Ebola Outbreak in Liberia : August 2014

Ebola Outbreak in
Liberia
August 2014
2014
Amit Bhagat
12/8/2014

Ebola Outbreak in Liberia 2014
2
Contents Page no.
 Ebola Cases 1
 What is Ebola? 2
Transmission 3
Signs and Symptoms 3
Diagnosis 4
Vaccine and Treatment 4
Prevention and Control 4
 Liberian Government Response 6
 World Health Organization (WHO) Response 6
 Centers for Disease Control and Prevention (CDC) Response 7
 Red Cross Response 8
 Medecins Sans Frontieres(MSF)/Doctors without Borders 8
 Samatarin’s Purse Response 9
 What can be done in future to prevent such an outbreak? 9
 References 10

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Ebola Outbreak in Liberia
An outbreak of Ebola Virus that has spread throughout the Central Africa between 1976 and 2015, cracks
headline around the world. This outbreak of Ebola has been ongoing in Liberia since March 2014. This
outbreak also affects Guinea, Nigeria, and Sierra Leone and is the largest outbreak of Ebola in history. The
2014 outbreak began in Guinea, but Liberia and Sierra Leone are currently facing the highest frequency of new
cases, while no new cases have been reported in Guinea for several days. The Government officials of Liberia
have announced Ebola outbreak as “National Emergency” and a “Humanitarian Crisis”. But the World Health
Organization (WHO) has declared it as “International Health Emergency”, meaning that the potential for it to
affect countries on a global scale is severe. Since the first outbreak in 1976, Ebola viruses have infected
thousands of people and killed about one-third of them. Symptoms can come on very quickly and kill fast.
Ebola cases
Liberia(updated
by WHO)
New Confirmed Probable Suspect Total
Cases 38 148 274 132 554
Deaths 12 132 117 45 294
Source: Samaritan’s Purse, WHO and CDC.
Affected districts in Liberia include Bomi County, Bong County, Gbarpolu County, Grand Bassa, Grand Cape
Mount, Grand Gedeh, Grand Kru, Lofa County, Margibi County, Maryland County, Montserrado
County(including the capital city of Monrovia), Nimba County and RiverCess County. Instances of civil unrest
and violence against aid workers have been reported in West Africa as a result of the outbreak. The public
health infrastructure of Liberia is being severely strained as the outbreak grows. According to the Situation

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Report on the EBOLA Virus disease epidemic in Liberia as of 22th May to 07 August 2014, following data have
been proposed by the Ministry of Health and Social Welfare, Republic of Liberia:
What is Ebola?
Ebola virus disease (EVD) (also known as Ebola hemorrhagic fever) is a severe, rare and deadly disease in
humans and nonhuman primates (monkeys, gorillas, and chimpanzees) that has appeared sporadically since
its initial recognition in 1976, with often fatal illness and fatality rate of upto 90%. EVD outbreaks occur
primarily in remote villages in Central and West Africa, near tropical rainforests. The disease is caused by
infection with Ebola virus first appeared in 1976 in 2 simultaneous outbreaks, in Nzara, Sudan, and in
Yambuku, Democratic Republic of Congo, named after a river in the Democratic Republic of the Congo
(formerly Zaire) in Africa, where it was first recognized. The virus is transmitted to people from wild animals
and spreads in the human population through human-to-human transmission. Fruit bats of
the Pteropodidae family particularly species of the genera Hypsignathus monstrosus, Epomops
franqueti and Myonycteris torquata, are considered to be the natural host of the Ebola virus. Severely ill
patients require intensive supportive care. No licensed specific treatment or vaccine is available for use in
people or animals.
Genus Ebolavirus is 1 of 3 members of the Filoviridae family (filovirus), along with genus Marburgvirus and
genus Cuevavirus. Genus Ebolavirus comprises 5 distinct species:
1. Bundibugyo ebolavirus (BDBV)
2. Zaire ebolavirus (EBOV)
3. Reston ebolavirus (RESTV)

