12 November 2014
Ebola situation assessment - 10 November 2014
Investigations undertaken by Ministries of Health in Mali and Guinea,
assisted by WHO, have clarified the early exposure history of Mali's
first Ebola case.
The index case in Mali, a 2-year-old girl who resided with her family
in the urban commune of Beyla, Guinea, was diagnosed with Ebola, in
Kayes, Mali, on 23 October and died on the following day.
In Guinea: a family devastated by an undiagnosed disease
The child's history while still residing in Guinea strongly suggests
that several members of her family died from Ebola virus disease. Most
of the patients described below were buried safely by Red Cross
volunteers, but not tested until late in the transmission chains.
The Guinea history reveals many difficult challenges faced by
ministries of health, local health officials, WHO and other partners in
the Ebola response.
The child's history begins with the death of her father, of unidentified causes, on 3 October.
The father was a Red Cross worker who also provided care at a private
medical clinic owned by his father (the paternal grandfather of the
index case). The paternal grandfather was a retired health care worker.
While working at the private medical clinic, the child's father had
contact with a farmer from another village who died, of undiagnosed
causes, on 12 September. The farmer sought treatment accompanied by his
two daughters. Both daughters died, of undiagnosed causes, in Beyla on
23 September, one at dawn and the other in the evening.
WHO data from Sierra Leone strongly suggest that Ebola care in
private health facilities, as opposed to care in publicly-funded or
MSF-run Ebola treatment centres, carries a higher risk of infection. In
Kenema, for example, 87% of new infections among health care workers
have been acquired in privately-run non-Ebola clinics.
Going home to die
The child's father fell ill sometime during the third week of
September. Fellow residents and neighbours in Beyla believed he was the
victim of a bad-luck "curse" following an argument with the village
chief. Witchcraft, and not Ebola, was suspected.
Shunned by the community, and on the advice of his own father (the
paternal grandfather of the index case and the head of the family), the
father returned to his native village of Sokodougou, in the
sub-prefecture of Moussadou – a trip of more than 70 kilometres. He died
there on 3 October.
This pattern of returning to a native village to grow old or die is
commonly seen in Guinea, Liberia, Sierra Leone and many other countries
around the world.
Such frequent travels by symptomatic Ebola patients, often via public
transportation and over long distances, unquestionably create multiple
opportunities for high-risk exposures – en route and also when the
patient reaches his home and is greeted by family and friends.
Diagnosis: Ebola
Meanwhile in Beyla, the paternal grandfather and family head lost his
wife to an unknown disease on 8 October. He then allowed health
officials to undertake contact tracing of 16 family members who had been
in close contact with his deceased son (the father of the index case in
Mali).
On the following day (9 October), two of his other sons were admitted
to hospital. The hospital referred them to a MSF-run Ebola transit
centre in Macenta.
The first son died the same day en route to Macenta. On 10 October,
samples from both sons tested positive for Ebola, strongly suggesting
that other family members had also died from Ebola virus disease.
On 16 October, the paternal grandfather travelled to Macenta, seeking
treatment for what he told medical staff was "rheumatoid arthritis". As
part of a thorough medical examination, he was tested for Ebola.
Positive results were received from the laboratory on 17 October. The
paternal grandfather died at an Ebola treatment centre in Gueckedou on
20 October.
Mali's index case leaves Guinea
Following news of the death of relatives in Guinea, the child's grand
aunt or "Grandma" (the second wife of the maternal grandfather)
travelled to Beyla, Guinea, to offer her condolences to her relatives.
The "Grandma" resides in Kayes, Mali.
She left Guinea to return to Mali on 19 October, taking the
2-year-old index case and her 5-year-old sister with her. A maternal
uncle, the mother's brother, also accompanied them. The index case was
showing haemorrhagic symptoms in Guinea when the three began their
extensive travels.
The mother is alive and is in regular telephone contact with the Mali
team. She has to remain in the village where her husband was buried for
40 days for the official mourning, before she can leave. Her
three-month-old baby is with her in Guinea. Both are under observation
and, to date, neither has shown any symptoms.
The family group travelled via public transportation, taking at least
one bus and 3 taxi rides as they journeyed more than 1200 kilometres
through Mali. The buses made frequent stops for fuel or to let
passengers on.
The four spent 2 hours in the capital, Bamako, visiting
relatives in a household with 25 people.
On 19–20 October, they travelled overnight in one bus from Bamako to
Kayes. Between Bamako and Kayes, only two persons left the bus at
Niamiga village. Persistent tracking eventually located both at their
final destinations, in Dakar, Senegal and Paris, France.
Once in Kayes, the Grandma and index case consulted two traditional
healers. The second healer took them to a retired nurse, who was alarmed
by the child's high temperature, which was above 40° C. When he learned
they had recently travelled in Guinea, he suspected Ebola and advised
them to seek treatment at a hospital.
The child was admitted to the hospital in Kayes on 21 October and
diagnosed with Ebola following receipt of positive laboratory results on
23 October. She was hospitalized and treated in isolation, with
infection prevention and control equipment and procedures in place. She
died on 24 October.
The emergency response in Mali continues
In collaboration with WHO, the Ministry of Health has established an
incident command structure to mount a coordinated response that includes
surveillance and contact tracing, case management, safe burials, social
mobilization and logistics.
To date, Malian health officials, aided by WHO, the US Centers for
Disease Control and Prevention (CDC), Mèdecins sans Frontières (MSF),
the International Federation of Red Cross and Red Crescent Societies,
and several other partners have identified 108 contacts of the
symptomatic patient, including 33 health care workers who were exposed.
Of the 108 contacts, 25 have been followed for 21 days and have been
released from the surveillance system.
Seventy-nine contacts were at the hospital where the child was
treated and in the Kayes community. All have been monitored. To date, no
one has shown signs of Ebola or tested positive for the disease.
The government has accelerated the completion of an isolation
facility at the Center for Vaccine Development in Bamako. Isolation
facilities were part of the strategies put in place in Senegal and
Nigeria to successfully contain Ebola.
Bamako has a well-functioning biosafety level 3 laboratory,
previously established with support from the US National Institutes of
Health to carry out diagnostic work with tuberculosis bacteria and HIV.
The laboratory has now been repurposed to safely test Ebola samples.
With persistent and thorough contact tracing, isolation and
monitoring in place, confidence is growing that no further spread within
Mali followed exposure to the index case,
who had haemorrhagic symptoms
but no diarrhoea or vomiting during her travels. http://allafrica.com/stories/201411120461.html
