Evolution of Ebola Virus Disease from Exotic Infection to Global Health Priority, Liberia, Mid-2014

M. Allison Arwady

, Luke Bawo, Jennifer C. Hunter, Moses Massaquoi, Almea Matanock, Bernice Dahn, Patrick Ayscue, Tolbert Nyenswah, Joseph D. Forrester, Lisa E. Hensley, Benjamin Monroe, Randal J. Schoepp, Tai-Ho Chen, Kurt E. Schaecher, Thomas George, Edward Rouse, Ilana J. Schafer, Satish K. Pillai, and Kevin M. De Cock

Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (M.A. Arwady, J.C. Hunter, A. Matanock, P. Ayscue, J.D. Forrester, B. Monroe, T.-H. Chen, T. George, E. Rouse, I.J. Schafer, S.K. Pillai, K.M. De Cock); Ministry of Health and Social Welfare, Monrovia, Liberia (L. Bawo, M. Massaquoi, B. Dahn, T. Nyenswah); National Institutes of Health, Bethesda, Maryland, USA (L.E. Hensley); US Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, USA (R.J. Schoepp, K.E. Schaecher)

Abstract

Over the span of a few weeks during July and August 2014, events in West Africa changed perceptions of Ebola virus disease (EVD) from an exotic tropical disease to a priority for global health security. We describe observations during that time of a field team from the Centers for Disease Control and Prevention and personnel of the Liberian Ministry of Health and Social Welfare. We outline the early epidemiology of EVD within Liberia, including the practical limitations on surveillance and the effect on the country’s health care system, such as infections among health care workers. During this time, priorities included strengthening EVD surveillance; establishing safe settings for EVD patient care (and considering alternative isolation and care models when Ebola Treatment Units were overwhelmed); improving infection control practices; establishing an incident management system; and working with Liberian airport authorities to implement EVD screening of departing passengers.

“Reviewing that first phase in the light of subsequent events, our townsfolk realized that they had never dreamed it possible that our little town should be chosen out for the scene of such grotesque happenings as the wholesale death of rats in broad daylight or the decease of concierges through exotic maladies.”

—Albert Camus, The Plague (1948)

The Ebola virus disease (EVD) epidemic in West Africa is recognized as the largest in history; more cases reported than in all previous EVD outbreaks combined (1). However, until the summer of 2014, the epidemic had not captured the world’s attention.

The EVD epidemic began in Guinea in late 2013. In neighboring Liberia, EVD was first diagnosed in a patient in mid-March 2014. A team of epidemiologists from the US Centers for Disease Control and Prevention (CDC) began working with the Liberian Ministry of Health and Social Welfare (MOHSW) in early April. By April 9, a total of 12 EVD cases (6 laboratory-confirmed) had been identified in Liberia, but no additional cases were reported in April or during most of May, and it appeared that the outbreak had been contained locally. However, on May 25, a patient who had traveled from Sierra Leone died of suspected EVD in Lofa County in northern Liberia. Within days, additional EVD cases were reported in Lofa County and in Monrovia, the capital city of Liberia. The MOHSW initiated investigations into what was considered a second epidemic wave of EVD.

Dr. Arwady is a physician specializing in internal medicine and pediatrics. She is currently in CDC’s Epidemic Intelligence Service and continues to work on the Ebola response. Her research interests include improving access to care and reducing health disparities in the United States and globally.

Acknowledgments

We thank Kiersten Kugeler for assistance with figures.

Other than MOHSW, WHO, and MSF, principal collaborating organizations in the early response included, alphabetically: Action Contre La Faim; the International Committee of the Red Cross; the International Federation of the Red Cross; Rebuilding Basic Health Services; Samaritan’s Purse; Tiyatien Health; the United Nations Mission in Liberia; United Nations Children’s Fund; the United States Agency for International Development and its Office of Foreign Disaster Assistance; the United States Department of Defense; the United States Department of State through its Embassy in Liberia; and the United States National Institutes of Health.

References

Centers for Disease Control and Prevention. Outbreaks chronology: Ebola virus disease [cited 2014 Jan 18].http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html
United Nations Development Programme. Human development report 2014 [cited 2014 Jan 18]. http://hdr.undp.org/en/2014-report
World Bank. GDP per capita, 2013 [cited 2014 Jan 18]. http://data.worldbank.org/indicator/NY.GDP.PCAP.CD
United Nations Educational, Scientific and Cultural Organization (UNESCO) Institute for Statistics. UNESCO eAtlas of literacy: Liberia. Adult literacy rate, population 15+, both sexes [cited 2014 Jan 18]. http://tellmaps.com/uis/literacy/
Liberia battles crippling shortage in health workers. Mail & Guardian. January 14, 2009 [cited 2014 Jan 18]. http://mg.co.za/article/2009-01-14-liberia-battles-crippling-shortage-in-health-workers
2014 Ebola response: CDC in action [cited 2014 Jan 18]. http://www.cdc.gov/vhf/ebola/pdf/cdc-in-action.pdf

Figures

Suggested citation for this article: Arwady MA, Bawo L, Hunter JC, Massaquoi M, Matanock A, Dahn B, et al. Evolution of Ebola virus disease from exotic infection to global health priority, Liberia, mid-2014. Emerg Infect Dis. 2015 Apr [date cited]. http://dx.doi.org/10.3201/eid2114.141490

DOI: 10.3201/eid2104.141940