Africa

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Estimated Case Counts

  • Total Confirmed: 15,334 [1]
    • Guinea: 2,047
    • Liberia: 7,082
    • Mali: 6
    • Nigeria: 20
    • Senegal: 1
    • Sierra Leone: 6,190
  • Fatalities: 5,458
    • Guinea: 1,214
    • Liberia: 2,963
    • Mali: 6
    • Nigeria: 8
    • Senegal: 0
    • Sierra Leone: 1,267
  • Imported: unk
  • In-country origin/transmission: unk

Updated 21 Nov 2014

Basis for Estimated Case Counts

The number, origin, and status of EVD cases in the Outbreak Zone can not be definitively determined. The information about cases which is presented here is based on the best available estimates taken from various national and international reporting agencies. A more thorough discussion of the issues involved in establishing case information can be found at Case Count.


Background by Country

  • Guinea:
On 23 March 2014, the WHOannounced that it had been notified by the Ministry of Health of Guinea of a “rapidly evolving” outbreak of EVD in the southeastern part of the country. [2] Further investigation and retrospective analysis traced the origin of the epidemic to an index case who became ill and died in December 2013 in the village of Meliandou, Guinea. [3] Since first being identified in Sudan (now South Sudan) and near the Ebola River in the Democratic Republic of the Congo in 1976 [4], known outbreaks of EVD have largely been confined to tropical areas of the sub-Saharan region of Africa. Health authorities on both the international and national levels were unaware of the presence of EVD in western Africa, which led to a delay in the testing and confirmation processes. This delay, combined with heavy cross-border traffic, are among the reasons that the EVD outbreak was able to spread so quickly and widely.

Like the other countries in the Outbreak Zone, Guinea has experienced frequent civil unrest and an unstable government, which have impacted the public health infrastructure. While 61% of the rural population has access to clean water, only 11% have improved sanitation facilities. [5] The ratio of physicians to population remains as low as 0.1 per 1,000 people. [6] Recent data from The World Bank shows that prior to the EVD outbreak, Guinea had only 0.3 hospital beds for every 1,000 people. [7]

Guinea's public health system has been augmented by the presence of numerous NGOs for decades. Reports from these organizations which described the severity of the rapidly widening EVD epidemic began surfacing in March, [8] even while the WHO continued to label the situation as “serious” but not an epidemic. [9] Internal reviews subsequently conducted by the WHO listed other failures which allowed the EVD epidemic to spiral out of control in Guinea. Among those factors were the “politically motivated appointments” made by the WHO representative in Guinea, who also blocked the issuance of visas for additional WHO staff to enter the country; a bureaucratic tangle that blocked the use of $500,000 in emergency funding; and a simple failure on the part of the WHO to read “some fairly plain writing on the wall”. [10] On 5 November 2014, the WHO replaced Dr. Luis Sambo, the head of its Regional Office In Africa (AFRO), with a former deputy director, Dr. Matshidiso Rebecca Moeti. [11]

Although the numbers of EVD cases which occurred in Guinea during the first half of 2014 can only be roughly estimated, anecdotal evidence suggests that the outbreak quickly became an outright epidemic, with a rapidly escalating, if not exponential, case count. One week after the WHO's initial announcement of 49 cases on 23 March, the agency reported that the number had more than doubled to 112. [12]

Several other factors further complicated the initial stages of the outbreak. Cultural beliefs in much of western Africa include a reliance on faith healers, whose 'hands-on' method of treatment served to create new chains of transmission. These were compounded by traditional funeral rites, in which family and friends of the deceased wash the body and touch or kiss it in an act of farewell. The WHO estimates that 60% of EVD cases in Guinea can be traced to local funeral practices. [13] Distrust of both government officials and NGO staff led to incidents of civil unrest and violence as early as April 2014. [14] These incidents eventually culminated in the death of 8 aid workers in the village of Womey in September of 2014. [15]

Another key element of the rapid spread of the outbreak beyond Guinea were the sites of the early cases. Many were located in a small triangle of Guinean territory which shares borders with both Liberia and Sierra Leone. The local population was accustomed to frequent cross-border travel to seek work or visit family and this practice continued in spite of the outbreak. This problem is described in comments made by Corinne Dufka, a senior researcher at Human Right's Watch Africa division.

