Public Health and the West African Ebola Virus Outbreak

By Ann-Charlotte Nilsson, ACN International Affairs Consulting AB

8 September, 2014

“Today, I counted 13 dead bodies in the street. There were no transportation to move these bodies. People are sick in their homes and are calling us to move them to treatment unit but no vehicle is responding.” (Account from Liberia, August 3, 2014)

“In a family of 10, eight of them have died, all women. The 8^th died two days ago and the body is still there. Today a young man fell ill and was rejected by everyone. He finally decided to move in the home with the dead body.” (Account from Liberia, August 3, 2014)

”Twelve women who partook in the bathing of their late friend’s body [who died from Ebola] have died just in St. Paul Bridge alone.” (Account from Liberia, August 7, 2014)

”No doubt, the Ebola virus is a national health problem. And as we have also begun to see, it attacks our way of life, with serious economic and social consequences. As such, we are compelled to bring the totality of our national resolve to fight this scourge.” (A Special Statement by the President of Liberia, Ellen Johnson Sirleaf, July 28/29 2014)

In Liberia already by the weekend of August 2-3, 2014 because so many doctors and health care workers had died from having been infected by the Ebola virus while treating and caring for Ebola patients, almost all the big hospitals had been closed. This was also due to that many health care workers because of the risk posed to them in tending to patients affected by Ebola have been afraid to go to work and  8thus have not turned up. As a consequence no health services are provided for any ailment or disease such as malaria and diarrhea and as a result children are dying from these diseases as they do not receive any treatment. Pregnant women cannot receive needed care and some women have died as a result. The Liberian President Ellen Sirleaf has recognized this situation in her Statement on the Declaration of a State Emergency that “Consequently, many common diseases which are especially prevalent during the rainy season, such as malaria, typhoid and common cold, are going untreated and may lead to unnecessary and preventable deaths.” Further since health clinics and hospitals have shut down, those patients currently hospitalized at treatment centers for Ebola that have been tested negative for the virus have no where to be taken and need to remain in the same rooms and at the same treatment center as confirmed Ebola patients.

The virus and what it entails has given rise to much fear, stigma as well as social rejection. The fear is so pervasive among the different affected countries’ populations that for instance in Liberia a small baby was found crying attached to her mother’s breast trying to nurse, while the mother was lying dead on the floor from having died from Ebola as had the father. Nobody in the community dared to touch the baby because of fears of contracting Ebola. Fear of health workers spreading the virus has also lead to much resistance to work with them as well as verbal and physical attacks towards them. Poverty and ignorance are also factors that challenge the work to eliminate the spread of the virus.  Some children have lost both parents to the Ebola virus, and a pattern has been detected in Liberia where more women have contracted the virus and died because they more often than men are taking care of sick family members.

Guinea, Liberia, Sierra Leone and Nigeria have declared a National State of Emergency because of the Ebola outbreak in these countries, however Médecins Sans Frontières (MSF) already at the end of June issued a statement that the Ebola outbreak was out of control: ““The epidemic is out of control”, said Dr. Bart Janssens, MSIF Director of Operations. “With the appearance of new sites in Guinea, Sierra Leone, and, Liberia, there is a real risk of it spreading to other areas.””. The response from the affected countries’ governments was very slow to begin with, and MSF has stated “that a massive medical, epidemiological and public health response is desperately needed to save lives and reverse the course of the epidemic”, as well as that “civil society and political and religious authorities are failing to acknowledge the scale of the epidemic, with few prominent figures spreading messages promoting the fight of the disease.” This is the time of a national crises situation and it requires a solid governmental approach and an all-out effort by the governments involved as a whole to address the crisis.

