Liberia's grim Ebola situation prompts call for 'nonconventional' help

Taxi in Africa
Taxi in Africa

Taxis carry families with suspected Ebola patients across Monrovia, Liberia's capital, the WHO says., Peeter Viisimaa / iStock

In an unusually grim statement today, the World Health Organization (WHO) said Ebola virus disease (EVD) illnesses are increasing exponentially in Liberia, where taxicabs are literal vehicles of disease transmission as they ferry sick people between treatment centers that are too full to admit them.

The WHO's latest assessment, based on reports from an emergency team in Liberia, said "nonconventional interventions" are needed to control the outbreak there, because the demands have outstripped the government's and partners' capacity to respond. The group's warning came as two countries—the United States and Britain—said they would mobilize military assets to help with outbreak response.

In another development today, the WHO said one of its doctors has been infected with the virus in Sierra Leone and will be evacuated to another country for treatment. The patient is the second WHO worker to be sickened by EVD.

US, Britain announce military involvement

President Barack Obama said yesterday on the NBC News show "Meet the Press" that the US military will help set up isolation units and equipment and provide security for international public health workers, the Washington Post reported yesterday. International aid workers have repeatedly been attacked and threatened by violence in some of the outbreak's hot spots.

The president's announcement comes in the wake of a recent visit to the outbreak region by US Centers for Disease Control and Prevention (CDC) Director Tom Frieden, MD, MPH, who said on Sep 2 that there was a window of opportunity to tamp down the outbreak, but the window is closing.

Britain's government will send military and humanitarian staff to Sierra Leone capital Freetown to set up a 62-bed facility, targeted to open within 8 weeks, British International Development Secretary Justine Greening announced today in a statement. The UK's support is based on a request from the WHO and Sierra Leone.

Military officials will be in Sierra Leone later this week to assess the site, which will be designed to treat the city's infected people, as well as international health workers and volunteers who contract the disease, according to the statement. Twelve beds will be earmarked for treating heath workers, one of the groups hit hardest by the disease and a sector that plays a crucial role. The UK government is working with Save the Children to form a long-term plan to manage and operate the facility.

The military involvement announcements from the two countries follow a strongly worded statement on Sep 2 from Doctors without Borders (MSF), which said world leaders were failing to address the worst-ever Ebola epidemic and called on states with biological disaster-response capacity—both civilian and military—to send assets and personnel to West Africa.

In a speech to the United Nations that same day, MSF International President Joanne Liu, MD, said the epidemic has overstretched the response capacities of West Africa's health ministries and of nongovernmental organizations.

In the past, MSF has discouraged military interventions in national health emergencies. However, the group said transmission levels in the epidemic have reached levels that can't be contained without a massive deployment of specialized medical units to boost control efforts.

MSF said countries can deploy trained civilian or medical teams in a matter of days, in an organized manner, with a chain of command structure that ensures high safety and efficiency standards. However, it warned that military deployments should not be used for quarantine, containment, or crowd control. The group added that forced quarantines typically increase fear and unrest, rather than help curb the spread of the virus.

Instead, the MSF said field hospitals with isolation units are needed, as are trained personnel, mobile labs, and air bridges to move personnel and material to and within West Africa. Several airlines have temporarily suspended service to the outbreak countries, which has led to supply and food shortages, hampering the global response.

Liberia report: No treatment beds, taxis fueling disease

The WHO, in its situation assessment today, provided a startling description of the situation on the ground in Liberia, where 14 of 15 counties now have confirmed cases. Its investigators focused on Montserrado county, which includes the capital, Monrovia.

The WHO team said 1,000 beds are urgently needed to treat the current number of EVD patients, but only 240 are available, and only 260 more are planned or being set up. For example, it said a 30-bed facility it quickly constructed for Liberia's health ministry was overrun by 70 patients as soon as it opened.

The situation is dire for Liberia's health workers, who are often unknowingly exposed to patients with the virus—with symptoms that mimic other diseases such as malaria—even while working in wards that aren't designed for EVD treatment. The WHO said 152 of Liberia's health workers have been infected with the disease, and 79 have died. With the doctor-to-patient ratio already stretched dangerously thin, "Every infection or death of a doctor or nurse depletes response capacity significantly," the group said in its statement.

