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DISPATCHESTable. Characteristics of family members in Ebola cluster, Bong and Montserrado Counties, Liberia, November–December 2014Date ofCity where EbolaPatient Relationship tosymptom Date admittedexposure likelyno.patient 0 Age, y/Sex Occupation onset to ETU* Outcome, date occurred†0 – 32/M Nurse’s aide Nov 14 – Died, Nov 24 Monrovia1 Father 78/M Farmer Dec 1 Dec 8 Recovered, Dec Monrovia242 Brother 39/M Auto Mechanic Dec 9 Dec 10 Recovered, Dec Monrovia233 Niece 15/F Student Dec 10 Dec 16 Recovered, Dec Monrovia304 Mother 55/F Vendor in the Dec 15 Dec 17 Died, Dec 22 Monroviamarket5 Son 3/M – Dec 16 Dec 17 Died, Dec 21 MonroviaGbarnga6 Cousin 29/F RubberplantationworkerDec 16‡ Dec 18 Recovered, Dec307 Sister§ 32/F Vendor in the Dec 18 Dec 19 Died, Dec 21 Monroviamarket8 Brother-in-law# 41/M Construction Dec 18 Dec 19 Died, Dec 27 Monroviaworker9 Niece 10/F Student Dec 20‡ Dec 20 Recovered, Jan 9 Gbarnga(2015)*ETU, Ebola treatment unit.†Gbarnga is located in Bong County; Monrovia is located in Montserrado County.‡Became symptomatic while under observation at the Bong County Holding Center.§Twin sibling of patient 0.#Husband of patient 7.The Monrovia investigation revealed that patients 1–3had contact with patient 1’s ill son, who was designated theputative source-patient (patient 0). Patient 0 was a nurse’saide at a community clinic. Fever, headache, joint pain, andabdominal pain developed in patient 0 on November 14,2014, and he was cared for at home by his family for 7 dayswhile his symptoms worsened. Although the patient andfamily members were aware of the EVD epidemic, theydid not think patient 0 had EVD because he had no vomiting,diarrhea, and hemorrhagic symptoms; they believedhe had a spiritual illness. On November 21, he was takento a church with the hope that he would be healed throughprayer. He died there on November 24, and his body wascarried to his residence for mourning and burial preparation.Because all unexplained deaths were presumed tobe Ebola related, an EVD burial crew retrieved his bodyfor cremation the following day, despite resistance fromthe family and only after persuasion by local communityleaders. No postmortem specimen was collected forEVD testing. After the body was removed, the home wassprayed with disinfectant, and the mattress, clothes, andother personal items used by patient 0 were burned. An attemptwas made to identify additional contacts; however,the family was reluctant to cooperate with health officialsand reported being angry about the cremation of patient 0and destruction of property, although these practices wereroutine at that time for controlling EVD in Monrovia. Thefamily in Monrovia began cooperating with MontserradoCounty health officials 3 weeks later, on December 18, afterlearning that 5 family members (patients 1–5) had EVDand after being provided with new mattresses and a smallration of food. At this time, they revealed 2 previously unreportedsymptomatic family members (patients 7 and 8).As of January 11, 2015, a total of 10 cases were includedin this cluster. Eight (80%) patients in this cluster were notidentified as contacts before their EVD diagnosis, and 4(40%) sought care outside the county where they resided(Table; Figure).ConclusionsIdentifying sources of infection for index patients and tracingcontacts are major components of EVD prevention andcontrol efforts (3), yet carrying out these policies is challengingwhen those ill with EVD do not reveal the names ofpossible sources or contacts who could have been exposedto disease. Detection delays and ineffective contact tracingoccurred in this cluster in part because the family believedthat the mandatory cremation and property destruction takenas public health actions in Monrovia harmed more thanhelped. Consequently, some family members sought carein Bong County, riding 4 hours in a taxi from their homein Monrovia, a distance of ≈197 kilometers. Furthermore,family members were reluctant to reveal contact names inMonrovia and initially concealed knowledge of symptomaticpersons.This cluster may have been prevented if patient 0, presumablyinfected at the clinic where he worked, had beentrained in infection control procedures and had accessto personal protective equipment. Additional exposuresand subsequent infections could have been prevented1254 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 7, July 2015
Cluster of Ebola Virus Disease, LiberiaFigure. Timeline (A) and transmission diagram (B) of Ebola virus disease cluster, Bong and Montserrado Counties, Liberia, November–December 2014.if he had been identified earlier as a suspected EVD patient,if testing had been performed on his body, if the resultshad been reported to the family, and if the Monroviacontacts had been followed daily to identify, isolate, andtreat symptomatic persons. Had contact tracing identifiedpatients 1–3 as patient 0’s contacts and isolated them immediatelyafter symptoms developed, 6 cases of EVD (inpatients 4–9) and 4 deaths (patients 4, 5, 7, and 8) mighthave been prevented.Rapid implementation of contact tracing to preventdisease transmission and increased coordination and communicationbetween jurisdictions are critical to control ofEVD. These efforts can identify case-patients who mayhave entered the community from another jurisdiction (tobetter understand importation and transmission patterns)and improve case finding and contact tracing to ensure thatno cases are missed (8,9). The effectiveness of these effortsdepends on trust between public health officials andthe communities they serve.AcknowledgmentsWe thank David Bell, Jacqueline Gindler, Olga Henao,Moses Kerkula-Jeuronlon, James Lange, Heather Lorenzen,Mutaawe Arthur Lubogo, Philip McKay, Sam Sampson, healthcare providers at the Bong County Ebola Treatment Unit, andthe US Navy Mobile Laboratory (LCDR Micheal Gregory,LT James Regeimbal Jr., HM1 Yusupha Kah) stationed inBong County.Mr. Nyenswah is the Head Minister of Health for the Ministryof Health and Social Welfare, Monrovia, Liberia. He has led theEbola response in Liberia since 2014.References1. Dixon MG, Schafer IJ. Ebola viral disease outbreak—West Africa,2014. MMWR Morb Mortal Wkly Rep. 2014;63:548–51.2. Raabe VN, Mutyaba I, Roddy P, Lutwama JJ, Geissler W,Borchert M. Infection control during filoviral hemorrhagic feveroutbreaks: preferences of community members and health workersin Masindi, Uganda. Trans R Soc Trop Med Hyg. 2010;104:48–50.http://dx.doi.org/10.1016/j.trstmh.2009.07.011Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 7, July 2015 1255
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July 2015SynopsisOn the CoverMarian
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1240 Gastroenteritis OutbreaksCause
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