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4. Sudan ebolavirus (SUDV)
5. Taï Forest ebolavirus (TAFV).
BDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa, whereas RESTV and TAFV
have not. The RESTV species, found in Philippines and the People’s Republic of China, can infect humans, but
no illness or death in humans from this species has been reported to date.
Transmission
It is one of the world’s most virulent diseases. The infection is transmitted by direct contact with the blood,
secretion, organs, body fluids and tissues of infected animals or people and indirect contact with environments
contaminated with such fluids. Ebola then spreads in the community through human-to-human transmission.
In Africa, infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats,
monkeys, forest antelope and porcupines found ill or dead or in the rainforest. Burial ceremonies in which
mourners have direct contact with the body of the deceased person can also play a role in the transmission of
Ebola. Men who have recovered from the disease can still transmit the virus through their semen for up to 7
weeks after recovery from illness.
Severely ill patients require intensive supportive care. During an outbreak, those at higher risk of infection are
health workers, family members and others in close contact with sick people and deceased patients. The
disease is native to several African countries and is caused by infection with one of the Ebola viruses (Ebola,
Sudan, Bundibugyo, or Taï Forest virus).
However, the only available evidence available comes from healthy adult males. It would be premature to
extrapolate the health effects of the virus to all population groups, such as immuno-compromised persons,
persons with underlying medical conditions, pregnant women and children. More studies of RESTV are needed
before definitive conclusions can be drawn about the pathogenicity and virulence of this virus in humans.
Signs and Symptoms
EVD is a severe acute viral illness often characterized by the sudden onset of fever, intense weakness, muscle
pain, headache, joint and muscle aches and sore throat. This is followed by vomiting, diarrhoea, skin rash,
impaired kidney and liver function, and in some cases, both internal and external bleeding. Laboratory findings
include low white blood cell and platelet counts and elevated liver enzymes.
People are infectious as long as their blood and secretions contain the virus. Ebola virus was isolated from
semen 61 days after onset of illness in a man who was infected in a laboratory.
The incubation period, that is, the time interval from infection with the virus to onset of symptoms, is 2 to 21
days.
Diagnosis
Other diseases that should be ruled out before a diagnosis of EVD can be made include: malaria, typhoid fever,
shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis and other viral
haemorrhagic fevers.
Ebola virus infections can be diagnosed definitively in a laboratory through several types of tests:

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 Antibody-capture enzyme-linked immunosorbent assay (ELISA)
 Antigen detection tests
 Serum neutralization test
 Reverse transcriptase polymerase chain reaction (RT-PCR) assay
 Electron microscopy
 Virus isolation by cell culture.
Samples from patients are an extreme biohazard risk; testing should be conducted under maximum biological
containment conditions.
Vaccine and treatment
No licensed vaccine for EVD is available. Several vaccines are being tested, but none are available for clinical
use.
Severely ill patients require intensive supportive care. Patients are frequently dehydrated and require oral
rehydration with solutions containing electrolytes or intravenous fluids.
No specific treatment is available. New drug therapies are being evaluated and an experimental drug named
“Zmapp” has been used to treat Ebola virus.
Prevention and control
Controlling Reston Ebolavirus in domestic animals
No animal vaccine against RESTV is available. Routine cleaning and disinfection of pig or monkey farms (with
sodium hypochlorite or other detergents) should be effective in inactivating the virus.
If an outbreak is suspected, the premises should be quarantined immediately. Culling of infected animals, with
close supervision of burial or incineration of carcasses, may be necessary to reduce the risk of animal-to-human
transmission. Restricting or banning the movement of animals from infected farms to other areas can reduce
the spread of the disease.
As RESTV outbreaks in pigs and monkeys have preceded human infections, the establishment of an active
animal health surveillance system to detect new cases is essential in providing early warning for veterinary and
human public health authorities.
Reducing the risk of Ebola infection in people
In the absence of effective treatment and a human vaccine, raising awareness of the risk factors for Ebola
infection and the protective measures individuals can take is the only way to reduce human infection and
death.
In Africa, during EVD outbreaks, educational public health messages for risk reduction should focus on several
factors:
 Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or
monkeys/apes and the consumption of their raw meat. Animals should be handled with gloves and