“First is the location of the outbreak: at the nexus of not one but three countries, literally within a few miles from each other, each necessitating separate plans, protocols and agreements with the international organizations working to contain it. As this effort got underway, the fluidity of cross-border social and trade relations – with large extended families and ethnic groups deeply rooted in two, at times three, nations – facilitated the often-silent spread.”[16]

The complexities of dealing with the epidemic multiplied as cases spread out from Guinea. As Brice de le Vingne, Director of Operations for MSF pointed out, “We knew we were going to have a problem with dealing with three different administrations.” [17]

In the months since the initial outbreak of EVD in Guinea, some progress has been made in the areas of availability of ETU's, logistical access and support, public health education campaigns, and emergency humanitarian assistance. Nonetheless, the case count has continued to increase, as has the geographical distribution. Of the 33 prefectures that comprise Guinea's 8 administrative regions, 14 are experiencing ongoing intense transmission of EVD. The total number of dedicated EVD treatment beds now totals 160, but at least 100 more are needed. [18] The infection rate of health care workers, combined with insufficient quantities of PPE and a lack of pay, has made it difficult to maintain necessary staffing at ETU's.

Collateral effects of the EVD outbreak include an increase in food insecurity even during the current harvest season, with some households reporting that adults are foregoing meals in order to feed their children. [19] Although statistics are not yet available, media reports indicate a growing trend among the Guinean population to avoid all clinics and hospitals, even those which don't accept EVD cases. If this trend continues, it will result in the unnecessary deaths of people suffering from treatable, curable illnesses and conditions. [20]


  • Liberia:
The confusion surrounding the early days of the EVD outbreak make it impossible to accurately identify the index case which created the first chain of transmission in Liberia. However, it is assumed that the initial cases were imported from Guinea as a result of the everyday cross-border traffic between the 2 countries. On 30 March 2014, the WHO confirmed the presence of EVD in a patient who died in the Foya district of Lofa County on March 21st. [21] The next day, a further statement from the WHO noted that additional “clinically compatible” cases had been identified from as early as 14 March. [22] The Liberian Ministry of Health and Social Welfare released a statement on 31 March 2014 in which it noted that a laboratory confirmed patient had traveled from Foyah to Monrovia and then on to Harbel in Margibi County. [23] By 11 April, Liberia reported a cumulative total of 26 probable or confirmed cases of EVD, including 13 deaths, across the counties of Lofa, Margibi, Bong, Nimba, Montserrado, and Grand Cape Mount. [24] Retrospective analysis and testing refined the case numbers to show a cumulative count of 12 cases (6 confirmed, 2 probable and 4 suspected) with 11 deaths. [25]

In conjunction with assistance from the WHO and several NGOs, the Liberian Ministry of Health was able to trace and isolate known contacts of the EVD cases. Additional steps taken included training for health care workers, increased supplies of PPE, and social awareness programs. [26] These actions, along with enhanced screenings, kept the situation stable until 16 June 2014, when the WHO reported 9 new cases. [27] By 1 July, EVD cases were present in Monrovia, and the case count began increasing on an almost daily basis. [28]

Like the other nations in the Outbreak Zone, Liberia is still recovering from decades of civil instability and armed conflict which has left it particularly vulnerable to a catastrophic event such as the EVD epidemic. Democratic elections which were held in 2005 began a period of economic growth and investment aimed at rebuilding the national infrastructure. However, the economic situation remains grim, with an estimated 80% unemployment rate. Liberia is ranked almost last in world listings of personal income, with a majority of Liberians living on less than $1.25 US per day. [29] [30] The impact of Liberia's economic status is reflected in its public health infrastructure. The country has only 0.8 hospital beds per 1,000 people, and the ratio of trained health care workers is 0.04, with only 0.1 physicians per 1,000 residents. [31]

