CDC assessment cites rural gaps in Liberia's battle with Ebola

Truck on rural road
Truck in rural Liberia.

Though the disease's spread in crowded urban settings has been a unique feature of West Africa's Ebola situation, rural areas feeling the outbreak's impact have faced their own challenges, such as investigation teams in Liberia walking up to 8 hours and crossing several rivers to probe new cases.

The issues that four rural counties in Liberia grapple with in responding to the epidemic were detailed in a report today from experts with the US Centers for Disease Control and Prevention (CDC) and a partner from Liberia's health ministry, published in an early edition of Morbidity and Mortality Weekly Report (MMWR).

Rural areas unprepared when first cases hit

During the first months of the outbreak, resources poured into the areas of Liberia reporting the most cases, Lofa and Montserrado counties, where disease activity has started to tail off. By October, the disease had spread to all 15 of Liberia's counties. In late August and early September the research team took a close look at the experience of four rural counties—Grand Cape Mount, Grand Bassa, Rivercress, and Sinoe—to identify challenges and response needs.

Their initial assessment found that county health teams weren't adequately trained in core Ebola response steps and struggled with poor transportation and communication networks, critical for successfully managing Ebola in remote locations. At that time, the four counties had reported 25 suspected, 16 probable, and 19 confirmed cases.

Counties varied in their response gaps, the authors found. For example, only Grand Bassa county reported that teams had been trained to investigate cases and trace contacts when the first Ebola case was reported. Three countries reported that corpses had been transported by people who hadn't been trained in safe burial practices. Only two of the counties had a functioning ambulance, and only one of those had a crew trained to handle suspected Ebola patients. Sinoe county didn't have any lab technicians that were trained to handle Ebola specimens.

During the rainy season that ran from July through December, county health workers struggled with impassable or difficult roads that made it hard to transport lab specimens or get sick patients to Ebola treatment centers in Monrovia. In addition, many communities didn't have telephone coverage, which made it hard for local health officials to report suspected patients, to arrange clinical evaluation, or get timely lab results. For example, workers in Rivercress county had to take a 6-hour round trip to a neighboring county to submit an online surveillance report to Liberia's health ministry, and health officials in Sinoe county reported a 3-day delay in getting lab results back.

When the researchers checked back in November, they found that some areas still didn't have trained personnel and continued to have problems with transportation and communication. They concluded that, like their urban counterparts, rural health workers need adequate training in case reporting, investigation, case management, contact tracing, safe burials, safe blood specimen management, and county-level incident management systems. The group also emphasized that innovative solutions are needed to help rural locations navigate challenges ranging from poor road conditions to lack of internet access.

Report offers bird's-eye view of outbreak

In a separate report in the same edition of MMWR on the status of the outbreak in the three hardest-hit countries, Guinea, Liberia, and Sierra Leone, the CDC's incident management team and country health ministries said cases are widely distributed among districts in all three, with Mamou prefecture in Guinea as a newly affected area.

During the 4-week period between Nov 9 and Dec 6, the three countries reported 4,281 new Ebola cases, compared to the 2,705 new cases reported during the 3-week period between Oct 19 and Nov 8. During both time spans, Ebola case counts were highest around Monrovia in Liberia, in the western and northwestern districts of Sierra Leone, and in Conakry in Guinea.

The team said that although decreasing disease incidence has been reported in Lofa and Montserrado districts in Liberia, cases continue to be reported there, especially in Montserrado.

Other developments

  • Mali has released the final 13 people who were undergoing Ebola monitoring, and the country has no other suspected cases, Reuters reported today, citing a World Health Organization (WHO) official. All patients finished their 21-day quarantine at midnight yesterday. So far the country's total stands at 8 cases, 6 of them fatal.

  • The first trial of convalescent therapy for Ebola in West Africa was launched in Liberia last week, with researchers collecting plasma from survivors at the ELWA 2 hospital in Monrovia and treating the trial's first patient, according to a news story yesterday in Nature. The trial, funded by the Bill & Melinda Gates Foundation, is being conducted by ClinicalRM in coordination with Liberian health authorities and the WHO. The trial will involve 70 participants and will include a control group of Ebola patients who will not receive plasma, because their blood type is incompatible with available plasma, but who will be given the same standard of care as the treatment group. The report said a larger trial will launch in Guinea at the end of the year, led by a consortium of European and African researchers along with blood transfusion organizations.

  • Men recovering from Ebola should follow the current recommendation of waiting at least 3 months before having unprotected sex, despite a lack of research supporting the advice, according to a report today in the journal Reproductive Sciences. A research team from Colombia reviewed studies between 1977 and 2007 on men who were recovering from Ebola. They identified only four involving male survivors who donated convalescent semen. The virus persisted an average of 66.6 days, and in one case 91 days. The authors wrote that larger studies are needed to flesh out the social, clinical, and biological determinants of Ebola disease.

See also:

Dec 16 MMWR report on challenges in rural Guinea

Dec 16 MMWR Ebola epidemic update

Dec 16 Reuters story

Dec 15 Nature news story

Dec 15 Clin Infect Dis abstract

Dec 16 Reproductive Sciences report


This week's top reads