The current total number of confirmed/probable/suspected deaths[i] of the Ebola outbreak in Guinea, Sierra Leone and Liberia is 1841 as of 4 September 2014 according to WHO, however it is well understood that this number is not the correct number as many cases have gone unreported and a number of unknown people that died of Ebola have been buried without the health authorities being contacted. WHO issued on August 22 2014 a ‘Situation Assessment’ on “Why the Ebola outbreak has been underestimated” wherein it explains that a new phenomenon is taking place in Liberia that has not before been observed in an outbreak of Ebola. WHO states that “[A]s 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.” This situation clearly shows both the need of and how challenging it is to reach out to people in the different communities as soon and efficiently as possible, as well as being able to provide treatment. In this context it is important to note that the WHO states in its Global Alert and Response (GAR) that in the Ebola outbreak now occurring in West Africa, “the survival rate has been higher than in previous outbreaks.” People also need to be informed about this fact, which also might help lessen denial and fear, and result in that people will seek treatment. However this means that treatment facilities must be available.

The latest Ebola outbreak is said to have originated in December 2013 in Guinea and moved quickly to the neighboring countries Sierra Leone and Liberia, and it is the first time that these countries experience an Ebola outbreak. It is also the largest such outbreak known so far. The health minister Felix Kabange Numbi of DRC-Congo declared in a statement on TV on 24 August 2014 and notified the WHO that the country was facing an epidemic of Ebola even if the outbreak was limited to the area of Boende in the north- west of the country which has been put under quarantine, however the strain of the Ebola virus in DRC-Congo has now been confirmed not to originate from the same epidemiological source as the one currently being active in West Africa the WHO has stated. WHO has said that there is no link between these two strains and that this means that there has been no spread of the virus to the DRC from West Africa at this time. Also it is not the first outbreak of Ebola in the DRC-Congo. In Senegal the first Ebola victim has been identified as of 29 August 2014 which was a student from Guinea. As Reuters reported the Guinean authorities had put this student under surveillance because he had interacted with people who had been infected by Ebola in Guinea, but that he had disappeared until he turned up in Senegal. Because of the situation, Senegal decided to close their borders to Guinea, and flights to and from Sierra Leone, Liberia and Guinea has been banned.

Providing information about how the virus is spread the U.S. Centers for Disease Control and Prevention (CDC) states that:

• A person infected with Ebola virus is not contagious until symptoms appear;
• The virus is spread through direct contact (through broken skin or unprotected mucous membranes in, for example, the eyes, nose, or mouth) with the blood or body fluids such as, but not limited to, feces, saliva, urine, vomit, and semen of a person who is sick with Ebola, or with objects like needles that have been contaminated with the virus, or infect animals;
• Ebola is not spread through the air and water or, in general, by food; however. In Africa. Ebola mat be spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats.

In the case of Liberia while the government launched a National Action Plan on July 30, 2014 do deal with the outbreak the resources are not making it to many people infected by the Ebola virus in the communities.  The government’s “immediate strategy” in the National Action Plan has been “to contain the spread, care for the afflicted with the goal of “No New Cases””, and all schools [which were already closed due to school holiday] were ordered closed.  In the Action Plan the quarantine of affected communities were taken into account and that “[W]hen these measures are instituted, only health care workers will be permitted to move in and out of those areas. Food and other medical support will be provided to those communities and affected individuals.” Further Liberia’s security forces, under the directive of the Ministers of Justice and National Defense, were “to enforce all of these measures announced by the National Task Force on Ebola.”  That the Ebola outbreak also affects the economy and social fabric of the country was acknowledged by President Johnson Sirleaf in her Statement on the Declaration of a State of Emergency on 6 August 2014, where it is stated that “…beyond the public health risk, the disease is now undermining the economic stability of our country to the tone of millions of dollars in lost revenue, productivity and economic activity.”

