On the morning of March 5, a 58-year-old English teacher stood outside an Ebola treatment center in the Liberian capital city of Monrovia, flanked by a row of health-care workers. The smiling woman, Beatrice Yardolo, had contracted the deadly hemorrhagic fever on February 19. Now, just two weeks later, she was at the center of a public discharge ceremony from the Chinese-run facility.
With public health officials, media, and politicians in attendance, Yardolo gave interviews expressing her happiness at being declared Ebola-free. At the time, the teacher was one of 9,249 Liberians who had contracted the virus during the deadliest Ebola outbreak on record, which had by then killed more than 9,800 people throughout Liberia, Guinea, and Sierra Leone — a death toll that has since surpassed 11,250.
"I am one of the happiest human beings today on Earth because it was not easy going through this situation and coming out alive," Yardolo told the Associated Press after her release.
But a sense of unease loomed, even as officials expressed optimism over the fact that Yardolo, for the time being, was the last confirmed Ebola patient in Liberia. For the first time in nearly 10 months, there was not a single person infected with the virus in any of the country's emergency treatment units.
The sentiment was clear that hot Wednesday morning: The fight against Ebola was not over for the country of 4.2 million people. Officials were still monitoring more than 100 individuals living in Liberia who had come in contact with an Ebola patient in the last 21 days — the incubation period for the virus. It would take a total of 42 days without a new confirmed case of hemorrhagic fever for the World Health Organization (WHO) to officially declare Liberia free of the virus.
The push for zero cases, while difficult, is an essential mark for the afflicted countries to achieve. At its most basic level, Rick Brennan, the director of WHO's Ebola response, explained to me that until we "get to zero cases there's always the possibility that it could flare up again and spread again." Just as important, the fight against Ebola has had devastating effects on health systems, economies, and human resources that will take time to rebuild. "Ebola cases took a lot of energy and resources from the health system," Brennan told me, "and until we end the outbreak, it will be very challenging to fully reestablish essential and comprehensive health services."
Health officials were still concerned that new infections were being regularly reported in Sierra Leone and Guinea, just across Liberia's porous borders. Obstacles in the way of keeping tabs on contacts, public trust, and disease awareness continued to hinder local and international efforts to reach the only milestone that could mark the end of the Ebola outbreak in West Africa — zero cases in all three countries for 42 days straight.
Later that afternoon, I called Liberia's assistant health minister, Tolbert Nyenswah, from a parked car in the New Georgia Estate area of Montserrado County, Liberia's most populous county.
"We don't have any confirmed cases in the ETU, but this does not mean that the fight against Ebola is over," he said, being sure to emphasize in various ways that the country needed to remain vigilant.
"Of course, everything should remain tight. There is no room for complacency — every citizen should take measures so that Liberia remains at zero, and also support our neighbors," Nyenswah explained.
This was a phone call I'd made many times over the last 10 months to a man who had quickly emerged as the public face of the government's Ebola response efforts. When Nyenswah and I first spoke, in June 2014, the Ebola virus had descended on Monrovia. Traditionally, hemorrhagic fever has plagued isolated rural villages in Central and East African countries like the Democratic Republic of the Congo (DRC), Gabon, and Uganda. The recent epidemic marked the first time the virus hit major cities. The three hardest-hit countries have all reported cases in their capitals — Conakry, Guinea; Freetown, Sierra Leone; and Monrovia.
During a phone conversation in June of 2014, Nyenswah was in a car making his way to various parts of the city to coordinate response efforts. It was a time when public health officials were as hands-on in the fight against Ebola as anyone. Nyenswah told me he had visited a traditional healing center that day where multiple dead bodies and suspected cases were picked up. The assistant health minister was clear about the situation: Liberia needed help.
"The situation is not stable; it's volatile," he said then, going on to stress the country's need for international doctors and help in training local medical staff. At that point, West Africa's first-ever experience with Ebola had become the worst outbreak since the virus was discovered, in 1976 in the DRC, then known as Zaire. A total of 400 confirmed deaths had occurred since December 2013, when the first infection showed up in Guinea's Guéckédou Prefecture. It is thought that a two-year-old boy from the village of Meliandou became patient zero after contracting the virus from a bat — a natural reservoir for Ebola.
That June marked the death of Liberia's first healthcare worker from the virus. Top surgeons, doctors, and nurses would soon follow. International medical charity Doctors Without Borders and WHO announced that the outbreak was getting serious, as infection numbers inflated in Sierra Leone and Guinea as well.
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But it wasn't until August, 1,711 cases and 932 deaths later, that WHO declared a public health emergency of global concern and visuals from the ground started to catch international attention. While the world was just waking up to the crisis, Liberians were already in the midst of an unprecedented and chaotic situation, even from the perspective of a country still recovering from 14 years of civil war.
"Sometimes there were bodies all over. September, the month of September, it was very bad," a case investigator named Victoria Kolakeh told me three days after Yardolo's hospital discharge in March.
"By that time it was difficult," she said, recounting the outbreak, which peaked in Liberia during the months of August and September 2014.
In July of that year, when the government put out an urgent request for health-care workers to help with Ebola response efforts, Kolakeh, a nurse by profession, volunteered. The 40-year-old went through training with a group of five other people to learn basic prevention measures for the virus. Afterward, she joined a group of 14 volunteers, including case investigators, drivers, nurses, and hygienists, who were divided into two teams. They worked in 24-hour shifts, from 8an to 8am the following day, covering the city in its entirety to track down suspected cases and transport people to the hospital.
