Ebola Epidemic and Response

When the first reported cases of Ebola appeared in Liberia on March 30, it was completely unexpected. Cases of Ebola had been officially confirmed in Guinea just over a week before, and the spread to Liberia occurred quickly due to the level of cross border movement between both countries. The cases at the time were confined to Lofa County, until one woman traveled to Margibi County, where she died.

Ebola was unprecedented in Liberia, and the health system was not set up to deal with it. Actors such as Médecins Sans Frontières mobilized quickly to set up an Ebola Treatment Unit in Lofa County, and the private company Firestone moved to isolate contacts in Margibi, where the woman had died.

As the number of cases dwindled, and it seemed as though Ebola had left Liberia, the daily meetings transitioned to just few a week, and the number of partners attending dropped dramatically with the thought that Ebola was no longer in the country. However, in June, cases again appeared in Liberia, and on June 17 cases were officially reported in the capital of Monrovia in Montserrado County, a densely populated county with approximately 1.5 million of the 4 million people in Liberia.

Incident Management System (IMS)
To effectively manage the EVD crisis an IMS was formed with various technical committees. The technical committees that make up the Incident Management System were case management, contact tracing, psychosocial, social mobilization, dead body management and EPI surveillance.

The IMS is composed of key technical partners and donors, which has changed somewhat as the response grows and new organizations arrive in Liberia to support the EVD response. From the beginning partners such as USAID, UNICEF, WHO, CDC, MSF, IFRC/LNRCS, were involved, which has grown to include other organizations such as the World Bank, UNMEER, UNFPA, UNDP, WFP, and others, such as representatives from the Foreign Medical Teams deployed to the country to support the management of ETUs and the like.

The IMS as a body represents more than 137 organizations, from a geographically diverse spread of countries from around the world. There are representatives from the foreign medical teams involved, including Cuba, China, Germany, Sweden, United States and Uganda, as well as support from multilateral organizations such as the African Union that includes delegates from across the African continent. This also includes more than 53 Liberian NGOs that are involved in the response, and more than 59 international NGOs, all working together to end the outbreak in Liberia.

Data is the foundational tool that underpins all the work of the IMS. During the outbreak, the capacity of the Health Information System Unit at the Ministry of Health was expanded with additional staff members, to facilitate effective generation and analysis of EVD data for rapid response and informed decision-making. The responsibilities of the EPI team is to produce the EVD daily situational analysis report (SitRep), to present the daily SitRep at the IMS meetings, to cross check lab results with reported cases, to collect daily surveillance reports from counties and conduct trainings on EVD data collection and management.

Case Management
When Ebola first hit, there was nowhere to treat patients safely. With the second wave reaching Monrovia, the chapel at ELWA compound was converted into one of the first ETUs in the country. As of December 31st there were approximately 510 beds available for EVD patients in 16 ETUs, with the capacity to scale up immediately to 1350 beds should the need arise. Additional ETUs are still being built, in order to ensure that every county has an ETU to care for suspected and confirmed cases.

Key also within the Case Management portfolio was the creation of the CCC concept, or Community Care Centers. This concept has never been seen before in any response to EVD, but as the concept has evolved there are no temporary spaces to care for suspected patients as they await their test results as a part of rapid interventions, and also more permanent structures that provide effective triage as CCCs near normal health facilities.

ETUs and CCCs are being managed or supported (such as non-medical management, construction) by the following organizations: International Organization on Migration, International Medical Corps, Partners in Health, US Public Health Services, Médecins Sans Frontières, MSB, Project Concern International, Samaritan’s Purse, Medical Teams International, Save the Children, Welthungerhilfe, PAE, Aspen Medical Services, Goal, WAHA, International Rescue Committee, Heart to Heart International, American Refugee Commission, Plan International, and Concern Worldwide. Also, foreign medical teams were involved in the establishment and management of ETUs: Germans (German Armed Forces and German Red Cross), Chinese Government, Cubans and African Union.

