How Liberia’s Latest Ebola Case Slipped Through the Cracks

How Liberia’s Latest Ebola Case Slipped Through the Cracks

It was like a story from the early days of the Ebola epidemic. Fifteen-year-old Nathan Gbotoe was weak and bleeding from the mouth, traveling with his father and four other people in a neighbor’s car from a crowded clinic, seeking treatment. Finally Gbotoe ended up at John F. Kennedy Medical Center, Liberia’s largest public hospital, located in the heart of the capital, Monrovia. His father claimed his son had been cut during an accident. His temperature was checked and he didn’t have a fever — none of the health workers responsible for triaging patients suspected him of being infected with the virus. Unable to walk, Gbotoe’s father pushed him in a wheelchair to the trauma ward. A nurse wearing her everyday scrubs pulled on latex gloves and examined the inside of Gbotoe’s bleeding mouth. Finding no cut, she sent him to the children’s emergency ward. Two days later, doctors tested him for Ebola. When it came back positive a few hours later, he was taken to an Ebola treatment unit. Three days after that, he was dead.

Gbotoe’s case, which was announced on Nov. 20, put an end to Liberia’s official “Ebola free” designation for a second time this year — doing so days after Guinea discharged its last patient and Sierra Leone counted its second week without a known case of the virus. While the source of Gbotoe’s infection is currently being investigated, the mismanagement of his case at the nation’s largest public hospital raises questions about Liberia’s preparedness to handle future outbreaks.

What went wrong? Seemingly a lot.

Gbotoe should have been fully checked by a triage at the entrance at the hospital where health workers screen for patients who may have Ebola and need to be isolated. The doctors and nurses who handled his case didn’t wear the correct equipment for treating possible Ebola cases that protects against the highly infectious virus. Dr. Mosoka Fallah, the leader of the outbreak response who traced most of the cases through Monrovia and Liberia during the heat of the outbreak, said there was an overreliance in medical facilities on fever being an indicator of possible infection. “There should be a high level of suspicion because 90 percent of the patients lie,” said Fallah. In other words, Gbotoe should never have slipped through the cracks.

Still, Dr. Francis Kateh, the chief medical officer and acting head of the Incidence Management System that manages Ebola cases, denied there had been a breach of protocol. “No one would walk around with full [personal protective equipment] in this climate,” he said over the phone. After the initial lapse, the official mechanism for dealing with an outbreak clicked on. The nine medical workers who came into contact with Gbotoe are now quarantined and 152 contacts have been identified, among them patients and health workers, according to Kateh. Tracers who monitor all the people that have been in contact with the Ebola patient, should they become symptomatic, are still looking for 18 persons. “They are trying to evade us and avoid our calls; it is very concerning,” Fallah said.

The children’s emergency ward at the hospital has been decontaminated and remains closed, the patients discharged to their homes and currently under observation. The nurse who examined Gbotoe in the trauma unit has been quarantined, but the ward itself has not been decontaminated. According to a worker at the hospital, Gbotoe spent only a very short amount of time in the ward.

The late Gbotoe’s 8-year-old brother and father also contracted the virus but remain in stable condition, along with his mother and his two young siblings. All are receiving ZMapp — an experimental medication for Ebola — for treatment, according to a report by the Ministry of Health. After they were removed from their home on Thursday night, Nov. 19, a spray team came in later the following day and finally decontaminated the house.

What is so worrisome about Gbotoe’s case, however, is that what should have been obvious red flags went uninvestigated for critical days. Since the darkest days of the epidemic, which claimed the lives more than 11,000 people throughout the region — including many doctors and nurses at hospitals such as John F. Kennedy — the World Health Organization, and other NGOs have conducted mass trainings of medical workers in identifying the symptoms of the virus and the precautions needed when handling a suspected Ebola case. Bleeding is uniquely associated with Ebola and Lassa fever, a common virus in West Africa, but was not as typical among Ebola patients during the West African outbreak that started in December 2013 as it has been in previous outbreaks. Other more common symptoms of the virus such as diarrhea, fever, nausea, and vomiting are linked to diseases that are endemic to the region such as malaria, typhoid, and cholera and make the virus more difficult to detect.

A worker at the Ebola unit where Gbotoe was being treated until his death, who wished to go unnamed because of fear of punishment, expressed amazement that the case had initially gone unnoticed. “You think that they would have picked it up, that it would be obvious by now,” the worker said.

The questions raised by the case go beyond how it was handled, underscoring concern about how little is known about its origins.

