Health officials who fought Ebola during the world’s deadliest outbreak of the disease in Liberia, Sierra Leone and Guinea have resurrected the tools they used during that crisis to stave off the coronavirus. Initially this led to a swift and coordinated response, and these nations have kept the number of infections low compared to many other countries around the world. But coronavirus is presenting additional challenges, and cases are on the rise.
When COVID-19 first appeared in the region in mid- to late March, health officials employed the strategies honed during the 2014–16 Ebola outbreak, including isolating people who test positive for the virus and quarantining those who may have been in contact with it. These actions probably slowed the spread of the virus. The incidence of COVID-19 reported in the three West African countries — between 2 and 5 cases per 10,000 people — is at least 12 times less than in South Africa, and 22 times lower than the rate in the United States. “We had the experience of Ebola, so the political will was there from the start,” explains Mosoka Fallah, the director of the National Public Health Institute of Liberia.
But infection rates are rising, and for complex reasons. Researchers in these West African nations say that infections are hard to spot, owing to asymptomatic cases among the overwhelmingly young population. Another challenge is that the three countries are among the world’s poorest, and their health systems lack resources to protect staff and care for people with the disease.
Fallah says that slowing the transmission of the virus has become especially hard as it reaches impoverished communities without running water and electricity. There, people share latrines and wells, and go to markets regularly to purchase food that cannot be stored at home. He says, “My fear is that the coronavirus is beginning to spread from the affluent to the poor, where social distancing is almost impossible.”
Following China’s lead
As the coronavirus spread in January, Fallah met with Liberian President George Weah to form a coronavirus task force that included many of the same doctors and public-health experts who led the Ebola response. The group resurrected the main pillars of outbreak response. This included acquiring coronavirus tests from the World Health Organization (WHO), coordinating teams of people to trace contacts and communicating health messages to the public. In operation centres in the capitals of the three countries, each COVID-19 task force began to meet regularly to adapt responses to the latest situations, just as they had done during the Ebola outbreak.
Tolbert Nyenswah, the former director of Liberia’s public-health institute, says the US Centers for Disease Control and Prevention (CDC) had helped to teach health officials these methods during the Ebola outbreak. Now based in Baltimore, Maryland, as a researcher at Johns Hopkins University, Nyenswah says he was stunned that the CDC downplayed these essential procedures in its own country. “I was shocked to see the US struggling to understand what contact tracing is, to organize a response, to put in place risk communication,” he says.
The coronavirus task forces in Liberia, Sierra Leone and Guinea decided to follow China’s lead; they isolate everyone who tests positive — regardless of symptoms. People who are very sick go hospitals, while those with no symptoms or mild illness are sent to special facilities until they test negative. Baimba Idriss, a physician at 34 Military Hospital in Freetown, Sierra Leone, explains that isolating at home is impractical in the country. “A young person might be healthy, but they live with their grandmother, their aunts, their neighbours, and we need to break that chain of transmission — and also monitor people so that if they have breathing difficulties, we can treat them early,” he says.
But Idriss says that a growing number of people who test positive refuse to relocate to the isolation facilities — especially as word gets around that many people never need medical care. And he says some people aren’t listening to public-health advice to wear a face mask, because they aren’t sufficiently worried about the disease. “With COVID, people are dying, but it’s not nearly as horrific as Ebola,” Idriss explains.
Idriss and other doctors and researchers suspect that the virus might be causing milder illness in countries in sub-Saharan Africa compared with other nations, because the populations skew younger. More than 40% of people in Liberia, Sierra Leone and Guinea are younger than 15 years old and just 3% are older than age 65, according to World Bank statistics. And although Sierra Leone and Liberia have the same rate of COVID-19 deaths per confirmed cases as the United States — around 4% — John Nkengasong, the director of the African CDC based in Addis Ababa, Ethiopia, says he suspects that many mild and asymptomatic cases are going undetected. Guinea and many other countries in sub-Saharan Africa have case fatality rates below 2%.
Yet, as infections climb, the number of people in need of serious medical care has mounted, too. This concerns Idriss because hospitals in Sierra Leone are already running out of beds, basic medicines, disinfectants and fuel for vehicles to carry severely ill people to hospitals. Issa French, a nurse at Kenema Government Hospital in Sierra Leone, says his team lacks protective gear, gloves and face masks. “We’re using what we have left over from Ebola,” he says.
What’s more, some health-care workers say they have not been paid in two months, and have stopped coming to work as a result. This problem vexed the Ebola response as well, leading to strikes among health-care workers. “Since they never paid us what they owed us during Ebola, I’ve decided not to risk my life again for COVID,” says Christopher White, an ambulance driver at Kenema Hospital. A report from the Center for Global Development, a think tank in Washington DC, projects that such problems are likely to grow worse as shutdowns and trade disruptions owing to COVID-19 damage the economies of low-income countries. Current trends suggest that falling economies will translate into a reduction of US$2 billion in the health budgets of all low-income countries between 2020 and 2024.
The lack of funds for health-care staff and supplies might already be leading to a rise in deaths from COVID-19 and other causes, including childbirth and malaria. White says that many people in Kenema are staying at home when they are unwell because they don't trust the hospital to properly care for them, given the lack of supplies and staff. Marta Lado, an infectious-disease specialist based in Kono, Sierra Leone, at the non-profit organization Partners in Health, agrees. She says that although philanthropists have donated ventilators to the country, Sierra Leone can’t use them because it lacks staff trained to use the equipment, as well as intensive care units. Basic needs — such as insulin, antibiotics, gloves and oxygen generators — are much more urgent, she says. Across the three countries, tests for COVID-19 are now beginning to run short because of competition on the global market. And aid to help the countries staff clinics and purchase supplies has slowed to a trickle, she adds.
The situation in Guinea is slightly different from its neighbours. Cases are twice as high, but the fatality rate as of 20 July is lower — just 0.6%. One reason for the larger epidemic could be political unrest. The media has reported the violent suppression of opposition groups before and after Guinean President Alpha Condé altered the constitution to extend his rule to a third term. And deaths might seem artificially low if people are dying at home, and not being tested. However, Billy Sivahera, a physician and public-health expert with the non-profit organization ALIMA, based in the Guinean capital, Conakry, says another reason could be that hospitals in the city are successfully treating severe cases — and they have sufficient room to treat many more. However, he says, “If the outbreak goes deeper into the country outside of Conakry, people won’t have the same access to good hospital care.”
The spread of the epidemic to rural regions worries researchers in Sierra Leone and Liberia, too, because of the weakness of clinical care outside cities. Nkengasong is calling on communities in Africa’s poorest nations to do all they can to stop the spread of the virus through social distancing, adhering to quarantines and wearing masks. The number of confirmed cases in sub-Saharan Africa rose by 27% in the second week of July, according to the WHO. “If we get to the situation of the United States and South Africa,” he says, “it will be impossible to catch up with testing and contact tracing.”
Nature 583, 667-668 (2020)