Ebola epidemic

The most necessary practical information about Ebola is
how it is spread.
The CDC has a web page on that.
As of 2014-09-30, that web page contains the following,
which raises some questions:
Ebola is not spread through the air or by water, or in general, food.
However, in Africa, Ebola may be spread as a result of handling bushmeat (wild animals hunted for food)
and contact with infected bats.
The web page also points out that Ebola is, among other things, a STD.


For general background on the 2014 epidemic, see Wikipedia.
The news reports state that this is the worst outbreak in history.
I am curious as to why this occurred now.
What caused this in 2014, rather than, say, any time earlier?
I have not seen discussion of that, but I have only read a few stories.
But even so, that seems an obvious issue that people would be curious about.
Sort of the "Why?" in the famous "Who? What? When? Where? Why?" quintet.

A question:
How can the current Ebola epidemic be "out of control" in Africa,
but pose no threat at all to the United States?

Anyhow, here are some news articles on the outbreak:

CDC Telebriefing on Ebola outbreak in West Africa
Remarks by Stephen Monroe of the CDC


I want to underscore that Ebola poses little risk to the U.S. general population.
Transmission is through direct contact of bodily fluids of an infected person
or exposure [to] objects like needles
that have been contaminated with infected secretions.
Individuals who are not symptomatic are not contagious.
The mortality rate in some outbreaks can be as high as 90 percent,
but in this outbreak, it is currently around 60 percent,
indicating that some of our early treatment efforts may be having an impact.


While it’s possible that someone could
become infected with the Ebola virus in Africa
and then get on a plane to the United States,
it’s very unlikely that they would be able to spread the disease to fellow passengers.
The Ebola virus spreads through direct contact with
the blood, secretions, or other body fluids of ill people,
and indirect contact –
for example with needles and other things
that may be contaminated with these fluids.
Most people who become infected with Ebola
are those who live with and care for
people who have already caught the disease and are showing symptoms.

Nevertheless, because people do travel between West Africa and the U.S.,
CDC needs to be prepared for the very remote possibility
[Just why is that a "very remote possibility"?
That comment seems literally insane.]

that one of those travelers could get Ebola and return to the U.S. while sick.
We are actively working to educate American healthcare workers about
how to isolate patients and how they can protect themselves from infection.
Today, we are sending out a Health Alert Notice
to remind U.S. healthcare workers of the importance of
taking steps to prevent the spread of this virus.


[Well, I am not a doctor,
but I wonder what can guard against the possibility that
a significant number of people who have been infected with the Ebola virus,
but are not yet showing symptoms of that infection,
will hop on planes and fly to the United States,
then developing the symptoms and starting the spread of the disease
in the United States.
Just how can all these geniuses running the health care system
guard against that possibility?
And, if enough people did that,
could they not effectively overwhelm the U.S.'s defenses against the spread of the disease,
which seem quite man-power intensive in the need to track the contacts
of all those who might have the disease.

It seems to me that Dr. Monroe's "Ebola poses little risk to the U.S." statement
is either ignorant or a bald-faced lie.

For press reporting on this story, click here.]

People are struggling to bury the Ebola dead. Here’s why.
By Abby Ohlheiser
Washington Post, 2014-08-07


in Liberia,
where more than 282 people have died from the disease this year
and widespread reports describe Ebola victims laying on the streets for days,
increasing the risk of infection by others.

To make things even worse,
these logistical issue extend backwards through the Ebola response process,
to those seeking treatment.
Liberia’s capital city of Monrovia has run out of room for its living patients ...

Those treating Ebola victims are especially at risk of infection:
When a Liberian-American government official named Patrick Sawyer
managed to fly to Nigeria with the disease,
which is spread only by direct contact
with the bodily fluids of a symptomatic victim,
several health workers in Lagos fell ill after treating him.
Both Sawyer and one of his nurses have since died of the disease...

But there is a second group of people especially at risk for infection:
those who treat and bury the bodies of the dead,
which are even more contagious than living Ebola patients.

And a combination of inadequate infrastructure, logistical issues,
conflicts with Western health care workers
and burial traditions
has contributed to widespread difficulties in containing
the spread of the disease among mourners and those caring for the dead.

The World Health Organization provides specific guidelines
for how to safely transport and bury Ebola victims.
They include instructions to
“be aware of the [victim's] family’s cultural practices and religious beliefs,”
and to “help the family understand why some practices cannot be done
because they place the family or others at risk for exposure.”