Unfortunately a forceful effective response from the Liberian government’s side has been late in coming, while also other challenging factors as seen in West Point, a slum of 110.000 inhabitants in Monrovia, where community leaders agreed among themselves to keep secret that the Ebola virus had indeed also inflicted West Point where an unaccounted number of people have died from the virus. Some of them had been buried on an island by the sea without any safety measures taken. In the end with persistent negotiations between health officials and the community leaders of West Point, the community leaders admitted that Ebola had stricken the community and agreed to have a community holding treatment center for Ebola patients to be set up. On the day of the opening of this center, the center was ransacked by some youth which lead to delays in the setting up of the center. In the end it was agreed that the center would be set up again, and West Point was put under quarantine because the government was afraid that with people moving in and out of West Point there was a real risk of the Ebola virus spreading given the situation of the community leaders previously not notifying the authorities and the outbreak not being under control. While the community leaders wanted to have the quarantine relaxed, the government wanted the quarantine to remain in place until an effective mechanism was developed to identify all cases and contacts in West Point. However after much tension, protests and clashes in West Point with reports that people did not have access to enough food and water [which the government has pledged to provide in the National Action Plan] and with a male youth of 15 years that died after having gone into hypothermic shock after having been shot in the legs by security forces while participating in the protests, the quarantine was lifted after ten days on August 29 2014. However the nationwide curfew that was ordered on 19 August 2014 was to remain in place the government announced.

The WHO issued on August 8, 2014 a statement on “the Meeting of the International Health Regulations Emergency Committee Regarding the 2014 Ebola Outbreak in West Africa,” in which its Emergency Committee “advised” that:

• the Ebola outbreak in West Africa constitutes an ‘extraordinary event’ and a public health risk to other States;
• the possible consequences of further international spread are particularly serious in view of the virulence of the virus, the intensive community and health  facility transmission patterns, and the weak health systems in the currently affected and most at-risk countries;
• a coordinated international response is deemed essential to stop and reverse the international spread of Ebola.

Several known factors in each of the countries where the current Ebola strain has appeared make this current situation worse such as:

• their health care systems are fragile with significant deficits in human, financial and material resources, resulting in compromised ability to mount an adequate Ebola outbreak control response;
• inexperience in dealing with Ebola outbreaks: misperceptions of the disease, including how the disease is transmitted, are common and continue to be a major challenge in some communities;
• high mobility of populations and several instances of cross-border movement of travellers with infection;
• several generations of transmission have occurred in the three capital cities of Conakry (Guinea); Monrovia (Liberia); and Freetown (Sierra Leone); and
• a high number of infections have been identified among health-care workers, highlighting inadequate infection control practices in many facilities.

Some of the recommendations or “advice” that the Committee has given the WHO Director-General include that the Head of State in a country with Ebola transmission “should declare a national emergency; personally address the nation to provide information on the situation, the steps being taken to address the outbreak and the critical role of the community in ensuring its rapid control; provide immediate access to emergency financing to initiate and sustain response operations; and ensure all necessary measures are take to mobilize and remunerate the necessary health care workforce.” As noted Guinea, Sierra Leone, Liberia and Nigeria declared state of emergencies and DRC Congo declared a national epidemic.

While the WHO Committee acknowledges in its Statement the reality on the ground that lack of quality health care is in indeed the main factor also in the context of resource-stricken countries, in order to reduce the risk of the movement of people in the areas of intense transmission (such as the cross border areas of Sierra Leone, Guinea and Liberia), the WHO Committee also advises that quality clinical care, and material and psychosocial support be provided to the people living in these areas.  However how assistance would in all practicality be carried out is not mentioned, and one wonders to what extent such a statement is helpful?

The WHO Committee addresses the fact that so many doctors and health care workers have become infected and have died from having attended to patients infected by the Ebola virus, by stating that “States should ensure health care workers receive: adequate security measures for their safety and protection; timely payment of salaries and, as appropriate, hazard pay; and appropriate education and training on infection prevention and control (IPC), including the proper use of personal equipment (PPEs)”. Some of the fundamental challenges in the response against Ebola in West Africa is the lack of equipment and gear in the context of the scale of the outbreak and the many people that have been infected. Attending health personnel need to change gloves and protective clothing after every patient they have been attending to which requires a massive amount of such items to be readily available also out in the different counties. The lack of such protective gear and gloves is one of the main factors for health personnel to have contracted the virus and for health personnel to leaving their work places and refusing to go back to work. Further some equipment is highly technical and requires skilled and trained personnel to use, skills and training that most health personnel do not have. All these measures are absolutely a necessity to have however some of these such as training are mainly long-term measures that will take time to develop and they do indeed require available resources.