In an attempt to shed light on this, scientists from the United States Army Medical Research Institute of Infectious Diseases arrived in Liberia on Monday, Nov. 23, to do genetic sequencing tests to determine whether the new infections are linked to a previous chain of transmission — a method that has been used over the past year to map out the course of the epidemic in the region. In July, tests were done when a mysterious case emerged in a community just outside of Monrovia, near Liberia’s international airport. The body of 17-year-old Abraham Memeigar tested positive for Ebola after a safe burial team dressed in hazmat suits took a swab from his body. The case emerged just weeks after Liberia was declared Ebola-free for the first time, on May 9. Memeigar’s body was exhumed from the grave so that a blood sample could be taken to gain more information about the chain of transmission. The tests determined that the virus present in Memeigar’s body was connected to the Ebola virus circulating in Liberia, rather than to other strains in Sierra Leone and in Guinea. Five others were infected. The origin of the case was never determined.

Memeigar’s case was not detected until his death. The clinic that he visited for treatment did not raise the alarm, but rather sent him home with malaria medication. Memeigar’s infection, like Gbotoe’s, was not detected by community members or health workers. A woman who was connected to Memeigar’s case was later quarantined and died.

“The fact that we picked it up means the system is working,” said Peter Graaff, the head of the United Nations Mission for Ebola Emergency Response, at the time of the outbreak. (UNMEER has since been dissolved.) “Unfortunately not every case is handled this way. In a sense we got lucky. … So it is a bit of a wakeup call.” Experts are now concerned that that wakeup call didn’t quite ring loud enough.

Memeigar’s case similarly raised concerns about basic infection prevention and control in health clinics and hospitals in Liberia.

“While ‘post-Ebola’ planning has focused on long-term aspirations, the very gaps in basic infection control that facilitated the epidemic’s growth in the first place have still not been addressed,” said Aitor Sanchez-Lacomba, the director of the International Rescue Committee in Liberia, after the Memeigar case was discovered. “These include having water, sanitation, and basic equipment at facilities; ongoing community surveillance; and triage procedures adapted not only for Ebola, but other epidemic diseases.”

The emergence of these two small outbreaks call into question more than the preparedness of health workers on the ground; they also cast doubt on the World Health Organization’s classification of countries as Ebola-free after they pass 42 days without a case. They also call into question scientific understanding of how the virus works. Fallah said Gbotoe’s mother “may have been a survivor” — a lead that investigators appear to be pursuing to explain the current outbreak. Research projects have been launched that explore the causes of outbreaks and nature of the virus, which will lead to a greater understanding of how it can be prevented. In June, the National Institutes of Health began a study into survivors, investigating the health problems they experience, their immunity, and how long the virus can remain in semen. A recent report by the Environmental Foundation for Africa looked at how the potential threat of viruses like Ebola will grow as humans continue to encroach on local wildlife; a comprehensive study into the role that encroachment on the human environment may be playing in Ebola outbreaks will soon begin.

“On one level, the 42-day approach makes a lot of sense given what we know, but if these flare-ups reoccur we may need to reassess it,” Ashish K. Jha, director of the Harvard Global Health Institute said in an interview. “Being Ebola-free forever may not be a realistic goal.”

Jha was part of an independent panel of 19 experts who released a report published in The Lancet on Nov. 22 that slammed the World Health Organization for its slow response and made a series of recommendations on how to improve both the global and domestic responses to outbreaks of disease in these countries. The report called on the global community to develop a “clear strategy” to ensure that the governments of Sierra Leone, Liberia, and Guinea invest in detecting, reporting, and responding to outbreaks. It also called for greater international support to these countries, including greater resources for rebuilding health care systems coupled with a “transparent central system for tracking and monitoring the results of these resource flows.”

Liberia’s Ministry of Health has developed a seven-year, $1.7 billion plan to revitalize the country’s health system. The first two years of the plan — which will involve training of health workers, remodeling health infrastructure, and improving emergency preparedness and response — will require $400 million of funding according to the minister of health, Dr. Bernice Dahn. While international donors have shown more of an interest in funding the health care system it is unclear whether many of them are committed for the long haul. The first two years are yet to be fully funded.

As the country begins to move past the Ebola nightmare, however, Gbotoe’s case is a fresh warning of how much still needs to be done. “We are better prepared than we were two years ago, but we are not where we need to be, not even close,” said Jha.

Photo credit: ZOOM DOSSO/AFP/Getty Images

Corrections, Nov. 30, 2015: Peter Graaff was the head of the United Nations Mission for Ebola Emergency Response; a previous version of this article misspelled his last name. A previous version of this article mistakenly referred to the mission as the United Nations Mission for Emergency Ebola Response.