WHILE THIS IS A LONG, AND SOMEWHAT DISJOINTED ARTICLE, I think it should be printed out as it details the step by step process allowing Ebola to GET COMPLETELY OUT OF CONTROL IN WEST AFRICA. 2015 will see an explosion of new Ebola cases.
http://fluboard.rhizalabs.com/forum/viewtopic.php?f=21&t=13222
Post subject: How Ebola Roared Back - NY Times
PostPosted: Mon Dec 29, 2014 7:33 pm
For a fleeting moment last spring, the epidemic sweeping West Africa might have been stopped. But the opportunity to control the virus, which has now caused more than 7,800 deaths, was lost.
By KEVIN SACK, SHERI FINK, PAM BELLUCK and ADAM NOSSITER
Photographs by DANIEL BEREHULAK for The New York Times
DEC. 29, 2014
On the flight back to Atlanta, Dr. Pierre Rollin snoozed in Seat 26C in his usual imperturbable way, arms folded, head bobbing, oblivious to loudspeaker announcements and the periodic passing of the galley cart.
The spread of Ebola during the first few months of the outbreak.
This routine had become part of his lore. During each viral outbreak, Dr. Rollin, the top Ebola expert at the Centers for Disease Control and Prevention, would outlast his younger colleagues in the hotel lobby, staying awake until 3 or 4 a.m. to plug new cases into a database. He managed to do this at 61 because he possessed an uncanny ability to sleep anywhere anytime, whether on the hardwood floor of a staff house in Zaire (Ebola, 1995) or in a back seat lurching down a cratered road in Madagascar (Rift Valley fever, 2008).
On this trip home from Guinea on May 7, Dr. Rollin (pronounced Ro-LAHN in his native French) found himself at particular peace. His five-and-a-half-week stay as the C.D.C.'s team leader in the opening days of Guinea’s effort to control Ebola had gone about as well as one could have hoped.
The number of Ebola cases reported each week had been declining steadily for a month. It had been more than 10 days since doctors had seen a new patient in Conakry, the capital, where Dr. Rollin worked alongside other early responders from the World Health Organization and Doctors Without Borders.
Dr. Pierre Rollin, the top Ebola expert at the Centers for Disease Control and Prevention, believed in early May that the outbreak in West Africa seemed to be burning itself out. Credit Jessica McGowan for The New York Times
New patients had slowed to a trickle in the Forest Region of southeastern Guinea, the center of the outbreak, and there had not been a report across the border in Liberia for four weeks. Sierra Leone, although surrounded by Guinea and Liberia, had not discovered a single confirmed case.
Like the 10 Ebola crises he had handled before, in Uganda and Sudan and the Democratic Republic of Congo, this first substantial outbreak in West Africa seemed to be burning itself out after a few months and a few hundred infections.
“This is close to over,” Dr. Rollin told himself, a view common among the virus hunters. “That’s it for this outbreak.”
Or so he thought. In fact, Dr. Rollin and other well-intentioned veterans of past Ebola campaigns had tragically underestimated this outbreak, overlooking clues that now seem apparent. Viewing the West Africa epidemic through the prism of nearly two dozen previous outbreaks across the continent, they failed to appreciate that the 2014 version would be unique in catastrophic ways.
By early May, cases were slowing and the Ebola outbreak in Guinea seemed to be following the pattern of previous outbreaks.
Dr. Pierre Rollin leaves
Guinea on May 7
After more than 20,000 cases and 7,800 deaths, it can be hard to recall that there was a moment in the spring when the longest and deadliest Ebola outbreak in history might have been stopped. But without a robust and coordinated response, an invisible epidemic was allowed to thrive alongside the one assumed to be contained.
Although conditions were ideal for the virus to go underground, some of the world’s most experienced Ebola fighters convinced themselves that the sharp decline in newly reported cases in April and May was real.
Tracing those exposed to Ebola and checking them for symptoms, the key to containing any outbreak, had been lacking in many areas. Health workers had been chased out of fearful neighborhoods. Ebola treatment centers had gained such reputations as deathtraps that even desperately ill patients devoted their waning strength to avoiding them.