The increasing numbers of EVD cases, and some of the measures taken in an attempt to contain the epidemic, have had a significant impact on Liberia's agricultural sector, which employs 70% of the labor force and accounts for 60% of the nation's GDP. [32] Quarantine actions and fear of infection have led Liberian farmers to abandon the traditional communal harvesting practice known as kuus. Travel restrictions have prevented goods from reaching urban markets and blocked distribution of imported seed and fertilizer from reaching rural areas. [33] An emergency assessment conducted in August by the Food and Agriculture Organization (FAO) showed that prices for the staple cassava had risen as much as %150 in Monrovia, [34] while shipments of imported rice to feed the rural population have been severely restricted. [35]

The current and future issues of food insecurity and unemployment are only part of the complexities present in Liberia which have allowed and even fostered the rampant spread of EVD in the country. Two incidents which occurred in July 2014 appear to have galvanized the government of Liberia to take more aggressive measures in an attempt to control the growing epidemic. The first of these created both an international diplomatic incident, as well as a public health emergency in Nigeria. Mr. Patrick Sawyer, a Liberian-American who was tangentially connected to the Liberian Ministry of Finance and Development Planning, received government approval to travel to a business conference in Nigeria. This official permission was granted in spite of the fact that the Liberian Ministry of Health and Social Welfare was aware that Mr. Sawyer had been exposed to EVD cases as early as 9 July 2014. Video surveillance from the James Spriggs Payne’s Airport in Monrovia showed that on 20 July 2014, while waiting for his flight, Mr. Sawyer appeared to be “terribly ill”. However, he was able to travel and he flew from Monrovia to Lagos, Nigeria, with a layover in Togo. [36] Mr. Sawyer collapsed while still at the Murtala Muhammed International Airport in Lagos. A representative from the ECOWAS conference sent to meet him took Mr. Sawyer directly to the First Consultant Hospital in Obalende where he later died of EVD on 24 July 2014. [37] Because the receiving hospital was unaware of Mr. Sawyer's previous contact with an EVD case, no special precautions were taken during his initial care. As a result, Nigeria recorded its first locally acquired case of EVD on 23 July 2014. Mr. Sawyer's arrival in Nigeria created a new chain of transmission which eventually led to 19 confirmed cases of EVD, of which 7 were fatalities. [38]

The second incident, although seemingly minor in comparison, had a significant impact on how Liberia's population perceived the growing EVD epidemic. On July 27 2014, the Liberian Ministry of Health and Social Welfare announced that Dr. Samuel Brisbane had died of EVD. Dr. Brisbane, who had once been the medical advisor to the former President Charles Taylor, had been working at the John F. Kennedy Memorial Medical Center in Monrovia. It is believed that he became infected while treating EVD patients at that hospital. Once he became ill, he was taken to a separate facility outside the city, where he eventually died. [39] In a country which has at best 1 physician for every 10,000 people, Dr. Brisbane was considered to be among the best and his death from EVD came as a shock. It also clearly illustrated how vulnerable even highly trained and experienced health care workers were to becoming exposed to EVD.

In response to these incidents and the escalating case count, on 27 July, President Sirleaf announced a new set of measures to be taken in a further attempt to curtail the spread of EVD. These included closing all schools; placing non-essential government employees on involuntary leave for 30 days; declaring that all public buildings and facilities would undergo disinfection procedures on 1 Aug.; stringent border controls; closure of markets located near borders; limiting the hours of operation of places of public entertainment and requiring that they have enhanced sanitation facilities for use by patrons; and, in an apparent reaction to the Sawyer incident, banning all but the most essential travel by government employees. [40] Growing incidents of civil unrest and friction between the local population and the staff of various NGO's led to the decision, announced on 30 July, to withdraw all Peace Corps volunteers from Liberia, Guinea and Sierra Leone. [41] In addition, a UNICEF report dated 30 July 2014 noted that “Due to security and other concerns, Samaritan’s Purse will not be involved in case management at the Ebola Treatment Units in Foya Borma Hospital in Lofa County, and at ELWA Hospital in Montserrado County. MSF has also evacuated from the Foya treatment unit.” [42]

