The road into Fish Town.

The road into Fish Town.

Adam Bjork

Exit interview: CDC epidemiologist sees hope for controlling Ebola in southeastern Liberia

Liberia has become synonymous with out-of-control Ebola and all the horrors that follow. But Liberia is a fairly large country, nearly the size of Denmark, the Netherlands, and Belgium combined. Adam Bjork, an epidemiologist with the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta, spent the last 2 weeks in the southeastern corner of the country, which has seen relatively few Ebola cases. He spoke with ScienceInsider on 6 October as he waited for his flight home at the airport in Monrovia, the country’s Ebola-ravaged capital.

Bjork had an unusually optimistic assessment about the opportunities to curb the epidemic in remote River Gee County, home to some 70,000 of Liberia’s 4.3 million inhabitants. But he also had a most frightening story about a sick family, traveling from place to place in a taxi in a desperate search for care, who inadvertently spread the virus.

CDC sent Bjork to Fish Town, the capital of River Gee County, a 3-day drive from Monrovia this rainy time of year, to assess the situation. He arrived on 15 September, one of three CDC employees sent to the southeast to “be eyes and ears on the ground and give our bosses in Monrovia a sense of what’s going on.”

Health workers in Fish Town told Bjork about a woman who died on 2 August in River Gee, presumably the county's first Ebola case. Before arriving in River Gee, she had been in Monrovia and in Grand Kru County, which borders River Gee, where she saw a pharmacist.

Five people who had been in close contact with the woman in either Grand Kru or River Gee fell ill—including her boyfriend, an aunt, and roommates—and became suspect, probable, or confirmed Ebola cases. (Confirmation requires evidence of the virus with a polymerase chain reaction test that was not readily available for most cases.) Three died. In a “secondary wave,” three people who cared for some of these five people became cases, and only one survived.

Fish Town didn't have an Ebola case until August.

Fish Town didn't have an Ebola case until August.

Adam Bjork

Later on, the pharmacist from Grand Kru and his son fell ill. They took a taxi with three other family members, presumably to seek care in Monrovia. First they drove through River Gee County toward a city on its northern border, Zwedru, the capital of Grand Gedeh County. “They got turned away at the border,” Bjork says, so they headed south toward Maryland County. The taxi driver and family members spent a night in River Gee en route. “Somewhere in River Gee the dad and son died in the taxi,” Bjork says. All three of the remaining family members became Ebola cases, as did the driver. Two were transported to Monrovia, where they died.

In all, the virus that infected the woman on 2 August spread to 10 others in River Gee, marking the county’s first 11 cases. Four others who are at least suspected to have had the disease were in Maryland County and Monrovia.

None of Liberia's four counties in the far southeastern corner of the country (dark blue) had a case of Ebola until August.

None of Liberia's four counties in the far southeastern corner of the country (dark blue) had a case of Ebola until August.

CDC, MMWR

When Bjork was in River Gee, a woman and her daughter showed up at the hospital; both were suspected Ebola cases. The infected taxi riders had stayed at their house when passing through River Gee.

One health care facility after another in River Gee County began shuttering its doors in fear. “They were all closed except for a maternity ward,” Bjork says. The reasons varied but were understandable, he says: "A lot of workers wanted to help and felt it was their duty, but they wanted to be trained.”

Bjork worked with local health officials to piece together the chain of transmission and to help mount an effective response. Despite the bleak situation, he's still optimistic about the Ebola outbreak in the remote area. “They could get in front of it out there,” Bjork says.

During his 2-week stay, Bjork worked with a team in Fish Town to do contact tracing. He was surprised by how well-organized the effort was already. “I came with a template to make sure they had initiated the tracing, but what they’d done had covered the vast majority of it,” Bjork says. But they were short on motorbikes and vehicles to do the fieldwork. “They know what to do, but they don’t have the resources,” he says. “And they need to communicate with nearby communities so they’re accepted there to do it.”

Contact tracing in Gee River County means motorbiking on muddy roads.

Contact tracing in Gee River County means motorbiking on muddy roads.

Adam Bjork

At first, the contact tracers were met with some hostility; one town threatened to burn the ambulance some of the workers were traveling in. The team held a community meeting with town leaders. “I’ve never seen a large-scale community gathering change its mood like that after getting information delivered and being heard,” he says. “By the end, they were OK with it.”

Bjork says he saw a lot of signs that the international response to the epidemic is being ramped up. Welthungerhilfe, a German nongovernmental organization, was helping build a community care center at a local school that would isolate suspected Ebola patients and provide some medical treatment. Samaritan’s Purse, the missionary group, flew a team in by helicopter to start building a more sophisticated Ebola treatment center. The World Health Organization and the Liberian ministry of health sent in trainers to teach health care workers how to safely do their jobs.

Ebola is exceedingly real at this training of health care workers.

Ebola is exceedingly real at this training of health care workers.

Adam Bjork

By the time Bjork left on 29 September, all the health care facilities had reopened or were preparing to do so soon.

Bjork says the outbreak in River Gee County is so "fresh" that with training of health care workers, educating communities, contact tracing, and swift isolation of patients, it can still be contained. “This Ebola treatment unit being built may never need to be used,” he says. “They have an opportunity—if that’s the right word—to get ahead, where more populated counties that got hit earlier in the outbreak were forced to play catch-up.”

*The Ebola Files: Given the current Ebola outbreak, unprecedented in terms of number of people killed and rapid geographic spread, Science and Science Translational Medicine have made a collection of research and news articles on the viral disease freely available to researchers and the general public.

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