Emergencies preparedness, response

Ebola in Sierra Leone: A slow start to an outbreak that eventually outpaced all others

One year into the Ebola epidemic. January 2015

The funeral of a faith healer ignited an outbreak characterized by innovative response measures, including the Western Area Surge that began in mid-December 2014.

Ibrahim Suri Kamara, himself suffering fever, joint and muscle pain and fever tries to cool his feverish 6 year old twin daughters, Sinna and Sento.
WHO/C: Black

In Sierra Leone, the outbreak began slowly and silently, gradually building up to a burst of cases in late May and early June. Cases then increased exponentially in the last quarter of the year, with November seeing the most dramatic jump.

A retrospective investigation by WHO revealed that the country’s first case was a woman who was a guest at the home of the index case in Meliandou, Guinea. When the host family became ill, she travelled back to her home in Sierra Leone and died there shortly after her return in early January. However, that death was neither investigated nor reported at the time.

On 1 April the country stepped up vigilance for imported cases when two members of the same family who had died from Ebola virus disease in Guinea were repatriated to Sierra Leone for burial.Though heightened vigilance yielded a number of suspected cases, all tested negative.

Death of a faith healer: the first two hot spots in Kailahun and Kenema

The burst of new cases seen in early June has been traced to the 10 May funeral of a respected traditional healer held in Sokoma, a remote village in Kailahun district, near the border with Guinea. The healer became infected while treating Ebola patients who crossed the border from Guinea, seeking her healing powers.

"This is a medical war my country is fighting and I believe that the only way to stop this disease is for us, health practitioners, to come on board. We need to identify all sick people and take them out of the community as soon as possible."

Stephen Kamara, medical student

That funeral sparked a chain reaction of more cases, more deaths, more funerals, and more cases in multiple transmission chains. Local epidemiologists eventually traced 365 Ebola-related deaths to that single funeral, which also seeded cases reported in Liberia.

On 12 June, a state of emergency was declared in Kailahun, calling for the closing of schools, cinemas, and places for night-time gatherings and the screening of vehicles at checkpoints along the borders with Guinea and Liberia.

Kailahun and, to its south, the larger city of Kenema, formed the early epicentre of the outbreak. WHO and other partners concentrated their response teams in that area.

Kenema benefitted from a laboratory and ageing isolation ward set up to manage cases of Lassa fever. That laboratory diagnosed the city’s first Ebola cases, but the poorly-maintained isolation ward was soon overwhelmed with Ebola patients and services collapsed.

At Kenema’s government-run hospital, two wards were converted to serve as an Ebola-designated treatment facility. Unfortunately, eight nurses working there became infected in July, adding to the problem of finding sufficient staff willing to work under life-threatening conditions. As the year progressed, that number grew to more than 40 deaths among doctors and nurses at the single district hospital, dealing a huge blow to the country’s already overstretched health system.

On 24 June, MSF opened an Ebola treatment centre in Kailahun. As an emergency coordinator with the charity noted, “We came too late when villages already had dozens of cases. We don’t know where all chains of transmission are taking place.” By mid-July, so many people were dying of the disease that teams trained by WHO buried more than 50 bodies over a 12-day period.

The MSF 50-bed treatment centre in Kailahun managed more than 90 confirmed cases in the first four weeks after it opened. To meet diagnostic needs, WHO helped establish a mobile laboratory provided by Public Health Canada. However, the number of new cases continued to outstrip both treatment and laboratory capacity.

In both Kailahun and Kenema, the greatest need was for more treatment facilities backed by greater and faster laboratory support. Pending the availability of those facilities, WHO worked, in collaboration with UNFPA, to reduce the number of new cases by training and equipping hundreds of local volunteers to search for cases, use mobile phones to send alerts to health authorities, and conduct contact tracing.

However, a shortage of experienced staff meant that much of this work was not supervised. In particular, the quality of contact tracing suffered. Too many people with a history of high-risk exposure were missed, cases were not detected and managed early, and chains of transmission continued to multiply.

In July, partners working in Kenema and Kailahun agreed that containment would require an enormous and robust scaling up of response capacity. Much stronger basic health infrastructures had to be quickly put in place and made to function well. As the WHO emergency coordinator in Kailahun noted at that time, “We need to step up the response and we need to do it fast.” Partners further recognized the need for far greater engagement of community leaders, especially paramount chiefs and religious leaders, to promote local acceptance of control interventions.

Death of a national hero: safety issues raised

Tragedy struck on 29 July, when Sheik Humarr Khan, the country’s only expert on viral haemorrhagic fevers, who had been leading the Ebola response in Kenema, died of the disease at the treatment facility in Kailahun. The death of Dr Khan, who was regarded as a national hero, and surrounding publicity removed many public doubts about whether Ebola was “real”, but it also introduced questions about the safety of the area’s treatment facilities.

In August, WHO urged governments and the international community to make available, in all three Ebola affected countries, incentives, protection, and treatment for health personnel to improve their safety and provide the motivation needed to ensure uninterrupted health care services.

