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Mali case, Ebola imported from Guinea

Investigations undertaken by Ministries of Health in Mali and Guinea, assisted by WHO, have clarified the early exposure history of Mali’s first Ebola case.

The index case in Mali, a 2-year-old girl who resided with her family in the urban commune of Beyla, Guinea, was diagnosed with Ebola, in Kayes, Mali, on 23 October and died on the following day.

In Guinea: a family devastated by an undiagnosed disease

The child’s history while still residing in Guinea strongly suggests that several members of her family died from Ebola virus disease. Most of the patients described below were buried safely by Red Cross volunteers, but not tested until late in the transmission chains.

The Guinea history reveals many difficult challenges faced by ministries of health, local health officials, WHO and other partners in the Ebola response.

The child’s history begins with the death of her father, of unidentified causes, on 3 October.

The father was a Red Cross worker who also provided care at a private medical clinic owned by his father (the paternal grandfather of the index case). The paternal grandfather was a retired health care worker.

While working at the private medical clinic, the child’s father had contact with a farmer from another village who died, of undiagnosed causes, on 12 September. The farmer sought treatment accompanied by his two daughters. Both daughters died, of undiagnosed causes, in Beyla on 23 September, one at dawn and the other in the evening.

WHO data from Sierra Leone strongly suggest that Ebola care in private health facilities, as opposed to care in publicly-funded or MSF-run Ebola treatment centres, carries a higher risk of infection. In Kenema, for example, 87% of new infections among health care workers have been acquired in privately-run non-Ebola clinics.

Going home to die

The child’s father fell ill sometime during the third week of September. Fellow residents and neighbours in Beyla believed he was the victim of a bad-luck “curse” following an argument with the village chief. Witchcraft, and not Ebola, was suspected.

Shunned by the community, and on the advice of his own father (the paternal grandfather of the index case and the head of the family), the father returned to his native village of Sokodougou, in the sub-prefecture of Moussadou – a trip of more than 70 kilometres. He died there on 3 October.

This pattern of returning to a native village to grow old or die is commonly seen in Guinea, Liberia, Sierra Leone and many other countries around the world.

Such frequent travels by symptomatic Ebola patients, often via public transportation and over long distances, unquestionably create multiple opportunities for high-risk exposures – en route and also when the patient reaches his home and is greeted by family and friends.

Diagnosis: Ebola

Meanwhile in Beyla, the paternal grandfather and family head lost his wife to an unknown disease on 8 October. He then allowed health officials to undertake contact tracing of 16 family members who had been in close contact with his deceased son (the father of the index case in Mali).

On the following day (9 October), two of his other sons were admitted to hospital. The hospital referred them to a MSF-run Ebola transit centre in Macenta.

The first son died the same day en route to Macenta. On 10 October, samples from both sons tested positive for Ebola, strongly suggesting that other family members had also died from Ebola virus disease.

On 16 October, the paternal grandfather travelled to Macenta, seeking treatment for what he told medical staff was “rheumatoid arthritis”. As part of a thorough medical examination, he was tested for Ebola. Positive results were received from the laboratory on 17 October. The paternal grandfather died at an Ebola treatment centre in Gueckedou on 20 October.

Mali’s index case leaves Guinea

Following news of the death of relatives in Guinea, the child’s grand aunt or “Grandma” (the second wife of the maternal grandfather) travelled to Beyla, Guinea, to offer her condolences to her relatives. The “Grandma” resides in Kayes, Mali.

She left Guinea to return to Mali on 19 October, taking the 2-year-old index case and her 5-year-old sister with her. A maternal uncle, the mother’s brother, also accompanied them. The index case was showing haemorrhagic symptoms in Guinea when the three began their extensive travels.

The mother is alive and is in regular telephone contact with the Mali team. She has to remain in the village where her husband was buried for 40 days for the official mourning, before she can leave. Her three-month-old baby is with her in Guinea. Both are under observation and, to date, neither has shown any symptoms.

The family group travelled via public transportation, taking at least one bus and 3 taxi rides as they journeyed more than 1200 kilometres through Mali. The buses made frequent stops for fuel or to let passengers on. The four spent 2 hours in the capital, Bamako, visiting relatives in a household with 25 people.

On 19–20 October, they travelled overnight in one bus from Bamako to Kayes. Between Bamako and Kayes, only two persons left the bus at Niamiga village. Persistent tracking eventually located both at their final destinations, in Dakar, Senegal and Paris, France.

Once in Kayes, the Grandma and index case consulted two traditional healers. The second healer took them to a retired nurse, who was alarmed by the child’s high temperature, which was above 40oC. When he learned they had recently travelled in Guinea, he suspected Ebola and advised them to seek treatment at a hospital.

The child was admitted to the hospital in Kayes on 21 October and diagnosed with Ebola following receipt of positive laboratory results on 23 October. She was hospitalized and treated in isolation, with infection prevention and control equipment and procedures in place. She died on 24 October.

The emergency response in Mali continues

In collaboration with WHO, the Ministry of Health has established an incident command structure to mount a coordinated response that includes surveillance and contact tracing, case management, safe burials, social mobilization and logistics.

To date, Malian health officials, aided by WHO, the US Centers for Disease Control and Prevention (CDC), Mèdecins sans Frontières (MSF), the International Federation of Red Cross and Red Crescent Societies, and several other partners have identified 108 contacts of the symptomatic patient, including 33 health care workers who were exposed. Of the 108 contacts, 25 have been followed for 21 days and have been released from the surveillance system.

Seventy-nine contacts were at the hospital where the child was treated and in the Kayes community. All have been monitored. To date, no one has shown signs of Ebola or tested positive for the disease.

The government has accelerated the completion of an isolation facility at the Center for Vaccine Development in Bamako. Isolation facilities were part of the strategies put in place in Senegal and Nigeria to successfully contain Ebola.

Bamako has a well-functioning biosafety level 3 laboratory, previously established with support from the US National Institutes of Health to carry out diagnostic work with tuberculosis bacteria and HIV. The laboratory has now been repurposed to safely test Ebola samples.

With persistent and thorough contact tracing, isolation and monitoring in place, confidence is growing that no further spread within Mali followed exposure to the index case, who had haemorrhagic symptoms but no diarrhoea or vomiting during her travels.