Ebola Transmission Linked to a Single Traditional Funeral Ceremony — Kissidougou, Guinea, December, 2014–January 2015

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On December 18, 2014, the Guinea Ministry of Health was notified by local public health authorities in Kissidougou, a prefecture in southeastern Guinea (pop. 284,000), that the number of cases of Ebola virus disease (Ebola) had increased from one case reported during December 8–14, 2014, to 62 cases reported during December 15–21. Kissidougou is one of the four Guinea prefectures (the others are Macenta, Gueckedou, and Conakry) where Ebola was first reported in West Africa in March 2014 (1), and the mid-December increase was the largest documented by any prefecture in Guinea in a single week since the beginning of the epidemic. The Guinea Ministry of Health requested assistance from CDC and the World Health Organization to investigate the local outbreak, identify and isolate persons with suspected Ebola, assess transmission chains, and implement control measures. The investigation found that 85 confirmed Ebola cases were linked to one traditional funeral ceremony, including 62 (73%) cases reported during December 15–21. No additional cases related to this funeral ceremony were reported after January 10, 2015. After the outbreak was identified, rapid implementation of interventions limited additional Ebola virus transmission. Improved training for prompt reporting of cases, investigation, and contact tracing, and community acceptance of safe burial methods can reduce the risk for Ebola transmission in rural communities. Epidemiology and Laboratory Testing On December 19, 2014, rapid response teams including epidemiologists, clinicians, and local public health officials were deployed to villages where potential cases had been reported. The teams interviewed patients and household contacts and conducted active identification of cases and contacts. Ebola case investigation forms were reviewed to identify and characterize cases reported during December 1, 2014–January 10, 2015 as either suspected, probable, or confirmed. A suspected case was defined as one with Ebola-compatible symptoms (i.e., fever and malaise with other nonspecific signs and symptoms, including myalgia, headache, vomiting, and diarrhea) in a Kissidougou resident; a probable case was defined as Ebola-compatible symptoms reported for a decedent for whom no specimens were collected; and a confirmed case was defined as Ebola-compatible symptoms in a person with ≥1 Ebola virus–positive specimen tested by reverse transcription–polymerase chain reaction (RT-PCR) (2). Patients with suspected Ebola were isolated and transported to an Ebola treatment center (ETC) for confirmation of Ebola virus by RT-PCR. For decedents with suspected Ebola, oral swabs were collected within 24 hours upon notification of death, and the swabs were sent to an ETC for confirmation of Ebola. Specimens from 62 persons tested positive for Ebola virus by RT-PCR. Review of case investigation forms and reports indicated that all 62 confirmed cases lived in Kissidougou and were clustered in six villages: 29 (47%) in Ouendero, 13 (21%) in Kamandou, eight (13%) in Mandou, five (8%) in Kongola, four (6%) in Tangolto, and three (5%) in Gbeninkoro. Thirty-two (52%) of the patients were male. Median age was 35 years (range = 2–80 years); four (6%) patients were aged <15 years, 37 (60%) were aged 15–49 years, and 21 (34%) were aged ≥50 years. Fifty-six (90%) of the 62 patients had Ebola-compatible symptoms. Fifty-one (82%) died; 33 (65%) died in an ETC, and 18 (35%) decedents were reported as community deaths. These community deaths occurred during December 14–17 in three villages in Kissidougou: Mandou (seven deaths), Kamandou (six), and Ouendero (five). Patients who died in the community had not sought medical treatment; instead, family members reported the deaths to local health authorities, who considered them as suspected Ebola cases. Oral swabs were collected from all 18 decedents within 24 hours upon notification of death; all tested positive for Ebola virus and were reclassified as confirmed Ebola cases. The Funeral of the Midwife Assistant Interviews with household contacts of the 18 decedents reported from the community revealed that they all occurred in persons who had attended the funeral ceremony in early December of a well-known local male midwife assistant (patient 1) who regularly performed circumcisions in the community. Patient 1 had traveled from Ouendero to Djomakoidou, a village 3 hours away in Macenta, to perform a circumcision on an infant in mid-November 2014; a villager reported that the child subsequently died of an unknown cause. Approximately 1 week after he returned to Ouendero, patient 1 reportedly became ill with Ebola-compatible symptoms and died on December 4, 2014. However, he did not seek medical attention, and the cause of his death was reported as unknown. His funeral ceremony on December 4, 2014 was attended by approximately 100 persons from Ouendero and neighboring villages. Traditional burial practices in Guinea and other West African countries typically involve washing, touching, and kissing of the body of the