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On the trail of the West African Ebola virus

This is the story of the present outbreak from December 2013 to now.
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Hello again and welcome to this video on Ebola from Lancaster University. In this video, we’ll be following the story of the current outbreak as it unfolded from December 2013 onwards. It all began in a small village called Meliandou in southeastern Guinea where there were nine unexplained deaths from the beginning of December, 2013 to the beginning of February, 2014. We don’t know exactly what happened, but an outline of the likely course of events was pieced together by a team from the Guinean Ministry of Health who arrived in the village on March 14, 2014 and then a medical team from Medecins Sans Frontieres, who got there four days later.
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They quickly tracked down 14 living cases and one recently dead case in the towns of Gueckedou, Macenta, Kissidougou, and Nzerekore, from which blood samples were taken. Sent for testing in Lyon in France and Humburg in Germany, the samples soon came back positive for the Zaire Ebola virus– the original and most dangerous of the five species in the genus. On the 23rd of March, 2014, the World Health Organisation issued a formal notification of the outbreak. Of that first group of 15 cases, 12 are known to have died. Investigation in surrounding areas revealed that the disease had by then already spread. The neighbouring villages of Dandu Pombo, Gbandou, and Dawa had already reported six, three, and eight deaths, respectively.
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Slowly, the picture began to be pieced together. The first case– which in epidemiological investigations of this sort is known as the index case– was a two-year-old child in Meliandou village who became ill on the 2nd of December, 2013 and died four days later, showing symptoms of fever and vomiting and black faeces, indicating some internal bleeding. The next three victims were all in the immediate family– the child’s mother, three-year-old sister, and grandmother. But it was the sixth case that was the one that led the virus to radiate out from Meliandou. The village midwife who’d been helping to care for the family was ill by the end of January.
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It was the midwife’s sister, caring for her in turn, who carried the disease on to the village of Dandu Pombo from Meliandou. When the funerals of the first victims took place, many people came from neighbouring villages. Two of them took the disease back with them to Dawa village. The role of funerals in the spread of the virus is something we’ll be looking into in more detail later. Another turning point was reached when the midwife from Meliandou? was taken to Gueckedou Hospital for treatment. Her symptoms were reported to be just fever, and there was no particular reason for her to be treated any differently to the numerous other fever cases that crowded the wards of the hospital.
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By the time the midwife died on the 2nd of February, 2014, a health care worker in the hospital was also infected. This member of medical staff was transferred, in turn, to another hospital in the nearby town of Macenta. A doctor in Macenta Hospital was the next victim, who died on the 24th of February, 2014. The body was taken to Kissidougou for the funeral, with consequent transmission to that town. Meanwhile, the disease had escaped the confines of Macenta Hospital via the family members of the dead doctor and was beginning to spread in the town and the neighbouring town of Nzerekore. This was a particularly difficult situation for the control of the disease.
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Gueckedou, in particular, is a town that’s expanded rapidly in size in recent years and which has very little infrastructure. One Ebola had a foothold in Gueckedou’s Baladu and Fariko shanty towns, it was very difficult to stop its spread. Contact tracing is difficult because of the unplanned nature of shantytowns, where there are no official maps or even necessarily street names. And physical prevention is also difficult because of the almost complete lack of running water. Any disease like Ebola, which transmits through close contact with body fluids, is sure to find such conditions ideal for its dissemination. A further factor in the initial spread was the vagueness of the symptoms which we looked at in the previous session.
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Of the first 15 cases determined on arrival by the special Guinean government and MSF teams, only four had hemorrhagic fever symptoms. And of a further earlier 17 cases going right back to Meliandou and other villages that were the initial epicentre, only seven exhibited bleeding. There was no particular reason in that case to suspect an outbreak of Ebola to occur in eastern Guinea since none had occurred before. Ebola was supposed to be a disease of Central Africa, not West Africa.
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And even if the cases with hemorrhagic symptoms had drawn attention earlier, there are other less dangerous viruses that could have been responsible, such as Lassa fever, which is endemic– which means regularly present in that part of West Africa– and can also cause a hemorrhagic fever. So the delay between the first case in December and the announcement of the outbreak in March is understandable. From there on, events moved increasingly quickly. A commercial traveller from the affected region soon made a trip northwards to the town of Dabola. There he became ill and died in a boarding house. The same boarding house had among its guests another traveller coming down from Watagala in the north of Guinea to visit Conakry, the capital city.
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This second man was the vector that took the disease into a city of 2.1 million people. He died there on the 17th of March, 2014 and within a month, there were over 50 cases in the shantytowns of Conakry. Meanwhile, his body was returned to Watagala, seeding the virus in the northern Dinguiraye province of Guinea. Just as the disease was spreading first north, then west, then north again, through Guinea, it was also spreading into the neighbouring countries of Liberia and Sierra Leone. The virus was taken into Liberia by a woman who had been visiting a market across the border in Guinea near Gueckedou and who died in the Liberian town of Foya in March.
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Her sister, who had been caring for her, also became ill and possibly realising she would die like her sister, decided to visit her husband who was working at the Firestone rubber plantation. She took an overnight ride on the 29th of March, 2014, down from Foya to the Liberian capital of Monrovia in a communal taxi and then hitched a lift on the back of a motorbike for the remaining journey to Firestone. Having succeeded in her plan to be reunited with her husband, she died here on the 2nd of April, 2014. However, this rather touching story had the possibly expected cruel aftermath.
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Almost everybody in the communal taxi that the women took subsequently died of Ebola and the motorbike rider who gave her a lift up to Firestone rubber plantation was never found, despite a nationwide manhunt. Monrovia, the capital, then became one of the worst hot spots in the current outbreak. A similar story can be told for Sierra Leone, where the virus entered by two routes. In May, 2014, the first of these was a traditional healer who had been working in Guinea and who had developed Ebola and died. And at her funeral, over a dozen other people are believed to have become infected, who then spread the virus on to several other areas of Sierra Leone.
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The second point of entry into Sierra Leone was a medical worker, also returning from Guinea, who hitched a lift on the highway with a lorry driver to the town of Jawi in central Sierra Leone. The lorry driver contracted Ebola from his passenger and subsequently took it on himself to his own final destination– the town of Mambolo, near Sierra Leone’s capital, Freetown. Like the other two capitals– Conakry in Guinea and Monrovia in Liberia– Freetown is now the epicentre of an urban Ebola outbreak. Over the months of June and July, as West Africa’s wet season intensified, Ebola became entrenched in Guinea, Sierra Leone, and Liberia, accumulating just over 1,000 cases in total by that time.
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But on the 20th of July, 2014, something happened which underscored the potential of Ebola to spread more widely. A Liberian traveller arrived by air in Lagos, Nigeria, suffering from the disease. He had been ill throughout his flight from Monrovia, but as far as is known, didn’t transmit the virus to anybody until he arrived in Nigeria. There, a government official who met him at the airport and a doctor and a nurse in the hospital where he was treated became the next links in the transmission chain.
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The Nigerian government imposed a strict quarantine regime or on who had contact with the index case, but the official who had met him at the airport broke quarantine and travelled to Port Harcourt– another large city in southern Nigeria. Having become ill there, he was treated in a hotel room by a doctor who by the 11th of August, 2014 was ill himself. Nevertheless, the doctor continued to practise, placing his other patients at risk and eventually infecting members of his own family. Despite these various problems, Nigeria managed to limit the outbreak to 20 cases, of whom eight died.
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This success story partly reflects the greater wealth of Nigeria, perhaps, compared to the other countries involved, but it also illustrates the advantages of preparedness. Senegal– a country to the north of Guinea, which also had an index case arrive at almost the same time as the Nigerian index case– also managed to avoid any secondary transmission. In contrast to this, the wet season in West Africa saw a marked deterioration in the situation in the three countries. In particular, there were sudden surges in caseloads in both Liberia and Sierra Leone. By the end of August, there were 3,707 total cases– a month later, 7,178.
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Around this time, it was calculated that if the disease was unchecked, there might be as many as 1 million cases by the middle of 2015, with consequent complete collapse of West African society and a high danger of the disease spreading to other continents. This alarming prospect served to escalate the international response to the outbreak, which moved from funding of local systems to direct governmental intervention. As the wet season ended, the situation began to relax slightly. The rate at which new cases appeared slackened, indicating that all the efforts at control, both local and international, might be starting to have an effect.
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As I speak to you in mid November, 2014, the outlook is cautiously optimistic compared to what it was six weeks ago, but we still cannot completely predict when the outbreak will end, and the prospect of resurgence remains very real.

