Ebola uptick underscores response challenges

In a sign that West Africa's Ebola response still faces several challenges, Guinea, Liberia, and Sierra Leone all reported an uptick in cases last week, the first time this year that all three countries have seen an increase, the World Health Organization (WHO) said today.

Some of the remaining problems include stubborn pockets of community resistance in some areas, the disease's increased reach in Guinea, and widespread transmission in Sierra Leone, the agency said. The WHO warned of an urgent need to curb the outbreak in as many areas as possible, with the approach of the wet season that will make remote areas difficult for responders to reach.

In the last week of January, the countries reported 124 new confirmed cases—80 in Sierra Leone, 39 in Guinea, and 5 in Liberia. Guinea's weekly increase is its second in a row.

The new cases lift the outbreak total to 22,460 confirmed, probable, and suspected cases, with the number of deaths rising to 8,966.

In other Ebola news, the US Centers for Disease Control and Prevention (CDC) said today in a report that a lab incident in late December likely did not involve live Ebola virus.

Shifting country patterns

Sierra Leone's case incidence, its first rise of the year, came with 80 newly confirmed cases, compared with 65 the week before. The western part of the country is still the main transmission area; Freetown reported 22 more confirmed cases, and the neighboring district of Port Loko reported a resurgence of cases—36, compared with just 6 the week before. Nine of Sierra Leone's 14 districts reported at least 1 new case last week.

Guinea's main hot spot is Forecariah, which reported 13 of the newly confirmed cases. The WHO said an unsafe burial in early January in the eastern district of Lola, near the border with Ivory Coast, has resulted in 11 confirmed cases, with an additional case in a northern province near the Mali border also linked to the Lola area.

The northern Guinea district of Tougue, also bordering Mali, reported its first two confirmed cases, both of which have links to Ebola transmission in Dubreka, in the western part of the country. The WHO said the recent cases in northern Guinea have triggered cross-border meetings between Guinea, Mali, and Senegal to beef up surveillance for the disease and deployment of a rapid response team to the Lola area to gauge the risk and boost surveillance.

Liberia's case increase was slight last week, with five cases reported, compared with four the previous week. All of the new confirmed cases were in Montserrado County, an area that includes Monrovia, the country's capital.

Community resistance, unsafe burials

Community resistance to Ebola responders has recently been reported in 10 of Guinea's districts and in three of Sierra Leone's districts, the WHO said.

In its tracking of unsafe burials, one of the riskiest behaviors linked to the spread of the disease, the WHO said 35 were reported in Guinea last week and 11 were reported in Sierra Leone.

Deaths in the community are also thought to pose a risk, with Ebola deaths ideally occurring in treatment units, where the virus threat can be managed and contained. The agency said that Sierra Leone last week reported 12 such deaths, with 8 of them reported in Guinea.

The WHO has said the next phase of the Ebola battle focuses on identifying all transmission chains and finding each and every case. The metric it's watching is the percentage of new cases reported in known contacts, which should ideally be 100%. For Guinea, 54% of new confirmed and probable cases are in known contacts, an increase from the previous week; for Liberia, the most recent number is 100%, but for Sierra Leone the figure is 21%.

CDC: Live virus unlikely in incident

The CDC, meanwhile, released the results of its investigation into a lab worker's potential exposure to live Ebola virus at one of its labs on Dec 22. No illness has been found in the lab worker, who has since completed 21-day monitoring.

The CDC said scientists from its Viral Special Pathogens Branch (VSPB) were conducting experiments with Guinea pigs in biosafety level 4 (BSL-4) lab conditions to see if the current strain in West Africa had become more virulent and if oral fluid swabs could be used to help diagnose the disease.

Scientists were processing swabs for two sets of experiments, preparing one set of vials for virus isolation in BSL-4 conditions and one set of vials containing inactivated virus for work in lower containment BSL-2 conditions. During the preparation, tube caps didn't provide a cue to distinguish between the two sets of samples, and two different individuals were involved with the preparation, which might have contributed to the potentially live virus samples being sent to the BSL-2 lab, where they were handled by the potentially exposed lab worker.

The CDC found no detectable Ebola virus on swabs collected during the experiments on those days, suggesting that no live virus was in the samples mistakenly taken out of the BSL-4 lab on Dec 22, the agency said.

The report said the main causes of the incident were inadequate safeguards related to the lack of an approved written study plan and a workflow plan that didn't adequately minimize the risk of human error that could have led to exposure.

The CDC said that although it has made progress over the past several months in addressing lab safety concerns, the incident highlights the need for continued improvements. It also said that, after the report's recommendations are implemented, it will order an external safety review of the VSPB.

Other developments

  • Of the $2.89 billion that the international community has pledged to help battle the Ebola battle, only a little more than 40% has made it to the region, according to an analysis published yesterday in BMJ. The report, by Karen Grepin, PhD, of New York University, is based on donations tracked by the United Nations Office for the Coordination of Humanitarian Affairs (OCHA). She said that, like the response in general, financial pledges and donations were slow to kick in, with the funding delay likely contributing to the spread of the virus. Although the amount countries pledged was greater than what global officials asked for, the money that actually materialized met only two thirds of what was needed. Grepin noted that the problem wasn't donor generosity but that resources weren't deployed quickly enough. The patterns suggest a need for a mechanism, such as a dedicated fund, that can more rapidly disperse funds for public health threats like Ebola, she wrote. WHO reform proposals include a dedicated fund for health crisis response.

  • An independent investigation into the recent Ebola infection of Scottish nurse Pauline Cafferkey, who got sick after returning from working in a Save the Children treatment center in Sierra Leone, found that her infection might have stemmed from her use of a visor rather than goggles. Save the Children said in a press release today that both visors and goggles are safe, but there are slight differences in clothing used with each and in the protocols for donning an doffing. The group added that the panel found a delay in noting instances when Save the Children protocols weren't followed or prescribed equipment wasn't used, which might have led to a delay in corrective action. Lessons from the incident have led the group to further tighten its protocols and procedures, and workers have received refresher training in use of personal protective equipment. Cafferkey left Sierra Leone on Dec 28 and started feeling sick as her flight arrived in Glasgow. She was treated at Royal Free Hospital in London and recovered from her infection.

See also:

Feb 4 WHO situation update

Feb 4 CDC report on potential exposure to Ebola virus

Feb 3 BMJ report

Feb 4 Save the Children press release

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