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other appropriate protective clothing. Animal products (blood and meat) should be thoroughly cooked
before consumption.
 Reducing the risk of human-to-human transmission in the community arising from direct or close
contact with infected patients, particularly with their bodily fluids. Close physical contact with Ebola
patients should be avoided. Gloves and appropriate personal protective equipment should be worn
when taking care of ill patients at home. Regular hand washing is required after visiting patients in
hospital, as well as after taking care of patients at home.
 Communities affected by Ebola should inform the population about the nature of the disease and about
outbreak containment measures, including burial of the dead. People who have died from Ebola should
be promptly and safely buried.
Pig farms in Africa can play a role in the amplification of infection because of the presence of fruit bats on these
farms. Appropriate bio-security measures should be in place to limit transmission. For RESTV, educational
public health messages should focus on reducing the risk of pig-to-human transmission as a result of unsafe
animal husbandry and slaughtering practices, and unsafe consumption of fresh blood, raw milk or animal
tissue. Gloves and other appropriate protective clothing should be worn when handling sick animals or their
tissues and when slaughtering animals. In regions where RESTV has been reported in pigs, all animal products
(blood, meat and milk) should be thoroughly cooked before eating.
Controlling infection in health-care settings
Human-to-human transmission of the Ebola virus is primarily associated with direct or indirect contact with
blood and body fluids. Transmission to health-care workers has been reported when appropriate infection
control measures have not been observed.
It is not always possible to identify patients with EBV early because initial symptoms may be non-specific. For
this reason, it is important that health-care workers apply standard precautions consistently with all patients –
regardless of their diagnosis – in all work practices at all times. These include basic hand hygiene, respiratory
hygiene, the use of personal protective equipment (according to the risk of splashes or other contact with
infected materials), safe injection practices and safe burial practices.
Health-care workers caring for patients with suspected or confirmed Ebola virus should apply, in addition to
standard precautions, other infection control measures to avoid any exposure to the patient’s blood and body
fluids and direct unprotected contact with the possibly contaminated environment. When in close contact
(within 1 metre) of patients with EBV, health-care workers should wear face protection (a face shield or a
medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some
procedures).
Laboratory workers are also at risk. Samples taken from suspected human and animal Ebola cases for
diagnosis should be handled by trained staff and processed in suitably equipped laboratories.
Liberian Government response
The Liberian government has recently instituted enhanced measures to combat the spread of Ebola, many of
which will likely make travel to, from, and within the country difficult. The government has taken the following
steps:

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 Closed all borders except major entry points (Roberts International Airport, James Spriggs Payne
Airport, Foya Crossing, Bo Waterside Crossing, and Ganta Crossing).
 Instituted prevention and screening measures at entry points that remain open. This new travel policy
will affect incoming and outgoing travelers.
 Instituted restrictions on public and other mass gatherings.
 Instituted quarantine measures for communities heavily affected by Ebola; travel in and out of those
communities will be restricted.
 Authorized military personnel to aid in enforcing these and other prevention and control measures.
Relief Organizations recommend that people should avoid nonessential travel to Liberia. If you
must travel, such as for humanitarian aid work in response to the outbreak, protect yourself by following advice
for avoiding contact with the blood and body fluids of people who are ill with Ebola.
This recommendation to avoid nonessential travel is intended to facilitate control of the outbreak and prevent
continued spread in two ways: to protect people who may be planning travel to the affected areas and to enable
the Liberian government to respond most effectively to contain this outbreak. Many organizations remain
committed to the multinational effort to assist Liberia in controlling the outbreak and are scaling up their
response activities by, among other things, deploying additional staff to the affected countries. International
humanitarian assistance must continue, and encourage airlines to continue flights to and from the region to
facilitate transport of teams and supplies essential to control the outbreak.
World Health Organization (WHO) response
WHO provides expertise and documentation to support disease investigation and control.
It has provided recommendations for infection control while providing care to patients with suspected or
confirmed Ebola haemorrhagic fever are provided in: Interim infection control recommendations for care of
patients with suspected or confirmed Filovirus (Ebola, Marburg) haemorrhagic fever, March 2008. This
document is currently being updated.
WHO has created an aide–memoire on standard precautions in health care (currently being updated).
Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens. If
universally applied, the precautions would help prevent most transmission through exposure to blood and
body fluids.
Standard precautions are recommended in the care and treatment of all patients regardless of their perceived
or confirmed infectious status. They include the basic level of infection control—hand hygiene, use of personal
protective equipment to avoid direct contact with blood and body fluids, prevention of needle stick and injuries
from other sharp instruments, and a set of environmental controls.
Centers for Disease Control and Prevention (CDC) response
The Centers for Disease Control and Prevention has issued its highest alert activation over the Ebola outbreak.
CDC Director Dr. Tom Frieden announced that their operations center has moved to a Level 1 response. The
Centers for Disease Control and Prevention (CDC) is rapidly increasing its ongoing efforts to curb the
expanding West African Ebola outbreak and deploying staff to four African nations currently affected.

