Infectious Disease
Progress Seen in Ebola Epidemic
Published: Nov 23, 2014
The response to the Ebola outbreak in Liberia is showing encouraging signs of progress, with downward trends in new cases especially in two regions of the country that had been hot spots, the CDC reported.
Three reports online in Morbidity and Mortality Weekly Report document the changing face of the epidemic in Liberia overall and apparent progress in the regions of Lofa and Montserrado.
But it's too early to say if the trends will be sustained, according to CDC Director Tom Frieden, MD.
"The recent decrease in cases suggested by these reports shows how important it is to continue to intensify our Ebola response," Frieden said in a statement.
"We have to keep our guard up," Frieden said, noting that in neighboring Guinea, where the outbreak began last December, cases have "increased and decreased in waves."
"We can't stop until we stop the last chain of transmission," he said.
The latest official numbers for the epidemic, from the World Health Organization, suggest a global total of more than 15,000 cases and 5,400 deaths in the six affected countries.
Nearly all have been in the three countries where transmission is intense -- Liberia, Guinea, and Sierra Leone.
Liberia is the hardest hit, with 6,878 cases and 2,812 deaths, but the WHO began reporting an apparent slowdown in Lofa in early October.
And aid organizations in Monrovia, the country's capital, have also been reporting fewer cases. Monrovia, with a population of about a million people, makes up most of the region of Montserrado.
Those reports appear to be based on reality, the CDC reports argue.
In Lofa, according to data from June 8 to Nov. 1, the weekly number of new cases rose from 12 in that first week to 153 in the week ending Aug. 16, and have since declined to four reported cases in the week ending Nov. 1, the CDC said in one of the three reports on Liberia.
The Liberian outbreak began in Lofa with a case imported from Guinea in March. But weekly admissions to the county's Ebola treatment unit peaked at 133 in the week ending Aug. 16 and fell to just one in the week ending Nov. 1.
In Montserrado, a second report says, data for June 13 through Nov. 1 indicate a similar pattern, with a peak of 255 cases in the week ending Sept. 29 and falling to about 70 a week by Nov. 1.
Half of Liberia's cases have been in Montserrado, but since mid-September admissions to Ebola treatment units have fallen 73%, blood samples positive for Ebola have dropped 58%, and there has been a 53% decline in body collections.
Expansion of the treatment centers, as well as safe burials and public education appear to have played important roles in the improvement, the CDC said.
On the other hand, the agency cautioned, transmission continues in both regions, so the trends could change quickly.
In an overview report, the CDC paints a picture of Liberia's evolving epidemic that also has some important red flags -- transmission continues everywhere in the country and more and more clusters are being seen in hard-to-reach outlying regions.
But it also documents some promising increases in capacity:
- By Nov. 8, the country had 697 beds available in nine Ebola treatment units. The WHO target is 2,732.
- By Oct. 5, there were 54 safe burial teams trained and equipped, up from fewer than 10 in August. The WHO is aiming for 220 teams.
- The number of specimens tested for Ebola in June and July was less than 50 a week but the number peaked at about 700 a week in September and early October, owing to increased lab capacity. Across the region, the WHO said all districts have access to labs within 24 hours, meeting its target.
An important element in the West African epidemic has been its impact on healthcare workers in an already fragile system, the CDC said in a separate report.
Indeed, even outside West Africa, healthcare workers are most at risk: of the five cases diagnosed elsewhere, four occurred among healthcare workers -- a nurse treating Ebola patients in Spain, two nurses treating a man in Dallas (who later died), and an American doctor who treated patients in Guinea.
The WHO said it now has reports of 570 cases and 324 deaths among healthcare workers. The CDC report looked at cases in Liberia up to Aug. 14, by which time the country had a total of 810 cases of Ebola.
They included 97 healthcare workers, of whom 62 were working in facilities -- mainly hospitals -- that were not Ebola treatment units.
Analysis of the cases, which fell into 10 distinct clusters, suggested some common themes that led to exposure and infection, the CDC said:
- Inconsistent recognition and triage of Ebola patients
- Overcrowding
- Limitations in physical layout of hospitals
- Shortages of personal protective equipment, as well as lack of training in how to use it
- Limited supervision of and adherence to infection control
The most common victims of infection were nurses and nurses' aides, with doctors, lab techs, and physician assistants following, the CDC said.