Among the traditional practices the WHO says
cannot be followed with Ebola victims:
family-led body preparation and religious rituals
that require direct contact with the corpse.

Muslim tradition, for instance, requires that
family members of the same gender
should wash the body themselves before burial.

There are religiously driven rules about
who can handle a dead body, and how.
But those rules are often in direct conflict with
the procedures health officials must follow
to minimize the risk that the disease will spread,
because after death is a particularly dangerous time for Ebola infection.

“When the person has just died, that is when the body is most contagious,”
WHO spokesperson Tarik Jasarevic told The Post on Thursday.
“It’s when the virus is overtaking the whole body.”

The problem is compounded because Ebola can force a victim’s body
to release infectious fluids including blood, vomit and diarrhea,
especially in later stages of the disease.
That includes the most visually harrowing symptom of Ebola,
present in some late-stage patients:
bleeding from bodily orifices and rashes covering the skin.

Some Ebola victims are sent for burial straight from a treatment center,
which minimizes improper handling and exposure to family members.
In these cases, as the Red Cross explained,
family members often opt to have the bodies of their loved ones
buried outside of their communities,
in a dedicated space for Ebola victims,
out of fear of infecting others.

But when a victim dies in a community,
and workers must retrieve the body,
the situation is more complicated.
In these cases, the Red Cross follows a procedure
similar to the one recommended by the WHO:
First, the body is repeatedly disinfected.
Then, it’s placed in at least two body bags.
When the burial happens, anything the body touched —
pillows, bedsheets, the protective clothing worn by the workers who prepared it —
are either burned or buried with it.

Despite the prevailing narrative of cultural differences
presenting a dangerous situation on the ground,
Jasarevic, the WHO spokesman, said that his organization believes
the bigger problem [is] that
there simply aren’t enough trained people on the ground in Liberia, Sierra Leone and Guinea
who are capable of dealing with the daily deaths in a proper manner.

“The problem is not so much to explain to people”
why some traditional burial practices are dangerous in the case of an Ebola death,
he said.
Instead, infected areas need teams of trained people “on call, with cars,”
who can respond to reports of Ebola infection or death “on short notice.”

Health officials are working on improving response times,
but as the burial problems in Liberia have shown,
it’s taking too long for trained workers to deal with dead bodies,
leading to increased risk of infection and tension with officials
once they do arrive.

And in many communities, people blame outsiders for the spread of the disease.
People working on the front lines of the outbreak with Doctors Without Borders
have described being physically attacked
while trying to enter communities with reported Ebola cases.
The New York Times reported late last month that
Doctors Without Borders has classified over a dozen villages in Guinea
as infected but inaccessible
because of the group’s hostile reception there.

The WHO’s Jasarevic said international health officials are trying to figure out
how to improve local reporting of suspected Ebola cases and deaths within the community.
“The problem of reporting itself was a problem,
but I think the communities understand now,”
he explained.
In other words: more communities are reporting their dead,
even if the system itself isn’t perfect.

But success rates vary country to country. In Sierra Leone, Jasarevic said, the WHO is identifying and training villagers to report dead bodies and suspected cases to officials — and it’s working relatively well.

“It’s really like organizing surveillance,” he said. Trained reporters are often given mobile phones and “maybe some money” as an incentive to report deaths and suspected cases to authorities, Jasarevic added.

The Red Cross also singled out Sierra Leone as a relative success case. Officials there have created “dead body management” teams, often staffed by paid members of the community, to bury the dead, and the system seems to be improving overall.

But, said Red Cross team leader Daniel James:
“There are still many other communities who do not believe Ebola is real,
and who continue with the local custom of preparing bodies for burial themselves.”

Tracing Ebola’s Breakout to an African 2-Year-Old
New York Times, 2014-08-10

[The article in the NYT has several excellent, informative graphics
in addition to this text.]

Patient Zero in the Ebola outbreak, researchers suspect, was a 2-year-old boy who died on Dec. 6, just a few days after falling ill in a village in Guéckédou, in southeastern Guinea. Bordering Sierra Leone and Liberia, Guéckédou is at the intersection of three nations, where the disease found an easy entry point to the region.

[That seems like a strange way of putting it.
Why should "the intersection of three nations" be "an easy entry point to the region"?]

A week later, it killed the boy’s mother, then his 3-year-old sister, then his grandmother. All had fever, vomiting and diarrhea, but no one knew what had sickened them.