At the beginning of August, an increasing number of reports demonstrated that government authorities in some communities were unable to provide even basic services. In one section of Monrovia, known as Clara Town, residents told journalists that 2 corpses had been left lying in the street for 4 days, although a government spokesman said that it had only been a few hours before sanitation workers collected the bodies. [43] Attempts by government sanitation workers to bury Ebola victims at a site near Kpeh-kpeh Town resulted in clashes between villagers and both police and soldiers from the Armed Forces of Liberia. [44] A number of similar incidents in both the rural areas and cities resulted in a government declaration which required that all EVD fatalities undergo cremation instead of being buried by family as dictated by long-standing tradition. [45]

An emergency meeting of the Mano River Union was held on 1 Aug 2014. Dr. Margaret Chan, the Director of the WHO, urged the countries to work together to control the spread of EVD in the 'cross-border' regions, which accounted for some 70% of known EVD cases. The leaders of the 3 nations most affected by the EVD epidemic (Guinea, Liberia, and Sierra Leone) agreed to impose a cordon sanitaire on the areas of their mutual borders. Some elements of the joint action plan included [46] :

  • “We have agreed to take important and extraordinary actions at the inter-country level to focus on cross- border regions that have more than 70 percent of the epidemic. These areas will be isolated by police and the military. The people in these areas being isolated will be provided with material support. The health care service in these zones will be strengthened for treatment, testing and contact tracing to be done effectively. Burials will be done in accordance with national health regulations.
  • We agree to provide our health personnel incentives, treatment and protection so they could come back to work. We shall ensure the security and safety of all national and international personnel supporting the fight against Ebola.
  • Member States may consider restriction of movement and prohibiting mass gatherings as appropriate.
  • We the Heads of State want to assure the international community that the disease is not being exported. We assure the International Community that we have instituted measures at international ports of entry and the information will be provided to each Member State so these people will not be able to travel outside of their respective countries until surveillance has been lifted.
  • We also appreciate the support of international organizations and NGOs but ask that they work within the framework of our national plans. Communication shall be transparent and coordinated using the structures that have been established within each Member State. We the Member States shall be transparent in how we use your resources to achieve results and we request that all partners shall be transparent and accountable.

The imposition of a cordon sanitaire was controversial and experts questioned it's effectiveness. As Dr. William Schaffner, an infectious disease expert at the Vanderbilt Medical Center noted, “The 'cordon sanitaire' can become a ‘cordon porous'. It may not be sufficiently structured so it can prevent people from leaving.” [47] The use of the military to enforce the quarantine in countries with a history of repeated civil wars and brutal repression was also problematic, as noted by Dr. Schaffner, "It seems like a reflexive movement by the governments to show that they’re doing something, and since they have armies more elaborate than their health care systems, they use the army". [48]

Nonetheless, the move was indirectly endorsed by the WHO on 8 Aug 2014, in its statement which declared the EVD outbreak to be a Public Health Emergency of International Concern (PHEIC) [49] The use of such an extreme public health measure is almost unprecedented in modern history. With the exception of a small-scale, localized version imposed during the Ebola outbreak in Kikwit in 1995, [50] the centuries old technique of cordon sanitaire had not been used since a typhus outbreak on the borders of Poland and Russia in 1918. [51] Although the WHO announced plans to work with the UN's Food and Agriculture Organization (FAO) to provide food and material support to the quarantined area, there were media reports that local residents were alarmed about how the travel restrictions would affect them, “Inside the cordoned area of Sierra Leone and Liberia, alarmed residents have told reporters that they fear starving because food prices are rising. Many farmers have died, and traders who cannot travel cannot earn money. It is not clear whether plans to deliver food, water and care are underway.” [52]

By 6 Aug 2014, the EVD case count was estimated to be 554, with at least 294 deaths. Faced with the rapidly growing epidemic, Liberia's President Ellen Johnson Sirleaf exercised the power granted to the Presidency under Article 86 of the Liberian Constitution and declared a 90 day State of Emergency. “Under this State of Emergency, the Government will institute extraordinary measures, including, if need be, the suspensions of certain rights and privileges.” She further specified that “... the deadly Ebola virus now poses serious risks to the health, safety, security and welfare of the nation and beyond the public health risk, the disease is now undermining the economic stability of the country to the tone of millions of dollars in lost revenue, productivity and economic activity.” [53]