An appropriate response to address the Ebola epidemic includes several components and one such component includes contact tracing which has proven a serious challenge in the current Ebola outbreak in West Africa. Contact tracing is conducted to find and identify those individuals in the communities that show symptoms of Ebola, at the earliest stage possible, for them to be taken to a treatment center to get medical care and to be isolated from the rest of the community members in order to limit the exposure to the virus and thus the spread of the disease and to find a way to put an end to the cycle of transmission. However for instance in Liberia health care workers working as contact tracers have at times met a lot of resistance from community members as well as having been physically attacked. Because of fear of the virus in combination of ignorance about the virus and its spread some people as well as whole communities have kept quiet about Ebola victims and not alerting the authorities and having both tended to such persons without taking into account proper safety measures and buried persons who have succumbed to the disease without proper burial procedures. In other instances people who have contracted the virus have been left to fend for themselves because people have not dared to touch them and care for them. Bodies have been left for days before they have been taken away to be buried. Others who have had family members die from the virus have themselves moved away to other areas without having tested themselves and thus risking further spreading the virus. It takes up to 21 days for a person to show symptoms of Ebola and contact tracing and surveillance of persons suspected of having been infected by the virus are vital components of an effective response. As WHO reports “[T]he incubation period from time of infection to symptoms is 2 to 21 days”.

Denial and fear are very difficult challenges to address for the governments and their health care workers, and one way to deal with this situation is to step up community awareness and to provide information about the disease nationwide. In Liberia The Task Force has asked a ranged of its country’s organizations to participate in its work including women and youth organizations, the Inter-Religious Council, the Traditional Council, the Labour Union, the Market Organizations, the political parties, the Press Union, the Transport Unions, and the Motor Bikes Associations. One way to effectively get information out nationwide into the different communities is to gather the community leaders and get them involved. As health care workers in Liberia has explained, to get community leaders and their communities involved and engaged in the Ebola response has been shown in other countries that have successfully broken the cycle of transmission of the Ebola virus to be the main factor to break the cycle. As has also been shown in Liberia, “spread of Ebola in some communities in Lofa County has been reversed because of community involvement,” one Liberian health care worker has remarked.

WHO has further convened a panel of expert where it was decided by consensus that “it is ethical to offer unproven interventions with as of yet unknown efficacy and adverse effects as potential treatments or prevention.” that untested medication will be able to be used by medical personnel in the stricken countries to minister to people who have become affected by the virus. Ethical issues such as not having a real understanding of any potential side effects of taking the medication were not considered to be in jeopardy in a crisis such as the current Ebola outbreak. Further WHO issued a statement where it says that WHO does not advice banning any air travel to the areas and countries affected by the outbreak because there is a low risk of transmission stating that “the risk of transmission of Ebola virus disease during air travel remains low.” However for instance Kenya Airways that had continued to fly between Nairobi and Monrovia, Liberia and Freetown, Sierra Leone cancelled all such flights on 19 August 2014 midnight until the situation becomes under control.

To establish and build up national health care systems require first of all that a workable health care sector has been established as a priority sector for a State to develop where deliberate allocation of a state’s budget is going to this objective. Under so called peaceful circumstances and non-emergency situations to establish a functional national health care systems take years to develop as well as substantial resources, and to do this at a time of a health emergency such as an Ebola outbreak is not to be expected.  However the experiences gained and properly identified will be of great use in the planning for the establishment of a stronger health care sector in the future.

The Ebola outbreak in Guinea, Liberia and Sierra Leone is taking place in countries where sanitation services and the provision of clean water are very limited.

