Since the Ebola outbreak in West Africa was officially declared on 22 March in Guinea, it has claimed 4,877 lives. The outbreak is the largest ever, and is currently affecting three countries in West Africa: Guinea, Liberia and Sierra Leone. The WHO has declared an official end to the epidemic in Nigeria and Senegal because there have been no active cases for 42 days. Two people in the United States of America (USA) and one person in Spain are currently being treated for Ebola. One person in the USA has died.

Simultaneously, there is an unrelated outbreak of Ebola in DRC. Around 60 MSF staff are working on this outbreak and two case management centres have been established: one in Lokolia (24 beds) and one in Boende (10 beds). On September 29, a case of Marburg fever was declared in Uganda; however no new cases of the disease have been declared in the last 21 days.

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 3,288 staff working in Guinea, Liberia and Sierra Leone, treating a rapidly increasing number of patients. Twenty-three MSF staff have been infected with Ebola since March, seven 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 now counts activities in three countries: Guinea, Liberia and Sierra Leone.

• MSF currently employs 270 international and around 3,018 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 admitted more than 4,900 patients, among whom around 3,200 were confirmed as having Ebola.
• Around 1,140 have survived.
• More than 877 tonnes of supplies have been shipped to the affected countries since March.
• The estimated budget for MSF’s activities on the West Africa Ebola outbreak until the end of 2014 is 46.2 million euros.

Guinea

There are still huge challenges in controlling the Ebola outbreak in Guinea and each MSF Ebola case management centre (CMC) in the country has reached its capacity. Despite Guéckedou and Donka treatment centres continuing to expand, they have recently been close to capacity. While the epidemic is unpredictable, epidemiologists foresee another rise and our centres may be unable to admit more patients.

This will not only be extremely difficult for MSF teams, but also for the humanitarian crisis. Moreover there is a grave risk of infected people returning to their homes or remaining in their communities,  increasing the likelihood of new chains of transmission. There is a dire need for experienced actors to step in and start activities such as the distribution of protection kits, health promotion and community sensitisation. More effective contact tracing and surveillance systems are also needed. MSF has reinforced biosecurity and safety measures to reduce risks for its staff and patients’ families and continues to provide medical and hygiene training to Ministry of Health (MOH) staff and volunteers with the Guinean Red Cross.

In Conakry, MSF has started to clear the 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.  

MSF’s Guéckédou CMC has expanded by 15 beds in the last week but is unable to stretch any further.

Construction continues for the new CMC in Macenta which should be fully functional with 30 beds by mid-November. MSF will manage the CMC and simultaneously train the Red Cross staff in order for them to take it over.

Liberia

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

Monrovia

The number of admitted is still stable, at around 140 patients as of 20 October. The centre has a 250-bed capacity and the teams continue to work hard to ensure that more patients are admitted. Many people are reaching the centre by their own means, which suggests that the ambulance and referral systems are not working properly. Additionally, taxis have largely stopped accepting patients for fear of contamination. Other issues such as the mandatory cremation policy and a lack of outreach activities have been identified as reasons for the decrease in patients in the facility.

The household protection kit distribution campaign continues: so far, over 32,000 have been handed out in Monrovia. This is an attempt to slow transmission at the household level, but it was not devised to substitute for care provided in case management centres.

There are also efforts to reach communities and inform them about the case management centres – over the past ten days, MSF has held seven focus group discussions with different communities in Monrovia.

Foya

The number of admissions in Foya has been low for the past few weeks, with an average of around seven to ten patients in the CMC at any one time. The majority of patients are coming from Gbegbedu (Quardu Bondi) or Voinjama city and Boi (Zorzor). In the last 21 days, there has not been a confirmed case coming from Foya or Kailahun districts.

MSF activities in Voinjama and Quardu Bondi are increasing accordingly. Health promotion teams are active in the villages of Barkedu and Gbegbedu in Quardu Bondi district near the Guinean border. 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 outpatient department (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 preventive health promotion activities to villages where outbreaks have not yet occurred and is training local associations to deliver MSF health promotion messages to more remote areas that MSF has not yet reached.  In Voinjama the health promotion team is training trainers in other NGOs and organisations to ensure best practices are passed on.

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.

Sierra Leone

Every district in Sierra Leone is now affected by the epidemic. Current hotspots for the disease include the capital, Freetown, and the areas of Port Loko, Bombali and Moyamba. There are continued issues with poor surveillance systems, full transit centres, delays with lab testing and too few ambulances which all increase risks of cross-contamination. The government has now moved the national Emergency Response Committee from the jurisdiction of the Ministry of Health to the Ministry of Defence.

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

As the health system has collapsed due to the Ebola crisis, MSF is planning an intervention to reduce mortality. This includes a distribution of 250,000 protective and disinfection kits, and 500,000 anti-malarial kits, mosquito nets, oral rehydration salts and medications for respiratory tract infections.

The international response is beginning to get underway, but it is slow and uncoordinated. Governments 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

There has been an increase in patient numbers from the Kailahun district and over 20 from Chiefdom of Yawei.  As a result the team has increased health education, promotion and training in the area. However, patients are still arriving at our Ebola case management centre (CMC) on a daily basis from parts of the district.  MSF is supporting a team of 800 health promoters who are tasked with passing Ebola awareness messages throughout the district of 429,000 inhabitants.

The MSF CMC 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. 

The social mobilisation and sensitisation activities have increased as the Health Promotion team together with the medical team are reaching out to public health units, community stakeholders and the community at large to raise awareness. 

Bo

In Bo our new 35-bed Ebola CMC, which opened on 19 September, has now seen 35 people discharged, having recovered from the disease. With a regular number of patients admitted each day there are plans to scale up its bed capacity in the coming weeks and so training for national staff is ongoing. Our Norwegian staff member who caught Ebola while working in Bo was discharged from hospital in Oslo on 20 October 2014.

On 15 October, MSF took the very difficult decision to temporarily suspend medical activities at Gondama Referral Centre (GRC), near Bo, because of the strain the current response to the Ebola outbreak has put on the organisation’s capacity in the country.

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 deployed to Lokolia and Boende in response to the outbreak, and teams are running two treatment centres, one with 24 beds and the other with 10 beds. The outbreak is not controlled yet with the last confirmed case being on 4 October.

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 controlNo new cases of the disease have been declared in the last 21 days.