Concurrent with the Declaration of Emergency, the Liberian Ministry of Defense commenced Operation White Shield, with the stated intent to “support the policy decisions of the National Task Force on Ebola”. The operation consisted of 4 separate task forces, each assigned to a different geographic area, which would support the local civil administrations. Additional missions included providing border control, internal and external checkpoints, enforcement of quarantines, and protection of health care workers and treatment facilities. In announcing the operation, the Defense Minister also “urged politicians to avoid political interference in the operations of the military as political interference will not be tolerated by the forces at those places of assignment.” [54] The use of military troops was also meant to allow the re-opening of medical facilities which had closed over the previous months due to a lack of health care workers, a shortage of proper equipment, and incidents of civil unrest. These closures had led to an increasing number of collateral deaths due to non-EVD medical conditions, which could have been treated if the hospitals had been open. This lack of available care served to further fuel distrust of the government and added to the fear and frustration which permeated the general population. [55]

By 11 Aug 2014, with the case count still increasing, the government announced that "Lofa county in the north has been quarantined by the army". [56] Expanding the 'cordon sanitaire' to a 3rd county created what the media described as “plague villages” in the largely rural area. NGO's questioned the effectiveness of the quarantine as food and material assistance remained scarce. Aid workers described the problem, “If sufficient medication, food and water are not in place, the community will force their way out to fetch food and this could lead to further spread of the virus” [57]

The deep mistrust which most Liberian's feel toward both their government and international assistance agencies has further complicated the process of raising social awareness and educating people about EVD. This problem was illustrated in a media report about one of Monrovia’s slums, known as New Kru Town.

“Like many Liberians, Doe does not fully believe that Ebola is real; she is suspicious of hospitals and health workers and the government. “Government saying this and saying that,” she says, asking if Liberia is expected to come to a standstill in order to end the outbreak. Nevertheless, Doe, like some people here, is starting to take note of public health messages.

...Others in New Kru Town are even more skeptical about the Ebola threat. As Doe and the health workers talk, her brother, 27-year-old Richard Koffa, who stands shirtless beside her house, interrupts the conversation. “I don’t believe it! I don’t believe it! I haven’t seen an Ebola patient.”

...But Koffa says he is unconvinced. Many here are deeply distrustful of the government, which they view as corrupt.” [58]

The public perception that Ebola is not real was reported by the media as early as the beginning of July. [59] Some Liberian's felt that the Ebola outbreak was created so that the government would receive increased funding from international aid sources. The corruption, nepotism, and lack of transparency which has been endemic to the Liberian government for decades made others question whether any of the funds would actually be spent on the 'so-called' epidemic, or if the money would end up lining the pockets of various government officials. [60] These beliefs were reinforced when Liberia's largest newspaper published an article in early September in which it alleged that, like AIDS, Ebola had also been created by collusion between western pharmaceutical corporations and the United States Department of Defense. [61]

The atmosphere of distrust in the government, combined with the inaccurate but widely held beliefs about Ebola and 'western medicine', led to repeated and more serious incidents of civil unrest. On 9 August 2014, riot police were called in to control a crowd of demonstrators who were blocking one of Liberia's major highways. The demonstration had been called to protest the latest example of the government's failure to properly dispose of the bodies of Ebola victims. Demonstrators cited the fact that several bodies had been left lying near a road in the town of Weala for at least 2 days. [62] A demonstration to protest the suspension of civil rights imposed by President Sirleaf's Declaration of a State of Emergency was held on 11 August 2014 near the Ministry of Foreign Affairs. Officers of the Liberian National Police used rattan canes to whip the protestors as they were arrested. Among the people jailed was a journalist from Front Page Africa. The newspaper quoted Police Commissioner Geogery Coleman, who “...warned Reporter Karmo and other reporters in the country to avoid the police in these 90 days of the state of emergency because according to him while the country is under a state of emergency some rights of Liberians will be violated...”. The article also notes that in the letter which President Sirleaf sent to Liberia's legislature regarding the State of Emergency, she said, “...the government would clamp down on media institutions or individual’s sensationalizing the Ebola outbreak.” [63]