With the affected countries often lacking the most basic medical infrastructure, the health care challenges proved staggering. But the most tragically missed opportunities stemmed from the poor flow of information about who was infected and whom they might have exposed.
A two-month investigation by The New York Times into this largely unexamined period discovered that the W.H.O. and the Guinean health ministry documented in March that a handful of people had recently died or been sick with Ebola-like symptoms across the border in Sierra Leone. But information about two of those possible infections never reached senior health officials and the team investigating suspected cases in Sierra Leone.
As a result, it was not until late May, after more than two months of unchecked contagion, that Sierra Leone recorded its first confirmed cases. The chain of illnesses and deaths links those cases directly to the two cases that were never followed up in March. Sierra Leone has since tallied about 9,400 reported Ebola infections, more than any other country. The same missed cases are linked to Liberia’s vast second-wave outbreak, identified in late May, with almost 8,000 reported infections to date.
The leaders of the initial response agree that they did not deploy nearly enough people to the region, and that they withdrew too soon. There was managerial confusion in the W.H.O., which was already stretched by budget cuts and competing demands. Some in the W.H.O. along with Guinean officials played down the threat, leading to overconfidence and inattention. Other international and nongovernment groups devised public-education campaigns that in some instances did more harm than good.
Dr. Peter Piot, who helped discover Ebola in 1976, and Jeremy Farrar, a British infectious disease specialist, called the West Africa outbreak “an avoidable crisis” in an editorial published online in September in The New England Journal of Medicine. In the same issue, W.H.O. officials said of the March to July period that “modest further intervention efforts at that point could have achieved control.”
Like all who followed them, the early responders demonstrated remarkable courage and dedication. But those qualities did not guarantee an understanding of how geography and culture would make this outbreak so distinctive.
Most previous outbreaks had started in remote villages in Central and East Africa, where the virus could be surrounded and isolated. All told, they had killed 1,590 people over four decades, only a fifth of the toll of the epidemic still unfolding across West Africa.
In some of the worst luck in epidemiological history, this outbreak occurred at the bustling intersection of three of the world’s poorest and least developed countries. Doctors in the region were rarer than paved roads — Liberia, for instance, had fewer than 250 physicians for four million people — and clinics and hospitals, where they existed, often lacked essentials like running water, hand soap and gloves.
International health groups had largely pulled out of West Africa during the civil wars that devastated Liberia and Sierra Leone during the 1990s. When the Ebola outbreak began, the C.D.C.'s staff in the region consisted of one malaria researcher in Guinea.
Complicating matters, the same ethnic group — the Kissi — inhabited the forested region across all three nations, and extended families moved easily on foot and by dugout canoe across a pinwheel of disregarded national borders. Although roads were unpaved and bumpy, they were passable enough for villagers to ride motorcycles into dense capital cities, carrying the virus on board.
Distrust of government ran so high after decades of civil war and corruption that many West Africans had to be convinced Ebola was real and not a plot to attract foreign aid. They reacted with indignation to outsiders who demanded they stop providing hands-on care to the sick, considered a sacred obligation by many West Africans, whether Muslim, Christian or traditionalist.
Governments attempted to broadcast the message that Ebola was spread through contact with vomit, feces and blood, and that bodies remained highly contagious after death. But communities often continued to wash the bodies of the dead, a step considered essential to a dignified burial and a contented afterlife. The arrival of moon-suited health workers in convoys of white trucks, armed with chlorine sprayers and thermometers, bred resistance and secrecy.
“Old disease in new context will bring you surprises,” Dr. Margaret Chan, the director-general of the W.H.O., said in an interview in December in her office in Geneva.
On conference calls before leaving Guinea last May, Dr. Rollin advised his supervisors in Atlanta that the situation seemed stable enough that the C.D.C. could probably pull out after another month. Having stayed beyond the standard four-week tour, he looked toward reuniting with his wife, Dominique, a C.D.C. microbiologist he met in high school, and to seeing what their three young grandchildren had learned in his absence.
But not long after his return, Dr. Rollin noticed disturbing trends in the reports landing in his inbox. First, an uptick in cases in southeastern Guinea. Then the first confirmed infections in neighboring Sierra Leone. Then a death at a hospital in Monrovia, Liberia’s capital, and the first case in Conakry in a month.
