Emergencies preparedness, response

Guinea: The Ebola virus shows its tenacity

One year into the Ebola epidemic. January 2015

As the first country affected, Guinea illustrates – sometimes to an extreme – some of the many problems that compromised control efforts elsewhere.

The district hospital staff attend training on Ebola infection prevention, Guinea, 2014
WHO/T. Jasarevic

Since the outbreak was officially declared in mid-March 2014, Guinea has experienced three cyclical patterns of intense transmission followed by an apparent decline in cases and then a return to intense transmission. The first dip in the number of probable and confirmed cases occurred in the week starting 28 April. Cases subsequently increased then dropped again in mid-June. A sudden flare-up occurred during the week starting 11 August, initiating a pattern of high-level transmission that continued for the rest of the year.

The first cycle led to early optimism that the outbreak was under control. As early as 15 April, the outbreak was being publicly described by staff in the Ministry of Health as “nearly under control”. By 25 April, the government had begun the countdown of passing through 21 days, the recognized incubation period, with no cases in the affected prefectures. At that time, Gueckedou was the epicentre of the outbreak, with Macenta also showing a slow rise in new cases.

Early optimism – and calls for caution

Guinea illustrates key issues that have compromised control efforts both within and beyond its borders.

On 1 May, the country’s President visited WHO headquarters in Geneva to discuss the outbreak with Director-General Dr Margaret Chan. He cited several signals that the outbreak had peaked and expressed his hope that WHO could soon declare an end to the event. Dr Chan argued for caution and continued high vigilance. As she stressed, the outbreak could be declared over only after 42 days (twice the incubation period) had passed with no new cases detected under conditions of intense surveillance.

Indications of an apparent decline in cases were noted by others, including Médecins Sans Frontières (MSF) and staff from the US Centers for Disease Control and Prevention (CDC). In early May, MSF put its team in Macenta on standby, while likewise calling for continued vigilance.

"When we got the results from Conakry confirming that Ebola had reached our place, we were scared. But we knew that we, health workers, have the responsibility to fight it.”

Dr Beuvogui, District Hospital, Telimele, Guinea

As events would prove, these early signals were false.

Other WHO staff, including its leading Ebola expert, also called for caution, arguing that the outbreak had most likely moved underground, as families hid their sick in homes and buried bodies in secret ceremonies after dark. In other words, the outbreak had moved underground, invisible in the statistics. That warning was supported by two phenomena never before observed during previous Ebola outbreaks.

First, as new treatment beds became available, they were filled – virtually overnight – by a hidden caseload largely made up of previously unidentified patients.

Second, zones of intense transmission were kept in the shadows by the refusal of communities to accept investigations by foreign medical staff, including WHO teams. In these “shadow zones”, WHO epidemiologists were often forced to use proxy indicators, such as the number of fresh graves, to produce crude maps of areas with intense transmission. Almost from the beginning, WHO epidemiologists working in Guinea recognized that the true scale of the outbreak was being underestimated by officially reported data, though the magnitude of underreporting could not be accurately measured.

With each cyclical rise in the number of cases, the outbreak demonstrated the virus’ remarkable tenacity, repeatedly returning in ways that were impossible to hide either intentionally or – more likely – because of gaps in the surveillance system and the difficulty of uncovering what was happening in the many shadow zones.

Community resistance to an extreme: mobs and murders

Community resistance has been a major barrier to control in all three countries but took on extreme dimensions in Guinea.

The first recorded incident occurred on 4 April, when an angry mob attacked an MSF treatment facility in Macenta, claiming that staff had introduced the disease into the community. Fear spread faster than the virus. In early June, when an MSF emergency coordinator reported a resurgence of Ebola in West Africa, she attributed the rise in cases to community resistance and the challenges of conducting cross-border contact tracing.

By mid-June, incidents of violence against response teams were being reported in communities across the country. In some incidents, response teams were forced to hide in the bush, fearing for their lives. Facilities, equipment, and vehicles were vandalized. Some riots followed disinfection campaigns, as communities believed that the spraying of chlorine was actually disseminating contagion, not stopping it. That impression was further enforced by the fact that spray teams wore equipment that protected themselves from head to toe. People in other communities believed that foreign teams were causing deaths in order to harvest organs.

In the worst incident of violence, an 8-member team of outbreak responders was found murdered in a village on 18 September. A second severe incident followed on 23 September, when Red Cross volunteers who had safely buried a body in the town of Forecariah were attacked by an armed mob. They seriously injured two volunteers, uncovered the grave, removed the highly infectious corpse from its body bag, and hid it somewhere in the village.

At that time, Forecariah, a mining town in western Guinea, had a case fatality rate among Ebola patients of at least 80% and had experienced a serious incident of spread among patients and staff in a large regional hospital. Moreover, cases in this hotspot had established two chains of transmission in Conakry and a third in Sierra Leone.