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CDC is rapidly sending more disease-control experts to the four nations currently reporting cases. As CDC
announced last week, 50 additional disease control experts will be in the region within 30 days. Some staff have
completed their deployments and are rotating out of country but overall staff numbers are increasing. As of
Monday Aug. 4, CDC staff deployments are:
 Guinea: 6 currently deployed,
 Liberia: 12 currently deployed
 Nigeria: 4 currently deployed
 Sierra Leone: 9 currently deployed
This sustained, agency-wide response will continue until the outbreak is under control, an effort expected to
take three to six months.
In West Africa, CDC disease detectives are directing efforts to pinpoint cases and their contacts using a new
tool developed at CDC. This Epi Info viral hemorrhagic fever (VHF) application speeds up one of the most
difficult parts of disease detection: finding everyone exposed to the virus. Other CDC experts will educate the
general public about how to avoid Ebola infection; ensure that healthcare personnel strictly follow protocols
that protect them against infection; strengthen laboratory aspects of the response; and improve
communications among all stakeholders (the public, patients and their families, healthcare workers,
governments and non-government organizations, and the media).
CDC efforts are not confined to West Africa. At home, CDC has updated infection-prevention protocols for
hospitals where travelers with suspected Ebola exposures may present for treatment; for aircraft crew and
airport personnel; and for laboratories handling specimens from suspected Ebola cases.
Red Cross response
In coordination with the Ministry of Health, Unicef, Médécins Sans Frontiéres and other partners, the Red
Cross had stepped up sensitization on the ground. “As soon as the outbreak was announced, Red Cross
volunteers were immediately deployed to the affected areas to inform people how to prevent or limit the spread
of the disease,” explains Dr Diawara. “However, there is a need for more volunteers to be trained and
mobilized, both in already affected areas as well as in other regions.”
International Federation of Red Cross and Red Crescent Societies (IFRC) has deployed a Field Assessment
Coordination Team (FACT) to Guinea, including an infectious disease specialist from the French Red Cross
Society, as well as a psychosocial support delegate.
The Ebola outbreak comes at a time when the Red Cross Society of Guinea and other partners are already
working with the government to address a cholera epidemic and an outbreak of measles. Symptoms of Ebola
resemble those of cholera and measles, making it difficult to identify and confirm cases.
IFRC has launched an emergency appeal in Guinea to support the National Society in interventions aimed at
preventing the further spread of the Ebola virus disease. Similar operations are being implemented in
neighbouring Liberia and Sierra Leone after cases were confirmed there. The Red Cross is also proactively
launching preventative operations in three west African countries (Cote d’Ivoire, Mali, Senegal) at risk if the
virus does continue to spread.

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Medecins Sans Frontieres/Doctors without Borders response
MSF emergency teams are continuing their efforts to fight the Ebola epidemic in West Africa. The disease has
claimed 932 lives, according to the WHO, since the outbreak began in March this year.
Over recent weeks, MSF teams have seen a worrying surge in the epidemic, with the number of cases increasing
dramatically in Sierra Leone and Liberia, and the disease spreading to many more villages and towns.
MSF currently has 676 staff working in Guinea, Sierra Leone and Liberia, but warns that it has reached its limit
in terms of staff, and urges the WHO, health authorities and other organizations to scale up their response.
MSF currently have nine international staff and 10 Liberian staff responding to the Ebola outbreak in
Liberia.
The situation in the Liberian capital, Monrovia, is “catastrophic”, according to Lindis Hurum, MSF Emergency
Coordinator in Liberia.
There are reports of at least 40 health workers being infected with Ebola over recent weeks. Most of the
city’s hospitals are closed, and there are reports of dead bodies lying in streets and houses.
MSF teams are providing technical support to an Ebola treatment centre in Monrovia with the Ministry of
Health, and we have started construction of a new treatment centre.
An MSF team based in Guékédou, Guinea, has recently launched a response in Liberia’s Lofa region, alongside
the Guinean border, which has been badly affected by Ebola.
MSF is reinforcing its current team, but they are reaching the limits of their capacity.
Samaritan’s Purse response
Samaritan's Purse stands ready to respond at a moment’s notice whenever and wherever disaster strikes.
Samritan’s Purse specializes in meeting critical needs for victims of conflict, disaster, famine, and epidemics
throughout the world, often working through ministry partners on the ground. We provide food, water, shelter,
medicine, and other assistance.
Samaritan’s Purse have been working closely to combat Ebola since the current outbreak began in Liberia in
March. Dr. Brantly was serving as medical director for the Samaritan’s Purse Ebola Consolidated Case
Management Center in Monrovia and tested positive for Ebola. Nancy Writebol, with her husband David
Writebol work with SIM which manages ELWA Hospital, a partner organization that has been working with
Samaritan’s Purse to combat Ebola. She had been working as a hygienist who decontaminated those entering
and leaving the isolation ward of the Case Management Center at the hospital. Dr. Brantly, who contracted the
Ebola virus while treating patients in Liberia, is being treated at a special unit set up in collaboration with the
Centers for Disease Control and Prevention (CDC) to treat patients who are exposed to certain serious
infectious diseases.
There is a dire need for the WHO, Ministry of Health and other organizations to rapidly and
massively scale up the response in Liberia.
What can be done in future to prevent such an outbreak?

