Why the Ebola outbreak has been underestimated

Handling ebola virus disease

The magnitude of the Ebola outbreak, especially in Liberia and Sierra Leone, has been underestimated for a number of reasons. Many families hide infected loved ones in their homes. As Ebola has no cure, some believe infected loved ones will be more comfortable dying at home.

Situation assessment - 22 August 2014

The magnitude of the Ebola outbreak, especially in Liberia and Sierra Leone, has been underestimated for a number of reasons.

Many families hide infected loved ones in their homes. As Ebola has no cure, some believe infected loved ones will be more comfortable dying at home.

Others deny that a patient has Ebola and believe that care in an isolation ward — viewed as an incubator of the disease — will lead to infection and certain death. Most fear the stigma and social rejection that come to patients and families when a diagnosis of Ebola is confirmed.

These are fast-moving outbreaks, creating challenges for the many international partners providing support. Quantities of staff, supplies, and equipment, including personal protective equipment, cannot keep up with the need. Hospital and diagnostic capacities have been overwhelmed.

Many treatment centres and general clinics have closed. Fear keeps patients out and causes medical staff to flee.

In rural villages, corpses are buried without notifying health officials and with no investigation of the cause of death. In some instances, epidemiologists have travelled to villages and counted the number of fresh graves as a crude indicator of suspected cases.

In parts of Liberia, a phenomenon is occurring that has never before been seen in an Ebola outbreak. As soon as a new treatment facility is opened, it is immediately filled with patients, many of whom were not previously identified. This phenomenon strongly suggests the existence of an invisible caseload of patients who are not being detected by the surveillance system.

For example in Monrovia, Liberia's capital, an Ebola treatment centre with 20 beds, which opened last week, was immediately overwhelmed with more than 70 patients.

An additional problem is the existence of numerous "shadow-zones". These are villages with rumours of cases and deaths, with a strong suspicion of Ebola as the cause, that cannot be investigated because of community resistance or lack of adequate staff and vehicles.

In some areas, most notably Monrovia, virtually all health services have shut down. This lack of access to any form of health care contributed to the mobbing incident on Saturday at an Ebola holding facility in the West Point township, Liberia's most disease-prone slum.

Rumours spread that the holding facility, hastily set up by local authorities in an abandoned schoolhouse, was actually a clinic for general health care. People from other communities brought their ailing family members there, where they were housed together with suspected Ebola patients.

The presence of patients from these other communities was resented by the West Point community, and this resentment contributed to the riot and subsequent looting, in which potentially contaminated materials were carried into these communities.

WHO epidemiologists in Sierra Leone and Liberia are working with other agencies, including Médecins Sans Frontières (Doctors without Borders) and the US Centers for Disease Control and Prevention, to produce more realistic estimates and thus communicate the true magnitude of needs.

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