deceased; therefore, it is likely that several attendees could have had direct contact with the body and body fluids. On December 18, 2014, patient 1 was classified as having probable Ebola. What is already known on this topic? Ebola can be transmitted through direct contact with the corpse or body fluids of an infected person, including during traditional funeral ceremonies. What is added by this report? During December 1, 2014–January 10, 2015, an outbreak of 85 confirmed Ebola cases was linked to one traditional funeral ceremony in Kissidougou, Guinea. Eighteen (21%) of the 85 with confirmed infection attended the funeral and had direct contact with the corpse, and 67 (79%) had direct contact with at least one attendee of the funeral. What are the implications for public health practice? Training in and adherence to hygienic burial of corpses infected with Ebola and community acceptance of culturally sensitive safe burial practices is an important component of the successful management of Ebola and prevention of further transmission. As of January 31, 2015, a total of 85 confirmed Ebola cases were linked to this one traditional funeral ceremony, including 62 (73%) cases reported during December 15–21 (Figure 1, Figure 2). Eighteen (21%) Ebola patients attended the funeral and had direct contact with the body of patient 1, and 67 (79%) had direct contact with at least one attendee of the funeral. Forty-one (48%) patients were male; median age was 33 years (range = 2–85 years). Sixty-three of the 85 patients with confirmed Ebola died (case-fatality rate = 74%). No additional cases related to this funeral ceremony were reported after January 10. Additionally, a total of 780 contacts were monitored in 12 villages by nine contact-tracing teams for 21 days following their last potential exposure. However, this effort might not have covered all contacts. Local public health authorities reported that they were not allowed to enter some villages and identify all contacts because of mistrust and resistance in several communities. Discussion This investigation encountered challenges associated with responding to the Ebola epidemic in Guinea, including incomplete ascertainment, reporting, and investigation of cases; unsafe burial practices; and community reticence, particularly in remote areas. To control Ebola transmission in Kissidougou and other difficult-to-reach communities in Guinea, targeted involvement of community leaders and enhancement of public health interventions are crucial for the proper implementation of Ebola prevention and control strategies. These enhancements include 1) educating the community regarding the signs and symptoms of Ebola and its modes of transmission, 2) stressing the importance of seeking medical care and reporting suspected Ebola cases, and 3) emphasizing the potential benefit of early diagnosis and treatment. Targeted education strategies and health communication messages in local languages can help decrease the concerns of groups resistant to the Ebola intervention efforts of local public health officials (3) and can facilitate the isolation and limited treatment of patients who are unwilling or unable to seek care at an ETC (4). This investigation also revealed that although mechanisms have been recommended for transporting persons with suspected Ebola to the nearest ETCs, intrinsic challenges of transportation in rural communities (i.e., poor transportation and communication infrastructure) remain a major problem. In Kissidougou, patients were transferred to one of the nearest ETCs in either Gueckedou (52 miles [2-hour drive]) or Macenta (83 miles [3-hour drive]), which delayed the time from identification to isolation, diagnosis, and treatment at an ETC, and created the potential for exposure of additional persons. Safe transportation support to link persons with suspected Ebola to treatment centers should be facilitated immediately after the cases are reported to health authorities. Special strategies such as implementation of communication plans to alert local public health authorities and deployment of rapid response teams have been shown to be very effective, especially in rural areas (4,5). Ebola can be transmitted through direct contact with the corpse or body fluids of an infected person, especially during traditional funeral ceremonies. As evidenced by this investigation, these exposures can result in outbreaks when there are obstacles to educating populations on adequate public health interventions. Improved training in hygienic burial of dead bodies and community acceptance of culturally sensitive safe burial are needed to ensure successful management of Ebola cases and prevent further transmission (6). The findings of this investigation highlight the importance of controlling local outbreaks in difficult-to-reach communities as a key component of the effort to eliminate Ebola (5). Although public health interventions were established before this local outbreak, they were not fully implemented in Kissidougou, where they could have prevented or reduced Ebola transmission at the funeral ceremony. After the outbreak was identified, rapid implementation of interventions limited further Ebola virus transmission.