Psychosocial support was recognized as integral to the response from the first case of EVD, as patients as well as families and communities affected by Ebola require the support of mental health clinicians and social workers. Mental health was an area prior to Ebola that had few qualified staff, and thus the psychosocial team was required to train and scale up their services quickly. As of December 31st, Psychosocial teams in the counties are providing support to those infected and affected by EVD, including over 3,000 children affected, through services such as Interim Care Centers where survivors and those affected can stay while they are being supported or their communities are being engaged to receive them.
The team is also working with Survivors and has set up a National Survivors Network, with almost 500 participants.

Social Mobilization
The Social Mobilization committee built upon the network of community-based actors, including gCHVs, as well as traditional leaders and chiefs, and media outlets in order to engage communities, broadcast messages on EVD and prevention and actions to take, for behavior change and community support. Through the latest push of training at the end of 2014, the Reach Every District (RED) strategy, in the space of 1 month the Social Mobilization team reached 83% of districts in 14 counties, and trained and deployed 2,158 chiefs and traditional and religious leaders, and 4,300+ district volunteers. The target of this latest strategy is to reach 651,036 households in a door-to-door nationwide campaign, through reaching 30,496 families each month.

When Ebola was first detected in Liberia, there was only the National Reference Lab in Margibi County. The logistics of getting samples to this lab, and the number of samples it was needing to test, meant that there was a long lag time between taking samples from suspected Ebola patients, and the receipt of results. Thanks to the generous support of partners such as the US Department of Defense, as of December 31st Liberia had 8 labs in country, in Montserrado, Grand Gedeh, Bong, Nimba, and Sinoe counties.

Contact Tracing
In both phases of the response, contact tracing has been one of the most important elements as it’s critical to follow up on those that may have contracted the disease and isolate them at the first sign of illness. Contact tracing first started with repurposing community-based volunteers, and evolved into a national structure of trained, supervised and incentivized contact tracers. At the end of December there were 5,919 contact tracers trained throughout the counties, following up an average of 6 contacts per confirmed EVD case.

Space for supplies at the beginning of the outbreak were extremely limited at the national level, and the Government was unequipped to deal with the logistics for the quantity of supplies that are needed for EVD. Immediately tents were set up within the MOH parking lot by WFP, and the former large conference room at the Ministry of Health was repurposed into a warehouse following a fire. From there a logistics hub was built with the support of partners at the SKD complex, and then an additional 5 Forward Logistics Bases (FLBs) were built in the counties in order to facilitate the transport of supplies from Monrovia to the county levels. These hubs are located in Zwedru, Harper, Buchanan, Voinjama and Gbarnga.

Key Strategies
There were two phases (Phase zero- Understanding the Virus and One- Hunting the virus) of the response in 2014 that led to the change of strategies. Below is a description of the key strategies employed during each phase:

Phase Zero-Understanding the Virus
The first phase of the epidemic was characterized by lots of unknown, disbelief, myth, limited political will, inadequate resources and fewer cases. The major strategy for prevention and control was training in contact tracing, case management and regular hand washing publicity.The conventional approach of dealing with EVD was initiated. However, due to limited understanding of the situation coupled with inadequate resources, the disease escalated to many parts of the country, devastating lives thus creating a state of national emergency. This period was mid March to August 2014.

Phase I-Hunting the Virus
Phase I of the EVD crisis was associated with active transmission of cases with huge geographic spread across the country. The strategies deployed included, Rapid Isolation and Treatment of EVD cases (RITE), active case search and contact tracing, event based surveillance, rapid testing of communities dead bodies (swap), community engagement, social mobilization, case management and psychosocial support for survivals and affected families.During this period, the response team was expanded to identify cases and contacts, rapidly remove dead bodies and live patients and vigorously conduct active case finding and contact tracing and cross border surveillance. This period was August 2014 to February 2015.

EVD Statistics
Since the EVD outbreak in March 2014, 8,048 cases (3,150-suspected; 1,786-probable and 3,112-confirmed) were reported across the country. The number of cases increased from 96 in March to 3,431 in September and declined to 696 in December.
The reduction in cases is attributed to improvements in the various response teams, support by the national Government, citizens, and partners.

Over 30,000 persons became contacts to EVD cases. The number of contacts ballooned from less than 500 in March to nearly 10,000 in September. With improved investigation of cases and contacts coupled with the reduction in cases, EVD contacts dropped to less than 4,000 in December.

