Since the Ebola outbreak in West Africa was officially declared on 22 March in Guinea, it has claimed 4,492 lives. The outbreak is the largest ever, and is currently affecting three countries in West Africa: Guinea, Liberia and Sierra Leone. Two countries in West Africa are in the period of counting days because there are no more active cases: Senegal and Nigeria. Two people in the United States of America (USA) and one person in Spain are currently being treated for Ebola.

Simultaneously, there is an unrelated outbreak of Ebola in DRC. Sixty-seven MSF staff are working on this outbreak and two case management centres have been established: one in Lokolia (40 beds) and one in Boende (10 beds). There has also been a confirmed case of Marburg fever in Uganda. MSF teams are supporting the response by reinforcing local capacities on infection control and treatment.

Following announcements made in the last weeks, deployment of international aid is slowly taking place in the three main countries affected. 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 3,253 staff working in Guinea, Liberia and Sierra Leone, treating a rapidly increasing number of patients. Twenty-one MSF staff have been infected with Ebola since March, six of whom have recovered. The vast majority of these infections were found to have occurred in the community.

Guinea

There are still huge challenges in controlling the Ebola outbreak in Guinea, with of the number of positive cases stabilising and then rising a few days later on two occasions. Each MSF Ebola case management centre in the country has reached its capacity. In order for the response to be more effective, a number of things are needed including: support and reinforcement in contact tracing and in the surveillance system; an adapted community awareness approach; and better referral of suspected cases to health structures.

On 12 October, MSF began construction on a new CMC in Macenta which should be fully functional with 30 beds by mid-November. MSF will manage the CMC and simultaneously train Red Cross staff in order for them to take it over.

In Conakry, after several days of having empty beds, MSF’s CMC is close to capacity. The Conakry CMC received 38 new confirmed cases last week. MSF has permission to build a new CMC in the centre of Conakry, and this has been welcomed given that three quarters of patients received at Conakry CMC are from the city.

MSF’s Guéckédou CMC has seen more patients in the last month than in the first eight months of operation. More and more cases arrive every day and the team expect to see another rise next week. As a result an extension of 15 beds is close to completion. Staff safety remains a priority for the project.

Liberia

On Monday, a health worker strike Ministry of Health structures over pay disputes and labour safety was averted and did not have an impact on MSF’s activities in Monrovia.

The MSF team is trying to understand the situation in local communities, as well as working with others to see the possibility of offering safe burials in addition to cremations. The perception of Ebola case management centres in Monrovia is poor – community understanding of what happens inside them is seemingly shrouded in mystery and fear, as well as widespread aversion to the enforced cremation practice which is not culturally well-accepted.

Monrovia

Over the past weeks, the number of admissions in Elwa 3 has stayed stable at around 130 patients admitted at any one time. Despite having increased to 250 beds, we do not see the expected rise in admissions in the case management centre. More and more reports suggest that families are choosing to keep suspect cases at home and are also practicing burials through various means, to circumvent the mandatory cremation policy enacted by the government.

A second round of mass distribution of home protection and disinfection kits in Monrovia has begun this week, with more than 800 kits distributed on the first day, 14 October. A mass distribution campaign of anti-malarial kits is due to start in Monrovia this week. This will take place in the same locations as the first round of home protection and disinfection kits distributed in past weeks.

Foya

The number of admissions in Foya have been low for the past few weeks, with only seven patients currently admitted. During the last 21 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. A health promotion team visited the villages of Barkedu and Gbegbedu in Quardu Bondi district near the Guinean border at the weekend, as a number of Ebola cases have come from there in the last two weeks. MSF continues to support the referral system for patients from these districts to the Foya CMC. MSF will soon open a Transit Unit 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.  Triage stations in the OPD and General Hospital of Voinjama are also being established.

As local health centres are starting to reopen MSF is making donations of protective equipment and providing training to the staff working in these centres for the safe use of this equipment. The decline in admissions has also allowed MSF to reorganise its outreach activities. In Foya MSF has expanded health promotion activities to villages where outbreaks have not yet occurred. In Voinjama the health promotion team is training trainers in other NGOs and organisations to ensure best practices are passed on for.

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 however, and is reinforcing health promotion messages with twice weekly radio shows in Foya and Kalahun and has recorded health promotion radio messages to be broadcast several times daily in Foya. Translation of these messages and recording in Bandi, Mandingo and Loma will take place next week.

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 CMCs, risking that positive cases infect those who are negative. As there are few CMCs, 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.

Kailahun

The Kailahun district has not seen a significant increase in patient numbers, however some new cases have come from the Chiefdom of Yawie. 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 Ebola case management 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 case management centre continues to receive patients from outside of Kailahun as there are not enough case management 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 major 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.  

Bo

In Bo our new 35-bed Ebola management centre, which opened on 19 September, is now open.  Since the centre opened, nine patients have been discharged after recovering from the disease.

Nigeria

International MSF teams left Nigeria on 5 October. The implementation of a transition plan is ongoing and focuses on various health education programmes and trainings. The outbreak will be declared officially over if there are no new cases by the 20 October. MSF will keep in contact with the authorities for follow up until that date.