After a deceptive lull, the virus was back, with ruthless force.
“Damn,” the old Ebola hand thought, “we missed it.″
Photo
The village of Meliandou, Guinea, where a 1-year-old boy named Emile Ouamouno came down with symptoms consistent with Ebola and died in late December 2013. Emile is considered Patient Zero in the current outbreak across Guinea, Sierra Leone and Liberia.
GUINEA
A Lagging, Mixed Reaction
When Dr. Rollin arrived in Guinea on March 31, the outbreak was already three months old. In Meliandou, a leafy village in the hills of southern Guinea, a year-old boy named Emile had taken ill in late December with fever, vomiting and bloody stool. He died Dec. 28, and a W.H.O. investigation would later conclude he was probably the first Ebola casualty. Members of his family, a nurse, doctor and other health workers soon died also.
“We thought it was a mysterious disease,” said Dr. Kalissa N’fansoumane, the director of the nearby Guéckédou Hospital.
Ebola’s Patient Zero
When a 1-year-old boy named Emile came down with a mysterious illness in late December 2013, a rural community reacted with terror and confusion. An exclusive video produced by the PBS series “Frontline” in Meliandou, Guinea, in association with The New York Times.
Local health officials accompanied by a Doctors Without Borders logistician investigated the cluster of deaths in January. They concluded that a cholera-like diarrhea had been the cause. Unaware of signs like persistent hiccups, health workers made faulty assumptions, and some paid with their lives.
Remarkably, it would take 12 weeks to diagnose the ravaging virus. Ebola was all but unknown in West Africa — there had been a single nonfatal case in Ivory Coast in 1994 — and its symptoms were similar to those of endemic diseases like malaria, cholera and Lassa fever.
At W.H.O. headquarters in Geneva on the morning of March 21, Dr. Robert Fowler sensed the buzz as soon as he walked into the Strategic Health Operations Center, where epidemiologists seated around a blond, horseshoe-shaped table were monitoring new reports. There had been suspicions for several days about hemorrhagic fever in West Africa.
At 2:13 a.m., an email from Sylvain Baize, an infectious disease specialist at the Pasteur Institute, had announced that initial testing on blood samples flown from Guinea by Doctors Without Borders revealed a filovirus, which can cause hemorrhagic fevers like Ebola and Marburg.
There were already 49 suspected cases and 29 deaths.
The researchers hovered intensely over their laptops as others talked in clusters beneath the digital world clocks. At 7:06 p.m., Dr. Baize sent another email: “Les résultats confirment la présence du virus Ebola.”
“Oh, God,” thought Dr. Fowler, a critical care physician from Canada who was spending a year helping the W.H.O. respond to crises around the world.
A list of the people suspected to have died of Ebola in and around the village of Meliandou, Guinea, during the current outbreak. The list, transcribed by a resident of Meliandou, begins with 1-year-old Emile Ouamouno, believed to be Patient Zero of the outbreak.
The timing could not have been worse. Created by the United Nations in 1948 to coordinate international health efforts, the W.H.O. had been hobbled by recessionary cutbacks and was strained to its limits by concurrent emergencies and outbreaks: the MERS virus in Saudi Arabia, a new avian influenza A strain in China, polio in war-torn Syria, conflicts in the Central African Republic and South Sudan. Now add Ebola.
“It’s like if a plane crashes in the Hudson in the morning, and there’s a snowstorm in the afternoon and floods in the subways in the evening,” Dr. Fowler said. “And then you have two planes hit the World Trade Center in the middle of the night.”
But a lack of resources was not the W.H.O.'s only problem. Its clunky governance structure and overlapping power bases invited political meddling and sowed confusion on the ground.
In addition to its headquarters staff in Geneva, the W.H.O. has largely autonomous offices in each of six regions. The powerful African regional director — Dr. Luis G. Sambo, an Angolan, who finishes his 10 years in the post next month — is nominated not by Geneva, but by the health ministers of the region’s 47 countries. His office, in Brazzaville, Republic of Congo, then proposes representatives in each country, with approval from headquarters.