Guinea spends but 6.3% of GDP (2012) on health and the WHO has not data available on the number of trained physicians or trained nurses and midwives. According to WHO about 70% of its population of 11,451,000 is using improved drinking-water sources and about 18% of its population is using improved sanitation facilities. Liberia spends 15.5 % of its GDP (2012) on health and only has 0.1 trained physicians per 10.000 persons, and about 2.7 nurses and midwives. About 75% of the population has improved drinking-water sources and about 17% has improved sanitation facilities. Sierra Leone spends about 15.1% of its GDP on health, and has about 0.2 trained physicians per 10.000 population, and 1.7% nurses and midwives. About 58% of its population use improved drinking-water sources and 10% use improved sanitation facilities.

While efforts have been made to build up the health care sector for instance in Liberia after the civil wars, and gains as an example have been made in increased number of trained midwives, as a result of the Ebola virus some midwives have contracted the virus after having tended to women who are pregnant and then died. This has had the consequence that midwives are now afraid to contract the virus and do not want to assist with deliveries of babies. Pregnant women are at great risk in the Ebola outbreak, and miscarriage is common among women who have contracted the virus. In other cases women at the time of delivery have died because of the virus and the child or in some cases twins have lost their mother. Another issue is that the work that has been done these past years to build up trust among the population to go to health clinics and hospitals risks being broken as some people have contracted the virus from health care workers, and in other instances, while people have been calling to the hotline set up by the government to respond to calls from people in communities to be taken to a health care clinic or to transport away a dead body has been to no avail. Therefore right now it is of great urgency that the government and the health ministry with the help from the international community put every effort into strengthening the health sector and the different health clinics and hospitals. Further there is great need to strongly send out messages to the population providing information on the virus, how it is being spread, but also on the need for the health authorities to gain knowledge about suspected cases in the communities. The information needs to be transparent and swift.

Sierra Leone lost Doctor Sheik Umar Khan who was the only medical specialist in viral haemorrhagic fevers including the Ebola virus in Sierra Leone, and this shows that such a loss may have far-reaching consequences for the whole health care system of a country that is already severely challenged. Doctor Khan had been tending to people who had contracted the Ebola virus at the Kenema hospital in Sierra Leone. Kenema hospital is the main hospital in Sierra Leone for the treatment of viral haemorrhagic fevers including Ebola. Given the fragility of such a health care system, the emergency aid that the international community is now giving and is going to provide to these affected countries needs to come with a demand that these countries make the establishment of workable and accessible quality health care available to all people including the most vulnerable populations a national priority.

Several issues need to be identified and addressed as much as is possible during the on-going crisis and then especially in the building up of an appropriate quality health care system in countries such as Liberia. It is an excellent opportunity to identify all the most pressing challenges that have become apparent in the current crisis both at the national level but also at the regional level with the countries most affected by the Ebola virus, but also in countries such as the Democratic Republic of Congo (DRC) and Uganda where Ebola has been recurring before. Issues that have quickly been identified in for instance Liberia that needs to be addressed include how to improve contact tracking, addressing those religious and cultural practices and beliefs that have proven detrimental to reducing the spread of the Ebola virus, which also President Ellen Johnson Sirleaf has acknowledged. Such religious and cultural practices and beliefs need to be identified and addressed from the very beginning of building up a health care system. Other critical issues include that samples sent from suspected Ebola cases to laboratories for testing have not been labeled correctly thus endangering the persons conducting the actual testing, that test results take a long time to develop, delay or non-response to contacts that are showing signs and symptoms of Ebola, dead bodies communities not being buried directly and unattended Ebola bodies in funeral homes. For instance people in communities in Liberia have become very angry as they have called the hotline and tracers but that no one comes and pick up the bodies, sometimes a body has remained on a street for five days.

