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The Resurgence of Ebola – Is Sierra Leone to Blame?

President Ernest Bai Koroma somewhat belatedly this week acknowledged the seriousness of the Ebola outbreak in the West African subregion when for the first time he delivered a national address to his people on the subject. (read Address by President on Ebola Outbreak))  The President urged all to join in the fight against the disease, describing it as a battle for all Sierra Leoneans. Up to this national address, the President had had little to say on the outbreak. In one of his few previous comments on the situation (https://www.statehouse.gov.sl/index.php/component/content/article/34-news-articles/869-president-koroma-attends-mru-summit-in-conakry ), on May 4, before attending a MRU summit in Monrovia, the President had said, "We will also be looking at how we can further collaborate in addressing our social issues. Don't forget that just recently we had the outbreak of Ebola, and it's as a result of effective collaboration within member states by using the institutions and the Ministries of Health plus the international partners that we were able to contain the situation, and I think that with collaboration we can achieve a lot more. So we need to build on this collaboration and cooperation,"

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In fairness to the President, he may have been lulled into an inappropriate complacency by similar projections from the international NGO MSF, which had been in the forefront of the battle against the outbreak in Guinea, where the disease was first confirmed in March (see Ebola in Guinea). In its release of May2, the organization was cautiously optimistic that the outbreak had been contained (read MSF remains vigilant.) In its release of June 3, the organization reported a resurgence of the disease (read resurgence of epidemic ebola). Subsequently new cases emerged, and news reports had the Guinean authorities and others blaming a resurgence in the disease on lax attitudes in Sierra Leone. (read Sierra Leone angered by criticism)  On June22 MSF declared the disease “totally out of control”, and beyond the limits of its resources (read Ebola out of control). It reported outbreaks in 60 separate locations in the region, an unprecedented geographic spread for Ebola.

Within Sierra Leone the disease has shown a steady relentless progression, with fear and panic leading its way, since the first cases were confirmed late in May. Initially the disease was said to be limited to one or two chiefdoms in the Kailahun district on the far Eastern border with Guinea. Subsequently it spread to other parts of Kailahun district and then to neighbouring Kenema district, where the major Ebola testing laboratory is located. Checkpoints were erected for medical screening of travelers from the entire Eastern province and on June 26 authorities announced closure of all checkpoints (and thus of movement through the checkpoints) from 7pm to 7am daily. Junior secondary school BECE examinations were postponed, first in Kailahun, but now throughout the country. Ebola suspected and confirmed case numbers continue to rise, and cases have now been reported in areas outside the Eastern region.

The terrible human tragedy of a disease that is 90% fatal, and whose mode of transmission is still not well understood despite the attentions of the best scientific institutions in the world, is well illustrated by the case of Mohammed Swarray, widely reported in the local media. It is unclear when or where Mohammed Swarray became ill or even whether he genuinely has Ebola and not just one of the myriad diseases of Africa with similar symptoms, but at some point in the last few weeks he sought refuge with his mother at her residence in a compound in Bo, in Southern Sierra Leone. Word soon spread that Mohammed was an Ebola suspect, and both he and his mother, Mariatu, quickly became outcasts. The area around their apartment became a no-go area. As word spread within the wider community Mohammed and Mariatu became the focus of fear, hostility and revulsion. They fled the area and were declared wanted by the health authorities. For days there was speculation as to their whereabouts, with conventional wisdom having them still in Bo. Eventually it was reported that Mohammed and Mariatu had been located in Freetown, in the West, where he was reportedly being treated by a health worker for typhoid, a disease which can have similar early symptoms. If Ebola really is spread by casual human contact, as feared by many, then this one case alone must have exposed a large number of people to the disease in various parts of the country. Part of the problem though is that no one, even the medical experts, seems certain of the mode of transmission, and so the slightest contact is deemed risky. The experts have stressed transmission by contact with bodily fluids, but have been largely silent on the possibility of airborne transmission.

Sierra Leone now the epicenter?

Figures from the WHO indicate that the disease is spreading faster in Sierra Leone than in the other two affected countries. Sierra Leone was the last of the three to confirm Ebola, but it now has far more cases than Liberia (252 vs 115 as of WHO’s July 3 update), which confirmed its first case in April. Guinea (412) has the highest number, but Sierra Leone is closing in. Sierra Leone had the highest number of new cases in June.

New cases of Ebola for June, 2014

When one looks at the figures reported by WHO, one is struck by the apparent difference in response to the outbreak from the three affected countries. The key statistic of contact tracing provides interesting reading. One of the main strategies for containing the spread of the disease is to trace all contacts of confirmed cases and monitor these contacts for signs of the disease. The WHO in its June 24 update provides figures for these contacts in the three countries. Guinea has registered some 4245 contacts, of whom 3098 have completed the mandatory 21 day observation period. Liberia has registered 391 contacts. Sierra Leone, with more confirmed cases than Liberia, has registered just 37. Sierra Leone ’s programme of contact tracing appears to have been very poor. The Guinean authorities, on the other hand, appear to have mounted a very robust programme of contact tracing, and perhaps this accounted for their earlier optimism that they had the disease under control. Guinea’s programme certainly looks as though it deserves further study. One wonders whether the SL medical authorities even have the capacity to trace and monitor upwards of 4000 contacts? How many people are currently working on this in the field, one wonders. In his national address President Koroma referred to ongoing training, belated one could argue, of field workers for contact tracing.