While acknowledging the importance of accuracy in the information being disseminated by the media, the police action appeared to many to be a first step toward suppressing a free press. Further actions against the Liberian press were taken by the government during the month of August. On 16 August, the National Chronicle suspended publication due to an ongoing investigation by the Liberian National Police. [64] Additional incidents of press harassment were carried out by various agencies of the Liberian government through August and into September 2014. [65] These actions eventually culminated in an announcement on 2 Oct. 2014 by the Liberian Ministry of Information that all journalists must have written advance permission from the Ministry in order to report from any ETU, or to conduct interviews with any health care worker, or to take pictures or video of patients or any health care facility. The Ministry also noted that even pre-approved media contact could be canceled without notice. [66] The Media Foundation for West Africa also reported that according to a statement made on 9 Oct. 2014, by Tolbert Nyenswah, an Assistant Minister of Health and the head of Liberia's Ebola Incident Management, “...henceforth, reports by journalists on the Ebola outbreak in Liberia will be based on statements made by governments rather than what the journalists saw for themselves.” [67] Aside from the debate about the rights granted by the Liberian constitution, which is outside the scope of this article, the primary effect of the curtailment of media freedom has been the loss of independent verification of the actual situation in the country of Liberia.

By the middle of August, the estimated case count in Liberia was at 786, with 413 fatalities. [68] Although the majority of cases continued to occur in the 'unified zone', where the cordon sanitare was in force, the outbreak had gained a foothold in Liberia's capital city of Monrovia. During the prior week, the Liberian government had quietly begun turning a former school in the West Point section of Monrovia into a holding center for possible Ebola cases. Patients from outlying rural areas were being transported to the quarantine center, apparently without any effort from the government to inform the local population. This lack of communication, coupled with popular misconceptions about Ebola, created the perception in the community that West Point was being used as a dumping ground for cases of the highly infectious disease. People living near the center could hear the patients calling for help, saying things such as, “We're not eating,’, ‘They’re just spraying us' and '‘We’re getting weak.’. [69]

Outrage in the West Point community led to a confrontation between local residents shouting “No Ebola in West Point!” and a burial team who had come with their police escort to collect the bodies of suspected Ebola victims. [70]This was followed by an attack on the quarantine center by hundreds of local residents over the weekend of 16-17 August 2014. The Head of the Health Workers Association of Liberia, George Williams, witnessed the incident. He reported that the unit held 29 patients who had “all tested positive for Ebola”, and who were receiving preliminary treatment before being transferred elsewhere. He also noted, "Of the 29 patients, 17 fled last night (after the assault). Nine died four days ago and three others were yesterday taken by force by their relatives"...[71] A hygienist who worked at the center told journalists, “I can tell you they were uncountable...The entire West Point community broke in — men, women, children, boys and girls.” [72] Another media report included comments from another staff member. “They told us that we don’t want an Ebola holding center in our community.” He said the intruders stole mattresses, personal protective equipment, even buckets of chlorine that had just been delivered. “They took everything.” [73] An anonymous police source told journalists that among the items looted from the center were “...medical equipment and mattresses and sheets that had bloodstains...”. Witnesses also said, “Some of the looted items were visibly stained with blood, vomit and excrement...”. [74]

Further...

  • Mali:
On 23 October 2014, the WHO announced that there was 1 laboratory confirmed case of Ebola in the city of Kayes in western Mali. The patient, a 2 year old child, died at the Fousseyni Daou Hospital the next day. [75]

Contact tracing conducted by combined teams from the Malian Ministry of Health and Public Sanitation and the WHO established that this imported index case had traveled extensively while infectious. Although some details remain unclear, it is now known that the child was brought from Kissidogou, Guinea (which is experiencing ongoing Ebola transmission), by her grandmother via commercial bus transport on 19 October. At that time, the child was already displaying symptoms, including bleeding from the nose. She remained infectious while traveling through the areas of Keweni, Kankan, Sigouri, and Kouremale, and eventually to Bamako and then Kayes.

