The magnitude of West Africa’s Ebola outbreak has been underestimated, the World Health Organization (WHO) said on Friday, warning that unknown numbers of infected people were being hidden by their family members, and dying in “shadow zones” — places where health care workers cannot go.
Despite initial assertions by regional health officials that the virus had been contained in its early stages, Ebola case numbers and deaths have ballooned in recent months as the outbreak has spread from its initial epicenter in Guinea. Nigeria, the fourth country affected, confirmed two new cases on Friday, bringing the total number of recorded cases there to 14. The country’s health minister said both patients caught the disease from people who were primary contacts of the Liberian man who first brought it to the economic capital Lagos.
Official estimates place the number of known, suspected and probable cases of Ebola at nearly 2,500, just over half of which have been fatal. However, in a detailed assessment of the true extent of the crisis, the WHO described a bleak situation in which “an invisible caseload of patients… are not being detected by the surveillance system.”
Independent experts raised similar concerns a month ago that the contagion could be worse than reported because some residents of affected areas are chasing away health workers and shunning treatment.
The WHO said it is now working with Medecins Sans Frontières (Doctors Without Borders) and the U.S. Centers for Disease Control and Prevention to produce “more realistic estimates.”
Hidden cases
Recording of Ebola cases has been hindered for a number of reasons, particularly in Sierra Leone and Liberia, which have seen the worst of the epidemic, the WHO said in its latest situation report.
Families are hiding infected loved ones, on the assumption that, because Ebola has no cure, it would be better for them to die at home rather than in the hospital. However, effective treatment can improve chances of survival – a message that health authorities have been struggling to communicate to increasingly fearful populations.
Isolation wards for Ebola patients are instead being viewed by many Africans as an “incubator for the disease”, the WHO said. Many medical facilities throughout the affected countries have closed, in many cases because medical staff have fled.
In other cases health centers are being suddenly overwhelmed with patients, suggesting there is an invisible caseload of patients not on the radar of official disease surveillance systems.
Patients wait outside of a new Ebola clinic being set up by the humanitarian group Doctors Without Borders. Based on the unexpected rush of patients at the new clinic, WHO officials believe many cases are going undocumented.
In the Liberian capital, Monrovia, where curfews aimed at slowing the spread of the virus have led to clashes between security forces and residents, hospitals and clinics have remained closed since authorities ordered them to be disinfected, and medical staff retrained to cope with Ebola three weeks ago. The WHO said that “virtually all health services have shut down” in the city, leading to a healthcare crisis beyond the impact of Ebola itself, with people forced to go without basic medical care.
Aphaluck Bhatiasevi, a WHO officer in Monrovia, said the re-opening of healthcare units was taking longer than expected, but that maternity services and obstetrics were now operating again at the city’s main hospital.
“The system wasn’t at its best to begin with. We are facing challenges getting the healthcare facilities up and running,” she said. “Roads are not in a perfect condition. We are in the rainy season, and there are patients who do not have Ebola unable to get the necessary healthcare.”
‘Shadow Zones’
In remote villages, corpses are being buried before authorities are notified. In some cases, according to the WHO, epidemiologists reaching the villages have been forced to “count the number of fresh graves” as a crude indicator of Ebola deaths.
The WHO also warned of “shadow zones” — rural areas where there are persistent rumors of Ebola cases and deaths that cannot be investigated because of strong community resistance. In some cases, distrust and fear have spilled over into violence, leading to attacks on health care workers. Back in July, officials from the International Federation of the Red Cross and the Red Crescent described one such incident:
We had an incident in Guéckédou, the epicenter of the outbreak in Guinea recently where people carrying knives surrounded one of our marked Red Cross vehicles.
It is not the first time we have had such an incident, and it likely will not be the last.
Widespread fears, distrust, and misinformation have greatly hampered efforts to control the spread of the virus, which has ravaged the West African countries of Liberia, Sierra Leone, and Guinea.
In these areas, the WHO cautions, it is possible to hide not only individual cases, but entire outbreaks. With a lack of basic sanitation and infection-control supplies, it is likely that the virus would spread quickly in such communities, the agency says, potentially adding a substantial number of cases to the outbreak’s rapidly growing toll.
Even in areas accessible to health care workers, strong resistance among the public has made it difficult to contain the virus in some communities. Last weekend, for instance, a mob attacked an Ebola clinic in West Point, Liberia’s largest ‘slum’ neighborhood. After a misunderstanding between local health authorities and West Point residents, a group of scared and frustrated residents lashed out by attacking the clinic, releasing 17 patients and looting infected materials in the process. The community elders later apologized for the behavior of the group.
Many months ahead
Based on the scale of the current outbreak — and the likelihood that many cases have gone uncounted — the WHO says there is undoubtedly a long road ahead for health care workers in the region.
“We think six to nine months is a reasonable estimate,” Keiji Fukuda, the WHO’s Assistant Director-General for Health Security, said during a visit to Liberia, speaking of the time the agency now believes will be required to halt the epidemic. An Ebola outbreak will be declared over in a country if two incubation periods, or 42 days in total, have passed without any confirmed case, the WHO said.
On Friday, the WHO said it had drawn up a draft strategy plan to combat the disease in West Africa, and details would be released early next week.
Above, UN health officials go door-to-door to speak with residents about Ebola prevention measures. The WHO says it could take another nine months to get the outbreak under control.
The affected West African countries were already struggling with few doctors and fragile healthcare systems before the Ebola outbreak. And health workers have been among the hardest hit by the disease.
In a sign of spreading regional alarm, Senegal, West Africa’s humanitarian hub, said it had blocked a U.N. aid plane from landing and was banning all further flights to and from countries affected by Ebola. Gabon also announced on Friday its suspension of air and sea links to the four affected countries, following the lead of a number of regional nations who have defied WHO advice in an attempt to isolate themselves from the disease.
The World Health Organization has repeatedly said it does not recommend travel or trade restrictions for countries affected by Ebola, saying such measures could heighten food and supply shortages.
Meanwhile, the two American aid workers who were brought back to the U.S. for treatment after contracting Ebola were released from the hospital this week. Both received an experimental Ebola treatment called ZMapp, which some say contributed to their rapid recovery.