Two mourners at the grandmother’s funeral took the virus home to their village. A health worker carried it to still another, where he died, as did his doctor. They both infected relatives from other towns. By the time Ebola was recognized, in March, dozens of people had died in eight Guinean communities, and suspected cases were popping up in Liberia and Sierra Leone — three of the world’s poorest countries,
recovering from years of political dysfunction and civil war.

In Guéckédou, where it all began, “the feeling was fright,” said Dr. Kalissa N’fansoumane, the hospital director. He had to persuade his employees to come to work.

On March 31, Doctors Without Borders, which has intervened in many Ebola outbreaks, called this one “unprecedented,” and warned that the disease had erupted in so many locations that fighting it would be enormously difficult.

Now, with 1,779 cases, including 961 deaths and a small cluster in Nigeria, the outbreak is out of control and still getting worse. Not only is it the largest ever, but it also seems likely to surpass all two dozen previous known Ebola outbreaks combined. Epidemiologists predict it will take months to control, perhaps many months, and a spokesman for the World Health Organization said thousands more health workers were needed to fight it.

[My question:
Why can't the Africans fight this problem by themselves?
Why do they need outside help?
From what I have read,
the basic steps to control and isolate the disease are quite simple,
but demand discipline, care, and avoiding panic.]

Some experts warn that the outbreak could destabilize governments in the region. It is already causing widespread panic and disruption. On Saturday, Guinea announced that it had closed its borders with Sierra Leone and Liberia in a bid to halt the virus’s spread. Doctors worry that deaths from malaria, dysentery and other diseases could shoot up as Ebola drains resources from weak health systems. Health care workers, already in short supply, have been hit hard by the outbreak: 145 have been infected, and 80 of them have died.

Past Ebola outbreaks have been snuffed out, often within a few months. How, then, did this one spin so far out of control? It is partly a consequence of modernization in Africa, and perhaps a warning that future outbreaks, which are inevitable, will pose tougher challenges. Unlike most previous outbreaks, which occurred in remote, localized spots, this one began in a border region where roads have been improved and people travel a lot. In this case, the disease was on the move before health officials even knew it had struck.

Also, this part of Africa had never seen Ebola before. Health workers did not recognize it and had neither the training nor the equipment to avoid infecting themselves or other patients. Hospitals in the region often lack running water and gloves, and can be fertile ground for epidemics.

Public health experts acknowledge that the initial response, both locally and internationally, was inadequate.

“That’s obviously the case,” said Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention. “Look at what’s happening now.”

He added, “A couple of months ago, there was a false sense of confidence that it was controlled, a stepping back, and then it flared up worse than before.”

Health experts have grown increasingly confident in recent years that they can control Ebola, Dr. Frieden said, based on success in places like Uganda.

But those successes hinged on huge education campaigns
to teach people about the disease
and persuade them to go to treatment centers.

Much work also went into getting people
to change funeral practices that involve touching corpses,
which are highly infectious.

[So much for those multicultural idiots.]

But in West Africa, Ebola was unknown.

In some areas, frightened and angry people have attacked health workers and even accused them of bringing in disease.

“Early on in the outbreak, we had at least 26 villages or little towns that would not cooperate with responders in terms of letting people into the village, even,” said Gregory Hartl, a spokesman for the World Health Organization.

The outbreak has occurred in three waves: The first two were relatively small, and the third, starting about a month ago, was much larger, Mr. Hartl said. “That third wave was a clarion call,” he said.

At a House subcommittee hearing on Thursday, Ken Isaacs, a vice president of Samaritan’s Purse, said his aid group and Doctors Without Borders were doing much of the work on the outbreak.

“That the world would allow two relief agencies to shoulder this burden along with the overwhelmed Ministries of Health in these countries testifies to the lack of serious attention the epidemic was given,” he said.

Guinea’s Monumental Task

In mid-March, Guinea’s Ministry of Health asked Doctors Without Borders for help in Guéckédou.

At first, the group’s experts suspected Lassa fever, a viral disease endemic in West Africa. But this illness was worse. Isolation units were set up, and tests confirmed Ebola.

Like many African cities and towns, this region hums with motorcycle taxis and minivans crammed with passengers.

The mobility, and now the sheer numbers, make the basic work of containing the disease a monumental task. The only way to stop an outbreak is to isolate infected patients, trace all their contacts, isolate the ones who get sick and repeat the process until, finally, there are no more cases.

But how do you do that when there can easily be 500 names on the list of contacts who are supposed to be tracked down and checked for fever every day for 21 days?