Taxis carry families, some with suspected EVD infections, across Monrovia looking for treatment beds. "There are none. As WHO staff in Liberia confirm, no free beds for Ebola treatment exist anywhere in the country," the WHO said. When turned away from treatment centers, patients are forced to return to their communities, where they infect others and keep the chains of transmission going.

One of the WHO's staff observed that motorbike and regular taxis are a hot source of potential EVD transmission, because the vehicles are not disinfected between rides.

The WHO said, however, that conventional methods seem to be keeping the disease under control in Nigeria, Senegal, and the Democratic Republic of Congo. For the hardest hit countries, the WHO investigators also recommend more community engagement and that key development partners scale up their efforts three- to four-fold.

Guinea, Sierra Leone developments

Elsewhere in the outbreak region, disease activity is surging again in an area of Guinea where health officials thought the virus had been tamped down, the Associated Press (AP) reported today. The Macenta region, near the border with Liberia, was one of the first outbreak areas and was the site of an MSF EVD treatment center. However, as cases ebbed, staff shuttered the center, leaving a small number of staff on standby.

However, EVD started flaring in Macenta again in the middle of August, with 30 new cases, the first in months, according to the AP report. MSF has opened a transit center at the site of the clinic and would like to open treatment centers in Macenta and Gueckedou, but it lacks personnel to staff the facilities.

In Sierra Leone, government officials have planned a 3-day countrywide lockdown starting on Sep 19 in an effort to reduce the spread of the virus, which would confine people to their homes, according to a Sep 6 Reuters story. The move is intended to curb infections and help health workers find people who are infected with the virus.

However, MSF said the tactic won't be helpful, because people could conceal cases and lockdowns have been known to jeopardize trust between people and health providers, according to the report.

Second WHO worker infected

The WHO's Sierra Leone office today announced that a WHO doctor working in an EVD treatment center in Kenema Government Hospital has tested positive for the disease. The center is located in an area that has been among the region's worst outbreak hot spots. In a statement e-mail to journalists, the WHO said the doctor is in stable condition in Freetown and will be evacuated shortly. It did not name the country that will receive the patient.

The WHO said the treatment center where the doctor worked is run by Sierra Leone's health ministry, and the WHO's initial role was to guide health officials in setting up and running the center until national staff could manage the center on their own. The group recommended that new admissions be limited at the facility while an investigation into the doctor's illness is launched. Three doctors will be moved to the clinic to continue patient care during the WHO's urgent assessment of the facility.

The physician is the second WHO-deployed aid worker to be sickened in the outbreak. On Aug 26 the WHO said it was pulling its staff from a site in Kailahun, Sierra Leone, after an epidemiologist from Senegal who is with the Global Outbreak Alert and Response Network (GOARN) was infected. The worker had been tracing EVD cases. The worker was flown to Germany on Aug 27 and is being treated at a hospital in Hamburg.

Animal vaccine study hints at durable protection

In EVD research developments, a study of an experimental adenovirus vector vaccine in macaques found that it conferred long-term immunity against the Zaire strain of the Ebola virus, which is currently spreading in West Africa. The international research team, led by the National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health (NIH), published its findings yesterday in Nature Medicine.

The vaccine is the same one for which human phase 1 trials were recently announced.

Investigators used a prime-boost strategy in which the animals were first inoculated with a vaccine containing an Ebola virus glycoprotein, then 8 weeks later injected with a different viral vector, MVA (modified vaccinia Ankara), carrying the same gene. The two-vaccine regimen was most effective, though a single dose of the first vaccine provided complete short-term and partial long-term protection, the group found.

The two-dose regimen protected the animals for a full 10 months; earlier tests challenged the macaques only 4 and 5 weeks after vaccination, according to the report.

Researchers used a chimpanzee adenovirus rather than a human one, because many humans have already been exposed to the human versions and have immune responses that can neutralize them. They noted that the vaccine contains genes for glycoproteins from the Zaire strain and another strain, Sudan, and that the vaccine might provide protection against both.

The team concluded that a vaccine with rapid onset and durable protection might someday help curb the spread of emerging Ebola viruses.

See also:

Sep 8 WHO situation assessment

Sep 7 Washington Post story

Sep 8 British government statement

Sep 2 MSF statement

Sep 8 AP story

Sep 6 Reuters story

Sep 7 Nature Medicine abstract

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