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Confronting Ebola at its Origins: GVN Member, The South African
National Institute for Communicable Diseases, Deploys their Mobile
Diagnostic Laboratory to Sierra Leone
Prof. dr hab. Janusz T. Paweska & Dr. Petrus Jansen van Vuren
Centre for Emerging and Zoonotic Disease of the National Institute for Communicable Diseases,
Johannesburg, South Africa
The 2014/15 outbreak of Ebola virus disease is the largest ever reported of this deadly, highly
infectious, hemorrhagic disease since its initial discovery in humans in 1976. The current
outbreak was first recognized in March, 2014 in Guinea and has since crossed international
boundaries into Sierra Leone and Liberia where case numbers have now surpassed those
recorded in the country of origin. Due to international travel of infected individuals, both
medical professionals and non-professionals, the virus has also been introduced and caused
smaller outbreaks in Mali, Nigeria, Spain and the United States. A worldwide response was
launched.
Like the infectious agent, this approach crosses interdisciplinary, geographical,
cultural and socio-political boundaries and includes research, professional and public education,
clinical care and respectful, safe disposition of the remains of those who died from the illness.
In this paper, we aim to reduce fears of the unknown and encourage continued efforts to
conquer the epidemic by describing the nature of the infectious agent, by providing a brief
overview of its history, scope, and impact and by detailing a specific response that is being used
to confront Ebola at its source.
What Is EBOLA?
Ebola is a short hand name for a group of viral infections caused by more than one type
(species) of virus from the same origin (genus). In the early stages of infection, the patient has
no symptoms and cannot transmit the disease to others. However, within 4 to 21 days after
exposure, the patient develops a fever over 101 (F) and can then transmit the virus to others.
Flu-like symptoms rapidly progress to severe vomiting and diarrhea with internal and external
bleeding of a hemorrhagic nature. The likelihood of death is high with or without treatment with
a mortality rate of approximately 30% to 90% depending on the specific viral infection. The virus
is transmitted in body fluids and secretions including blood, sweat, urine, vomit, stool, tears,
saliva, and mucous which puts family members, friends with close personal contact, caregivers,
laboratory personnel, sanitation workers and funeral personnel at high, but not insurmountable,
risk for infection. Understanding the nature of the virus spread aids in reducing fear and
enhancing safe practices.
Ebola viruses
The ebola viruses belong to a family called Filoviridae. The Filoviridae family consists of two
genera, Ebolavirus and Marburgvirus that comprise some of the most virulent pathogens known
to humans. The genus Ebolavirus is divided into five species: Zaïre, Sudan, Taï Forest,
Bundibugyo, and Reston ebolavirus. Four of these five species are known to cause disease in
humans: Zaïre, Sudan, Taï Forest and Bundibugyo ebolavirus. The most virulent is the Zaïre
ebolavirus, with case fatality rate (CFR) up to 90 percent, followed by Sudan ebolavirus (CFR:
~50%), and Bundibugyo ebolavirus (CFR: ~30%). Only a single known human infection with Taï
Forest ebolavirus has been recorded, which caused a less severe non-fatal disease. Reston
ebolavirus was discovered in monkeys used in research facilities, imported from the Philippines,
but has not been shown to cause any disease in humans.
FAMILY
Genus
Species
Causes
Human
Fatality
disease?
Ebolavirus
Filoviridae
Marburgvirus
Zaïre ebolavirus
Yes
<90%
Sudan ebolavirus
Yes
~50%
Taï Forest ebolavirus
Yes
0%*
Bundibugyo ebolavirus
Yes
~30%
Reston ebolavirus
No
Marburg marburgvirus Yes <90%
Ravn marburgvirus
Yes
unkn**
* Only a single non-fatal case has been recorded
** In the only large outbreak where Ravn virus was involved, it was co-circulating with
Marburg marburvirus thus the fatality rate could not be established. Fatality rate is
presumably the same as for Marburg marburgvirus as these two are also clinically
indistinguishable
Current available sequence analysis data of 99 Zaïre ebolavirus (ZEBOV) genomes from 78
patients in Sierra Leone indicates that the 2014 West African genetic variant likely diverged from
central African lineages about 10 years ago. It appears that a single animal-to-human
transmission of the ZEBOV occurred in December 2013 in the deep-forest area of south-eastern
Guinea. Since then, human-to-human transmission accounts for the continuing and widespread
infection throughout Guinea, Liberia, and Sierra Leone.
Many of the identified virus genome sequence differences compared to previously known
strains alter protein sequences and other biological targets. Thus, they should be monitored for
their impact on diagnostics, vaccines, and therapies that are critical to an effective outbreak
response. It is not clear whether the virulence or transmissibility of the 2014 ZEBOV in West
Africa is substantially different from the virus lineages associated with earlier outbreaks. The
greater spread and apparent lower CFR of the current outbreak may be caused either by factors
external to, or inherent virulence of the virus. Such factors include population density and
medical care in some affected areas that is more effective than in the remote villages affected in
earlier EVD outbreaks.