The Heads of State and Government of Member States of Sierra Leone, Liberia, Guinea and Cote d’Ivoire [the Member States of the Mano River Union], adopted a Joint Declaration for the Eradication of Ebola in West Africa on August 1, 2014 at a meeting in Conakry in Guinea that also the Director General of WHO and some other development partners attended. In the Declaration the governments acknowledged the high numbers of people that had contracted the virus including health personnel, and highlighted the monitoring, the contact tracing ad the community participation in taking care of cases and how to deal with resistance from community members as had been experienced by Guinea’s efforts to manage the Ebola outbreak. The governments also acknowledged “that the Ebola epidemic is a threat to health security at the national, sub-regional, regional and global levels”, and agreed:

[2.]…to focus on cross-border regions that have more than 70 percent of the epidemic. These areas will be isolated by police and the military. The people in these areas being isolated will be provided with material support. The health care service in these zones will be strengthened for treatment, testing and contact tracing to be done effectively. Burials will be done in accordance with national health regulations.

[3]…to provide our health personnel incentives, treatment and protection so they could come back to work. We shall ensure the security and safety to all national and international personnel supporting the fight against Ebola.

[4.] Member States may consider restriction of movement and prohibiting mass gatherings as appropriate.

[5.]…the International Community shall support Member States to build capacity for surveillance, contact tracing, case management and laboratory capacity.

[7.] We also appreciate the support of international organizations and NGOs but ask that they work within the framework of our national plans.

The African Union (AU) through its Peace and Security Council decided on August 21, 2014 to deploy a joint AU-led military and civilian humanitarian mission for about six months to address the Ebola epidemic. The AU Peace and Security Council applied Article 6(f) “relating to its mandate with regard to humanitarian action and disaster management”. The Commissioner for Social Affairs of the African Union Commission, Dr. Mustapha Sidiki Kaloko, said that “Using the infrastructure of the Peace Support Operations, the African Union Commission is finalizing the planning of the joint military and civilian code named Operation ASEOWA that could start deployment by the end of August 2014”. The purpose of the ASEOWA operation is to fill “the existing gap in international efforts” and it will “deploy civilian and military volunteers from across the continent to ensure that Ebola is put under control.”

Given the pace that the Ebola virus has spread in West Africa as well as the risk of the virus spreading further internationally WHO issued on 28 August 2014 a roadmap “to guide and coordinate the international response” to the Ebola virus outbreak in West Africa. The purpose of the roadmap is “to stop ongoing Ebola transmission worldwide within 6-9 months, while rapidly managing the consequences of any further international spread. It also recognizes the need to address, in parallel, the outbreak’s broader socioeconomic impact.” The priority of the roadmap is to focus on treatment and management centers, social mobilization and safe burials. The roadmap is a response to the fact that it is within the past three weeks alone (the month of August 2014), that almost 40% of all the confirmed cases of the Ebola virus have been formally reported.  This number of 40% does not take into account all the unreported cases of the Ebola virus that we know also exist.

Dealing with a crisis of such dimension and with far-reaching consequences for not only individual families and a country but that has developed into a crisis of international concerns must be much more costly in the long run than making the establishment of a health care system in a single country a deliberate priority to begin with. The experiences and lessons learnt from having dealt with the AIDS epidemic and all its devastating consequences for families, communities and entire countries, it is a necessity that the establishment of a functioning quality health care system becomes one of the most fundamental priorities in not only modern health care provision but in the development of a strong state that is capable of providing for the basic needs of its people. This includes paying ministers and governmental workers adequate pay with the goal of eradicating corruption and building a governmental culture that is conducive to meeting the real needs of its people in an adequate way.

Health care workers have lost colleagues, seen countless dead bodies and many are now also loosing family member to the virus.  In combination of the fact that so many people in for instance Liberia and Sierra Leone are still coping with the losses and grief after the civil wars, the new additional losses because of the Ebola outbreak will result in more grief and extra attention needs to be given to the traumatic consequences for people going through such grief and sorrow.

(Please do not quote without permission of author.)

