Ebola outbreak: A 'last battle' to stop deadly disease as experts warn against complacency

Amid conflicting reports of a decline in Ebola infection rates, and a danger of complacency setting in, new tactics will be required as the disease advances

The World Health Organisation is poised to launch a new drive against the Ebola epidemic in West Africa in response to the rapidly evolving situation – by getting victims to drink.

One of the most effective measures against the lethal infection turns out to be drinking large quantities – four litres or more a day – of fluids containing added salts.

Oral re-hydration is standard supportive treatment in cholera outbreaks and diarrhoeal disease across the globe, keeping the patient alive while their body fights the infection. But continuing medical disagreements over whether giving fluids intravenously, as practised in some Ebola treatment centres in West Africa, is preferable are delaying wide-scale implementation of the plan.

The new approach is gaining currency as experts recognise that the epidemic is spreading beyond the reach of current efforts to control it. The United National Ebola Emergency Response Mission has admitted it will miss its target of containing the virus by 1 December. Almost 16,000 people have been infected in the three worst-hit countries – Guinea, Liberia and Sierra Leone – and over 5,600 have died as the disease has spread panic, closing schools and hospitals.

In Liberia, cases appear to be declining in the capital, Monrovia, with recorded numbers down from 75 to 20 a day. But in rural areas they are still surging – and the international response is lagging behind.

Polly Markandya, head of communications for Médecins Sans Frontières (MSF), UK, said: “It is like Generals fighting the last battle. Beds are still being built in Monrovia for a rapidly reducing number of patients while in remote areas where there are no facilities there is a lack of visibility of what is going on.

“There are 500 beds in Monrovia and many are empty but the Chinese are still building another big treatment centre with 100 beds which may never be used. Large fixed buildings are good in the towns but we need a more mobile response in rural areas. Our concern is that this is a fast-moving virus and the response needs to be as nimble as the virus itself.”

As case numbers decline in Monrovia, experts warn people against relaxing their guard – but it is a losing battle. Where once bodies lay in the streets, now they are tucked out of sight. Motorcyclists carry four to a bike and children weave through the traffic at intersections hawking snacks through car windows.

Kevin De Cock of the US Centers for Disease Control (CDC) said that even though the infection rate had dropped it could not become “the new normal”.

“The danger is of complacency – accepting the unacceptable,” he told USA Today.

Guinea is well aware of the danger having twice seen the epidemic dwindle only to come surging back again. Last Spring, MSF had even prepared a press release hailing the end of the epidemic in Guinea when the disease flared once more. The cyclical nature of the epidemic was cited by the WHO in September as a unique feature compared with all previous outbreaks of the disease.

In contrast with Liberia, the epidemic is still raging in Sierra Leone – in the capital Freetown and beyond. Nearly one fifth of the total recorded cases in the country occurred in the first three weeks of November and transmission remains “intense”, according to the WHO.

Experts remain puzzled by the differing trajectory of the epidemic in the two countries. One theory is that Liberia has been more successful in promoting safe burial than Sierra Leone, where families still wash bodies using the same water to wash their hands. New outbreaks frequently erupt following the burial of an infected person. But the issue is highly sensitive and some burial teams have been attacked by angry mobs when they have tried to remove infected corpses wearing full protective “moon suits”.

Another possibility is that survivors of the disease in Monrovia are carrying the message about the life-saving effect of drinking fluids back to their communities.

A source at WHO said: “The rumour on the streets of Monrovia is that survivors who come out are saying all you need to do is drink because that is the treatment they were given. There has been very little intravenous administration of fluids in Liberia and none at all in the Congo which successfully halted an Ebola outbreak in the summer. Even in the US, patients have been given oral rehydration. The WHO is starting to distribute packets of oral rehydration salts to be dissolved in water for use while they are waiting for transport to a treatment centre.”

Ebola causes massive fluid loss through diarrhoea and vomiting of several litres a day. If the lost fluid is not restored the patient becomes dehydrated and progressively weaker, leading to organ failure and death.

Evidence shared by WHO and CDC is emerging that there is an eight-day window from when symptoms emerge in which victims need to drink four to five litres of fluid a day. Even at first they often don’t want to drink because they are too ill but by day three they may be too weak and need help. By day five it is too late and they need intravenous treatment to prevent organ collapse.

The WHO source said: “Most patients are presenting at treatment centres too late, when they are shrivelled up. Then the danger is they get litres of fluid shoved into them intravenously, their bodies can’t absorb it, their lungs fill with fluid and they drown.”

“We need to move from the forklift stage, building treatment centres in the capital, to the motorbike stage, delivering help to rural areas. Oral rehydration salts have been used for decades, are cheap and easy to administer. Oral rehydration is what saves lives.”

The epidemic is continuing to open new fronts – in west and north Sierra Leone and in Bong County, a few hours north-west of Liberia’s capital, where two big outbreaks are spreading. This week, two new cases were recorded across the border from Guinea in Mali, where at least six people have died, indicating that the outbreak there is still not under control.

With no vaccine or drug in prospect before next year at the earliest, new tactics will be required as the disease advances. The worst outbreak of Ebola in history is likely to have further surprises in store.