Scope and Impact of Ebola Virus Disease
The 2014 Ebola virus disease (EVD) epidemic in Western Africa caused by Zaire ebolavirus
(ZEBOV) is the largest in the recorded history of both the disease and public health control
efforts. The EVD outbreak, only officially recognized in March 2014, rapidly became the
deadliest occurrence of the disease since its discovery in 1976.
As of 20 January 2015, (at the time of writing) the World Health Organization (WHO) reported a
total number of 21 689 cases in Guinea, Sierra Leone, Liberia, Mali, Nigeria, Spain and the
United States of America, of which 8626 were fatal infections. Currently there is only
documented active transmission in the three worst affected countries of Guinea, Sierra Leone
and Liberia.
There are at least two EVD outbreak-related concerns. First, if the virus were to spread to a large
city in one of the countries with modest health care infrastructures and crowded, sub-standard
living conditions (slums), the scale of the outbreak would substantially enlarge. This already
seems to be the case, as exemplified by high number of cases in Monrovia, Liberia and
Freetown, Sierra Leone. Secondly, the spread of ZEBOV to large and densely populated cities
with limited health care resources may increase the likelihood of a change or mutation of the
virus -- the evolutionary trajectory of the virus such as a change of ZEBOV shedding patterns
and/or virulence. For these and other reasons, there is a need for a continued rapid,
coordinated, and properly matched international response to stop the epidemic.
Vulnerable Populations
Because the Ebola virus is carried in body fluids, anyone who has even minor or minimal physical
contact with the secretions of a symptomatic, infected person is at high risk for contracting the
disease. This includes family members and friends who come in close physical contact with the
patient, healthcare workers, laboratory personnel, sanitation workers and those preparing the
deceased for burial or other disposal.
The vulnerability of health-care workers in contracting EVD is particularly tragic. By 15 January
2015, 825 cases among medical staff in the three West African countries and 493 deaths were
reported by the WHO. This occurs in the backdrop of countries with severely understaffed
medical systems, thus even further decreasing the ability to properly care for and isolate
infected individuals, and putting those doctors and nurses left at higher risk by forcing them to
work longer hours. The figures are likely underestimates, given the difficulty in collecting the
data.
The current epidemic, which most likely began in late 2013 in Guinea, reached historic
proportions in the middle of 2014. When the virus entered large cities, it quickly outmatched
the health-care systems in West Africa and outraced the response from the global health
community. The fact that EVD cases were imported into urban areas from the original EVD
epidemic boundaries, coupled with global travel and trade, raises concerns that the outbreak
can extend around the world. Concerns for public health safety are magnified because, at this
time, we lack specific therapies and vaccines for EVD.
Confronting EBOLA: The Problem and a Practical Response
It has been difficult to track the current EVD outbreak due to a short supply of specialized
laboratories capable of conducting research and handling potentially infected blood samples
from EVD suspected cases in West Africa. The laboratories are essential to diagnosing and
treating patients. Undiagnosed and unmanaged patients pose a severe risk to families and
communities and contribute to the cyclical transmission pattern currently being seen. That
interrupting chains of Ebola virus transmission depends heavily on laboratory support cannot be
overstated. This support is needed not only to confirm or discard suspected cases, but also
guide triage and clinical decisions, aid contact tracing, and facilitate the early detection of cases
in people with an exposure history.
As a part of the World Health Organization’s Global Outbreak Alert Response Network (WHOGOARN) response to the Ebola outbreak in West Africa, Professor Janusz Paweska, Head of the
Centre for Emerging and Zoonotic Disease (CEZD) of the National Institute for Communicable
Diseases (NICD) and his team successfully established an Ebola Mobile Laboratory (EML) in
Freetown, Sierra Leone in the second half of August 2014. In addition to his scientific and
administrative roles at NICD, Professor Paweska is a member of the Global Virus Network (GVN)
based in Baltimore, Maryland. The goal of the GVN is to strengthen medical research and
response to current viral causes of human disease and to prepare for new viral pandemic
threats. GVN meets its mission in four ways: Support for cutting-edge research, training the next
generation of medical virologists, public education, and advocacy.
The operation of the NICD Ebola Mobile Laboratory in Sierra Leone is financially, technically and
logistically supported by the NICD, the Ministry of Health of the Republic of South Africa, WHOGOARN, Sierra Leonean Ministry of Health and Sanitation, the International Atomic Energy
Agency, and Centers for Disease Control and Prevention, USA.