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Ebola Viral Disease Outbreak — West Africa, 2014

Meredith G Dixon, Ilana Schafer (2014)

On March 21, 2014, the Guinea Ministry of Health reported the outbreak of an illness characterized by fever, severe diarrhea, vomiting, and a high case-fatality rate (59%) among 49 persons (1). Specimens from 15 of 20 persons tested at Institut Pasteur in Lyon, France, were positive for an Ebola virus by polymerase chain reaction (2). Viral sequencing identified Ebola virus (species Zaïre ebolavirus), one of five viruses in the genus Ebolavirus, as the cause (2). Cases of Ebola viral disease (EVD) were initially reported in three southeastern districts (Gueckedou, Macenta, and Kissidougou) of Guinea and in the capital city of Conakry. By March 30, cases had been reported in Foya district in neighboring Liberia (1), and in May, the first cases identified in Sierra Leone were reported. As of June 18, the outbreak was the largest EVD outbreak ever documented, with a combined total of 528 cases (including laboratory-confirmed, probable, and suspected cases) and 337 deaths (case-fatality rate = 64%) reported in the three countries. The largest previous outbreak occurred in Uganda during 2000–2001, when 425 cases were reported with 224 deaths (case-fatality rate = 53%) (3). The current outbreak also represents the first outbreak of EVD in West Africa (a single case caused by Taï Forest virus was reported in Côte d’Ivoire in 1994 [3]) and marks the first time that Ebola virus transmission has been reported in a capital city. Characteristics of EVD EVD is characterized by the sudden onset of fever and malaise, accompanied by other nonspecific signs and symptoms such as myalgia, headache, vomiting, and diarrhea. Among EVD patients, 30%–50% experience hemorrhagic symptoms (4). In severe and fatal forms, multiorgan dysfunction, including hepatic damage, renal failure, and central nervous system involvement occur, leading to shock and death. The first two Ebolavirus species were initially recognized in 1976 during simultaneous outbreaks in Sudan (Sudan ebolavirus) and Zaïre (now Democratic Republic of the Congo) (Zaïre ebolavirus) (5). Since 1976, there have been more than 20 EVD outbreaks across Central Africa, with the majority caused by Ebola virus (species Zaïre ebolavirus), which historically has demonstrated the highest case-fatality rate (up to 90%) (3). The wildlife reservoir has not been definitively ascertained; however, evidence supports fruit bats as one reservoir (6). The virus initially is spread to the human population after contact with infected wildlife and is then spread person-to-person through direct contact with body fluids such as, but not limited to, blood, urine, sweat, semen, and breast milk. The incubation period is 2–21 days. Patients can transmit the virus while febrile and through later stages of disease, as well as postmortem, when persons contact the body during funeral preparations. Additionally, the virus has been isolated in semen for as many as 61 days after illness onset. Diagnosis is made most commonly through detection of Ebola virus RNA or Ebola virus antibodies in blood (5). Testing in this outbreak is being performed by Institut Pasteur, the European Mobile Laboratory, and CDC in Guinea; by the Kenema Government Hospital Viral Hemorrhagic Fever Laboratory in Sierra Leone; and by the Liberia Institute of Biomedical Research. Patient care is supportive; there is no approved treatment known to be effective against Ebola virus. Clinical support consists of aggressive volume and electrolyte management, oral and intravenous nutrition, and medications to control fever and gastrointestinal distress, as well as to treat pain, anxiety, and agitation (4,5). Diagnosis and treatment of concomitant infections and superinfections, including malaria and typhoid, also are important aspects of patient care (4). Keys to controlling EVD outbreaks include 1) active case identification and isolation of patients from the community to prevent continued virus spread; 2) identifying contacts of ill or deceased persons and tracking the contacts daily for the entire incubation period of 21 days; 3) investigation of retrospective and current cases to document all historic and ongoing chains of virus transmission; 4) identifying deaths in the community and using safe burial practices; and 5) daily reporting of cases (4,7,8). Education of health-care workers regarding safe infection-control practices, including appropriate use of personal protective equipment, is essential to protect them and their patients because health-care–associated transmission has played a part in transmission during previous outbreaks (4,9). Efforts to Control the Current Outbreak To implement prevention and control measures in both Guinea and Liberia, ministries of health with assistance from Médecins Sans Frontières, the World Health Organization, and others, put in place Ebola treatment centers to provide better patient care and interrupt virus transmission. Teams from CDC traveled to Guinea and Liberia at the end of March as part of a response by the Global Outbreak Alert and Response Network to assist the respective ministries of health in characterizing and controlling the outbreak through collection of case reports, interviewing of patients and family members, coordination of contact tracing, and consolidation of data into centralized databases. Cases are categorized into one of three case definitions: suspected (alive or dead person with fever and at least three additional symptoms, or fever and a history of contact with a person with hemorrhagic fever or a dead or sick animal, or unexplained bleeding); probable (meets the suspected case definition and has an epidemiologic link to a confirmed or probable case); confirmed (suspected or probable case that also has laboratory confirmation).* In late April, it appeared that the outbreak was slowing when Liberia did not report new cases for several weeks after April 9, and the number of new reported cases in Guinea decreased to nine for the week of April 27 (Figure 1). Since then, however, the EVD outbreak has resurged, with neighboring Sierra Leone reporting its first laboratory-confirmed case on May 24, Liberia reporting a new case on May 29 that originated in Sierra Leone, and Guinea reporting a new high of 38 cases for the week of May 25. As of June 18, the total EVD case count reported for all three countries combined was 528, including 364 laboratory-confirmed, 99 probable, and 65 suspected cases, with 337 deaths (case-fatality rate = 64%). Guinea had reported 398 cases (254 laboratory-confirmed, 88 probable, and 56 suspected) with 264 deaths (case-fatality rate = 66%) across nine districts (Figure 1). Sierra Leone had reported 97 cases (92 laboratory-confirmed, three probable, and two suspected) with 49 deaths (case-fatality rate = 51%) across five districts and the capital, Freetown. Liberia had reported 33 cases (18 confirmed, eight probable, and seven suspected) with 24 deaths (case-fatality rate = 73%) across four districts. Major challenges faced by all partners in the efforts to control the outbreak include its wide geographic spread (Figure 2), weak health-care infrastructures, and community mistrust and resistance (10). Retrospective case investigation has indicated that the first case of EVD might have occurred as early as December 2013 (Figure 1) (2). To control the outbreak, additional strategies such as involving community leaders in response efforts are needed to alleviate concerns of hesitant and fearful populations so that health-care workers can care for patients in treatment centers and thorough contact tracing can be performed. Enhancing communication across borders with respect to disease surveillance will assist in the control and prevention of more cases in this EVD outbreak. In June 2014, the World Health Organization, via the Global Outbreak Alert and Response Network, requested additional support from CDC and other partners, necessitating the deployment of additional staff members to Guinea and Sierra Leone to further coordinate efforts aimed at halting and preventing virus transmission. Persistence of the outbreak necessitates high-level, regional and international coordination to bolster response efforts among involved and neighboring nations and other response partners in order to expeditiously end this outbreak.

