EBOLA/EVD [to 9 May 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

WHO: Ebola Situation Report – 6 May 2015
[Excerpts]
SUMMARY
:: A total of 18 confirmed cases of Ebola virus disease (EVD) was reported in the week to 3 May: Guinea and Sierra Leone each reported 9 cases. This is the lowest weekly total this year, and comes after a month-long period during which case incidence fluctuated between 30 and 37 confirmed cases per week. That both countries have each reported fewer than 10 cases is encouraging, but it is important to guard against complacency. Liberia has reported fewer than 10 cases per week since the start of January this year, but the outbreak will be declared to have ended only if no new cases are reported up to 9 May, which marks 42 complete days since the burial of the last confirmed case…

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION
:: There have been a total of 26,593 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11,005 reported deaths (outcomes for many cases are unknown). A total of 9 new confirmed cases were reported in Guinea, 0 in Liberia, and 9 in Sierra Leone in the 7 days to 3 May.

.
The Ebola outbreak in Liberia is over
WHO statement
9 May 2015
Today, 9 May 2015, WHO declares Liberia free of Ebola virus transmission. Forty-two days have passed since the last laboratory-confirmed case was buried on 28 March 2015. The outbreak of Ebola virus disease in Liberia is over.

Interruption of transmission is a monumental achievement for a country that reported the highest number of deaths in the largest, longest, and most complex outbreak since Ebola first emerged in 1976. At the peak of transmission, which occurred during August and September 2014, the country was reporting from 300 to 400 new cases every week.

During those 2 months, the capital city Monrovia was the setting for some of the most tragic scenes from West Africa’s outbreak: gates locked at overflowing treatment centres, patients dying on the hospital grounds, and bodies that were sometimes not collected for days.

Flights were cancelled. Fuel and food ran low. Schools, businesses, borders, markets, and most health facilities were closed. Fear and uncertainty about the future, for families, communities, and the country and its economy, dominated the national mood.

Though the capital city was hardest hit, every one of Liberia’s 15 counties eventually reported cases. At one point, virtually no treatment beds for Ebola patients were available anywhere in the country. With infectious cases and corpses remaining in homes and communities, almost guaranteeing further infections, some expressed concern that the virus might become endemic in Liberia, adding another – and especially severe – permanent threat to health.

It is a tribute to the government and people of Liberia that determination to defeat Ebola never wavered, courage never faltered. Doctors and nurses continued to treat patients, even when supplies of personal protective equipment and training in its safe use were inadequate. Altogether, 375 health workers were infected and 189 lost their lives.

Local volunteers, who worked in treatment centres, on burial teams, or as ambulance drivers, were driven by a sense of community responsibility and patriotic duty to end Ebola and bring hope back to the country’s people. As the number of cases grew exponentially, international assistance began to pour in. All these efforts helped push the number of cases down to zero.
Liberia’s last case was a woman in the greater Monrovia area who developed symptoms on 20 March and died on 27 March. The source of her infection remains under investigation. The 332 people who may have been exposed to the patient were identified and closely monitored. No one developed symptoms; all have been released from surveillance.

Health officials have maintained a high level of vigilance for new cases. During April, the country’s 5 dedicated Ebola laboratories tested around 300 samples every week. All test results were negative.

While WHO is confident that Liberia has interrupted transmission, outbreaks persist in neighbouring Guinea and Sierra Leone, creating a high risk that infected people may cross into Liberia over the region’s exceptionally porous 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 will maintain an enhanced staff presence in Liberia until the end of the year as the response transitions from outbreak control, to vigilance for imported cases, to the recovery of essential health services.

Evolution of the outbreak
The start of the outbreak was deceptively slow. Health officials were on high alert for cases following WHO’s confirmation, on 23 March 2014, of the Ebola outbreak in Guinea. Liberia’s first 2 cases, in the northern county of Lofa near the border with Guinea, were confirmed on 30 March 2014.

On 7 April, 5 more cases were confirmed, 4 in Lofa and 1 in Monrovia. All 5 died. The situation then stabilized, with no new cases reported during April and most of May.

Further cases were detected in early June, mainly in Lofa county, but the trend did not look alarming, especially when compared with the situation elsewhere. At the end of June, Liberia reported 41 cases, compared with 390 in Guinea and 158 in Sierra Leone.

The impression of a calm situation turned out to be an illusion. The first additional cases in Monrovia were reported in mid-June. The city was ill-prepared to cope with the onslaught of infections that rapidly followed as the virus raced through hospitals, communities, and eventually entire neighbourhoods.

Case numbers that had multiplied quickly began to grow exponentially. On 6 August, President Ellen Johnson Sirleaf declared a three-month state of emergency and announced several strict measures aimed at getting cases down.

In mid-August, a WHO team of emergency experts estimated that Monrovia needed 1000 beds just to treat currently infected patients. Only 240 beds were available.

In September, WHO began construction of a new treatment centre, using teams of 100 construction workers labouring in round-the-clock shifts. On 21 September, the Island Clinic was formally handed over by WHO to Liberia’s Ministry of Health and Social Welfare. The clinic added 150 beds to Monrovia’s limited treatment capacity. However, within 24 hours after opening, the clinic was overflowing with patients, demonstrating the desperate need for more treatment beds.

WHO supported the construction of 2 additional Ebola treatment centres, augmenting Monrovia’s treatment capacity by another 400 beds. The remaining need was eventually met by multiple partners. The rapid increase in treatment capacity, especially in Monrovia, likely did much to turn the outbreak around.

The outbreak began to subside in late October, when more new cases were detected early and rapidly treated in isolation, and more safe and dignified burials were performed. Case-fatality rates dropped. As the number of survivors grew, public perceptions changed from viewing treatments centres as “death traps” to seeing them as places of hope. That altered perception, in turn, encouraged more patients to seek early treatment.