As the mob in Forecariah grew to more than 3,000 heavily armed youths, the focus of anger shifted to a WHO-led team of epidemiologists. They fled for their lives. Meanwhile, all equipment and vehicles at the treatment centre were either stolen or vandalized by the mob. Weeks of persistent and effective efforts to slow the outbreak down were undone on that day. As the event also underscored, working with patients infected by a deadly and highly contagious virus was not the only life-threatening risk faced by outbreak responders.

Why community resistance persists

Many analysts have attempted to explain why community resistance is persisting in parts of all three severely affected countries.

Traditional belief systems that attribute adverse events, including diseases, to non-medical causes having magical or mystical dimensions, such as a curse or a payback for past sins, have been important factors in some areas.

Population literacy is known to be low, though evidence is lacking about the significance of this factor. A December report from the Assessment Capacities Project, or ACAPS, which assesses humanitarian needs, noted that the majority of Sierra Leoneans have no formal education: two-thirds of women aged 15-49 years and half of men in the same age group. A January 2015 ACAPS report on Guinea cites a literacy rate of 20% in rural areas and 59% in urban areas. In 2012, an estimated 38% of heads of household had no formal education and almost 50% of children aged 6–14 had never been to school. (*)

Still others look to shortcomings in the response, including delays – sometimes for days – in answering calls for an ambulance or burial team, especially in remote areas in Guinea. In Liberia and Sierra Leone, bodies were left on city streets; some communities waited more than a week for burial teams to arrive. Such failures undermine community trust in the response effort.

Lack of logistical support further fed this community resistance and unwillingness to cooperate with response teams. In parts of Guinea, for example, bad road conditions, lack of properly maintained vehicles and fuel, and fear on the part of ambulance crews have meant that patients may need to undergo an ambulance ride of 8 to 10 hours, sometimes with no food or water, to reach a treatment centre. Many died along the way. Relatives were understandably reluctant to submit loved ones to such an ordeal.

Different challenges in urban and rural areas

The outbreak in Guinea also demonstrated the different challenges faced in rural and urban areas. Whereas health services are more accessible in cities, contact tracing is harder and requires more staff given the numerous opportunities for close contact to occur.

In rural areas, the two biggest problems have been community resistance to safe burials and refusal to cooperate with contact tracing teams. As anthropologists learned, contact tracing was impeded by public interpretations of contact lists as “death” lists indicating who would be next to die. Again, people were understandably reluctant to add the names of a spouse, child, or neighbour to such lists, fearing that doing so condemned them to die.

The outbreak in Guinea further revealed the consequences of both the area’s exceptionally high population mobility and the cyclical pattern of a decline in new cases, followed by a return to intense transmission. When cases in Guinea declined, ill people from neighbouring countries with no available treatment beds flocked to the country seeking treatment after hearing stories that the outbreak there was under control. In all three countries, cross-border movements, especially of patients seeking treatment beds, introduced new chains of transmission, sometimes re-infecting areas that had been coming under control.

Plans versus the realities on the ground

As in Liberia and Sierra Leone, efforts to bring Guinea’s outbreak under control faced multiple barriers, including logistical problems linked to the country’s weak public health infrastructures.

The construction and opening of badly needed Ebola treatment centres took longer than planned. At year end, only 5 of 10 planned treatment centres were operational, leaving far too many patients without a treatment option.

For a long time, the country had only two treatment centres, in Conakry and Gueckedou, both run by MSF. In mid-November, a treatment centre opened in Macenta, run by the French Red Cross. In December, another centre became operational in Nzerekore, run by Alima, a French aid agency. Construction of a fifth centre, in Kankan, to be run by MSF, is nearing completion.

Likewise, plans to construct 62 community transit centres, where suspected patients could be held pending the results of diagnostic tests, were delayed as funding was available to construct and run only 10 of these centres.

WHO’s 31 December situation report singled out community resistance to response measures and an exceptionally mobile population as two major barriers to outbreak containment. To counter resistance to control measures, the concept of village “watch committees” had been put forward as a way to engage community leaders and secure public cooperation in case detection, contact tracing, and safe burials. Again, at year end, only half of planned committees were established and functioning.

Case management in several prefectures was impaired by a shortage of vehicles, lack of fuel, and poor road conditions which slowed the transportation of samples to laboratories and of patients to treatment or transit centres. For example, in the Siguiri area near the border with Mali, only one ambulance was available to transport patients and samples to facilities in Gueckedou, a distance which takes a day-long drive over rough roads each way. WHO secured a second ambulance, but transportation capacity still fell well below the need. Every delay that leaves a potentially infectious person in the community feeds opportunities for further virus transmission.

Continuing infections in health care workers

The continuing high number of newly infected health care workers in West Africa’s outbreaks is unprecedented. In previous Ebola outbreaks in equatorial Africa, infections among health care workers rapidly diminished soon after the causative agent was identified and measures for infection prevention and control were introduced. In contrast, the concluding months of 2014 saw a surge of infections in doctors and nurses in all three countries.