On 25 August 2014, the NICD EML was visited by the President of the Republic of Sierra Leone,
Mr. Ernest Bai Koroma, other governmental officials and local health authorities. The President
thanked the South African Government and the NICD for deploying EML staff to his country and
stressed the importance of the diagnostic capacity in fighting the Ebola outbreak. The same day
Prof. Janusz Paweska declared the NICD EML was at full operational capacity and tested its first
blood samples from EVD suspected cases.
The major activities of the laboratory include: logistics, processing specimens, reporting and
training. Logistically, the EML performs operational checklists of biocontainment devices,
preparation of decontamination solutions and other logistical arrangements to ensure
uninterrupted operation (e.g. timely purchasing and delivery of petrol for generators).
Processing specimens includes receiving specimens, data logging and matching clinical
specimens with EVD case investigation forms, “hot” processing and aliquoting of specimens,
extraction and molecular testing of viral nucleic acid from patient specimens, interpreting and
recording results. Updated results are entered into the Ebola report database. The results also
are reported, consultation sought and provided to the National Disease Prevention Center, the
WHO Ebola Coordination Center and local doctors and hospitals, including Ebola Treatment
Units. The South Africa NICD EML staff members are also training Sierra Leonean diagnosticians
in biosafety and Ebola assays procedures.
The NICD EML teams consist of, on average, four members in each team rotating in Sierra Leone
every 4-6 weeks. Up to January 2015, 6 teams had been deployed. It is envisaged that the
operation will be maintained until June 2015 requiring deployment of 4 additional teams, but
due to the constantly evolving situation in West Africa, this approach might be revised.
Before they begin their missions, teams undergo in-house pre-deployment training at the NICD
in South Africa, followed by 3-4 days additional training on site in Freetown by the preceding
team. The NICD EML is also greatly supported by the national Sierra Leonean staff that are
trained by the NICD EML members in operational, biosafety and diagnostic procedures.
The total financial costs of the NICD EML operation in Sierra Leone up to June 2015 are
estimated to be about 1million USA dollars. The full cost in terms of personal efforts in the face
of high-risk work is immeasurable; the benefits in terms of successful confinement and conquest
of this epidemic through international cooperative programs such as this are yet to be
actualized. But, there is no doubt, the problem is being confronted at its origins—a central
focus of GVN’s mission.
"Addendum: Dr. Paweska is the Director of GVN's Center of Excellence at the NICD, South
Africa. In this role, he works with Center Directors globally to identify collaborative
opportunities to advance research, support training of the next generation of virology leaders,
educate publics and advocate for the field. To learn more about GVN and its Centers of
Excellence worldwide, visit www.gvn.org"
Ebola posters and messages highly visible in Freetown, at the road sides, shops and public buildings as part of the
Ebola awareness health campaign efforts.
Sierra Leonean governmental delegation visiting the South African NICD Ebola Mobile Laboratory in Freetown, at
Lakka Tuberculosis Hospital compound (left). Prof. Janusz Paweska demonstrating to the President of the Republic
of Sierra Leone, Dr Ernest Bai Koroma, and Dr Abdul Kamara, the Manager of the National Laboratory Services, a
purified air powered respirator equipped with double shrouded full face hood used in biocontainment negative
pressure chamber during handling and processing of specimens collected from Ebola virus disease suspected cases.
Dr. Petrus Jansen van Vuren (left) and Prof. Janusz T. Paweska (right) dressed in personal protective equipment
(scrubs, Tyvek suits, surgical gown, triple surgical gloves, gumboots, overshoes and PAPR with full face hood)
processing blood collected from EVD suspected cases in Sierra Leone in negatively pressurized glove-box within the
biocontainment negative pressure chamber. South African Ebola Mobile Laboratory, Freetown- Lakka, Sierra
Leone, September 2014.
Dr Petrus Jansen van Vuren (SA NICD) training the Sierra Leonean staff in Ebola PCR diagnostics (left). Ms Busisiwe
Mogodi (South Africa) and Mr Kesela Conneh (Sierra Leone) matching clinical specimens samples with EVD case
investigation forms before accessing for “hot”’ processing and inactivation in the glove-box (right).
Prof. Janusz Paweska and members of the 1st & the 2ed (left, September 2014), and the 3rd (right, November
2014) South African NICD Ebola Mobile Laboratory teams, Sierra Leone, Freetown.
Prof. Janusz T. Paweska visiting a village in Sierra Leone during his second Ebola outbreak response mission,
December 2014.
References:

Nishiura H & Chowell G. Early transmission dynamics of Ebola virus disease (EVD), West
Africa, March to August 2014. Euro Surveill 2014, 19 (36): pii=20894.

Kelly JD. Make diagnostic centres a priority for Ebola crisis. Nature 2014, 513 (11 Sept.),
p.145.

Gire SK, et al. Genomic surveillance elucidate Ebola virus oriding during the 2014
outbreak. Science 2014 Sept 12:345(6202):1369-1372, doi.1126/science.1259657.