“They go to the field to work their crops,” said Monia Sayah, a nurse sent in by Doctors Without Borders. “Some have phones, but the networks don’t always work. Some will say, ‘I’m fine; you don’t have to come,’ but we really have to see them and take their temperature. But if someone wants to lie and take Tylenol, they won’t have a temperature.”

At Donka Hospital in Guinea’s capital, Dr. Simon Mardel, a British emergency physician who has worked in seven previous hemorrhagic fever outbreaks and was sent to Guinea by the World Health Organization, realized this outbreak was the worst he had seen. A man had arrived late one night, panting and with abdominal pain. During the previous few days, he had been treated at two private clinics, given intravenous fluids and sent home. The staff did not suspect Ebola because he had no fever. But fever can diminish at the end stage of the disease.

The treatment room at Donka was poorly lit and had no sink. There were few buckets of chlorine solution, and the staff found it impossible to clean their hands between patients.

The man died two hours after arriving. Tests later showed he had been positive for Ebola. Untold numbers of health care workers and their subsequent patients had been exposed to the disease.

Gloves, in short supply at the hospitals, were selling for 50 cents a pair on the open market, a huge sum for people who often live on less than a dollar a day. At homes where families cared for patients, even plastic buckets to hold water and bleach for washing hands and disinfecting linens were lacking.

Workers were failing to trace all patients’ contacts. The resulting unsuspected cases, appearing at hospitals without standard infection control measures, worsened the spread in a “vicious circle,” Dr. Mardel said.

Tracing an Epidemic’s Origins

As is often the case in Ebola outbreaks, no one knows how the first person got the disease or how the virus found its way to the region. The virus infects monkeys and apes, and some previous epidemics are thought to have begun when someone was exposed to blood while killing or butchering an infected animal. Cooking will destroy the virus, so the risk is not in eating the meat, but in handling it raw. Ebola is also thought to infect fruit bats without harming them, so the same risks apply to butchering bats. Some researchers also think that people might become infected by eating fruit or other uncooked foods contaminated by droppings from infected bats.

Once people become ill, their bodily fluids can infect others, and they become more infectious as the illness progresses. The disease does not spread through the air like the flu; contact with fluids is necessary, usually through the eyes, nose, mouth or cuts in the skin. One drop of blood can harbor millions of viruses, and corpses become like virus bombs.

A research team that studied the Guinea outbreak traced the disease back to the 2-year-old who died in Guéckédou and published a report in The New England Journal of Medicine. He and his relatives were never tested to confirm Ebola, but their symptoms matched it and they fit into a pattern of transmission that included other cases confirmed by blood tests.

But no one can explain how such a small child could have become the first person infected. Contaminated fruit is one possibility. An injection with a contaminated needle is another.
Continue reading the main story Continue reading the main story

Sylvain Baize, part of the team that studied the Guinea outbreak and head of the national reference center for viral hemorrhagic fevers at the Pasteur Institute in Lyon, France, said there might have been an earlier case that went undiscovered, before the 2-year-old.

“We suppose that the first case was infected following contact with bats,” he said. “Maybe, but we are not sure.”

Roaring Back in Liberia

Dr. Fazlul Haque, deputy representative of Unicef in Liberia, said that after a few cases there in March and April, health workers thought the disease had gone away. But it came roaring back about a month later.

“It reappeared, and this time, it came in a very big way,” he said. “The rate of increase is very high now.”

From July 30 to Aug. 6, Liberia’s government reported more than 170 new cases and over 90 deaths.

“Currently, our efforts are not enough to stop the virus,” Dr. Haque said.

He added that most health agencies believed the true case numbers to be far higher, in part because locals were not coming forward when relatives fell ill, and because detection by the health authorities has been weak. Rukshan Ratnam, a spokesman for Unicef in Liberia, said some families had hidden their sick to avoid sending them to isolation wards, or out of shame stemming from traditional beliefs that illness is a punishment for doing something wrong.

Dr. Haque said that the tracing of cases, crucial for the containment of the disease, was moving too slowly to keep up with new infections. Seven counties have confirmed cases, and the government has deployed security forces in Lofa County, where Liberia’s first case was detected, he said. But the government has given leave to nonessential employees in those areas, so it is not clear how they will have the staffing to isolate the sick. Some hospitals have closed because so many health workers have fallen ill.

Liberia has closed markets and many border crossings. It has said testing and screening will be done at immigration checkpoints.

But on Thursday, at a checkpoint staffed by at least 30 soldiers in Klay, Bomi County, there was no screening — just a blockade and a line of trucks loaded with bags of charcoal, plantains and potato greens.

