak Plan ahead for increased processing times at borders and international airports as countries implement health screenings of travelers from affected areas. Consider deferring nonessential travel to Guinea, Liberia, and Sierra Leone due to infrastructure difficulties and significant travel and medical evacuation restrictions. Be very aware of recent updates in travel restrictions and take these into your risk threshold matrix. Consider the potential supply chain difficulty as borders become restricted, inspections become more thorough, and transit times become more cumbersome. Some goods and services may take longer than others to arrive. Check with your insurance provider and assistance/response company prior to your departure to understand your level(s) of service, their policies and protocols, and their threshold for rapid decision making. Maintain contact with these partners during your trip and keep abreast of the current information for your decision making. |
Bear in mind that some restrictions may not apply only to Guinea, Liberia, and Sierra Leone. Some West African nations may be seen as “at risk” and treated with similar precautions of screening by other nations upon arrival. Certain facilities and laboratories throughout the world have been designated by their respective countries to receive and isolate any “suspected” EVD cases upon screening at points of entry. Special guidance and precautions have been sent out through many health ministries regarding the signs and symptoms of the disease, as well as the potential areas of exposures. There are a various other diseases that may mimic the initial phases of EVD. Fever, headache, nausea, vomiting, aches, and fatigue are seen in a plethora of West African ailments, including malaria, dengue, influenza, and others. Taking appropriate precautions against these diseases will lessen your chance of being identified and potentially quarantined by health personnel when entering or exiting a country.
There currently remain no definitive preventive vaccines or treatment options for EVD. Although recent research and efforts into several unique pharmaceuticals have shown promise in nonhuman primates and have been used experimentally during this crisis, it remains to be seen whether or not these are effective or safe treatments or preventive measures. Data from the field during an epidemic – which lacks supporting data or controls – is extremely difficult to assess. Numerous variables may account for the apparent success or failure of such an agent in any given individual. For example, the administration and subsequent recovery of two American patients from EVD after receiving one such medication may be due to the effectiveness of the medicine, may be coincidental, or may also be dependent on other factors. Likewise, the death of a Spanish missionary after receiving the same experimental treatment may or may not be indicative of that drug’s efficacy. Conclusions as to the effectiveness of these drugs are extremely premature at this juncture.
Originally published on Wednesday, October 29, 2014
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