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As Ebola virus is very infectious and no specific treatment or vaccine is yet available for it, using various
methods and approaches to stop the transmission of Ebola virus can help to overcome such an outbreak.
Significantly, by providing technical support to an Ebola treatment centre and construction of new treatment
centers can be beneficial. Thus, the technical information provided for further outdo must contain;
 Preparedness and Response – For Ebola disease epidemic, preparedness, alert, control and
evaluation must be very much essential.
 Infection Control – By taking interim infection prevention and control guidance for care of patients
with suspected or confirmed Filovirus Haemorrhagic fever in health care facilities maintaining hygiene
and proper management of waste from health-cares.
 Social Mobilization – With proper behavioural and social communication in the outbreak response.
 Patient Care – It is very much essential for controlling such type of outbreak. Best practices in
phlebotomy must be undertaken. Recommended steps for safe phlebotomy and principles for drawing,
collecting blood and transporting blood to laboratories/blood banks must be followed.
 Epidemiology – Case definition and study is highly necessary, investigating cause of death during an
outbreak of Ebola virus haemorrhagic fever and draft verbal autopsy instrument for a proper risk
assessment in an epidemic situation.
These above mentioned attributions are obligatory but most importantly, for a thoroughgoing prevention
for such an outbreak if all the countries come forward and support, then to conquer would become a lot
undemanding. Thus, by other Country’s support and unceasing succession of programmes for Epidemic
Alert and Verification(EAV), Strategic Health Operations Centers(SHOC), Logistics, Epidemic readiness
and intervention etc, the dispensation of repercussions would be much more superior.
References
1. World Health Organization (WHO) outbreak updates (till 11 August, 2014).
2. World Health Organization International and WHO Regional office for Africa reports and programmes
information resources on Ebola virus disease(August, 2014).
3. WHO Statement on the Meeting of the International Health Regulations Emergency Committee
Regarding the 2014 Ebola Outbreak in West Africa.
4. Centers for Disease Control and Prevention (CDC) Ebola Virus Disease Information for Clinicians in
U.S. Healthcare Settings(10 August, 2014)
5. CDC West Africa Outbreak Infographic and Outbreak Updates (8 August, 2014).
6. Samaritan’s Purse’s ‘Doctor with Ebola Being Treated in Atlanta’ article (5 August, 2014).
7. FrontPage Africa (Monrovia), “Liberia: Unheralded Fear - Ebola Pose Risks for Liberia Health
Workers” article (19 June, 2014).
8. International Federation of Red Cross and Red Crescent Societies (IFRC), “Using a multi-faceted
approach to stop the transmission of Ebola virus disease”, article at ifrc.org (3 August, 2014).
9. International Federation of Red Cross and Red Crescent Societies (IFRC), ifrc.org news stories
(Africa).
10. Medecins Sans Frontieres/Doctors without Borders, www.msf.org.uk, Ebola: latest updates from the
frontline, Update 8th August 2014.

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11. Medecins Sans Frontieres/Doctors without Borders, www.msf.org.uk, medical issues, Ebola
Emergency.

Ebola Outbreak in Liberia : August 2014

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