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Rapid Intervention to Reduce Ebola Transmission in a Remote Village — Gbarpolu County, Liberia, 2014

David Blackley, Kim Lindblade, Francis Kateh … (2015)

As late as September 14, 2014, Liberia’s Gbarpolu County had reported zero cases of Ebola virus disease (Ebola) (1). On October 25, the Bong County Health Team, a local health department in the Liberian Ministry of Health and Social Welfare (MOHSW), received confirmation of Ebola in a man who had recently left Geleyansiesu, a remote village of approximately 800 residents, after his wife and daughter had died of illnesses consistent with Ebola. MOHSW requested assistance from CDC, the World Health Organization, and other international partners to investigate and confirm the outbreak in Geleyansiesu and begin interventions to interrupt transmission. A total of 22 cases were identified, of which 18 (82%) were laboratory confirmed by real-time polymerase chain reaction. There were 16 deaths (case-fatality rate = 73%). Without road access to or direct telecommunications with the village, interventions had to be tailored to the local context. Public health interventions included 1) education of the community about Ebola, transmission of the virus, signs and symptoms, the importance of isolating ill patients from family members, and the potential benefits of early diagnosis and treatment; 2) establishment of mechanisms to alert health authorities of possibly infected persons leaving the village to facilitate safe transport to the closest Ebola treatment unit (ETU); 3) case investigation, contact tracing, and monitoring of contacts; 4) training in hygienic burial of dead bodies; 5) active case finding and diagnosis; and 6) isolation and limited no-touch treatment in the village of patients unwilling or unable to seek care at an ETU. The findings of this investigation could inform interventions aimed at controlling focal outbreaks in difficult-to-reach communities, which has been identified as an important component of the effort to eliminate Ebola from Liberia (2). Investigation Results On September 16, a girl aged 10 years (source patient) attending school in Kakata, Margibi County, returned to Geleyansiesu (southeastern Gbarpolu County, bordering Bong County) (Figure 1), a remote village accessible only by canoe and several hours walking. It was reported by the community that the aunt with whom the source patient resided had recently died of an illness consistent with Ebola. The child became ill on September 18 and was cared for by her stepmother (aged 37 years) before dying on September 27 in Geleyansiesu. At least 13 village residents in addition to the stepmother participated in her burial, none of whom contracted Ebola. The stepmother experienced symptoms consistent with Ebola on October 8, and became the only known patient with infection attributable to the source patient. The severely ill stepmother was carried in a hammock stretcher by at least nine persons from Geleyansiesu to a nearby town to seek medical care; she died on October 11. One of the hammock carriers, her husband (aged 39 years), traveled to a quarantine center for Ebola patient contacts in Gbarnga, Bong County, along with seven family members who had not participated in her transport. Eight of the carriers returned to Geleyansiesu, and none became ill with Ebola. The husband experienced symptoms including fever, vomiting, and diarrhea beginning on October 24 and was transported to the Bong County ETU (Bong ETU) on October 25, where he tested positive for Ebola virus. He recovered and was discharged on November 12; none of the seven immediate family members staying with him in the quarantine center became ill. On October 30, MOHSW, Gbarpolu County, and Bong County, CDC, and other international partners conducted a brief overnight assessment visit to Geleyansiesu. The purpose of the visit was to determine whether there was ongoing transmission in the village and gather situational information to mount a coordinated public health response, which was complicated by the difficult access to the community. During the visit, team members educated the community about the signs and symptoms of Ebola and the importance of early identification and treatment, along with the options for diagnosis and treatment at the Bong ETU. Although information provided by the community did not suggest any current cases or contacts of the previously identified cases in the village, they did report two recent deaths on October 27 (of farmer A) and October 28 (of farmer B). Farmer A was reported to have died of an injury, whereas farmer B’s death was unexplained. At the time, neither could be linked epidemiologically to the two previous cases. Despite the lack of evidence of ongoing transmission, a Bong county health official was stationed at the closest point to the community accessible by vehicle (Saint Paul River crossing) to provide mobile telephone updates to the county health team and to arrange safe transport to the ETU for any patients walking out of the community. On November 3, seven ill Geleyansiesu residents departed the village on foot and were later admitted to the Bong ETU; all tested positive for Ebola virus on November 4, and five died. Each of these seven patients was an immediate family member (two wives and five children) of farmer A or farmer B. Preparations were immediately begun by MOHSW and partners for a full investigation and public health response. Before the investigation could be launched, six additional Geleyansiesu residents were admitted to the Bong ETU; all tested positive for Ebola virus, and five died. Four of these six patients had visited or cared for farmer A after his reported injury