Confidence in the safety of medical staff was further eroded in the last week of August when a WHO-deployed epidemiologist working in Kailahun became infected. Just a few days later, three staff at a hotel where foreign medical teams were staying became infected.

Following those events, most foreign medical staff, included those deployed by WHO, suspended operations in Kailahun. A team of logisticians and experts in infection prevention and control was deployed by WHO to investigate exactly how health care workers were being infected and to ensure working conditions were safe. Confidence was gradually restored and operations resumed in early September.

In Kenema, more evidence that capacities were overwhelmed came on 30 August, when health care workers at the government-run hospital went on strike over unpaid salaries and poor and dangerous working conditions. Nurses and burial teams complained that they had not been paid for several weeks, had insufficient personal protective equipment, and were forced to use a single broken stretcher to transport bodies as well as patients. WHO made arrangements to pay their back salaries, but not enough could be immediately done to improve the safety of working conditions.

As the number of patients, doctors, and nurses dying at the Kenema government hospital continued to escalate, rumours grew that something other than a disease was responsible for the deaths. More deaths began occurring in the community as patients fled or avoided the hospital, again undermining the effectiveness of treatment in isolation as a control measure.

The "Kenema tent": isolation in reverse

Residents of villages near Kenema witnessed how quickly the virus could sweep through crowded households, but saw few alternatives to home care. Weak response capacity meant that people with suspected Ebola were often not moved to a treatment centre until positive test results became available, which could take up to four days. By that time, many more in the household would be infected. Spread within households, where five to six children might share the same mattress, was ruthlessly swift.

In discussions with village leaders, the WHO field coordinator in Kenema learned that what people wanted was a place where uninfected members of a household could go to “self-isolate”. They wanted a low-risk environment to stay in while waiting for the results of diagnostic tests. They had observed the high risk of being infected when people were trapped in a quarantined and crowded household with at least one confirmed Ebola case. The idea of providing a tent, offering sufficient space to keep a safe distance from others, was born.

The WHO office in Freetown provided the first tent. The International Federation of Red Cross and Red Crescent Societies supplied others, while UNICEF took care of sleeping mats, bednets, and cooking equipment.

This community-initiated innovation proved popular and effective. In the village of Mondema, for example, household contacts of confirmed cases able to self-isolate in the tents experienced no new cases. Though the impact on the overall outbreak was small, that innovation demonstrated one of the most important lessons to emerge during the first year: listen to the community. Communities know what they need. If that need is met in an acceptable way, it will be used.

Freetown: the new epicentre

The first confirmed case in Freetown was reported to WHO on 23 June. Cases in Freetown and the adjacent district of Port Loko initially rose slowly, with patients transferred to Kenema for treatment. Throughout July and August, Kailahun and Kenema remained the districts with the most intense virus transmission, and cases there continued to occur at an alarming rate.

On 6 August, the President declared a national state of emergency, with quarantines, enforced by the military, imposed on the areas and households hardest hit. Also in August, the government passed a law imposing a jail sentence of up to two years on anyone found to be hiding a patient. At the end of that month, the country reported a cumulative total of 1,026 cases, compared with 648 in Guinea and 1,378 in Liberia.

But the real surge in cases began in September as the virus gained a foothold in Freetown. Teams were soon struggling to bury as many as 30 bodies per day. As the situation rapidly worsened, South Africa deployed a mobile laboratory to Freetown and work began to construct Ebola treatment centres, as Kenema’s treatment capacity was quickly overwhelmed.

By the third week of September, the situation had begun to stabilize in Kailahun and Kenema, but Freetown, Port Loko, Bombali, and Tonkolili districts showed a sharp and alarming spike in a situation described by WHO as “continuing to deteriorate”. Nationwide, WHO estimated that more than 530 additional treatment beds were needed.

The biggest challenges in the densely populated capital were limited treatment and diagnostic facilities and the difficulty of undertaking contact tracing. In parts of Freetown, as many as three families occupied the same household in shifts, increasing even further the risks of disease spread within these families.

In early October in Port Loko, no treatment beds were available in any health care facilities. At one health facility, nurses had no personal protective equipment, no food, and no rehydration fluid. WHO organized the transportation of suspected cases to treatment facilities and provided a supply of essential medicines and equipment, but these did not last long as cases continued to mount and the demand continued to overwhelm existing capacities.

By mid-October, WHO described virus transmission in Freetown and the western districts as “rampant”, with more than 400 new suspected cases being reported each week. All administrative districts nationwide had reported at least one case. The impression of stability in Kailahun and Kenema was temporarily lost as cases once again began to rise.

In Freetown, the government and its partners recognized an increasingly urgent, almost desperate situation. On 21 October, the World Food Programme used its unparalleled logistical capacities, supported by funding from the World Bank, to airlift 20 ambulances and 10 mortuary pickup trucks to Freetown to support the government’s efforts to shorten response times. An additional 44 vehicles followed a few weeks later by sea. This support was in addition to the delivery, by that date, of food to more than 300,000 Ebola-affected people nationwide.

