Patient Zero in the Ebola
outbreak, researchers suspect, was a 2-year-old boy who died on Dec. 6,
just a few days after falling ill in a village in Guéckédou, in
southeastern Guinea. Bordering Sierra Leone and Liberia, Guéckédou is at the intersection of three nations, where the disease found an easy entry point to the region.
A
week later, it killed the boy’s mother, then his 3-year-old sister,
then his grandmother. All had fever, vomiting and diarrhea, but no one
knew what had sickened them.
Two
mourners at the grandmother’s funeral took the virus home to their
village. A health worker carried it to still another, where he died, as
did his doctor. They both infected relatives from other towns.
By the
time Ebola was recognized, in March, dozens of people had died in eight
Guinean communities, and suspected cases were popping up in Liberia and
Sierra Leone — three of the world’s poorest countries, recovering from
years of political dysfunction and civil war.
In
Guéckédou, where it all began, “the feeling was fright,” said Dr.
Kalissa N’fansoumane, the hospital director. He had to persuade his
employees to come to work.
On March 31, Doctors Without Borders,
which has intervened in many Ebola outbreaks, called this one
“unprecedented,” and warned that the disease had erupted in so many
locations that fighting it would be enormously difficult.
Now, with 1,779 cases, including 961 deaths and a small cluster in Nigeria,
the outbreak is out of control and still getting worse. Not only is it
the largest ever, but it also seems likely to surpass all two dozen
previous known Ebola outbreaks combined.
Epidemiologists predict it will
take months to control, perhaps many months, and a spokesman for the
World Health Organization said thousands more health workers were needed
to fight it.
Some
experts warn that the outbreak could destabilize governments in the
region. It is already causing widespread panic and disruption. On
Saturday, Guinea announced that it had closed its borders with Sierra
Leone and Liberia in a bid to halt the virus’s spread.
Doctors worry
that deaths from malaria, dysentery and other diseases could shoot up as
Ebola drains resources from weak health systems. Health care workers,
already in short supply, have been hit hard by the outbreak: 145 have
been infected, and 80 of them have died.
Past
Ebola outbreaks have been snuffed out, often within a few months. How,
then, did this one spin so far out of control? It is partly a
consequence of modernization in Africa, and perhaps a warning that
future outbreaks, which are inevitable, will pose tougher challenges.
Unlike most previous outbreaks, which occurred in remote, localized
spots, this one began in a border region where roads have been improved
and people travel a lot. In this case, the disease was on the move
before health officials even knew it had struck.
Also,
this part of Africa had never seen Ebola before. Health workers did not
recognize it and had neither the training nor the equipment to avoid
infecting themselves or other patients. Hospitals in the region often
lack running water and gloves, and can be fertile ground for epidemics.
Public health experts acknowledge that the initial response, both locally and internationally, was inadequate.
“That’s obviously the case,” said Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention. “Look at what’s happening now.”
He
added, “A couple of months ago, there was a false sense of confidence
that it was controlled, a stepping back, and then it flared up worse
than before.”
Health
experts have grown increasingly confident in recent years that they can
control Ebola, Dr. Frieden said, based on success in places like
Uganda.
But
those successes hinged on huge education campaigns to teach people
about the disease and persuade them to go to treatment centers. Much
work also went into getting people to change funeral practices that
involve touching corpses, which are highly infectious.
But in West Africa, Ebola was unknown.
In some areas, frightened and angry people have attacked health workers and even accused them of bringing in disease.
“Early
on in the outbreak, we had at least 26 villages or little towns that
would not cooperate with responders in terms of letting people into the
village, even,” said Gregory Hartl, a spokesman for the World Health
Organization.
The
outbreak has occurred in three waves: The first two were relatively
small, and the third, starting about a month ago, was much larger, Mr.
Hartl said. “That third wave was a clarion call,” he said.
At
a House subcommittee hearing on Thursday, Ken Isaacs, a vice president
of Samaritan’s Purse, said his aid group and Doctors Without Borders
were doing much of the work on the outbreak.
“That
the world would allow two relief agencies to shoulder this burden along
with the overwhelmed Ministries of Health in these countries testifies
to the lack of serious attention the epidemic was given,” he said.
Guinea’s Monumental Task
In mid-March, Guinea’s Ministry of Health asked Doctors Without Borders for help in Guéckédou.
At
first, the group’s experts suspected Lassa fever, a viral disease
endemic in West Africa. But this illness was worse. Isolation units were
set up, and tests confirmed Ebola.
Like many African cities and towns, this region hums with motorcycle taxis and minivans crammed with passengers.
The
mobility, and now the sheer numbers, make the basic work of containing
the disease a monumental task.
The only way to stop an outbreak is to
isolate infected patients, trace all their contacts, isolate the ones
who get sick and repeat the process until, finally, there are no more
cases.
But
how do you do that when there can easily be 500 names on the list of
contacts who are supposed to be tracked down and checked for fever every
day for 21 days?
“They
go to the field to work their crops,” said Monia Sayah, a nurse sent in
by Doctors Without Borders. “Some have phones, but the networks don’t
always work. Some will say, ‘I’m fine; you don’t have to come,’ but we
really have to see them and take their temperature. But if someone wants
to lie and take Tylenol, they won’t have a temperature.”