or had helped prepare his body for burial; they had not received training on safe burial practices. One of the six was linked to farmer B, whereas the epidemiologic link of one could not clearly be determined. Investigators returned to the village during November 9–11 to complete case investigations, find and monitor contacts, and conduct active house-to-house case finding. Using MOHSW case definitions, described previously (3), three probable cases and three suspected cases in the village were identified along with 20 contacts. Investigators provided technical assistance to families and local community health volunteers to isolate and treat patients with oral rehydration solutions and facilitate safe evacuation to the Bong ETU for those willing and able to walk out to the ambulance. One of the patients with a probable case of Ebola left to seek diagnosis and treatment at the Bong ETU and tested negative; another died in the village on November 11. One patient with a suspected case went to the Bomi County community care center (4), tested positive, and died. An international partner collected samples on November 11 for the remaining persons with suspected and probable cases, including one post-mortem, and confirmed three cases, all among contacts of farmer A. A clinical partner established isolation tents in the village and was prepared to provide no-touch care to the two remaining cases, but both declined treatment and isolation outside their homes. What is already known on this topic? Persons with Ebola virus disease (Ebola) can travel with the infection and spark outbreaks in remote areas. These outbreaks can cause large numbers of illnesses and deaths in the absence of public health interventions to find, isolate, and treat persons with Ebola. What is added by this report? In October 2014, CDC, the Liberian Ministry of Health and Social Welfare, and other partners investigated an outbreak in a remote community of Liberia, accessible only by canoe and foot, to confirm the outbreak and begin public health interventions. Although there were delays, ambulance support was established to help those patients who managed to walk out of the community reach an Ebola treatment unit; this intervention removed many patients from the community and contributed to the resolution of the outbreak. What are the implications for public health practice? Lessons learned from this outbreak were employed in the planning and interventions for subsequent outbreaks in isolated Liberian communities, improving response times and helping to shorten the course of the outbreak. On November 19, the clinical partner organization attempted to return to the village to reassess contacts and identify any new cases, but left because of resistance from a group of residents. A meeting with the Gbarpolu County health team and the district’s paramount chief (ranking traditional leader) led to successful reentry into the village on November 29 by MOHSW, CDC, and other partners. During follow-up interviews, it was determined that farmer B had cared for the stepmother of the source patient while she was ill; farmer A had been absent from the village during the weeks before his symptom onset, indicating there were likely two separate Ebola introductions into the village. No new cases were identified during the visit, and both of the previously identified confirmed patients had recovered. During September 18–November 6, a total of 22 Ebola cases (18 confirmed, two probable, and two suspected) were identified in Geleyansiesu, for an estimated attack rate of 28 cases per 1,000 residents (Figure 2). A total of 16 of the cases were fatal. Median age of patients was 34 years, and six patients (27%) were aged <18 years; 13 (59%) were male (Table). Fifteen of 22 patients were hospitalized at an ETU or community care center, and 18 had a diagnostic test for Ebola completed; samples for 15 were collected at an ETU or community care center, and three were collected in the village. Among those who were hospitalized, the median interval between reported symptom onset and admission to an ETU was 2 days (mean = 3.4 days; range = 2–8 days). Although the patients who became symptomatic before the initial investigation on October 30 generated an average of three secondary cases, no secondary cases were produced by any of the patients who became symptomatic after October 30. On December 20, 21 days after full recovery of the last patient, the outbreak was declared to be over. Discussion During late 2014, multiple outbreaks in remote areas of Liberia were sparked as a result of travelers from affected areas (such as Monrovia) returning to their rural homes. Geleyansiesu is accessible only by a combination of foot and canoe travel, and during this outbreak response, challenges were encountered that have been identified in other rural Liberian counties (5), including poor transportation and communication infrastructure. These challenges, in addition to instances of community resistance to outside intervention, likely delayed and complicated the public health response. A multidisciplinary team including domestic and international partners supported the community in responding to the outbreak, which was effectively controlled with interventions including education about Ebola and establishment of a communication plan to alert health authorities to potential cases and to arrange safe ambulance transportation to an ETU. Rapid response teams can initiate interventions to quickly interrupt Ebola virus transmission, even in remote areas. Flexible support networks, including onsite options for nonambulatory persons and transportation support to link patients to treatment centers, could help limit transmission in remote communities.

