‘Ebola-free’ Liberia’s fight may not be over

The WHO warn against “Ebola fatigue” setting in when the case numbers fall and individuals, authorities and communities become complacent.

Liberia’s last known Ebola patient, Beatrice Yardolo, in yellow, arrives for a ceremony at the Chinese Ebola treatment unit where she was treated. Liberia has suffered the most deaths since the virus broke out, accounting for more than 4,000 of the 10,000 deaths registered across African countries. James Giahyue / Reuters

If Liberia finally declares itself free of the deadly disease after months of struggle to contain it, authorities must be vigilant and not fall victim to ‘Ebola fatigue’ while also ensuring a stable healthcare system is in place.

The release of Beatrice Yardolo from an Ebola treatment centre in the Liberian capital on March 5 was a much bigger celebration than usual.

The English teacher, 58, was the last patient undergoing treatment for the disease and left the Chinese-run centre to cheers from her friends and family.

Her release marked the first week since May 26 of last year that no new cases were confirmed. The country has now been Ebola-free for two weeks and all attention is turning to eradicating the deadly disease.

Yardolo had been in the treatment centre in Monrovia for two weeks. She has lost three of her children to the virus, which the World Health Organisation calls “deadly, tenacious and unforgiving”.

Doctors believed she contracted the disease from one of her sons, who became infected when working as a dental hygienist in the St Paul’s Bridge suburb.

Since the outbreak began, Liberia has suffered the most deaths, accounting for more than 4,000 of the 10,000 total deaths.

On her release, she said: “It makes me feel happy. It makes me feel like our country is coming to the end of a very horrible period.”

If her country registers no confirmed cases by April 4, after 42 days, it will be declared officially Ebola-free. This is double the maximum incubation period for Ebola and is calculated “from the last day that any person in the country had contact with a confirmed or probable Ebola case”, according to the WHO.

It gives enough time to allow for possible missed cases, uncertainty in reporting dates or hidden chains of transmission.

While this would inevitably be a long-awaited success after the longest and largest Ebola outbreak yet recorded, experts are warning that there is more pressure than ever to remain vigilant and learn from last year’s experiences.

“One undetected case can lead to a surge,” Dr Joanne Liu, Medecins Sans Frontieres international president, warned European Union representatives earlier this month. “To reach zero, every single person who has been in contact with someone infected with Ebola must be identified.

Yet today, there is still almost no cross-border information sharing on contact tracing. Surveillance teams lack basic resources for active case finding.”

The WHO also warns of “Ebola fatigue” setting in when the case numbers fall and individuals, authorities and communities become complacent.

“As experiences in Guinea made clear, this is a virus that can go into hiding for some weeks, only to return again with a vengeance,” it said.

“In Liberia, as caseloads declined, evidence of some complacency and ‘Ebola fatigue’ appeared in some populations even though transmission continued.”

The WHO and UN was under fire last year for not acting fast enough when the Ebola outbreak started. Jim Yong Kim, the World Bank group president, and Paul Farmer, an American anthropologist, wrote in an opinion piece in the Washington Post that if they worked effectively the virus “could be contained and the fatality rate ... would drop dramatically, perhaps to below 20 per cent”.

On March 22, 2014, WHO declared a major outbreak of Ebola in Guinea, but did not recommend any trade or travel restrictions and waited until August to announce it had become a public health emergency of international concern, by which time there had already been more than 1,700 cases in total.

In January this year, it released a 14-document package to mark one year of the outbreak. There were very few mentions of the criticism levelled at it for the delayed reactions by the international agencies. The penultimate and final dossiers focus on lessons learnt in 2014 and what needs to happen this year.

The first important lesson learnt last year, it said, was how devastating an outbreak can be in places where the health system is already weak.

Many of the countries affected by the virus last year were already suffering the effects of civil wars which, in some places, had devastated public health infrastructures and left many without access to any adequate healthcare.

Reliable water and electricity had been lacking in some hospitals and clinics, and even basic medical supplies were often in short supply.

In September last year, nurses from one of the biggest hospitals in Liberia went on strike demanding better protection.

They complained that they had not been provided with any protective equipment and would not resume their duties until they were properly prepared and protected. What began as a health crisis, WHO said, “snowballed into a humanitarian, social, economic and security crisis” that was felt globally.

It emphasised that a failure to invest in a stable health system leaves countries with no chance of surviving “sudden shocks”.

Second, vigilance for imported cases and a readiness to treat the first case as a national emergency made a night and day difference, it said.

Nigeria, Mali and Senegal all took swift action and managed to avoid the catastrophe that struck their neighbours.

Third, WHO said: “No single control intervention is, all by itself, sufficiently powerful to bring an Ebola epidemic” under control.

Finally, community engagement is critical to successful control, WHO said.

Getting through to communities, especially those who hide cases and secretly bury bodies, is a linchpin for beating the disease.

Dr Liu of MSF also acknowledged this final point in her speech to the EU, saying: “Fear has been a dominant factor in the Ebola epidemic. This is a normal reaction to an unprecedented and lethal outbreak. Yet we must recognise that after a full year, community sensitisation efforts have failed to counter misinformation. The level of response there requires urgent improvement.”

To fully eradicate the disease, the WHO said that there are other certain conditions that must be met.

Health systems need to function again and put more emphasis on outbreak-related capacities, research into new medical products and vaccines must continue, success stories should be “mined” for lessons, incentives offered to those on the front line and “unwavering commitment at national and international levels”.

It also draws attention to “post-Ebola syndrome”, and the need for people who survived the disease, especially women and children, to get psychosocial counselling and support. Of course, another obvious tool in the fight to beat the disease is vaccination to prevent further outbreaks and to prevent outbreaks in unaffected countries.

In August, a panel of 12 experts agreed that in the current situation it was ethically acceptable to use medicines that had not been tested or registered.

Small shipments of experimental drugs were sent to West Africa to be given to Ebola patients. They were successful.

Now all eyes are on two vaccines in clinical trials in Liberia, Sierra Leone and Guinea.

In Liberia, researchers from America’s National Institutes of Health want to test the drug on more than 27,000 people. That trial is expected to last for 12 months.

Participants will be split into three groups. One will be given a placebo saline injection, the rest will be given a dose of either cAd3-EBOZ or the VSV-ZEBOV vaccine. Neither volunteers or administration will know who was given what.

They will then be contacted one month later, and then every month for the next year. The NIH acknowledges that with the current situation in Liberia, there will need to be flexibility in the conduct and design of the trial.

“The scale of the current Ebola outbreak in West Africa is unprecedented and specific medical countermeasures are needed for this and future outbreaks,” said Dr Anthony Faci, director of the National Institute of Allergy and Infectious Diseases, who developed one of the vaccines with GlaxoSmithKline.

“It is imperative that any potential countermeasures, including vaccines, be tested in a manner that conforms to the highest ethical and safety standards in clinical trials designed to provide a clear answer to the question of whether a candidate vaccine is safe and can prevent infection.

“This trial is designed to provide such answers.”