Since the Ebola outbreak in West Africa was officially declared on 22 March in Guinea, it has claimed 4,919 lives in the region. The outbreak is the largest ever, and is currently affecting four countries in West Africa: Mali, Guinea, Liberia and Sierra Leone. On 24 October, the first case of Ebola was confirmed in Mali, and that person has died. One person in the United States of America (USA) is currently being treated for Ebola, and one has died. One person in Spain and two people in the USA have recovered. Outbreaks in Nigeria and Senegal have been declared over.

On 23 October, the first case of Ebola was confirmed in Mali. The WHO, CDC and the Ministry of Health (MOH) in Mali are responding. An MSF team arrived in Mali this week to reinforce MSF’s regular mission in the country and provide technical support to the MOH.

There is an unrelated outbreak of Ebola in DRC. With no reported new cases since early October, the MSF teams in Lokolia and Boende have activated exit plans for the coming weeks. On 29 September, a case of Marburg fever was declared in Uganda; however no new cases of the disease have been declared since.

Following announcements made in the last weeks, deployment of international aid is slowly taking place in the three main countries affected: Sierra Leone, Liberia and Guinea. However, there is little indication that current efforts to increase capacity to isolate and take care of suspected and confirmed Ebola cases will address needs sufficiently.

The United Nations Mission for Ebola Emergency Response (UNMEER) has been set up and will be based in Ghana to pursue five strategic priorities: stop the spread of the disease; treat the infected; ensure essential services; preserve stability; and prevent the spread of the disease to countries currently unaffected.

MSF teams in West Africa are still seeing critical gaps in all aspects of the response, including medical care, training of health staff, infection control, contact tracing, epidemiological surveillance, alert and referral systems, community education and mobilisation.

MSF has been responding to the outbreak since March, and currently has a total of 3,347 staff working in Guinea, Liberia and Sierra Leone, treating a rapidly increasing number of patients. Since the response began, 23 MSF staff have been infected with Ebola, eight of whom have recovered. The vast majority of these infections were found to have occurred in the community.

Operational Highlights

MSF’s West Africa Ebola response started in March 2014 and counts activities in Guinea, Liberia and Sierra Leone. In response to a confirmed case in Mali, an MSF team arrived in the country this week to reinforce MSF’s regular mission and provide technical support to the Ministry of Health.

MSF currently employs 263 international and around 3,084 locally hired staff in the region. The organisation operates six Ebola case management centres (CMCs), providing approximately 600 beds in isolation. Since the beginning of the outbreak, MSF has sent more than 700 international staff to the region and admitted more than 5,200 patients, among whom around 3,200 were confirmed as having Ebola. More than 1,200 patients have survived.

More than 1,019 tonnes of supplies have been shipped to the affected countries since March.

The provisional 2014 budget for MSF’s Ebola response in West Africa is €51 million. MSF will continue its operational response in 2015, and is currently estimating operational budgets beyond 2014.  So far, MSF has approved institutional funding for a value of €20M and have raised some €28M in private funds.

Guinea

MSF welcomes the involvement of other actors in the response to Ebola in Guinea but these positive steps won’t be sufficient to stop the epidemic. The response must be structured and coherent; however it is still scattered and piecemeal. More health promotion activities and more support with contact tracing and safe burials, particularly in hotspots in the east of the country, are required. At the moment, only a few actors are providing the services required: for example, MSF is still the only organisation operating CMCs.

There is an urgent need for more transit centres and CMCs to get up and running in the affected rural districts. New chains of transmissions have appeared in Kerouane and Nzerekore, but existing CMCs are difficult to access from these areas.

On 24 October, an MSF international staff member who had been working in Guinea earlier this month tested positive for Ebola once he was back in the USA. The circumstances under which the staff member contracted Ebola have not yet been determined. A thorough investigation is underway by MSF.

Conakry

The situation in Conakry has slightly stabilised in the last week, but regular small sinks and peaks show that the epidemic is not under control. MSF is clearing a new site in Koloma for the construction of a new CMC. Once this has been constructed the Donka CMC’s activities will move here. The Donka facility was built with the expectation of running for six months and the structure can no longer keep up with the development of the outbreak. 

With the logistical and technical support of MSF, the Ministry of Health (MOH) opened a transit centre in Forecariah (southeast of Conakry), which will transfer patients to MSF’sCMC in Conakry.

Macenta/Gueckedou

The team has seen a slight increase in confirmed patients in Guéckédou, with many coming from Kerouane, revealing new chains of transmission.

On two occasions, the transit centre in Macenta narrowly avoided overflow by doubling the number of transfers to Guéckédou. MSF is speeding up construction of the new 30-bed CMC in Macenta to cope with increasing caseloads.

MSF and the French Red Cross (FRC) will start training FRC staff in November to eventually operate the Macenta CMC in November. The French Red Cross will take over in Macenta at the end of November.

Liberia

Monrovia

The number of patients in MSF’s ELWA 3 facility is dropping: as of 28 October, there were around 80 patients, in the 250-bed facility. MSF teams are looking into the reasons for this: a widespread aversion to the government’s mandatory cremation policy, poor ambulance and referral systems, changes in behaviour and other factors may play a role. All the while, MSF cannot rule out the possibility that patient numbers will go up again.  

Distributions of household protection kits is ongoing. As of 28 October, 44,154 kits had been distributed in several areas of Monrovia. These kits are designed for use by the families and communities of symptomatic individuals who haven’t been able to make it to a CMC for lack of means of transport, or who have died at home. They are in no way meant as a substitute for the care provided in CMCs like ELWA 3.

