Ebola: Bumpy road to zero trans­mis­sion

Liberia, Guinea and Sierra Leone re­main vig­i­lant as in­fec­tions decline in the three coun­tries

Africa Renewal - - Contents - By Kings­ley Igho­bor in Free­town, Sierra Leone

Paolo Con­teh, Sierra Leone’s de­fence min­is­ter and head of the coun­try’s Na­tional Ebola Re­sponse Cen­tre, was an ath­lete who set a 400-me­tres na­tional record in 1982 that re­mains un­beaten to this day. Th­ese days, Mr. Con­teh uses a sport­ing anal­ogy to ex­plain the fight against the Ebola virus dis­ease, which has re­sulted in more than 22,000 in­fec­tions and over 9,000 deaths in the three most af­fected coun­tries of Sierra Leone, Liberia and Guinea.

At a dis­cus­sion fo­rum in the Sierra Leonean cap­i­tal, Free­town, in Jan­uary, the mod­er­a­tor asked Mr. Con­teh to ex­plain the state of Ebola then.

“Let’s put it this way,” the for­mer sprinter be­gan. “We are run­ning a 400m race and we have just 20m to go. Al­ready, your legs are tir­ing and you are gasp­ing for breath. Other run­ners are com­ing fast and are about to over­take you. But you must fin­ish the race strong. At that stage, you dig deeper and draw on your last re­serves of en­ergy. You must do all you can to breast the victory tape.”

Although there were some chuck­les in the au­di­ence that in­cluded 80 Ebola so­cial mo­bi­liz­ers, who are in com­mu­ni­ties sen­si­tiz­ing peo­ple on Ebola, the mes­sage was clear: the race against Ebola can­not be won un­less there is a strong, fi­nal push.

De­clin­ing trans­mis­sion

On the ground, there is a strong sense of im­mi­nent victory in the three most af­fected coun­tries. Med­i­cal prac­ti­tion­ers, con­tact trac­ers, burial teams, sur­veil­lance teams, so­cial mo­bi­liz­ers, lo­gis­tics providers, and oth­ers work­ing to end the virus are in a some­what bois­ter­ous mood. Com­pared with the fig­ures in the last months of 2014, Ebola trans­mis­sion has de­clined sig­nif­i­cantly.

“We have moved from a phase where we were be­ing hounded and hunted to a sit­u­a­tion where we are now hunt­ing Ebola,” said Amadu Ka­mara, for­mer Sierra Leone’s Cri­sis Manager for the UN Mission for Ebola Emer­gency Re­sponse (UN­MEER).

By the end of Jan­uary 2015, there were only three pa­tients in the African Union-run Mag­binthi Treat­ment Cen­tre, in north­ern Sierra Leone. “With few Ebola pa­tients, we are plan­ning to start treat­ing oth­ers who test neg­a­tive to Ebola but may have other ill­nesses,” the co­or­di­na­tor of the Cen­tre, Dr. John Ssen­tanu, told Africa Re­newal then. They were treat­ing dis­eases such as malaria or ty­phoid un­til the clinic was fi­nally shut down in Fe­bru­ary.

The sud­den decline in Ebola trans­mis­sion is a wel­come sur­prise. The US, which had sent some 2,800 troops to Liberia, an­nounced in mid-Fe­bru­ary that its troops would pull out by the end of April 2015. “We have bent the curve of the epi­demic and placed it on a much im­proved tra­jec­tory,” read a White House state­ment.

Storm in a tea cup

But it was just in Septem­ber 2014 that the US Cen­ters for Dis­ease Con­trol and Pre­ven­tion (CDC) pre­dicted that there could be 1.4 mil­lion Ebola cases in Africa by 20 Jan­uary 2015. With a pro­jected 70% fa­tal­ity, that could have meant about a mil­lion deaths. While some ex­perts say that the dooms­day

sce­nario was a storm in a tea cup be­cause it was not based on any proper epi­demi­o­log­i­cal anal­y­sis, Martin Meltzer, who led the CDC study, in­sists that pro­jec­tions were made “on the as­sump­tion that no fur­ther in­ter­ven­tions and no fur­ther changes in hu­man be­hav­iour would take place. We knew, or we very much hoped that we would be wrong.”

How­ever, there is a down­side to the de­clin­ing trans­mis­sion num­bers. “We are no longer see­ing the buck­ets of chlo­ri­nated wa­ter in shops, su­per­mar­kets and other places. Peo­ple are be­com­ing tired and stub­born,” says Monte Jones, a spe­cial ad­viser to Sierra Leonean Pres­i­dent Ernest Koroma.

In Guinea, Pres­i­dent Al­pha Condé also warned: “It’s pre­cisely be­cause things are get­ting bet­ter that we have to stay vig­i­lant in or­der to get to zero cases,” adding that there should be no room for com­pla­cency.

The lead­ers of the Liberia, Guinea and Sierra Leone are walk­ing a tightrope, try­ing to re­turn their coun­tries to nor­mal life yet warn­ing that the Ebola fight was not over yet. Last Novem­ber, Liberia lifted the state of emer­gency de­clared in the wake of high trans­mis­sion and re­opened schools in mid-Fe­bru­ary 2015. Sierra Leone eased travel and trade re­stric­tions and re­opened schools in April.