Community care centres: invention born of necessity

Although the UK government and other partners were rapidly building new treatment centres, especially in Freetown and the adjacent western districts, inadequate bed capacity remained the outstanding problem for patients and their families. It was also a major problem for outbreak responders, as case detection and contact tracing have little impact in the absence of facilities where infectious patients can be removed from the community and safely treated. As field coordinators in all three countries noted, the different control measures were closely interlinked; the failure of one jeopardized the success of others.

Staff from the WHO country office worked closely with government officials, community leaders, and multiple partners active in the country to find immediate solutions that matched the emergency situation. Although a telephone hotline had been set up, those answering the calls had little to offer – not enough ambulances to collect suspected cases, too few treatment beds, and insufficient burial teams to collect all bodies promptly. People needed at least some form of treatment and care close to their families and homes.

As a first step, WHO staff worked with four communities to construct safe isolation units with eight to twelve beds. These were not hospitals, but community care centres – facilities that could be quickly and flexibly set up in areas with the greatest unmet needs. Strong support from UNICEF and from the UK’s Department for International Development made an immediate large-scale difference in the country’s capacity to care for many more patients close to their homes. In this way, Sierra Leone became the pathfinder in establishing these centres and making them work.

WHO consulted experts in infection prevention and control to establish floor plans that provided space for patient triage and separated high-risk from low-risk areas. To staff them, also safely, WHO trained village volunteers and teams of local nurses in the basics of infection prevention and control and patient care. WHO was assisted in these tasks by medics from the country’s armed forces. WHO also brought in ten experienced health care workers from Kenema, where cases had again declined to almost zero, to take on coordination and supervisory roles.

Though the level of care was not the same as in specialized treatment facilities, patients did receive essential first-line treatments delivered by trained staff – care that was far safer than that provided by family members in a home. The community care centres also responded to the reality of logistical constraints, including poor road systems and a shortage of ambulances to transport patients to distant facilities. Equally important, the centres allowed patients to stay near their homes. For families, low fences let them interact with patients from a safe distance, thus increasing the transparency of care and removing much anxiety about the fate of loved ones.

The Western Area Surge: listen to the community

In the first week of December, Sierra Leone surpassed Liberia as the country reporting the largest cumulative number of cases. The number of new cases reported that week, at nearly 400, was three times as many as in Guinea and Liberia combined. Though cases in Kailahun and Kenema had dwindled to only one or two each month, the country was still reporting new cases from 10 of its 14 districts.

As in Guinea and Liberia, the outbreak in Sierra Leone showed how quickly the dynamics of an outbreak could worsen once cases reached the capital cities. Freetown consistently accounted for around a third of the country’s cases. Other areas experiencing intense transmission were the neighbouring districts of Port Loko and Western Rural and, in the eastern part of the country, Kono district on the border with Guinea.

Against this backdrop, the government responded with a massive Operation Western Area Surge initiative, which was launched in mid-December and ran through the end of the year. As the government explained to populations in and around Freetown, the strategy aimed at correcting past deficiencies in the response and regaining the public’s confidence and cooperation, especially in the early reporting of cases.

Planning was meticulous. A malaria campaign, supported by the Bill and Melinda Gates Foundation, the UK government, MSF, and WHO, was conducted in targeted areas prior to launch of the surge. It involved distribution of antimalarial medicines, for preventive purposes, to tens of thousands of households in areas where fear of Ebola was causing people to avoid all contact with health services. Among infectious diseases, malaria is one of the biggest killers in Sierra Leone, especially of young children, and the campaign was well-received by the public.

On the technical side, preparations urgently increased bed and laboratory capacities, stepped-up the number of staff trained by WHO and CDC to undertake contact tracing, and made on-site assessments of treatment facilities to improve their safety for staff and patients alike. To support the anticipated surge in requests for testing, WHO added three strategically placed laboratories.

Considerable groundwork also reflected the lesson learned earlier: listen to the community. Well-known religious and traditional leaders were consulted to get a sense of community concerns and expectations. Well-known entertainment personalities were recruited to communicate messages, emphasizing how early detection and treatment greatly improved the prospects of survival.

Thousands of community volunteers came forward for training. This time the government made sure that calls to the Ebola hotline would be answered, with callers referred to local people, local services, local help, and local success stories.

The results of the campaign will be analyzed in January 2015. In a 19 December report, the Ministry of Health and Sanitation could already record a surge in the number of suspected cases being tested in the Western Area. As WHO staff present in Freetown and Port Loko observed, the fundamental systems and capacities for a stepped up response were now in place. Full community cooperation, however, remained a problem and contact tracing suffered as a result.

At year end, that view was shared by the country’s health officials, who noted that denial, traditional burials, and fear were still driving spread of the disease in Freetown and adjacent districts, where transmission remained intense.

The persistence of fear and denial was easy to understand. At the end of December, Sierra Leone – with its population of only 6.2 million – had recorded more than 9,000 cases of what all will agree is a terrible and terrifying disease.

Stories from Sierra Leone