Immediate consequences included closing of health facilities, the loss of routine health services, grief and fear among the workers, and public mistrust of both workers and hospitals.
But in the long run, the agency said, the deaths will undermine the healthcare system and healthcare education.
Both the short- and long-term ramifications are "likely to result in increased non-Ebola morbidity and mortality," the CDC report argued.
Closer to home, the death from Ebola of a Sierra Leone surgeon in a U.S. hospital is another reminder that early treatment is vital for successful care, doctors said.
Martin Salia, MD, died early Nov. 17 after arriving at the hospital late in the afternoon of Nov. 15, according to Philip Smith, MD, of the University of Nebraska Medical Center in Omaha where two other Ebola patients have undergone successful treatment. Smith is the medical director of the biocontainment unit.
"In the very advanced stages, even the most modern techniques we have at our disposal are not enough to help these patients once they reach a critical threshold," said Jeffrey Gold, MD, chancellor of the medical center.
Salia is the third patient with Ebola treated at Nebraska and the first to die there. He arrived at the institution on day 13 of his illness, compared with days six and eight for the two survivors.
The only other Ebola patient to die in the U.S. was Liberian native Thomas Eric Duncan, who was diagnosed in Dallas several days after his symptoms began.
Smith told reporters that when Salia arrived, he was in "very critical condition" after a long flight from Sierra Leone. Doctors and nurses worked "literally around the clock trying to reverse his condition but were unable to do so," Smith said.
Salia's deterioration was rapid, according to Daniel Johnson, MD, chief of critical care anesthesiology at the hospital
On arrival, "he had no kidney function, he was working extremely hard to breathe, and he was unresponsive," Johnson said.
Doctors had him on continuous dialysis within a few hours, but his breathing difficulty progressed within 12 hours to complete respiratory failure, requiring intubation and mechanical ventilation.
"Shortly thereafter, he developed severely low blood pressure and required multiple agents at very high doses to maintain even a marginal blood pressure," Johnson said. "He progressed to the point of cardiac arrest and we weren't able to get him through this."
Salia died despite receiving a transfusion of plasma from an unidentified survivor of the virus and a course of Zmapp, an investigational cocktail of Ebola antibodies, according to Chris Kratochvil, MD, the medical center's associate vice chancellor for clinical research.
Both interventions were made Saturday shortly after Salia arrived, Kratochvil said.
The use of Zmapp in Ebola survivors Kent Brantly, MD, and Nancy Writepol was reportedly associated with a short-term improvement in symptoms.
But Kratochvil could say only that the drug was well tolerated by Salia. Because he was so ill, "it's difficult to assess whether there was a significant clinical change or not," he told MedPage Today.
Salia, a U.S. resident, was working as a general surgeon at Kissy United Methodist Hospital in the Sierra Leone capital of Freetown but, according to Smith, was not treating Ebola patients.
"Even though he did not work in a specific Ebola hospital, he worked in an area where there was a lot of Ebola disease, much of it probably unrecognized, and there were many opportunities for him to have contracted it," Smith said.
Meanwhile, the CDC said it has added the West African nation of Mali to the list of Ebola-affected countries for which there are enhanced screening procedures in place for travelers to the U.S.
While there are no direct flights from Mali to the U.S., between 15 and 20 travelers a day -- mainly U.S. citizens and residents -- have itineraries that start there, the CDC said in a statement.
Health officials in Mali are scrambling to contain a cluster of Ebola cases that have developed recently, according to the WHO.
All travelers coming from Mali will now undergo the same entry screening, Ebola exposure assessment, and symptom monitoring as do those coming from the hard-hit nations of Liberia, Sierra Leone, and Guinea.
They will also be subject to the same 21-day monitoring and movement protocols and be obliged to make twice-daily temperature and symptom checks and report results to state or local public health authorities.
Mail had not had any cases of Ebola, despite sharing a 480-mile border with Guinea, until a 2-year-old child died of the virus Oct. 24. Although the child had traveled from Guinea to Mali while she had symptoms, that case has so far not led to any others, the WHO said late last week.
But a second cluster of cases -- sparked when a man from Guinea sought medical care in Mali and later died there -- is more worrisome, the agency said, since several of the man's contacts also have died, with either confirmed or probable Ebola, and others are ill.
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