But in re­sponse to a re­cent spike in new cases, the gov­ern­ment put 25 gov­ern­ment hos­pi­tals on spe­cial duty with new in­fec­tion and pre­ven­tion con­trol (IPC) units—the first of their kind in the coun­try.

On the road to zero

Even though “zero” is the buzz­word in the three most af­fected coun­tries, the World Health Or­ga­ni­za­tion ( WHO) pro­to­cols stip­u­late that a coun­try can only be de­clared Ebola-free if it records zero trans­mis­sion and has had no new cases for an­other 42 days from the day it records zero cases.

At an ex­tra­or­di­nary meet­ing in Fe­bru­ary 2015, pres­i­dents Ellen John­son Sir­leaf of Liberia, Koroma and Condé and a rep­re­sen­ta­tive of Pres­i­dent Alas­sane Ou­at­tara of Côte d’Ivoire met un­der the um­brella of the Mano River Union (MRU), a sub-re­gional group­ing, and re­solved to ar­rive at zero in­fec­tions within 60 days. That would mean un­til mid-April 2015. The lead­ers hoped to get sup­port from for­eign part­ners, in­ten­sify so­cial mo­bi­liza­tion and sur­veil­lance, en­hance co­or­di­na­tion and pro­vide men­tal and psy­choso­cial sup­port to vic­tims.

If th­ese coun­tries achieve zero trans­mis­sion by mid-April, the 42-day count­down would lead to end of May. If so, then, hope­fully, Sierra Leone, Liberia and Guinea – per­haps the world – could be de­clared Ebola-free.

Set­ting a 60-day tar­get is the easy part; achiev­ing it is much more dif­fi­cult. “We are go­ing to have a bumpy road to zero,” said Mr. Ka­mara, the for­mer cri­sis manager of UN­MEER in Sierra Leone. “We should not ex­pect a lin­ear pro­gres­sion. There will be a few sur­prises along the way.”

Sub-re­gional di­men­sion

A pre­sen­ta­tion by Dr. Daniel Kertesz, the then WHO Sierra Leone rep­re­sen­ta­tive, re­in­forces Mr. Amadu’s prog­no­sis. Drawing from pre­vi­ous out­breaks in Gulu in Uganda and Booué in Gabon, Dr. Kertesz said that the tail end of an Ebola out­break “can have a bumpy land­ing; can last for two to three months; or can get to zero and re­cur.”

Dr. Kertesz said any decline in trans­mis­sion should be treated with cau­tion as should any spikes. “We are not in con­trol of the epi­demic yet. Re­cent cases demon­strate that quiet ar­eas can flare up if we miss or lose con­trol of chains of trans­mis­sion.”

The sub-re­gional di­men­sion of Ebola also com­pli­cates the race to zero trans­mis­sion. MRU’s sec­re­tary-gen­eral Saran Daraba Kaba says Ebola can­not be de­feated un­less its re­gional im­pli­ca­tions are ad­dressed.

The MRU coun­tries have a com­bined pop­u­la­tion of 45 mil­lion of which 2.2 mil­lion are en­gaged in cross-bor­der ac­tiv­i­ties such as trad­ing and trans­porta­tion, ac­cord­ing to a re­port by the union. In ad­di­tion, bor­der com­mu­ni­ties forge so­cio-eco­nomic and cul­tural re­la­tion­ships. “This has led to a sit­u­a­tion where sus­pected bor­der [Ebola] cases and con­firmed cases have moved across bor­ders in public road trans­port or even on foot,” notes the re­port.

The MRU is there­fore urg­ing mem­ber states to reg­u­late how pa­tients, corpses and lab­o­ra­tory sam­ples are trans­ferred across bor­ders. De­fence min­is­ter Con­teh agrees with the MRU, even adding that if Liberia has zero cases and no trans­mis­sion for 42 days, the coun­try should not be con­sid­ered Ebola-free un­til Sierra Leone and Guinea at­tained sim­i­lar sta­tus. The virus should be treated as “one epi­demic with many fronts,” con­curs Mr. Ka­mara.

Mean­while, in­di­vid­ual coun­tries may keep an eye on hap­pen­ings across their bor­ders, but it doesn’t stop them from crow­ing about progress. Liberia, Guinea and Sierra Leone – and in­deed the world –are hop­ing that very soon ev­ery county, ev­ery dis­trict and ev­ery coun­try will be Ebola-free.

UN­MEER/Simon Ruf

Beatrice Yar­dolo, right, Liberia’s last Ebola pa­tient, walks out of the Chi­nese Ebola Treat­ment Unit (ETU) in Mon­rovia, Liberia, at the be­gin­ning of a short cer­e­mony cel­e­brat­ing her sur­vival and re­lease from the ETU on March 5.

UN­MEER/Mar­tine Per­ret

Af­ter be­ing kept closed for three months due to the Ebola out­look, schools across Guinea re­opened on 19 Jan­uary 2015.

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