Mali UN OCHA

On 20 October, the child was taken to the Quartier Plateau. After an initial exam, a health care worker immediately referred the patient to the Fousseyni Daou Hospital, where she was admitted on 21 October. Initial testing revealed that the child had typhoid, and follow-up tests determined that she was also positive for Ebola. [76]

As of 29 October 2014, 84 contacts have been identified in Kayes and Bamako, 11 of which are health care workers. Several suspect cases were identified and subsequently tested negative. An additional suspect case from the health district of Koutiala is currently being tested. [77]

Due to the extensive travel history, the Malian government and the WHO consider this incident to be an emergency and are taking aggressive action to both contain the situation and to prepare for the potential for additional EVD cases. Teams from both the WHO and the CDC were already present in Mali prior to the introduction of the first case, and they have since been augmented by additional personnel and equipment, including support from DWB/MSF and the International Red Cross. Steps taken in the past week include establishing an air bridge between Bamako and Kayes; designating the Regional Hospital of Kayes as the primary Ebola Treatment Center; training of health care workers, support staff, burial teams and community outreach workers; and implementing a public awareness campaign via local media. [78] The Ministry of Health and Public Hygiene has established hotline numbers for the public to get more information about Ebola: 80 00 88 88 (free for Malitel numbers), 80 00 77 77 (free for Orange Mali numbers) [79]. Additional contact tracing is still ongoing, which includes enhanced searching for any remaining unidentified contacts along the known travel route. [80]

It's important to note that there is ongoing military conflict in the northern portion of Mali between various Islamist and rebel factions and the government. In January 2013, France initiated a military intervention at the request of the UN via Operation Serval which was replaced in August 2014 by Operation Barkhane. As a result, there are several thousand French troops present in and around northern Mali who are actively engaged in military operations against insurgent forces. As of 30 October 2014, French Defence Minister Jean-Yves Le Drian announced that additional operations will be concentrated in northern Mali in response to an increase in activity by Al-Qaeda in the Islamic Maghreb (Aqim) and similar groups. [81] Although the current area of conflict is not near Kayes, an outbreak of EVD could potentially spread into northern Mali, where it could impact both French military and insurgent forces.

UPDATE: On 12 November 2014, the WHO confirmed that there were 3 additional confirmed or probable cases of EVD in the country, all 3 of which were fatal. [82] Media reports indicate that the Mali government has confirmed a 4th case, that of a doctor who worked at the clinic where the index case was treated. [83] These cases are not related to the previous fatal case in October.



  • Nigeria:
The initial case of EVD was imported to Nigeria in July by an infected man who traveled to Lagos via commercial airplane. This introduced EVD into the most populated city in Africa, and created a chain of transmission that eventually resulted in a total of 19 EVD cases, with 8 fatalities. The last known case was confirmed on 10 Sept., 2014.[84] [85]

On 20 Oct., 2014, the WHO, in collaboration with the Nigerian Federal Ministry of Health, officially announced that the outbreak of EVD in Nigeria has ended. [86] [87]

However, Nigeria remains extremely vulnerable to a reintroduction of EVD for a number of reasons. Although Nigeria does not share any land borders with other countries in the Outbreak Zone, it is a regional nexus for significant amounts of inter-continental and international air and sea travel. As noted, Lagos is a densely populated city of approximately 8,000,000 people [88] It's also the site of the Murtala Muhammed International Airport (MMIA), which is a major international aviation hub with a passenger count of over 14,000,000 people per year [89]

Nigeria's rapidly expanding economy, based largely on its oil reserves [90], has led to a significant increase in international maritime traffic through several major ports. Further economic development has led to an increased presence of multi-national corporations which employ both local and international workers who travel to and from their home states and countries.

Although Nigeria has made progress in establishing a stronger public health infrastructure, the country still has significant gaps in areas such as establishing and maintaining a cadre of trained health care workers and the availability and number of fully equipped hospital beds, as well as sanitation issues and simple access to clean water sources in rural areas. In 2008, Nigeria had 0.4 doctors per 1,000 people [91], and recent figures show a ratio of 5 hospital beds per 10,000 people [92]. Only 42% of the rural population has access to improved water sources, with only 28% having access to improved sanitation facilities [93] Nigeria's national health infrastructure has been extensively augmented by a variety of global assistance organizations and Non-Governmental Organizations (NGOs) for a number of years [94]. The outbreak of EVD brought additional support from international resources such as Doctors Without Borders/Médecins Sans Frontières (DWB/MSF), the CDCand the WHO. Now that the EVD outbreak in Nigeria has ended, some of those resources will be redeployed to other countries in the Outbreak Zone which desperately need further assistance.