During the EVD outbreak, all deaths were reported as Ebola deaths. This was because of the magnitude of the situation and the limited capacity to test and provide timely laboratories results to families’ members. A total of 3,446 deaths were documented as EVD related from July to December. The number of deaths increased from 169 in July to 1,088 in September and dwindled to 332 in December 2014.

The highest hit counties were Montserrado (54% of EVD cases) where one-third of the country’s population resides, Margibi (16% of EVD cases) and Lofa (8% of EVD cases). Counties that recorded lower cases include Grand Gedeh, River Gee, Maryland and Gbarpolu. Though over 8,000 EVD cases were reported nationally in 2014, only 42% were laboratory confirmed. The majority of the cases were suspected and probable. Three counties Grand Gedeh (3), Maryland (4) and Grand Kru (4) reported less than 5 EVD confirmed cases in 2014. Montserrado County recorded 56% of the confirmed cases, followed by Margibi and Lofa.

EVD Impact
The EVD crisis impacted the entire country enormously. The health sector was devastated bythe loss of health workers, schools were closed due to active transmission and fear of exposure to the virus, while the economic sector came to a near collapse due to the imposition of a state of emergency and restriction on flights and movement of people. Below is a brief description of the EVD impact on the country.

Health Sector
The extent of the crisis cannot be determined comprehensively until the outbreak cease and a post EVD evaluation is commission and executed. However, the EVD impact on the health sector is unprecedented due to the magnitude of the situation. Major referral and tertiary hospitals (e.g: Phebe, C. B. Dunbar, Catholic, Tellewoin, C. H. Rennie, J.F.K Medical Center, etc) were either closed or partially open. There was reduction in the already insufficient health workforce due to either fear of being infected by the virus or death. As of December 31, 2014, 370health workers were infected, 192 survived and 178 died. Most health facilities turned patients away who exhibited EVD like signs and symptoms with almost no referral facility to address their conditions. Additionally, patients were afraid of seeking health care due to the wave of cross infection in health facilities and infection of patients and care providers.

The EVD crisis exacerbated the already weak health system that had human resources for health challenge, erratic stock out of medical supplies, weak referral systems and poor quality of care including infection prevention and control. The health system in few counties collapsed (e.g; Lofa, Margibi, Bong and Montserrado) with others dysfunctional.

Educational Sector
The educational sector was impacted greatly also by the EVD crisis. All schools were ordered closed by the Government, which led to students wasting an academic year. Apart from students losing an academic year that delayed promotion and graduation, some teachers got exposed and died thus leaving vacancies in schools that might not be filled soon due to insufficient number of qualified teaching staff.The deaths of parents, sponsors and guidance might deny many students and children of achieving their dreams and aspiration in life. Many students are traumatized by the death of their friends, classmates, parents, teachers and sponsors. This could result into poor performance of students, if they had the opportunity to go back to school.

The EVD outbreak had far reaching implications on Liberian’s food security, local economy, and human development (child welfare). Counties (ie: Lofa, Nimba and Bong) that are major contributors to the country’s food basket became the epicenter of the Ebola virus and experienced high death toll on their farming population. This affected food security and the local economy because farming is a major source of income and livelihood for these counties’ population. Farmers could no longer farm because of the outbreak, deaths of close family members or heads of families (mothers and fathers), insecurity or abandonment of their products.

The economy was paralyzed due to the imposition of a state of emergency that scares away many investors, flights and traders and restricted movement in and out of the country. Major concessions closed and projects were abandoned thereby reducing tax revenues and employment. The Government experienced drastic declined in revenue that put a halt to many development projects including roads construction.

Apart from the food insecurity and local economy implications of the EVD, hundreds of children (persons below age 18) have become orphans and are expected to live in traumatic and difficult conditions. The level of care and support needed for proper development will be compromise due to the absence of parental care, control and support. Many children might not be able to attend or graduate from high school because of lack of financial support from their parents or the absence of schools because teachers are not available to teach. This has serious implication for child welfare and Liberia’s human development. The consequences of the outbreak far exceed expectation due to the loss of thousands of lives, devastation of families, and local communities.