Some sources:

1) African Union, Press Release No 184/2014, African Union to immediately deploy joint military and civil mission against Ebola, Addis Ababa, Ethiopia, 21 August, 2014

2) BBC Afrique, Quatre personnes mortes d’Ebola, 24 August, 2014, www.bbc.co.uk/afrique/region/2014/08/140824_ebolardc.shtml

3) BBC News Africa, Ebola crisis: Liberia orders curfew and quarantine, 20 August, 2014, http://www.bbc.com/news/world-africa-28862591

4) The Centers for Disease Control and Prevention (CDC), HAN 368: CDC Ebola Response Update#4, August 28, 2014, HANINFO-00368

5) Gander, Kashmira, Ebola Virus: Top Sierra Leone Doctor, Sheik Umar Khan, Dies of Disease, The Independent, 29 July, 2014, www.theindependent.co.uk

6) Médecins Sans Frontière, “Ebola In West Africa: Epidemic Requires Massive Deployment of Resources”, 23 June, 2014, http://www.msf.org.za/msf-publications/ebola-west-africa-epidemic-requires-massive-deployment-resources

7) Onishi, Norimitsu, Quarantine for Ebola Lifted in Liberia Slum, New York Times, http://www.nytimes.com/2014/08/30/world/africa/quarantine-for-ebola-lifted-in-liberia-slum.html?_r=0

8) Reuters, Guinean student is first case of Ebola confirmed in Senegal, Fri, August 29, 2014, Thomson Reuters 2014, http://in.reuters.com/article/2014/08/29/us-health-ebola-senegal-idINKBN0GT1CD20140829?feedType

9) Reuters, Kenya Airways to suspend flights to Freetown, Monrovia due to Ebola, Sat, August 16, 2014, Thomson Reuters 2014, http://www.reuters.com/article/2014/08/16/us-health-ebola-kenya-airways-idUSKBN0GG0F520140816

10) Silver, Marc, Liberia’s President Apologizes to the Mother of a Slain Teenager, NPR, August 25, 2014, http://www.npr.org/blogs/goatsandsoda/2014/08/25/343172859/liberias-president-apologizes-to-the-mother-of-a-slain-teenager

11] Special Statement by President Ellen Johnson Sirleaf on Additional Measures in the Fight Against the Ebola Virus Disease, Wednesday, July 30, 2014, www.emansion.gov.lr

12) Special Statement by President Ellen Johnson Sirleaf, July 28/29, 2014

13) Statement on the Declaration of a State of Emergency by President Ellen Johnson Sirleaf, R.L., August 6, 2014. www.emansion.gov.lr

14) A Special Statement by the President, Republic of Liberia, July 28/29 2014

15) World Health Organization (WHO), Media Centre, www.who.int:

-Global Alert and Response (GAR), Ebola response roadmap, accessed 5 September, 2014

-Global Alert and Response (GAR), Ebola virus disease outbreak-west Africa, Disease outbreak news, 4 September, 2014

-Virological analysis: no link between Ebola outbreaks in west Africa and Democratic Republic of Congo, Situation assessment, 2 September, 2014

-WHO Health Profiles and Statistics for Guinea, Liberia and Sierra Leone, Countries, accessed 30 August, 2014

– WHO: Ebola Response Roadmap Situation Report 1, 29 August 2014

-WHO issues roadmap to scale up international response to the Ebola outbreak in West Africa, Statement, 28 August, 2014

-Global Alert and Response (GAR), Ebola virus disease- Democratic Republic of Congo, Disease outbreak news, 27 August, 2014

-Unprecedented number of medical staff infected with Ebola, Situation assessment, 25 August 2014, Media Centre

-“The risk of transmission of Ebola virus during air travel remains low”, 14 August, 2014

-Ethical considerations for use of unregistered interventions for Ebola virus disease (EVD), 12 August, 2014

-WHO Statement on the Meeting of the International Health Regulations Emergency Committee Regarding the 2014 Ebola Outbreak in West Africa, 8 August, 2014