Hilary Wesseh, a truck driver who was sucking the last drops of juice out of a small lime, said he had been stuck there for two days.

“They are holding us hostage,” he said.

A Desperate Call for Help

By June and July, Sierra Leone was becoming the center of the outbreak. At the government hospital in Kenema, Dr. Sheik Umar Khan was leading the efforts to treat patients and control the epidemic.

But he was desperate for supplies: chlorine for disinfection, gloves, goggles, protective suits, rudimentary sugar and salt solutions to fight dehydration and give patients a chance to survive. Early in July, he emailed friends and former medical school classmates in the United States, asking for their help and sending a spreadsheet listing what he needed, and what he had. Many of the lines in the “available” column were empty. One of his requests was for body bags: 3,000 adult, 2,000 child.

Before his friends could send the supplies, Dr. Khan contracted Ebola himself. He died on July 29.

Nigeria Struggles to Cope With Ebola Outbreak
New York Times, 2014-08-11

Ebola, one of the world’s most fatal diseases, has surfaced in Africa’s most populous country.

Nigerian health officials have announced 10 confirmed cases and two deaths in the country from the Ebola outbreak that is sweeping West Africa, including a nurse and a man from Liberia whom the nurse had been caring for.

The man, Patrick Sawyer, a naturalized American citizen, had flown to Nigeria in late July and died soon after. He had infected at least eight other people, including the nurse, who died on Tuesday, officials said.


Newspapers in Liberia and Nigeria were brimming with accounts of the strange tale of Mr. Sawyer’s sickness, which began in Liberia, where the disease is exploding.

According to a report in The National Chronicle, a Liberian newspaper, Mr. Sawyer’s sister, who died of Ebola in early July, had arrived at a hospital bleeding. But when doctors and nurses tried to put her in isolation, the report said, Mr. Sawyer refused to allow it, demanding that she be given a private ward. He undressed her, put her into a wheelchair and offered the hospital workers cash, the paper said.

And in an account in another Liberian newspaper, The New Dawn, which cited footage from a security camera in the airport in Monrovia, Mr. Sawyer behaved strangely as he waited for his flight out of Liberia. He sat alone, avoiding physical contact with people, including an immigration agent who tried to shake his hand, and even lay flat on his stomach on the floor of a corridor of the airport, the paper reported.

The episode prompted the president of Liberia, Ellen Johnson Sirleaf, to publicly apologize to Nigeria about Mr. Sawyer, who she said had sneaked out of Liberia, where he was being tracked as a potential Ebola case, according to The Daily Independent, a Nigerian newspaper.


Liberia: Ebola fears rise as clinic is looted
by Associated Press
Washington Post, 2014-08-18

MONROVIA, Liberia —

Liberian officials fear Ebola could soon spread through the capital’s largest slum after
residents raided a quarantine center for suspected patients
and took items including bloody sheets and mattresses.

The violence in the West Point slum occurred late Saturday
and was led by residents angry that
patients were brought to the holding center from other parts of Monrovia,
Tolbert Nyenswah, assistant health minister, said Sunday.

Up to 30 patients were staying at the center
and many of them fled at the time of the raid, said Nyenswah.
Once they are located they will be transferred
to the Ebola center at Monrovia’s largest hospital, he said.

West Point residents went on a “looting spree,”
stealing items from the clinic that were likely infected,
said a senior police official,
who insisted on anonymity because he was not authorized to brief the press.
The residents took medical equipment and mattresses and sheets
that had bloodstains, he said.
Ebola is spread through bodily fluids including blood, vomit, feces and sweat.

“All between the houses you could see people fleeing with items looted from the patients,”
the official said, adding that
he now feared “the whole of West Point will be infected.”

Some of the looted items were visibly stained with blood, vomit and excrement,
said Richard Kieh, who lives in the area.

The incident creates a new challenge for Liberian health officials
who were already struggling to contain the outbreak.


Patients reported missing after Ebola clinic attacked in Liberia
Elise Zoker and Caroline Chen
theage.com, 2014-08-18

Monrovia: Residents of Liberia's capital have attacked a clinic treating suspected Ebola patients, complicating already strained efforts to contain the spread of the deadly virus.

Initial reports suggest that upto 17 patients disappeared during the upheaval. Patients began to "mingle" with the crowd and some didn't return, Frank Sainworla, who runs Catholic radio station Veritas in Monrovia, said by phone.

The Associated Press reported that bloodied mattresses were stolen by armed men at the centre in the West Point neighbourhood.

"The community residents in West Point went to the isolation centre to get mattresses placed at the newly established Ebola Isolation centre," he said.