The incidence of new cases stabilized in mid-November, with daily reports showing only 10 to 20 new cases. During the early months of 2015, cases dwindled further, eventually allowing detection and investigation of the last remaining chains of transmission. From late March on, daily reports consistently showed zero cases.

Factors that contributed to success: big dreams
A number of factors contributed to the success of Liberia’s Ebola response.

The first decisive factor was the leadership shown by President Sirleaf, who regarded the disease as a threat to the nation’s “economic and social fabric” and made the response a priority for multiple branches of government. Her swift and sometimes tough decisions, frequent public communications, and presence at outbreak sites were expressions of this leadership.

As President Sirleaf famously stated in her memoir, “The size of your dreams must always exceed your current capacity to achieve them. If your dreams do not scare you, they are not big enough.”

Second, health officials and their partners were quick to recognize the importance of community engagement. Health teams understood that community leadership brings with it well-defined social structures, with clear lines of credible authority. Teams worked hard to win support from village chiefs, religious leaders, women’s associations, and youth groups.

One of the first signs that the outbreak might be turned around appeared in September 2014, when cases in Lofa county, Ebola’s initial epicentre, began to decline after a peak of more than 150 cases a week in mid-August. Epidemiologists would later link that decline to a package of interventions, with community engagement playing a critical role.

In Lofa, staff from the WHO country office moved from village to village, challenging chiefs and religious leaders to take charge of the response. Community task forces were formed to create house-to-house awareness, report suspected cases, call health teams for support, and conduct contact tracing.

See-through walls around the treatment centre replaced opaque ones, allowing families and friends to watch what was happening inside, thus dispelling many rumours. Calls for transportation to treatment facilities or for burial teams were answered quickly, building confidence that teams were there to help.

The effectiveness of this response, which was duplicated elsewhere, points to a third factor: generous support from the international community, including financial, logistical, and human resources. This support added more treatment beds, increased laboratory capacity, and augmented the number of contact tracing and burial teams. The deployment of self-sufficient foreign medical teams from several countries had a dramatic impact on the outbreak’s evolution.

Finally, strong coordination of the international and national response was essential for success. International support was slow to start, but abundant when it arrived. Innovations such as the Presidential Advisory Committee on Ebola and introduction of a incident management system helped ensure that resources and capacities were placed where needed.

Many of these lessons and experiences are reflected in WHO’s new response plan, which aims to identify all remaining cases in West Africa by June 2015.
WHO strategic response plan 2015: West Africa Ebola outbreak

.
Milestone Expected to Be Reached in Liberia’s Fight against Ebola, Senior Officials Tell Security Council
Speakers also Warn Against Complacency, Stress Continued Need for Support
5 May 2015
SC/11882
Security Council 7438th Meeting* (PM)
[Excerpts; Editor’s text bolding]
With Ebola nearly eradicated from Liberia, it was now critical to address factors that contributed to the epidemic’s spread in the country, particularly given the continued drawdown of peacekeepers, the Secretary-General’s Special Representative told the Security Council this afternoon.

“Ebola highlighted Liberia’s underlying fragility,” Karin Landgren, who is also Head of the United Nations Mission in Liberia (UNMIL), said in a briefing that also heard from Olof Skoog of Sweden, Chair of the Peacebuilding Commission and its country-specific configuration on Liberia, as well as the country’s Minister for Justice, Benedict Sannoh.

All three speakers spoke of the enormous milestone expected to be reached on 9 May, when, if no new case had been confirmed by then, the World Health Organization (WHO) was expected to declare Liberia Ebola-free “after almost 14 months spent under the cloud of Ebola”, as Ms. Landgren put it. At the same time, all three speakers warned against complacency and stressed the continued need for international support for the country.

Ms. Landgren introduced the Secretary-General’s latest bi-annual report on Liberia (document S/2015/275), which welcomed the eradication of the Ebola but said that the epidemic revealed the degree of distrust in the Government and the weakness of institutions in the country.

Liberians were angered, Ms. Landgren added, by the Government’s initial slow response and the rising cost of basic commodities, while the declaration of the state of emergency fuelled fears of misuse of power.

The report noted that, however, in line with the Secretary-General’s recommendations, UNMIL would continue its drawdown authorized through resolution 2215 (2015), reducing military personnel from 4,811 to 3,590 and its police from 1,795 to 1,515 by September 2015. June 2016 was set as the deadline for the Government to fully assume security responsibilities from the Mission…

…At the same time, she said that the Ebola epidemic showed that societal divisions existed and that reconciliation was a work in progress. Dialogue targeted to social exclusion and the crimes of the past was needed. In addition, more work was needed with neighbouring countries to promote regional stability…

She stressed that in all such areas, much would be at stake in 2017, when Liberia’s next presidential election was planned. In anticipation, she said, the political environment had become increasingly intense. The international community must consider how to frame its own support for the process and determine the proper peacekeeping presence that would sustain the country’s — and the Mission’s — successes and prevent a reversal.

Mr. Skoog, in his briefing… stressed the importance of a regional approach to recovery from the Ebola crisis and to cementing stability in West Africa. Relevant initiatives towards that end deserved greater international support. The priority for the Commission was to safeguard and strengthen all gains made in the country as UNMIL drew down, with the transition well-coordinated with Ebola recovery efforts…
:: Twenty-ninth progress report of the Secretary-General on the United Nations Mission in Liberia
United Nations Security Council
S/2015/275
23 April 2015

.
CDC/MMWR/ACIP Watch [to 9 May 2015]
http://www.cdc.gov/media/index.html
:: Liberia Travel Alert Revised from Level 3 to Level 2: “Practice Enhanced Precautions” – Media Statement
MONDAY, MAY 4, 2015