Liberia ends Ebola emergency; Mali cluster grows

Liberia's president today announced that a state of emergency called in August to address the country's Ebola outbreak would be allowed to expire, signaling a shift in the fight against the virus amid a recent real but fragile drop in cases.

In Mali, a doctor tested positive for Ebola, part of an illness cluster linked to a clinic in Bamako, the country's capital. Local media reports also hint at another case in the city, in a young girl who was brought to a local hospital, where she died shortly before initial tests reportedly came back positive for the virus.

Expiring emergency signals response shift

Liberian President Ellen Johnson Sirleaf said on the state-run ELBC radio that she decided to let the emergency declaration expire not because the battle against Ebola is over but because recent progress allows the country to refocus its efforts, Agence France-Presse (AFP) reported today.

Sirleaf called the 90-day state of emergency on Aug 6, allowing the country to take extraordinary steps to help battle the disease, including measures that suspended certain rights and privileges, according to earlier reports. The steps included border closures, curfews, quarantines, shutting schools, and restricting public gatherings.

Liberia has been the hardest hit of the three West African countries most affected by the outbreak, with 6,822 Cases and 2,836 deaths reported so far, according to the latest update from the World Health Organization (WHO). The WHO has said that on a national level, case numbers have decreased in Liberia and Guinea, though disease transmission is still high in some districts. Other experts have warned that Ebola activity could surge again, fueled by weak health systems and pockets of denial that still persist.

In a situation update today, the United Nations Mission for Ebola Emergency Response (UNMEER) reported concerns about an emerging repeated pattern of "violent" Ebola outbreaks in three remote locations near the border between Liberia's Bong and Gbarpolu counties over the past 2 weeks. The report said it takes a 3- to 4-hour walk through the forest and canoeing a river to reach the area, and it aired concerns that residents might flee the area looking for safety.

Earlier this week, Doctors without Borders (MSF) warned that cases could start rising in Liberia again and that rapid response teams are needed to extinguish new hot spots.

At the United Nations yesterday, Liberia Ambassador Marjon Kamara asked the UN not to reduce its peacekeeping force, because the epidemic threatens peace and social cohesion, according to the UNMEER update today. The UN's peacekeeping chief, Herve Ladsous, said the UN supports extending the mission in Liberia until September 2015 and postponing troop and health staff reductions until the crisis is over.

More Ebola in Mali

A doctor who worked in the same clinic as a nurse who recently died from Ebola has tested positive for the virus, according to the UNMEER report. The clinic where the two health workers were employed treated a sick imam from Guinea who, along with a friend who visited of him, died from suspected Ebola infections, but weren't tested.

Meanwhile, a local media report in French, translated and posted by the FluTrackers infectious disease message board, said a young girl died today in an Ebola isolation center in Bamako. She was isolated dafter her family brought her to the city's Gabriel Toure Hospital. If confirmed, the girl's illness and that of the doctor would push Mali's Ebola total to six.

About 20 UN peacekeepers who are being treated at the clinic for injuries they sustained during their mission in northern Mali are among those being monitored in Bamako for the virus, UNMEER said. The WHO said yesterday that 28 health workers at the Pasteur Clinic where the imam was treated were under observation and that public health teams were tracing contacts in the community, including a mosque in Bamako where his body was washed in a funeral ritual—a process that has been implicated in the spread of Ebola.

Today, Reuters photojournalist Joe Penney reported on Twitter that Malian health officials said a woman who attended the ritual washing of the deceased imam had a positive preliminary test for Ebola. Penney said the woman died.

Treatment trials to launch at MSF centers

In other developments today, MSF announced that it will host clinical trials of experimental Ebola drugs at three of its treatment centers, two in Guinea and one at a site still to be named.

In one of the trials, the French National Institute of Health and Medical Research (INSERM) will lead a test of the antiviral drug favipiravir at a treatment facility in Gueckedou. In another, the Antwerp Institute of Tropical Medicine (ITM) will test the use of convalescent whole blood and plasma at the Donka Ebola center in Conakry. At a third undetermined site, the University of Oxford on behalf of the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) will conduct a Wellcome Trust-funded trial of the antiviral drug brincidofovir.

The two drugs were selected from the WHO's short list of potential treatments, after careful review of safety and efficacy, product availability, and ease of administration, the group said.

MSF said the protocols are in the final development stages and will have a simple target: 14-day survival with broad inclusion criteria. Trial designs have been shared with the countries' ethical authorities, with the first trials to start in December and initial results due in February 2015.

For all three trials, research teams will use community engagement and get informed consent from patients or their representatives.

Peter Horby, MBBS, PhD, chief investigator of ISARIC's trial, said in the statement, "Conducting clinical trials of investigational drugs in the midst of a humanitarian crisis is a new experience for all of us, but we are determined not to fail the people of West Africa."

Other developments

  • A trial of a modified chimpanzee adenovirus vaccine (ChAD3 ZEBOV) against Ebola, developed by the National Institutes of Health and GlaxoSmithKline, is expected to start in Liberia and Sierra Leone by January, Anthony Fauci, MD, told the Senate Appropriations Committee at hearing on the Ebola response yesterday. Fauci, who is director of the National Institute of Allergy and Infectious Diseases (NIAID), said if the trials go smoothly, officials should know by the middle of 2015 if the vaccine is effective.

  • A case report yesterday in the New England Journal of Medicine on two US medical missionaries treated at Emory University School of Medicine in Atlanta for EVD demonstrated the importance of aggressive rehydration, according to the authors, who included one of the case patients, Kent Brantly, MD. Both Brantly and missionary Nancy Writebol contracted EVD in Liberia in July and were later transported to Emory. Their care teams focused on "aggressive volume and electrolyte replacement with a special focus on replacing potassium and calcium," as well as intensive nursing care. The authors said supplements were necessary because WHO-recommended oral rehydration solution does not contain enough potassium, calcium, or magnesium. An accompanying editorial agreed that intensive fluid management is crucial.

  • The US Centers for Disease Control and Prevention (CDC) released four more Ebola resources over the past 2 days. Two guidance documents released today target West African health settings, addressing hand hygiene at healthcare facilities apart from Ebola treatment units and the mixing and use of chlorine solutions in general health settings. Yesterday the CDC posted guidance on screening and care of pregnant women with Ebola in US health facilities and a Q and A document on Ebola and pet dogs and cats.

See also:

Nov 13 AFP story

Nov 13 UNMEER update

Nov 12 WHO Ebola situation report

FluTrackers Mali Ebola thread

Joe Penney Twitter account

Nov 13 MSF statement

Nov 12 N Engl J Med report

Nov 12 N Engl J Med editorial

CDC Ebola resource page

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