Nigeria now has an active EVD control and prevention plan in place, which includes enhanced contact tracing, additional certified laboratory facilities, and dedicated Ebola Treatment Units in several hospitals. The Nigerian government addressed the importation of EVD into their country with “forceful interventions” [95] and aggressive public health measures. The combined efforts of the Nigerian government and its international partners have clearly proven that an outbreak of EVD can be controlled.

However, as long as the EVD epidemic in West Africa continues to escalate, the threat of further cases remains, as noted by the Nigerian Federal Ministry of Health [96]:

"...Nigeria like other countries will not have the control over the presentation of the disease at any of its ports of entry. However, it is the responsibility of the country’s surveillance system to ensure that any case presenting at any of our ports of entry is rapidly identified and isolated. That is the only way the country will remain safe from the Ebola Virus Disease pending its global elimination. I would therefore, urge the Federal Ministry of Health and its agencies to remain watchful, while I urge Nigerians and other residents of Nigeria to sustain and even improve upon the new level of sanitation and personal hygiene practices.”


  • Senegal:
There has been only one confirmed case of EVD in the country of Senegal, that of a 21 year old student who became infected while in Guinea and then traveled to Dakar, where he arrived on 20 August 2014 [97]. The student was known to public health authorities in Guinea, where he was subject to isolation after having been identified as a contact of a confirmed EVD case in Conakry. On 26 August, the student was admitted to a hospital suffering from EVD symptoms. An international alert was issued by public health authorities in Guinea when they realized that the student had left the area. This alert allowed the Senegalese Ministry of Health to find and identify the man, who subsequently tested positive for EVD.

The WHO classified this case as a “top priority emergency” [98] and immediately sent assistance to Senegal. On 31 August, the Senegalese Ministry of Health [99] announced that all contacts had been traced and were undergoing monitoring.

The index case has recovered and there were no additional cases traced to him. On 17 October 2014, the WHO declared Senegal to be free of EVD cases. [100]

Due to its location, Senegal remains vulnerable to reintroduction of EVD from bordering countries including Mali and Guinea. In partnership with various international agencies, Senegal has made significant progress towards meeting the targets of the Millenium Development Goals for public health. Advances in public health infrastructure include an increase in available hospital beds, clean water and sanitation facilities, but there is still a shortage of trained health care workers, as the density of physicians and nurses remains less than 1.0 per 1,000 residents. [101]

However, Senegal has now adopted a strict prevention and surveillance program which includes a dedicated Center of Operations and Emergencies, as well as a logistics corridor, located in Dakar, from which they can quickly receive any needed humanitarian or medical relief supplies.

As part of Operation United Assistance, the U.S. Department of Defense is in the process of establishing locations in Senegal to serve as logistics and transport corridors for increased relief efforts in other countries within the Outbreak Zone. The Joint Task Force-Port Opening Senegal Operation (JTF-PO) currently includes a cargo hub at Léopold Sédar Senghor International Airport, near Dakar. [102] U.S. Military personnel in Senegal who are now temporarily assigned to this operation will be closely monitored for any potential exposure to EVD, which will also serve to augment the prevention and surveillance protocols put in place by the Senegalese government.
  • Sierra Leone:


Travel Restrictions

  • Official Travel Advisories and Warnings
  • Suspended Outgoing Flights
  • Suspended Incoming Flights


Entry/Exit Control and Restrictions

  • Officially Designated Entry Airports, Border Crossings and Harbors
  • Quarantine/Monitor Policies for Incoming Travelers
  • Quarantine/Monitor Policies for Outgoing Travelers
  • Quarantine/Monitor Policies for HCW's Returning from Outbreak Zone
  • Passport and Visa Controls


Public Health Preparations and Actions

  • Official Government Announcements
  • Public Awareness and Education
  • Designated Hospitals, Quarantine Facilities, and Ebola Treatment Units (ETU's)

  • WHO Certified Laboratory Support and Testing
  • Evacuation of Ebola-positive Citizens from Outbreak Zone
  • Drills and Exercises


Sources for Official Information

  • Further




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