The Ebola outbreak in West Africa continues, albeit with decreasing intensity. The virus has infected more than 23,700 people across the region since the outbreak was declared 11 months ago. While the number of new patients in Liberia is declining, numbers are still fluctuating in both Guinea and Sierra Leone. A total of 99 new confirmed cases were reported across the three worst affected countries during the week up to 22 February 2015. The unpredictable nature of the epidemic means that teams from Médecins Sans Frontières/Doctors Without Borders (MSF) are maintaining a flexible approach and continuing to respond where the needs are greatest in Guinea, Liberia and Sierra Leone.

Guinea: Local population remains resistant to health messages

There have been 35 new confirmed cases in Guinea this week, most in the capital Conakry, according to WHO figures. Despite large-scale education campaigns, many communities are still resistant to the public health messages put out by authorities and international organisations. MSF teams have had to deal with a number of security incidents this month in the town of Faranah and several villages, including an MSF vehicle being set on fire and teams being pelted with stones. “People are afraid of the virus, and many in the community have lost confidence in the health system,” says Claudia Evers, MSF emergency coordinator in Guinea. “The recent attacks against aid workers show that serious gaps in awareness still need to be addressed.”  

Despite these difficulties, MSF has increased its capacity and deployed two mobile teams to the prefectures of Faranah and Boffa to assess the epidemiological situation. Both of these areas have been largely uncovered by the surveillance systems, and community resistance to health messages is known to be high. “We need to continue our work and hold discussions with all the influential people in the community in order to open up villages,” says Evers. “This will be key if we are going to get the epidemic under control.” Tracing contacts and identifying chains of transmission in Guinea also remain a challenge. 

MSF is currently running two Ebola management centres in Guinea – one in Guéckédou and the other in Conakry – as well as conducting surveillance, social mobilisation and training in infection control.

Liberia: Lack of access to healthcare for other deadly diseases

Liberia has seen the sharpest decline in Ebola cases, with only eight confirmed cases currently reported in the country. MSF’s ELWA 3 Ebola management centre in Monrovia currently has three patients with suspected Ebola. MSF teams are also focusing on the needs of Ebola survivors, who face multiple physical and psychological challenges, and have opened a clinic catering specifically to their needs.

Liberia’s already weak public health system has been seriously damaged by the epidemic, with many hospitals shut down. In March, MSF will open a 100-bed paediatric hospital in Monrovia for children with non-Ebola related health problems.

As health facilities begin to reopen, infection control will be crucial to help restore public confidence in the health system. MSF is supporting rehabilitation and infection control in James David Jr. Memorial Hospital in Monrovia and has deployed one doctor and two nurses there to help improve quality of care. Elsewhere in Monrovia, MSF is running full infection prevention activities in 16 clinics, including building triage and isolation areas and conducting medical and water and sanitation training for staff. In another six clinics, MSF is providing support with infection control.

Mobile teams are running health promotion activities in the Monrovia suburbs of New Gardnersville, Bardnesville and New Georgia, as well as training local health staff in triage and infection control, and filling gaps in basic healthcare. There are also major gaps in maternity care and treatment for emergency trauma, and there are too few inpatient beds. “Restoring and improving access to healthcare must be a first step towards rebuilding health systems in the region,” says Dr Adi Nadimpalli, Head of Mission in Liberia.

Vaccinations for preventable illnesses are also urgently needed. There have been outbreaks of measles in Lofa, Margib and Montserrado counties, where MSF is assisting the Ministry of Health with surveillance and case management, and suspected cases of whooping cough in Maryland county. “It is important to respond immediately to these outbreaks of infectious diseases, rather than waiting until a bigger epidemic occurs,” says Dr Adi Nadimpalli.

Sierra Leone: Focus moves from Ebola centres to the community

Sierra Leone remains the country most affected by Ebola, with 63 new confirmed cases across seven districts reported in the week up to 25 February 2015. Hotspots persist in the northwest of the country as well as in the densely populated capital, Freetown.

The past week has seen a change in direction for MSF’s response in Sierra Leone with the closure of two of MSF’s Ebola management centres – one in Kailahun, in the remote west of the country, and the other in Freetown. Kailahun centre closed on 20 February after the district was declared Ebola-free, with no new cases recorded since 12 December. The Prince of Wales centre, in Freetown, was closed on 23 February following an announcement by the government that all Ebola management centres constructed on school grounds be demolished and decontaminated ahead of the scheduled recommencement of classes at the end of this month.

With increasing numbers of Ebola management centres run by other organisations, and with decreasing needs for beds, MSF now has the chance to reinforce its response where it is most needed and most difficult to deliver – in the community. “The closures have allowed us to reallocate our resources to community activities, including surveillance and health promotion activities. We will also continue to focus on providing health services to survivors, including referral and mental health follow-up, as required,” says Dana Krause, MSF emergency coordinator in Sierra Leone.

At the same time, MSF has deployed additional teams as new hotspots have emerged across Freetown, while a cross-border surveillance team is working in Kambia district, which borders Guinea, where some 10,000 people cross between the two countries each week.

“A broader public health surveillance system must be put in place across the region if we are to end the epidemic,” says Krause. “The number of new cases in Sierra Leone is still a cause for alarm, and the coming weeks are going to be crucial.”

MSF opened a maternity unit for pregnant women with Ebola in late January in Kissy, on the outskirts of Freetown. The unit enables medical teams to provide specialised care for pregnant women who have suspected or confirmed Ebola. The government is keen to keep this specialised service, but will move it from the grounds of the Methodist Boys High School to another location.

Research and development efforts underway

A clinic trial into the experimental Ebola treatment favipiravir is being run at MSF Ebola management centres in Guinea. At the same time, other avenues are being explored, including a trial in Conakry in which Ebola patients receive blood plasma from volunteer survivors of the disease. In March, also in Guinea, MSF will begin a study of an experimental vaccine to protect against Ebola. “All of these efforts should result in innovations that are suitable for use in the affected countries,” says Dr Bertrand Draguez, MSF medical director. “These will be key to protecting the population in both this epidemic and any outbreaks in the future.”