What You Need to Know About the Ebola Outbreak
At
Donka Hospital in Guinea’s capital, Dr. Simon Mardel, a British
emergency physician who has worked in seven previous hemorrhagic fever
outbreaks and was sent to Guinea by the World Health Organization,
realized this outbreak was the worst he had seen. A man had arrived late
one night, panting and with abdominal pain.
During the previous few
days, he had been treated at two private clinics, given intravenous
fluids and sent home.
The staff did not suspect Ebola because he had no
fever. But fever can diminish at the end stage of the disease.
The
treatment room at Donka was poorly lit and had no sink. There were few
buckets of chlorine solution, and the staff found it impossible to clean
their hands between patients.
The
man died two hours after arriving. Tests later showed he had been
positive for Ebola. Untold numbers of health care workers and their
subsequent patients had been exposed to the disease.
Gloves,
in short supply at the hospitals, were selling for 50 cents a pair on
the open market, a huge sum for people who often live on less than a
dollar a day.
At homes where families cared for patients, even plastic
buckets to hold water and bleach for washing hands and disinfecting
linens were lacking.
Workers
were failing to trace all patients’ contacts.
The resulting unsuspected
cases, appearing at hospitals without standard infection control
measures, worsened the spread in a “vicious circle,” Dr. Mardel said.
Tracing an Epidemic’s Origins
As
is often the case in Ebola outbreaks, no one knows how the first person
got the disease or how the virus found its way to the region.
The virus
infects monkeys and apes, and some previous epidemics are thought to
have begun when someone was exposed to blood while killing or butchering
an infected animal. Cooking will destroy the virus, so the risk is not
in eating the meat, but in handling it raw.
Ebola is also thought to
infect fruit bats without harming them, so the same risks apply to
butchering bats. Some researchers also think that people might become
infected by eating fruit or other uncooked foods contaminated by
droppings from infected bats.
Once
people become ill, their bodily fluids can infect others, and they
become more infectious as the illness progresses.
The disease does not
spread through the air like the flu; contact with fluids is necessary,
usually through the eyes, nose, mouth or cuts in the skin. One drop of
blood can harbor millions of viruses, and corpses become like virus
bombs.
A
research team that studied the Guinea outbreak traced the disease back
to the 2-year-old who died in Guéckédou and published a report in The New England Journal of Medicine.
He and his relatives were never tested to confirm Ebola, but their
symptoms matched it and they fit into a pattern of transmission that
included other cases confirmed by blood tests.
But
no one can explain how such a small child could have become the first
person infected. Contaminated fruit is one possibility. An injection
with a contaminated needle is another.
Sylvain
Baize, part of the team that studied the Guinea outbreak and head of
the national reference center for viral hemorrhagic fevers at the
Pasteur Institute in Lyon, France, said there might have been an earlier
case that went undiscovered, before the 2-year-old.
“We suppose that the first case was infected following contact with bats,” he said. “Maybe, but we are not sure.
Roaring Back in Liberia
Dr.
Fazlul Haque, deputy representative of Unicef in Liberia, said that
after a few cases there in March and April, health workers thought the
disease had gone away. But it came roaring back about a month later.
“It reappeared, and this time, it came in a very big way,” he said. “The rate of increase is very high now.”
From July 30 to Aug. 6, Liberia’s government reported more than 170 new cases and over 90 deaths.
“Currently, our efforts are not enough to stop the virus,” Dr. Haque said.
He
added that most health agencies believed the true case numbers to be
far higher, in part because locals were not coming forward when
relatives fell ill, and because detection by the health authorities has
been weak.
Rukshan Ratnam, a spokesman for Unicef in Liberia, said some
families had hidden their sick to avoid sending them to isolation wards,
or out of shame stemming from traditional beliefs that illness is a
punishment for doing something wrong.
Dr.
Haque said that the tracing of cases, crucial for the containment of
the disease, was moving too slowly to keep up with new infections.
Seven
counties have confirmed cases, and the government has deployed security
forces in Lofa County, where Liberia’s first case was detected, he
said.
But the government has given leave to nonessential employees in
those areas, so it is not clear how they will have the staffing to
isolate the sick. Some hospitals have closed because so many health
workers have fallen ill.
Liberia
has closed markets and many border crossings. It has said testing and
screening will be done at immigration checkpoints.
But
on Thursday, at a checkpoint staffed by at least 30 soldiers in Klay,
Bomi County, there was no screening — just a blockade and a line of
trucks loaded with bags of charcoal, plantains and potato greens.
Hilary
Wesseh, a truck driver who was sucking the last drops of juice out of a
small lime, said he had been stuck there for two days.
“They are holding us hostage,” he said.
A Desperate Call for Help
By
June and July, Sierra Leone was becoming the center of the outbreak. At
the government hospital in Kenema, Dr. Sheik Umar Khan was leading the
efforts to treat patients and control the epidemic.
But
he was desperate for supplies: chlorine for disinfection, gloves,
goggles, protective suits, rudimentary sugar and salt solutions to fight
dehydration and give patients a chance to survive.
Early in July, he
emailed friends and former medical school classmates in the United
States, asking for their help and sending a spreadsheet listing what he
needed, and what he had.
Many of the lines in the “available” column
were empty. One of his requests was for body bags: 3,000 adult, 2,000
child.
Before his friends could send the supplies, Dr. Khan contracted Ebola himself. He died on July 29.