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Rapid Response to Ebola Outbreaks in Remote Areas — Liberia, July–November 2014

Francis Kateh, Thomas Knue Nagbe, Abraham Kieta … (2015)

West Africa is experiencing its first epidemic of Ebola virus disease (Ebola) (1). As of February 9, Liberia has reported 8,864 Ebola cases, of which 3,147 were laboratory-confirmed. Beginning in August 2014, the Liberia Ministry of Health and Social Welfare (MOHSW), supported by CDC, the World Health Organization (WHO), and others, began systematically investigating and responding to Ebola outbreaks in remote areas. Because many of these areas lacked mobile telephone service, easy road access, and basic infrastructure, flexible and targeted interventions often were required. Development of a national strategy for the Rapid Isolation and Treatment of Ebola (RITE) began in early October. The strategy focuses on enhancing capacity of county health teams (CHT) to investigate outbreaks in remote areas and lead tailored responses through effective and efficient coordination of technical and operational assistance from the MOHSW central level and international partners. To measure improvements in response indicators and outcomes over time, data from investigations of 12 of 15 outbreaks in remote areas with illness onset dates of index cases during July 16–November 20, 2014, were analyzed. The times to initial outbreak alerts and durations of the outbreaks declined over that period while the proportions of patients who were isolated and treated increased. At the same time, the case-fatality rate in each outbreak declined. Implementation of strategies, such as RITE, to rapidly respond to rural outbreaks of Ebola through coordinated and tailored responses can successfully reduce transmission and improve outcomes. Outbreaks in remote areas posed a significant challenge to CHTs to mount an effective investigation and rapid response because of limited resources, personnel, and means to reach remote areas. The RITE strategy provided a framework to coordinate assistance from the central MOHSW and other agencies under the leadership of the CHT and developed several tools to help plan, manage, and track a response effort. The objectives of the investigation and response teams were to 1) rapidly isolate and treat Ebola patients, either by establishing isolation and treatment facilities in the community or by safely transporting patients to existing Ebola treatment units (ETUs); 2) ensure proper collection and safe transportation of samples for Ebola laboratory confirmation; 3) ascertain the index case (the first person in the transmission chain who entered the community from another county in Liberia) in each outbreak to better understand importation and transmission patterns; 4) identify all generations of cases by improving case finding and contact tracing to ensure no cases were missed; 5) train teams in safe burial procedures; and 6) observe contacts for 21 days from the death or ETU admission of the last case to ensure interruption of transmission. Investigation and response teams included Liberian MOHSW national and county representatives, CDC, WHO, the United Nations Children’s Fund, and other multilateral and nongovernmental organizations. The RITE strategy clearly articulated the role of CHTs to coordinate efforts of partners involved in response activities to rapidly mobilize resources that could be tailored to the needs in each outbreak. After initiation of the RITE strategy in October, outbreak responses were supported with structured rapid response microplanning tools implemented by CHTs that delineated each intervention component (e.g., isolation of patients, laboratory testing, and health promotion) and the organizations responsible for implementation. Outbreaks and response activities were reviewed on a weekly basis at the national level at the county operations subcommittee of the national incident management system (2), allowing MOHSW and partner organizations to plan and prioritize resources for the rapidly changing situation. An additional intervention beginning in November was the packaging of RITE kits that could be prepositioned in the counties, containing all commodities required for the first 14 days of response interventions (e.g., essential medicines for treatment of patients such as oral rehydration solution, antimalarial medication, and antibiotics; personal protective equipment; and construction materials for temporary isolation and treatment facilities). The availability of RITE kits at the county level would provide further flexibility to CHTs to tailor rapid responses appropriately for the community involved in the outbreak and add to their ability to rapidly deploy the necessary resources to the affected area. For this report, Ebola outbreaks that occurred in remote areas, produced at least one generation of transmission in the community and had complete investigations were analyzed. An Ebola outbreak was defined as two or more epidemiologically linked Ebola cases. Cases were classified as suspected, probable, or confirmed using the Liberian case definitions (3). Initial alerts of possible Ebola outbreaks were received by CHTs as rumors, reports of clusters of ill persons or unexplained deaths, or reports of patients admitted to ETUs. Case investigation reports were gathered through interviews with ill persons or their proxies. Databases from ETUs were searched to supplement incomplete case investigation reports. Transmission-chain diagrams were constructed back to the first case to enter the county from another county in Liberia (the index case). The first generation of cases was defined as resulting from contact with the index patient, and the total number of generations was determined from the transmission-chain diagrams. To monitor the effectiveness of rapid response to outbreaks over time, the number of days between the symptom onset of the index patient and the date the CHT was first alerted to a potential outbreak, and the date the CHT first sent in a team to investigate were computed for each outbreak. Outbreak duration was calculated as the number of days between the symptom onset date of the index case and the last case in the outbreak, defined as the last case in a chain of transmission to occur before 21 days passed with no new cases. Demographic characteristics of patients and the proportion of patients isolated and treated in an ETU or similar facility were summarized by outbreak. Among 15 Ebola outbreaks in remote areas of nine counties with index case symptom onset dates during July 16–November 20, 2014, 12 investigations had complete data (Figure 1). Investigations of these 12 outbreaks identified 263 patients (Table), including 155 (59%) with laboratory-confirmed cases of Ebola, 71 (27%) with probable cases, and 37 (14%) with suspected cases. There were 190 deaths (case-fatality rate = 72%). The median number of cases in an outbreak was 22 (range = 4–64), and the median population in the affected communities was 800 (range = 301–6,200). Attack