One witness said the centre was looted and the patients were "all gone".

The report has been confirmed by residents and the head of Health Workers Association of Liberia, George Williams.

Mr Williams said the unit housed 29 patients who "had all tested positive for Ebola" and were receiving preliminary treatment before being taken to hospital.

"Of the 29 patients, 17 fled last night (after the assault). Nine died four days ago and three others were yesterday (Saturday) taken by force by their relatives" from the centre, he said.

The attackers, mostly young men armed with clubs, shouted that President Ellen Johnson Sirleaf "is broke" and "there's no Ebola" in Liberia as they broke into the unit in a Monrovia suburb, according to reports.

Residents had opposed the creation of the centre, set up by health authorities in part of the city considered an epicentre of the Ebola outbreak in the Liberian capital.

"We told them not to (build) their camp here. They didn't listen to us," said a young resident, who declined to give his name.

"We don't believe in this Ebola outbreak."


Clashes in Liberian slum sealed off to halt spread of Ebola virus
By Jonathan Paye-Layleh, Wade Williams and — Associated Press
Washington Post, 2014-08-21


“We have been unable to control the spread” of Ebola,
[Liberian President President Ellen Johnson Sirleaf] said
in an address to the nation Tuesday night.
She blamed the rising case toll on
denial, defiance of authorities and cultural burial practices,

referring to the way bodies are handled.
But many feel the government has not done enough
to protect them from the spread of Ebola.

Outbreak in Sierra Leone Is Tied to Single Funeral Where 14 Women Were Infected
New York Times, 2014-08-29

Sierra Leone’s explosion of Ebola cases in early summer appears to stem from one traditional healer’s funeral at which 14 women were infected, according to scientists studying the blood of victims.

The funeral, which took place in mid-May, constitutes a “super-spreader” event comparable to one in 2003 in a Hong Kong hotel in which one doctor from China dying of SARS infected nine other guests who spread the virus throughout the city and to Vietnam and Canada.

The funeral was in Koindu, a diamond-mining town across the border from Guéckédou in Guinea, where the outbreak is thought to have begun in December, and the healer was known for treating victims of a mysterious illness that turned out to be Ebola.

The funeral’s central role, which local doctors had anecdotally suspected, was confirmed by geneticists at the Broad Institute of M.I.T. and Harvard who sequenced the virus found in 78 patients treated at Kenema Government Hospital in northeastern Sierra Leone, near the borders with Liberia and Guinea, two countries that are also at the heart of the outbreak.


The scientists not only found that all 78 had virus traceable to funeral guests, but also showed that the West African Ebola strain was quite different from a strain that has been circulating thousands of miles away in Central Africa since 1976, and that the two probably diverged as far back as 2004.


The work had a sobering footnote: Before it could be published, five of its co-authors died of Ebola. They included Dr. Sheik Humarr Khan, Sierra Leone’s leading hemorrhagic fever expert, and four other staff members at the Kenema hospital. By midsummer, so many hospital staff members and patients had died that it was considered a death trap and partly vacated.

...It’s not known why only they became infected. Women normally wash the bodies, “but at a traditional burial, presumably everyone had some interaction with the body,” Dr. Garry said.

(Several scientists, including Dr. Sabeti, complained that many Westerners describe African funeral rites as bizarre, when it is actually routine around the world to wash and dress corpses — though in wealthy countries, undertakers are paid to do it. In many countries, including the United States, it is not uncommon for mourners to touch or kiss a loved one in an open coffin.)

[I've never heard of that, but then maybe I'm in the wrong circles.]



Dozens attended the healer’s funeral, said Robert F. Garry Jr., a Tulane University hemorrhagic fever expert whose teams searched for attendees and persuaded 40 to give samples.

Fourteen — all women — were infected, Dr. Sabeti said, although the DNA in two samples was too degraded to sequence.


Sierra Leone: a traditional healer and a funeral
Ebola at 6 months

The first confirmed case in Sierra Leone was
a young woman who was admitted to a government hospital in Kailahun
following a miscarriage on 24 May, 2014.
A health worker suspected Ebola, given the outbreak in neighbouring Guinea.
She was tested for Ebola on 24 May and placed in isolation on 25 May;
the results were positive.
WHO was notified about the Ebola outbreak in Sierra Leone by the Ministry of Health and Sanitation almost immediately.

Swift action

All the right precautions were taken.
No one else at the hospital, neither patients nor medical staff,
contracted Ebola virus disease.
Fortunately, the young woman made a full recovery.