In this video you will learn about how Ebola caught the world unawares in West Africa.

  • Watch the video and read the notes below.

  • Make a note of some of the factors that allowed Ebola to spread so rapidly.

You can download additional support notes and follow links to optional materials below.

Our story begins in the last month of 2013, in the village of Meliandou in south-eastern Guinea.

Somehow a 2-year old boy, Emile Ouamouno, had contracted Ebola. We’ll probably never know exactly how, but a team of biologists and anthropologists who visited Meliandou came to the conclusion that some children in the village may have been playing with the carcasses of dead bats found lying on the ground after a fire in a tree.

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Whatever the exact origins of this first index case, the disease had soon spread to most of Emile’s family. Village medical workers involved in caring for them also soon contracted Ebola and took the infection to nearby hospitals and other villages. By the time the Guinean and international medical agencies realised what was happening, there was already a disseminated outbreak, with cases in several locations in south-eastern Guinea, and the beginnings, via a long-distance traveller of what would become an outbreak in Guinea’s capital Conakry.

Arguments about how it took so long – from the end of December 2013 to mid-March 2014 – to realise what was happening are sure to rage for a while, especially as more details of those crucial first weeks are revealed. However, one thing which is certain is that no clinical case of Ebola had been recorded before in West Africa, apart from one non-fatal case of the extremely rare Tai Forest ebolavirus species in Ivory Coast away back in 1994. The appearance of a lethal species of Ebola in such force in the countries west of Mount Nimba was completely unprecedented.

Before long the risks of transmission via international travel became apparent. Patrick Sawyer travelled from Liberia to Lagos in Nigeria and became the index case in that country. A traveller with Ebola also turned up in Senegal to the north-west of Guinea. A small outbreak occurred in Mali to the north. Returning medical workers took the disease back to the USA and UK, and an airlifted victim passed Ebola to a nurse in Spain.

The outbreak reached its peak in West Africa in October 2014 when there were over 7,000 new cases in that month alone. Since then, things have eased a little, but as long as there is one transmitting case remaining, the possibility of a resurgence of the disease remains very real, both within Africa and more widely.

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