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A gravedigger at the cemetery of the Ebola treatment unit in Suakoko District in Bong County.

A gravedigger at the cemetery of the Ebola treatment unit in Suakoko District in Bong County.

K. Kupferschmidt/SCIENCE

A new phase in the Ebola war

MONROVIA—When Kevin De Cock flew home from this city of 1 million in August, he was leaving behind an apocalyptic scene. More than 100 people were coming down with Ebola daily. Patients were dying outside of treatment units filled to capacity, and bodies lay rotting in the streets. Some mathematical models projected that Liberia would face thousands of new cases weekly by December. "There was really no way of knowing how much worse this might get,” says De Cock, an epidemiologist at the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta.

But when he returned to Monrovia on 9 November, the situation was very different. The grim projections had been wrong. Although the Ebola epidemic is still growing in Sierra Leone, and Guinea's numbers are swinging up and down, Liberia is now reporting only about 20 new patients a day. Treatment units have hundreds of empty beds, and Liberian President Ellen Johnson Sirleaf has lifted the state of emergency put in place in August. Now the country faces new challenges: rebuilding a shattered health care system, tamping down local outbreaks, and looking for ways to drive the number of new cases to zero.

No one here is quite sure what has caused the epidemic to wane. Safe burials may be a big factor, says Katri Jalava, a Finnish veterinarian and an epidemiological consultant to the World Health Organization. It's a local custom to wash the corpse and then use the same water to wash the hands of the bereaved, she says. “In terms of a disease like Ebola that is absolutely mad.” Most agree that people's everyday behavior has changed as well. Ubiquitous street signs warn that “Ebola is real” and tell Monrovians “Don’t be the next case.” Outside many homes are small hand-washing stations with bleach, and Liberians have stopped hugging and shaking hands.

Yet "this is still a catastrophe,” De Cock says. Even 20 daily Ebola cases would have been unimaginable a year ago. And Guinea has shown that success in fighting Ebola can be short-lived: Twice, that country was on the cusp of ending the outbreak, and twice the virus came roaring back.

Some have even questioned whether Liberia’s recent drop in cases is real. At a meeting at the Liberian ministry of health last week, a U.S. Agency for International Development representative said he had been sent specifically to find out if the numbers can be trusted. "Yes," answered Swedish statistician Hans Rosling, who has spent the past month in Monrovia helping the Liberian government interpret epidemiological data. CDC researchers, for instance, have used mouth swabs to test dead bodies in Monrovia for Ebola; about 20% to 30% are now positive, down from close to 90% during the height of the epidemic. The real number of cases may be twice the reported number, but not much more, Rosling says. “We're in a new phase now.”

The international response has been slow to adapt. Although the Pentagon has said it will build fewer new Ebola treatment centers, their construction is ongoing. "That doesn’t make sense at all," says Thierry Goffeau, head of the Doctors Without Borders (MSF) mission in Liberia. "It's clearly a waste of human and financial resources.” Rosling, too, says tactics have to change. In September, the main job was building clinics, removing the dead, and keeping as many patients as possible isolated. Now, it's about setting up a flexible system to respond to new outbreaks, identifying patients quickly, and tracing their contacts to prevent more infections. "What we needed to do in the first phase was rugby," Rosling says. "Now it is chess."

Liberia's medical system, which collapsed under the weight of Ebola, is gearing up again. Doctors are returning to work, clinics are reopening. Goffeau says that is sorely needed: “People are dying at home of many other diseases than Ebola, because they have no access to health care." But medical staff still face an important risk. One in every hundred or thousand patients may carry the Ebola virus—which could start new cycles of infection. There are reports that doctors at some clinics are now doing surgery and delivering babies in Ebola protection suits.

At Redemption Hospital in Monrovia, whose inpatient department was closed this summer after several doctors died from Ebola, MSF is trying to protect staff with a new triage unit, which opened on 19 November. Patients with Ebola-like symptoms are interviewed; if they meet the criteria for a suspect case, they stay in one of 10 small rooms while their blood is tested. Those who test negative can enter the inpatient ward, while an ambulance takes Ebola patients to a treatment unit. MSF has also started distributing malaria drugs to hundreds of thousands of people, not just to lower the burden of that disease, which was neglected for months, but also to reduce the number of people visiting hospitals with a fever.

Reopening Monrovia's schools poses similar quandaries. One idea is to screen pupils’ temperature as they enter the school. “But what do you do if a 10-year-old kid has a high temperature and the other kids start pointing at him and shouting ‘Ebola’?” Rosling says. In a meeting with President Sirleaf, he has argued for a cautious approach: Opening some schools and carefully studying what happens.

The capital region still serves as a reservoir from which patients travel to rural areas and spark fresh outbreaks, De Cock says—and now that the rainy season has ended, travel may pick up. In Bong County, for instance, a few hours northwest of Monrovia, two big outbreaks are spreading, at least one seeded from the capital. The treatment unit in the district of Suakoko, run by the International Medical Corps, is full, and new patients are brought in daily. Sambhavi Cheemalapati, the unit's program coordinator, says she is seeing far more patients than are accounted for in the official numbers. Aid should focus on spreading prevention messages in these remote locales, Goffeau says. “If the people really understand what Ebola is and how to avoid infection, we might stop this epidemic,” he says.

Such regional flare-ups make it unlikely that the Liberian epidemic will be over anytime soon, Rosling says. Still, he believes it's possible that the country may see its first day without a single case as early as December. Given the cataclysmic projections of just 2 months ago, that would be a remarkable turnaround.

*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.