Tracking of her source of infection pointed to an earlier event and told a very different story.
The vicinity around Kailahun was home to a well-known and widely-respected traditional healer.
Her famous healing powers were also known across the border in Guinea.
As the outbreak in Guinea continued to swell,
desperate patients sought her care.

Predictably, the healer became infected with the Ebola virus and died.
Mourners came by the hundreds, also from other nearby towns,
to honour her memory by participating in the traditional funeral and burial ceremony.
Quick investigations by local health authorities suggested that
participation in that funeral could be linked to
as many as 365 Ebola deaths.

Meanwhile in Guinea,
60% of all cases had been linked to traditional burial practices.

By mid-June, an explosive outbreak was clearly under way in Kailahun,
and the government hospital could no longer cope.
Several nurses working there were quickly infected, and 12 of them died.

Nearby Kenema district became the country’s second major hotspot.
Kenema Government Hospital already had a well-equipped isolation ward –
in fact, the only Lassa fever isolation ward anywhere in the world.
Initially, the country’s Lassa Fever Programme used its contact-tracing staff and skills
to try to contain the outbreak,
but that capacity was rapidly overwhelmed.

The outbreak takes hold

As in Guinea, the virus spread quickly and widely,
with a large proportion of doctors and nurses among the dead –
severely depleting response capacity.
As in Guinea, the virus marched into the capital city, Freetown,
where it took advantage of overcrowded living conditions and fluid population movements
to grow in explosive numbers.

On 29 July, another heart-breaking tragedy struck: the head of the country’s Lassa Fever Programme, Dr Sheik Humarr Khan, a virologist and world-renowned expert on viral haemorrhagic fevers, died of Ebola virus disease at the age of only 39. Sierra Leone – and the international public health community – lost one of its most respected and influential medical giants.

A breakthrough in the scientific understanding of Sierra Leone’s outbreak came on 28 August, when the journal Science published the results of a major surveillance study of Ebola virus genomes, involving 99 complete virus sequences, that traced the start of the outbreak and its further spread. No such massive study had ever been undertaken before.

Understanding the outbreak

The study confirmed the healer’s funeral as a seminal event at the outbreak’s explosive start,
demonstrated that the virus’s genome is changing fairly quickly
and pinpointed 2004 as the year when the virus changed.
The study also demonstrated a pattern of adaptive mutation;
the authors called for an urgent scaling up of control measures –
lest the virus adapt to establish permanent residence in the affected areas.

The study was not, however, designed to determine whether
changes in the virus were linked to either the epidemiology
or the severity of this outbreak.
Nonetheless, understanding of the outbreak now has cutting-edge science on its side;
this can only contribute to response efforts in affected countries.

In yet another human tragedy in this heart-breaking outbreak,
five co-authors of the study,
who contributed greatly to public health and research in Sierra Leone,
contracted Ebola virus disease and died before the paper was published.

The needs today

Today, Sierra Leone’s most urgent needs include opening up more Ebola care facilities –
which means more trained staff to meet a severe shortage.
Controlling the spread of the disease will also require
stronger district surveillance and epidemiology, contact tracing and burial teams.

Oxford study predicts 15 more countries are at risk of Ebola exposure
by Abby Phillip
Washington Post, 2014-09-09

Until this year's epidemic, Ebola did not exist in West Africa. Now with nearly 2,300 people dead from the virus, mostly in Liberia, Guinea and Sierra Leone, scientists still don't fully understand how Ebola arrived from Central Africa, where outbreaks of this strain of the virus had occurred in the past.

A new model by Oxford University, published in the journal eLife, takes a look at the most likely explanation -- that Ebola's animal reservoir, fruit bats, could spread the disease in the animal kingdom and to humans through the dense forest that spans 22 countries.

Several species of fruit bats are suspected -- though not confirmed -- to carry Ebola without showing symptoms. Unlike humans and other animals who are likely to die from an Ebola infection, bats can carry the disease and infect other bats and animals, such as monkeys and rodents through migratory activities.

Bats along with other animals, such as monkeys, are also one form of "bush meat" consumed in some African countries where there have been reports of Ebola outbreaks. And though consuming cooked bush meat is unlikely to spread the virus, hunting or preparing raw meat for consumption increases the likelihood that an infection might occur.