rates ranged from 1 to 71 cases per 1,000 population. The median age of the patients was 32 years (range = 15 days to 84 years), and 144 (55%) were female. Eight (67%) outbreaks began with the introduction of an Ebola case from Monrovia, two from a neighboring county, and the source of introduction for three outbreaks was not identified (one outbreak had two index cases) (Table). Transmission of Ebola occurred through close contact with persons who were ill with Ebola, including providing care to a patient at home, or contact with a person who had recently died from Ebola. In Small Ganta, Nimba County, the death and burial of a woman who cared for the index patient resulted in 16 (25%) of the 64 Ebola cases in that outbreak. Although several traditional healers were infected in these outbreaks, no cases in health care workers from public or private health facilities were identified. The median time between symptom onset in the index patient and an alert received by the CHT was 33 days (range = 0–58 days); the median time to alert was 40 days for the six outbreaks before October 1 (prior to initiation of the RITE strategy) and 25 days for the six outbreaks with onset after October 1 (after the RITE strategy) (Figure 2). The median duration of the outbreaks was 43 days (range = 7–97 days). The median duration of the early outbreaks was 53 days, compared with 25 days for the later outbreaks. The median number of generations of cases was four (range = 1–7) for the early outbreaks and two (range = 1–4) for the later outbreaks. Interventions in the 12 outbreaks included 1) engagement of traditional and community leaders in response activities; 2) community education about Ebola virus transmission and prevention; 3) active case finding, contact tracing and monitoring; 4) quarantine of asymptomatic high risk contacts at home or in designated quarantine facilities; 5) isolation and treatment of patients; and 6) safe burials. In each community, the appropriate level of intervention was determined by the community’s requests, the number and severity of cases, the remoteness and accessibility of the community, and the distance to Ebola treatment facilities. Resistance to assistance was encountered in several communities, and response was suspended until discussions with county and traditional officials or the increasing burden of cases and deaths encouraged community acceptance of intervention. In two outbreaks (Kayah District, Rivercess and Quewein, Grand Bassa), the availability of nongovernmental partners to rapidly establish isolation and treatment facilities permitted on-site or nearby care of patients. In these and other outbreaks, some patients were able to reach ambulances at the closest road access point and were taken to established ETUs. In one outbreak (Jenewonde, Grand Cape Mount), delays in the establishment of an isolation and treatment facility resulted in only one patient being cared for in the facility before the outbreak was over. Over time, the proportion of patients in each outbreak that were isolated and treated increased from a median of 28% in the early outbreaks to 81% in the later outbreaks (Table). The proportion of laboratory-confirmed cases increased from a median of 44% in the early outbreaks to 81% in the later outbreaks because a greater proportion of patients reached treatment facilities and specimen collection in the field improved as part of the RITE strategy. The case-fatality rate of each outbreak also improved over time; the median case-fatality rate in the early and later outbreaks were 87% and 50%, respectively. As of January 8, 2015, all of these outbreaks had ended with no further cases identified within 21 days of exposure to the last patient. Discussion Implementing an effective rapid response is critical to limiting the magnitude and duration of Ebola outbreaks. The remoteness and complexity of the outbreaks described in this report have posed challenges to rapid response; movement of personnel and supplies was greatly hindered by distance, river crossings, poor or nonexistent roads (Figure 3), and limited communication options (4). Nonetheless, implementation of the RITE strategy resulted in substantial reductions in the time from symptom onset of the index patient to outbreak alerts, in the duration of outbreaks, and in the case-fatality rate. Four of the six outbreaks that occurred before development of the RITE strategy remained undetected until they were in at least the third generation of transmission, whereas five of the six later outbreaks were detected in the first or second generation. In addition to the RITE strategy, greater community awareness of Ebola helped alert authorities earlier to clusters of unexplained deaths or illness consistent with Ebola and also facilitated faster community acceptance of interventions. Availability of ETU beds for isolation and treatment of patients also improved significantly over the period covered by these outbreaks (5), and the increasing proportion of patients reaching an ETU or other type of isolation and treatment facility likely contributed to the shorter duration of outbreaks. Continued access to early treatment, efforts to improve community awareness, and deployment of rapid, coordinated, and effective responses to remote rural outbreaks will need to continue until Ebola transmission in West Africa is halted. What is already known on this topic? The epidemic in West Africa has resulted in the largest number of Ebola cases in history. Ebola is associated with a high case-fatality rate that can be reduced through supportive care. Ebola transmission can be interrupted through isolation of infected patients, infection control, monitoring of patients’ contacts, and safe burial of dead bodies. Remote rural areas pose challenges for rapid isolation and treatment of patients because of their distance, difficult access, and lack of communications infrastructure. What is added by this report? A national strategy in Liberia to coordinate rapid responses to remote outbreaks of Ebola reduced by nearly half the time between the first new case in remote areas and notification of health authorities. As coordination of the rapid response strategy improved over time, the median duration of outbreaks decreased from 53 to 25 days as the number of generations of cases decreased from a median of four to two. The proportion of patients isolated increased from 28% to 81%; survival improved from 13% to 50%. What are the implications for public health practice? Ebola outbreaks in remote rural areas require rapid responses, including the movement of patients to treatment facilities. Interventions can be as simple as arranging safe ambulance transport for patients who might have to walk out of remote areas, but might also require establishment of mobile isolation and treatment facilities if patients are too ill to move or delays in transport are anticipated. Comprehensive and innovative rapid response units can improve outcomes and shorten duration of Ebola outbreaks, and should be employed wherever possible.