Senegal

MSF teams have now finished their intervention programme in Senegal. If the active surveillance for new cases that is currently in place continues, and no new cases are detected, WHO will declare the end of the outbreak in Senegal on Friday 17 October. Teams will keep in touch with the government as part of routine follow up.  

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 deployed to Lokolia and Boende in response to the outbreak, and teams are running two case management centres, one with 40 beds and the other with 10 beds. As of 14 October, 59 people have been admitted at the two facilities. So far 12 deaths have been reported, infection has been confirmed in 25 cases and 12 people have recovered. The outbreak is not controlled yet with one new confirmed case from 4 October.

Guinea

There are still huge challenges in controlling the Ebola outbreak in Guinea, with of the number of positive cases stabilising and then rising a few days later on two occasions. Each MSF Ebola case management centre in the country has reached its capacity. In order for the response to be more effective, a number of things are needed including: support and reinforcement in contact tracing and in the surveillance system; an adapted community awareness approach; and better referral of suspected cases to health structures.

On 12 October, MSF began construction on a new CMC in Macenta which should be fully functional with 30 beds by mid-November. MSF will manage the CMC and simultaneously train Red Cross staff in order for them to take it over.

In Conakry, after several days of having empty beds, MSF’s CMC is close to capacity. The Conakry CMC received 38 new confirmed cases last week. MSF has permission to build a new CMC in the centre of Conakry, and this has been welcomed given that three quarters of patients received at Conakry CMC are from the city.

MSF’s Guéckédou CMC has seen more patients in the last month than in the first eight months of operation. More and more cases arrive every day and the team expect to see another rise next week. As a result an extension of 15 beds is close to completion. Staff safety remains a priority for the project.

Liberia

On Monday, a health worker strike Ministry of Health structures over pay disputes and labour safety was averted and did not have an impact on MSF’s activities in Monrovia.

The MSF team is trying to understand the situation in local communities, as well as working with others to see the possibility of offering safe burials in addition to cremations. The perception of Ebola case management centres in Monrovia is poor – community understanding of what happens inside them is seemingly shrouded in mystery and fear, as well as widespread aversion to the enforced cremation practice which is not culturally well-accepted.

Monrovia

Over the past weeks, the number of admissions in Elwa 3 has stayed stable at around 130 patients admitted at any one time. Despite having increased to 250 beds, we do not see the expected rise in admissions in the case management centre. More and more reports suggest that families are choosing to keep suspect cases at home and are also practicing burials through various means, to circumvent the mandatory cremation policy enacted by the government.

A second round of mass distribution of home protection and disinfection kits in Monrovia has begun this week, with more than 800 kits distributed on the first day, 14 October. A mass distribution campaign of anti-malarial kits is due to start in Monrovia this week. This will take place in the same locations as the first round of home protection and disinfection kits distributed in past weeks.

Foya

The number of admissions in Foya have been low for the past few weeks, with only seven patients currently admitted. During the last 21 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. A health promotion team visited the villages of Barkedu and Gbegbedu in Quardu Bondi district near the Guinean border at the weekend, as a number of Ebola cases have come from there in the last two weeks. MSF continues to support the referral system for patients from these districts to the Foya CMC. MSF will soon open a Transit Unit 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.  Triage stations in the OPD and General Hospital of Voinjama are also being established.

As local health centres are starting to reopen MSF is making donations of protective equipment and providing training to the staff working in these centres for the safe use of this equipment. The decline in admissions has also allowed MSF to reorganise its outreach activities. In Foya MSF has expanded health promotion activities to villages where outbreaks have not yet occurred. In Voinjama the health promotion team is training trainers in other NGOs and organisations to ensure best practices are passed on for.

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 however, and is reinforcing health promotion messages with twice weekly radio shows in Foya and Kalahun and has recorded health promotion radio messages to be broadcast several times daily in Foya. Translation of these messages and recording in Bandi, Mandingo and Loma will take place next week.

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 CMCs, risking that positive cases infect those who are negative. As there are few CMCs, 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.

Kailahun

The Kailahun district has not seen a significant increase in patient numbers, however some new cases have come from the Chiefdom of Yawie. 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 Ebola case management 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 case management centre continues to receive patients from outside of Kailahun as there are not enough case management 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 major 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.  

Bo

In Bo our new 35-bed Ebola management centre, which opened on 19 September, is now open.  Since the centre opened, nine patients have been discharged after recovering from the disease.

Nigeria

International MSF teams left Nigeria on 5 October. The implementation of a transition plan is ongoing and focuses on various health education programmes and trainings. The outbreak will be declared officially over if there are no new cases by the 20 October. MSF will keep in contact with the authorities for follow up until that date.

Senegal

MSF teams have now finished their intervention programme in Senegal. If the active surveillance for new cases that is currently in place continues, and no new cases are detected, WHO will declare the end of the outbreak in Senegal on Friday 17 October. Teams will keep in touch with the government as part of routine follow up.  

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 deployed to Lokolia and Boende in response to the outbreak, and teams are running two case management centres, one with 40 beds and the other with 10 beds. As of 14 October, 59 people have been admitted at the two facilities. So far 12 deaths have been reported, infection has been confirmed in 25 cases and 12 people have recovered. The outbreak is not controlled yet with one new confirmed case from 4 October.