I met Kolakeh and her team members on a Saturday morning in March, in a war room set up in Monrovia's John F. Kennedy Medical Center. Case-investigation teams had tacked up maps, schedules, and lists of contacts being monitored. Kolakeh was coming fresh off of a 21-day quarantine after entering a treatment center without proper protective gear. She arrived that morning wearing a graphic T-shirt, chlorine-stained pants, and a gray hat. From this meeting she would spend her eight-hour shift waiting for calls to come in with reports of suspected Ebola cases in Monrovia's Sector 1, which included some of the city's most densely populated neighborhoods.
When Kolakeh started, however, case investigations were less organized. She and her teammates responded to calls from all over the city and county, at a time when reports of suspected cases were constantly coming in and the sound of ambulance sirens on the busy streets of Monrovia was constant.
When I asked Kolakeh how exhausted she was during the height of the outbreak, working 24 hours straight and often well past the 8am shift change, she responded bluntly, as Liberians often do.
"Very much, but what to do?" she said. "For me, it was for the sake of my people. I gave myself to work for my country."
Case investigations and contact tracing require intense efforts to locate and monitor all the people an Ebola patient has recently encountered. These response activities are integral to containing the disease. As an outbreak slows down, the process becomes easier, but effective tracing becomes even more essential in the race to zero.
Liberia began seeing a drop in the number of new Ebola infections starting in October, steadily lowering through the beginning of 2015 — even as Guinea and Sierra Leone struggled to control the disease. Brennan explained that at this point, the Ebola response shifted to a phase when detailed epidemiological work became the focus.
"By January, we had reduced the incidents to around a hundred to a hundred and 50 cases per week, but those kinds of big-picture interventions aren't enough to end the outbreak," Brennan told me. "The last mile is all about the detailed epidemiological fieldwork, which we could do once we got to those lower numbers: finding every case, going out to villages, finding each person who's sick, and finding each one of their contacts."
Even as I sat in their dispatch room, the exhaustion of the last several months was still visible on the staff's faces while they waited for calls. As Kolakeh walked me through the layout of Sector 1, she received a phone call from SOS Children's Village, a clinic run by an international charity, saying that a woman with Ebola-like symptoms — vomiting, diarrhea, and exhaustion—had just been dropped off at their entrance.
The team quickly jumped into action, grabbing their bags and loading up a vehicle and ambulance to drive to the site. When
they got there, the sick woman, sprawled out on the cement, refused to board the ambulance and go to an Ebola treatment unit: The stigma and fear around the virus that comes even with just going to the clinic for testing is still alive in the minds of many Liberians. Kolakeh and a social worker spent time coaxing the woman for more personal information, but she refused to provide the contact details of family members.
By chance, the vehicle driver recognized the woman from his neighborhood and called community members until he obtained her sister's phone number. Kolakeh got on the phone immediately and began the long process of compiling a definitive list of anyone who might have come into contact with the woman. Once this was finished, contact tracers working with Kolakeh would attempt to follow up with the individuals for 21 days until they had passed Ebola's incubation period without exhibiting any symptoms.
Eventually, after more than 30 minutes of discussion, Kolakeh managed to get the woman into the ambulance and take her to ELWA 3 hospital, the largest Ebola treatment center in the world. With a 250-bed capacity, the facility now sits mostly empty.
As with many of the suspected cases Kolakeh and her colleagues had taken for Ebola testing in recent days, the women from SOS Children's Village tested negative for the virus. Diseases like malaria and cholera are commonplace in the region and present Ebola-like symptoms in the early stages. With the virus maintaining its grip in neighboring countries, case investigators must remain vigilant in responding to phone calls and burial teams must continue to perform safe interments until all three nations reach the point of zero Ebola infections.
After I left Kolakeh, Liberia enjoyed a streak of 15 days without a new Ebola case. But on March 20, just six days short of the 21-day incubation period, a 44-year-old woman tested positive for the virus in a Monrovia hospital. Though this was a major setback for the country, health-care workers managed to contain the disease and safely transport the patient to ELWA 3. Not a single person who came into contact with the patient showed signs of the illness.
The woman died on March 27, but six weeks later, Liberia finally hit the milestone it had been chasing for a year. On May 9, the country had managed 42 days without incidence of the disease. Officially, the country was Ebola-free and the outbreak was over.
While WHO said it was confident the country had interrupted transmission, it underscored the fact that Guinea and Sierra Leone were still reporting Ebola outbreaks near their borders. "The government is fully aware of the need to remain on high alert and has the experience, capacity, and support from international partners to do so," WHO concluded.
In the more than two months since, both Guinea and Sierra Leone have continued to report new cases of the illness. In June, the countries recorded an average of 20 infections per week.
Brennan said that while there have been major behavioral changes in communities experiencing continued transmission, much work still needs to be done to overcome obstacles of resistance and awareness.
"If all those communities changed their behavior overnight, we'd end this outbreak in twenty-one days," Brennan explained, adding that he expected to see fluctuation but overall a larger trend downward in the number of cases. While he expressed that WHO is confident West Africa will get to zero cases, he reemphasized the need for detailed and almost flawless epidemiological work in this "last mile" of the outbreak.
"To end an Ebola outbreak requires a level of programmatic excellence that's unusual for most humanitarian programs," he said. "We have to find every case; we have to find every contact."
Just days later, on June 30, one month and three weeks after the outbreak in Liberia was declared over, Nyenswah announced that the dead body of a 17-year-old boy had tested positive for Ebola. A safe burial was performed, and nearby houses in the Margibi County village were placed under quarantine. Suddenly, community health teams had more than 100 new contacts to follow.
Source: Kayla Ruble via Vice News