Dr. Chan and her staff in Europe sent aid and experts, but largely delegated leadership of the early response to W.H.O. regional representatives on the ground.
The paucity of health care in West Africa meant that the W.H.O.'s central coordinating role would be critical. But its capacity had shrunk. In recent years, its epidemic response department, including a network of anthropologists to help overcome cultural differences, had dissolved, with duties parceled out to other branches.
The African region’s budget for epidemic preparedness and response had been more than halved over five years to $11 million for 2014-15, from $26 million in 2010-11, according to Dr. Sambo. Nine of 12 emergency response specialists had been laid off, said Dr. Francis C. Kasolo, the region’s director of disease prevention and control.
The W.H.O. country representatives were, in the view of many who worked with them, earnest but overmatched. Recent W.H.O. audits had found alarming accounting deficiencies in the offices in Guinea, Liberia and Sierra Leone, as well as in the regional office.
Dr. Nils Daulaire, who until February sat on the W.H.O. executive board as the assistant secretary for global affairs at the United States Department of Health and Human Services, said the Africa office had long been seen as “a place where politics often trumps substance” and where key appointees “often are not the cream of the crop.”
Dr. Sambo wrote in response to emailed questions that such criticism “is not fair at all,” adding that “W.H.O. is not a political organization.”
The disconnect between the W.H.O.'s offices in Geneva and in Brazzaville revealed itself almost immediately in the agency’s dealings with the C.D.C., which was accustomed to being brought into outbreaks quickly and given a primary role. It perturbed the C.D.C.'s director, Dr. Thomas R. Frieden, to hear in late March that the team headed by Dr. Rollin, which was being dispatched at the W.H.O.'s request, had been held up by bureaucratic demands.
He got in touch with Dr. Keiji Fukuda, the W.H.O. assistant director-general for health security in Geneva. “They are asking to see résumés of our staff, they are asking if they are qualified to go,” Dr. Frieden said he had complained. He had been told by a high-level W.H.O. official that the regional staff in Africa wanted to prove they could handle this one without help, he said.
“People shouldn’t die because someone’s embarrassed that they can’t do it themselves,” Dr. Frieden said. Dr. Fukuda fixed the problem.
Similarly, Dr. Pierre Formenty, the W.H.O.'s top Ebola authority, said that when he arrived in April, he was passed over as team coordinator in favor of a W.H.O. official in the Guinea office who had never been involved in an Ebola outbreak.
“Obviously,” said Dr. Formenty, 54, who had worked on 17 outbreaks, it was “only because I was coming from Geneva.”
Which part of the W.H.O. was in charge? “It was not clear to us,” Dr. Frieden said.
World Health Organization headquarters
Geneva
Provided logistical and technical support to the regional and country offices, but did not quickly enough grasp the seriousness of the threat posed by the outbreak.
World Health Organization, African region
Brazzaville, Republic of Congo
Led the initial response to the outbreak with country W.H.O. offices, but was underfunded and underprepared.
Centers for Disease Control and Prevention
Atlanta
Sent a team of Ebola experts but did not have a leadership role.
Doctors Without Borders
Geneva
Quickly opened several Ebola isolation and treatment units and sent 60 health care workers, some arriving even before the virus was confirmed.
The virus quickly jumped Guinea’s Forest Region, and by the end of March, cases had been confirmed in densely populated Conakry, and across the border in northwest Liberia.
Along with Dr. Rollin, the seen-it-all veterans parachuted into Conakry, joining forces with in-country staff from Unicef, the Red Cross and other aid groups. The virus hunters revived the camaraderie of past campaigns with bear hugs in the lobby of the Palm Camayenne Hotel, while casting wary eyes at potential competitors for groundbreaking research.
The affable Dr. Rollin, born in colonial Morocco to French parents (he is white but refers to himself impishly as an African-American), was well-suited for deployment to French-speaking Guinea. He developed an instant rapport with the country’s president, Alpha Condé, and convinced him it would be counterproductive to close borders and schools, a decision later reversed.