According to the Oxford model, in addition to the seven countries who have reported Ebola outbreaks in this epidemic and in past outbreaks since the disease was identified 1976, 15 other countries are at risk. There are five known strains of Ebola, and the one currently causing the West African outbreak, Zaire, is the most virulent. The other strains, Sudan, Taï Forest and Bundibugyo, have caused contained outbreaks in Ivory Coast, Sudan, and Uganda in the past. And the Reston species has not caused any known outbreaks, according to the World Health Organization.

According to the Oxford prediction, these countries are at risk of animal-to-human transmission of Ebola by virtue of their geography: Nigeria, Cameroon, Central African Republic, Ghana, Liberia, Sierra Leone, Angola, Togo, United Republic of Tanzania, Ethiopia, Mozambique, Burundi, Equatorial Guinea, Madagascar and Malawi.

"Our map shows the likely ‘reservoir’ of Ebola virus in animal populations, and this is larger than has been previously appreciated," said the study's author Nick Golding, a researcher at Oxford University’s Department of Zoology. "This does not mean that transmission to humans is inevitable in these areas; only that all the environmental and epidemiological conditions suitable for an outbreak occur there.’"

Red Cross team attacked while burying dead Ebola victims
by Boubacar Diallo and Sarah Dilorenzo (AP)
Fox News, 2014-09-24


There are deeply held beliefs about
how dead bodies should be treated and buried in the region
and teams that are forced to interfere with those practices
are often targeted,
said the Red Cross spokesman, [Benoit] Carpentier.
Much of the resistance is in remote, insular areas,
where attitudes change slowly —
a difficult task even on issues that aren't so sensitive as burials.

"You need to reach almost one person by one person,
so they all understand and there's not one person who doesn't believe
and they drag the entire village around by spreading wrong messages,"
he said.

[Normally, just one person cannot sway an entire region,
cannot "drag [an] entire village around",
unless the villagers are predisposed to believe that person's "wrong message".

It seems truly remarkable that the people described in such reports
seem to be having so much difficulty understanding
how to minimize the possibility of
Ebola being transmitted from those who have it to those who don't.
E.g., that their "traditional burial practices" in fact
maximize the transmission of the virus.]


Ebola: Five ways the CDC got it wrong
By Elizabeth Cohen
CNN.com, 2014-10-13

Denial and Disconnect Add to Toll of Ebola in Sierra Leone
New York Times, 2014-10-17

WATERLOO, Sierra Leone —

At first, the chief said nobody was sick in his community.
Then he said that if anybody was sick it was because of witchcraft.
Then he acknowledged that health workers were removing
several suspected Ebola patients every day.
In fact 15 corpses had been taken in less than a week from the community,
but the chief did not admit that.

Persistent denial has been harmful to the fight against the virus.
It stretches from the village to the state house,
and it echoes into the circles of some of the international agencies
now thick on the ground in Sierra Leone
and the other Ebola-afflicted nations in West Africa.

That tendency to minimize the damage being caused by the disease —
the hardship and death it is inflicting —
has been perceptible since the outbreak was first discovered in March.
But the denial’s effect is to prolong the suffering.

There is a disconnect between what is happening on the ground,
inside houses, hospital wards and the grim holding centers
where children, women and men are painfully dying of Ebola,
and much of the official response.


One of the most contentious examples of the disconnect in Sierra Leone is the death statistics reported by the government. Nobody except the health ministry here thinks that they bear much relation to reality. But if the number of victims is sharply undercounted, how can the response be adequate?

Some days, no Ebola deaths are reported for the whole country. On other days, five or so are registered. And then, suddenly, there will be 100 or so deaths reported.

Meanwhile, a visit to a single holding center can easily turn up a half-dozen or more deaths in one night. These places are simply death traps for many Ebola patients unable to find a scarce hospital bed. At the main cemetery in Freetown, the capital, the burial-workers’ daily haul runs to 15 or more.

“We know they are undercounting,” said one leading international health official in Freetown. “We don’t know by what factor,” he said. Yet the World Health Organization continues to rely on the government’s statistics.

A former top official, Sylvia Olayinka Blyden, who left the government two weeks ago, was more blunt in a recent online post, calling the health ministry’s statistics “dishonest, deceitful” and “shameful.” The ministry “continues to make a FOOL of the Government with ridiculous numbers being announced,” wrote Ms. Blyden, until recently one of President Ernest Bai Koroma’s top advisers.

Doctors Without Borders Hits Ebola Breaking Point
by Abby Haglage and Kent Sepkowitz
The Daily Beast, 2014-10-21

Contact tracing—tracking down an Ebola patient’s immediate circle—is doable in the West. But in West Africa, with limited transportation, fuel, and health workers, it’s daunting.

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