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Journal ID (nlm-ta): MMWR Morb Mortal Wkly Rep

Journal ID (iso-abbrev): MMWR Morb. Mortal. Wkly. Rep

Journal ID (publisher-id): MMWR

Title: MMWR. Morbidity and Mortality Weekly Report

Publisher: U.S. Centers for Disease Control

ISSN (Print): 0149-2195

ISSN (Electronic): 1545-861X

Publication date Collection: 17 April 2015

Publication date (Electronic): 17 April 2015

Volume: 64

Issue: 14

Pages: 386-388

Affiliations

[1 ]Epidemic Intelligence Service, CDC

[2 ]Division of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, CDC

[3 ]Office of Public Health Scientific Services, Center for Surveillance, Epidemiology, and Laboratory Services, CDC

[4 ]World Health Organization, Kissidougou, Guinea

[5 ]Guinea Ministry of Health, Kissidougou

[6 ]Global Immunization Division, Center for Global Health, CDC

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Corresponding author: Kerton R. Victory, kvictory@ 123456cdc.gov , 513-841-4544

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Publisher ID: 386-388

PMC ID: 5779538

PubMed ID: 25879897

SO-VID: f21b165b-46eb-4e1a-acc6-a46b44d1b07d

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All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

Ebola Transmission Linked to a Single Traditional Funeral Ceremony — Kissidougou, Guinea, December, 2014–January 2015

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Ebola Viral Disease Outbreak — West Africa, 2014

Rapid Intervention to Reduce Ebola Transmission in a Remote Village — Gbarpolu County, Liberia, 2014

Rapid Response to Ebola Outbreaks in Remote Areas — Liberia, July–November 2014

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