He stood repeatedly before gatherings of government officials and health workers, his hair wispy white, a slight paunch overhanging his belt, and explained the science of Ebola. He was known for his ability to demystify the disease for any audience, and his recorded remarks were converted into public-service announcements.
As the team leader, he set his four colleagues about the tasks of debugging new software to track the virus and establishing a process to trace anyone who had been exposed. After long and wearying days, they typically continued working over dinners in the hotel restaurant with their laptops open next to their meals.
As the coordinating agency, the W.H.O. took a decidedly anti-alarmist approach. In March, the organization’s offices placed 38 people in Guinea: epidemiologists, logisticians, data managers and others, most from the Africa region. By comparison, there are 338 W.H.O. personnel in West Africa now.
On March 23, the day the outbreak was announced, the W.H.O. spokesman Gregory Härtl took to Twitter from Geneva to stress that “there has never been an #Ebola outbreak larger than a couple of hundred cases.” He doubled down two days later when the agency classified the outbreak a Level 2 emergency out of three. “Ebola has always remained a very localised event,” he posted.
Not everyone saw it that way. Doctors Without Borders, which received the Nobel Peace Prize in 1999 for its humanitarian work, had a longstanding malaria project in Guéckédou in the Forest Region. Within 10 days of the initial diagnosis, it had opened an Ebola isolation ward there, as well as in the nearby town of Macenta and in a hospital in Conakry. The private charity dispatched 60 health care workers and flew in 40 tons of equipment.
“We are facing an epidemic of a magnitude never before seen in terms of the distribution of cases in the country,” Mariano Lugli, the coordinator of the group’s Conakry clinic, said in a March 31 news release.
A three-day Twitter war ensued.
“No need to overblow something which is already bad enough,” Mr. Härtl wrote.
A villager on a path that is used to cross between Sierra Leone and Guinea. Relatively unfettered passage among those countries and Liberia has contributed to an Ebola outbreak that has claimed more than 7,800 lives.
GUINEA
Failure to Track
Closer to the action, some early responders suspected that subduing the outbreak would be complicated. There were so few beds and so little staff to treat or isolate Ebola patients that doctors found themselves stepping over the dying and the dead in hospital corridors.
What alarmed Dr. Kamalini Kalahe-Lokuge, a Doctors Without Borders epidemiologist working in Conakry, was that the patients were coming from all across the city, many from unrelated chains of viral transmission. That meant they had probably infected others who had not been found. In April in the staff tent at Donka Hospital, she unfolded a giant city map she had dotted with red, blue and green ink to track cases.
“This is just the tip of the iceberg,” she told her colleagues. “This is going to blow up.”
Guinea’s government worked to paint a rosier picture. In morning meetings in April, Dr. Aboubacar Sidiki Diakité, the health official in charge of the early response, spoke about the need for “positive communication” so as not to scare away airlines and mining companies, according to several people present.
Dr. Diakité insisted that only test-confirmed cases — a third to half of all known potential cases at that point — be reported to the local news media, said Dr. Formenty of the W.H.O. and Dr. Rollin of the C.D.C.
Underreporting of all kinds hampered the crucial process of locating those with possible exposure, isolating them if needed and monitoring them daily. When the C.D.C. team began working in Conakry on April 2, they found a single pair of W.H.O. trackers ping-ponging across town, managing to see fewer than half of the 71 registered contacts, said Andrea McCollum, an epidemiologist on Dr. Rollin’s crew. When she arrived in the Forest Region two weeks later, only 67 of 390 contacts were being seen, she said.
There had been little effort to recruit volunteers, and there were problems making even nominal payments of $4.25 a day to contact tracers. “It’s really not clear to me why more wasn’t being done,” Dr. McCollum said.
Cross-border cooperation was sporadic. In the early weeks, the W.H.O. hosted daily teleconferences involving officials from West Africa. But it did not set up a regional coordinating center in Guinea until July, and two earlier meetings in border towns were devoted to generic updates rather than an exchange of data on chains of transmission, according to several people present. Many officials met their counterparts from neighboring countries for the first time and exchanged phone numbers.
“In French, we call it ‘un grand mess,'” said Michel Van Herp, an Ebola expert with Doctors Without Borders who was in Guinea.
