Monrovia earlier this year.

Monrovia earlier this year.

United Nations Development Programme/Flickr (CC BY-NC-ND 2.0)

Liberia's Ebola progress real, but epidemic far from under control

Two months ago, when clinician Tim Flanigan arrived in Monrovia to help Liberia combat its Ebola epidemic, it took ambulances a few days to respond to calls, dying people were turned away from designated treatment units, health care workers ran short of personal protective equipment, and dead bodies were left in the street. “There was not enough help and there was a sense that the world did not understand how grave this epidemic was,” says Flanigan, who works at Brown University and formerly headed the infectious disease program there. “Now it’s dramatically different in Monrovia, which is wonderful to see.”

Bruce Aylward, the assistant-director general in charge of the operational response to Ebola at the World Health Organization (WHO), confirmed at a press conference today that the number of reported cases has declined in Liberia, the country hardest hit in this Ebola epidemic. “It appears that the trend is real in Liberia and that there may indeed be a slowing of the epidemic there,” said Aylward, who noted that treatment units in several locales have available beds.

But both Aylward and Flanigan immediately cautioned against premature optimism. "My god, the single biggest mistake right now would be if people start thinking, ‘Do we really need all those new beds?’ ” Aylward said. “I’m terrified that the information will be misinterpreted and that people will start to think, ‘Oh, great, this is under control.’ This is like saying your pet tiger is under control. This is a very, very dangerous disease.”

Flanigan stressed that now is the time “to redouble our efforts,” especially when it comes to tracking contacts and monitoring their health. “That’s an enormous task and we need to do a much better job,” he says.

The apparent decline in cases could mean that families are hiding patients and secretly burying the dead, but it is more likely that a combination of factors has reduced the spread of the disease, Aylward said. “There was a rapid scale up in safe burial practices in the month of September,” he said, adding that many people were isolated in Ebola treatment units, further curbing spread. There has also been intensive education of communities about the disease, including how it is spread, the value of seeking care, and self-protection strategies.

The situations in Guinea and Sierra Leone, the other two hard-hit countries, have not changed as dramatically.

In a disconnect with the drop of cases in Liberia, Aylward noted that WHO has tallied 13,703 cases—a jump of more than 3000 from the figures released on 25 October. He said the steep increase reflects reporting on a backlog of cases: “With the huge surge in cases in certain countries, particularly in September and October, people got behind on their data,” he said. “They ended up with huge piles of paper and we knew we were going to see jumps in cases at certain times that are going to be associated with more new data coming in that are actually old cases.” He said about 2000 of the latest cases came from old data collected in Liberia, where reporting of cases continues to be a problem. “Data for Liberia are missing for 19, 20, 21, 26 and 27 October,” the latest update from WHO notes.

WHO has warned that models suggested the epidemic would increase exponentially and that the virus was ahead of the response. Aylward noted the progress, but pointedly did not say the response was now ahead of the virus. “We are seeing a slowing of the rate of new cases very definitely,” Aylward said. “The danger now is instead of a steady downward trend that gets us down to zero, we end up with an oscillating pattern where the disease starts going up and down and areas start getting reinfected. What gets the heat out of this thing and slows it down isn’t necessarily what gets us down to zero.” 

Flanigan says the challenge now is to get better data from counties, not countries, to better understand the contours of the epidemic and how to respond. “Every last case needs a very aggressive response,” he says.

*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.