Of the total of 153 infected health care workers in Guinea, of whom 90 died, 60 national staff became infected from the start of October to end-December, representing nearly 40% of the total.

Initial investigations indicate that most of these recent infections occurred in non-Ebola health care facilities, both privately run and government funded. Insufficient supplies of personal protective equipment in these facilities may help explain the continuing high level of infections in health care workers. As long as case detection and contact tracing remain weak, the risk is high that patients receiving health services for other conditions, including such high-risk events as childbirth, may be infected with Ebola yet not diagnosed.

Finally, all three outbreaks have demonstrated the dangers of using growth in GDP as the sole measure of a nation’s socioeconomic progress as it conceals vast social inequalities and hides the vulnerability to national security created by large numbers of desperately poor populations. The economies in all three countries were on the upswing following years of civil war and unrest, yet crumbled under the severe shock delivered by Ebola.

Supportive care reduces case fatality

As the outbreak in Guinea evolved, evidence emerged that good supportive care saves lives. Following confirmation of the outbreak in March, WHO deployed clinicians to Conakry to treat the first patients there. A retrospective clinical study, coordinated by WHO, examined data on 37 laboratory-confirmed cases treated at a hospital during the first month of the outbreak. Fourteen of the patients were health care workers, and 12 of them acquired their infection in a health care setting. These figures demonstrate the role that hospitals can play in amplifying transmission once cases begin occurring in an urban setting.

The study benefitted from careful and thorough daily data collection, laboratory records, and case histories compiled by clinicians from the Ministry of Health, MSF, and WHO. To replace fluids lost through severe diarrhoea, 36 patients (97%) received oral rehydration solution. Additional intravenous fluid resuscitation was given to 28 (76%) patients. The case fatality rate, at 43%, was lower than that recorded at other outbreak sites, also in Guinea, and in previous outbreaks caused by the Zaire species of the Ebola virus.

Good supportive care, especially to correct substantial fluid loss from copious diarrhoea, is thought to have contributed to the larger number of survivors. However, two limitations compromised the quality of bedside care: staff were too few in number, and the duration of time spent providing care at the bedside was too short, as heat exposure and dehydration in staff wearing personal protective equipment limited the amount of time they could spend on the ward.

Despite these encouraging results, the case fatality rate in all three countries has remained high, at around 71%. As experiences during 2014 revealed, communities will not seek early testing and treatment – even when laboratory results are rapid and sufficient treatment beds are available – if they have no trust in the outbreak response. In Guinea, a WHO staff member who spent several months in the Forest Zone in the last quarter of the year noted a strong sense of resignation among residents: having lived with this deadly and poorly understood disease for so long, they see no end in sight and little reason for hope.

An upsurge in cases

By late November, Guinea was reporting more new cases, over a broader geographical area, than ever before. Areas that had been reporting no new cases were once again affected. In December, Forecariah again experienced an upsurge in the number of cases, as did the capital, Conakry, and the Dubreka prefecture, north of the capital. Newly affected areas included villages near the borders with Mali and Cote d’Ivoire, increasing the risk that more cases would be exported across exceptionally porous borders. In early December, Telimele reported its first new cases since June.

These areas of resurgence point to the need to tailor responses to the situation in individual prefectures and sub-prefectures. They also call for the deployment of staff and the channelling of funds from the central to the local level.

Control efforts continued to face a high level of community resistance, especially to contact tracing and safe burials. In early December, the opening of a new 50-bed treatment centre in Conakry was initially delayed by a rioting mob. Geographical expansion of the outbreak continued as December progressed. WHO epidemiologists estimated that more cases in recognized hot spots likely meant more cases elsewhere, given the increase in population movements with the start of the dry season.

To date, Conakry has not witnessed, on a large scale, the horrific scenes that unfolded in Monrovia in September and in Freetown in November and December – of uncollected bodies on the streets, patients dying on the grounds of overflowing treatment facilities, and orphans shunned by the community and left to die. However, the country’s sheer geographical size, coupled with the persistence of extreme and often violent community resistance, continue to impede control efforts.

Whereas only 7 prefectures reported cases in October, that number had grown to 17 by mid-December. During the third week in December, Guinea reported 156 confirmed cases, the highest weekly case incidence recorded during the year-long outbreak.

On 31 December, WHO recorded 25 sub-prefectures where response efforts encountered community resistance. These sub-prefectures are located in prefectures adjacent to Conakry (Dubreka, Forecariah, Coyah and Kindia), in the Forest Region (Bela, Kissidougou, Gueckedou, Lola, Macenta, Nzerekore), in Upper Guinea (Dabola), and in Western Guinea (Telimele and Labe).

At year end, it looked like Guinea – where the outbreak started, simmered, and then resurged time and time again, nationwide and in individual areas – could present an especially hard challenge in bringing the Ebola epidemic under control.

* Corrigendum: The section was modified on 31 January 2015 to include more information on literacy rates provided in ACAPS country profiles.