Mass distributions of anti-malaria treatment began on 25 October. The objective of these distributions is to reduce deaths and illness from malaria in the poorest and most densely populated areas of Monrovia where access to health care is limited, and to reduce the risk of people becoming contaminated with Ebola in health facilities. MSF aims to reach 300,000 people – or around 50,000 households – with this distribution.

Foya

The number of admissions in Foya has been low for the past few weeks, with very few patients currently admitted. During the last 33 days, there has only been one confirmed case in the western districts of Foya, Kolahun and Vahun and this patient was infected outside of Lofa County. Most patients are coming from the east of the county, near the border of Guinea and increasingly further afield, from Zorzor, Saleya and close to Bong county. MSF activities in Voinjama and Quardu Bondi are increasing accordingly.

The decrease in the number of cases in Foya has occurred as a result of a comprehensive package of medical care, outreach activities, health promotion and contact tracing. There has been a strong acceptance of MSF within the community, and they have significantly changed their behaviours and daily routines to help stop the spread of the epidemic.

However, the lower number of cases, particularly in the west of the county, is leading to a concerning perception among the community that Ebola may soon be over. MSF is remaining vigilant, and is reinforcing health promotion messages and activities. In Foya MSF has expanded health promotion activities to villages where outbreaks have not yet occurred. The organisation is also training local groups to deliver health promotion messages in remote areas that MSF has not yet reached.  In Voinjama the health promotion team trained health promotion trainers for 17 NGOs and local organisations to ensure that best practices are passed on.

MSF will soon open a transit centre to accommodate patients identified late in the day. They will spend the night at the unit and be transferred the next morning to the centre in Foya. Ebola triage stations in the outpatient department (OPD) and General Hospital of Voinjama are also being established.

MSF is now training key partners in the Foya CMC and in its outreach activities.

As local health centres begin to reopen, MSF is making donations of protective equipment and providing training to the staff working in these centres on how to use this equipment safely.

Sierra Leone

Every district in Sierra Leone is now affected by the epidemic. New hotspots for the disease include the capital, Freetown, and the areas of Port Loko, Bombali and Moyamba. The government has put five of the worst affected districts under quarantine, setting up checkpoints on roads to prevent people leaving the area - measures which affect between one and two million people.

The government’s response is hampered by a lack of resources and coordination at both national and district level. There is no strong surveillance system in place, while up to 85 percent of calls to the national telephone helpline get no response. Transit centres are full and management is really an issue, creating the risk of cross-contamination. As a result of overcrowding, delays in lab testing, and too few ambulances, staff in transit centres are obliged to send people untested to treatment centres, risking that positive cases infect those who are negative. As there are few treatment centres, and these are often far away, people often die on the long journey there. Dead bodies have the highest viral load possible, putting other passengers at risk.

With so many deaths from Ebola, we are seeing an increasing number of orphaned children in our centres, and a lack of caregivers.

The international response is beginning to get underway, but it is slow and uncoordinated. Governments (including the UK and China) and various NGOs have sent teams to construct new centres at different locations around the country, including Jiu, Port Loco and Freetown. Getting these new centres up and running is a matter of urgency. The need for more resources on the ground continues to exist. Community sensitisation is an area of increasing concern.

MSF has been conducting training for organisations interested in joining the response. So far three international organisations have been trained within MSF centres in Bo and Kailahun with more trainings planned in the coming weeks.

Kailahun

There has been an increase in patient numbers from the Kailahun district. The new hotspot is the Chiefdom of Yawei. The three transit centres that were previously receiving large numbers of cases from throughout the district are for the moment empty.  However, patients are still arriving at our treatment centre on a daily basis from parts of the district, and worryingly some are coming from Kailahun town itself which is a new development. MSF is supporting a team of 800 health promoters who are tasked with passing Ebola awareness messages throughout the district of 429,000 inhabitants.

Our treatment centre continues to receive patients from outside of Kailahun as there are not enough treatment centres in the country. The patients are being transported from the heavily affected districts of Bombali and Tonkilili, travelling over eight hours by car which is a serious medical concern as the conditions inside the ambulances can create cross-contamination and people are very sick. Sometimes people travel for hours with a dead body next to them.  

We are seeing an increase in the number of households and communities under quarantine in the Kailahun district which is of some concern as it limits sick people’s access to medical care.

Social mobilisation and sensitisation activities have increased as the health promotion and medical teams reach out to public health units, community stakeholders and the community at large to raise awareness.

Bo

In Bo MSF’s new 35-bed Ebola management centre, which opened on 19 September, has now seen more than 35 people discharged since its opening. With the provision of trained staff, the CMC will be looking to scale up its bed capacity in the coming weeks. Capacity building of national staff is ongoing.

Nigeria

WHO declared 20 October as the official end of the epidemic after 42 days without a case. The MSF intervention has been closed.

Senegal

WHO declared 17 October as the official end of the epidemic after 42 days without a case. The MSF intervention has been closed. MSF’s West African Unit (Dakar) will keep in contact with the government for follow up as part of their routine activities.

Democratic Republic of Congo (DRC)

The current outbreak in DRC’s Equateur province is unrelated to the one in West Africa. Around 60 MSF staff have been working on this outbreak and two case management centres have been established: one in Lokolia (24 beds) and one in Boende (10 beds). With no reported new cases since early October, the MSF teams in Lokolia and Boende have activated exit plans for the coming weeks.

Uganda

On September 29, a case of Marburg fever was declared in Uganda. MSF has helped reinforce local capacities for treating confirmed cases and for infection control. No new cases of the disease have been declared since.

Mali

On 23 October, the first case of Ebola was confirmed in Mali. The WHO, CDC and the Ministry of Health in Mali are responding. An MSF team arrived in Mali this week to reinforce MSF’s regular mission and provide technical support to the Ministry of Health.