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Biological Health Hazard – Mysterious Fatal Undiagnosed disease (public health threat): Liberia


Published Date: 2017-05-01 12:38:11
Subject: PRO/AH/EDR> Undiagnosed disease – Liberia (04): (SI) fatal MoH/WHO
Archive Number: 20170501.5005335

Political Map of Liberia

Political Map of Liberia Map based on a UN map. Source: UN Cartographic Section

Date: Sat 29 Apr 2017
Source: Liberia Ministry of Health/WHO situational report [edited]

Unexplained cluster of health event: Sinoe county, 29 Apr 2017
Sat 29 Apr 2017, no new admission reported from Sinoe county.
Cumulatively, there are 20 cases and 11 deaths (10 deaths in Sinoe county and one death in Montserrado county).
5 patients being managed at the FJ Grante hospital have stabilized and none is critical.
All samples collected were confirmed negative of Ebola virus disease (EVD).

The Ministry of Health with support of WHO is accelerating the process of deploying a pathologist to conduct autopsy on the remaining corpse in Monrovia.

Situational overview
On Tue 25 Apr 2017 at 10:30 GMT, Sinoe County Health Team (SCHT) notified the National Public Health Institute of Liberia (NPHIL) and the Ministry of Health (MoH) of a cluster of unexplained health events involving 14 cases with 8 deaths in Greenville city. From 25-27 Apr [2017], the number of cases increased to 20 with 11 deaths reported (case fatality rate is 55 per cent). Most of the cases presented with headache, diarrhea, vomiting, and mental confusion. Over the past 48 hours, no new cases were reported from Sinoe and Montserrado counties.

As of 29 Apr 2017, twenty (20) cases have been reported from 8 communities
– 19 cases reported from Sinoe and one from Montserrado counties
– 11 deaths recorded (Sinoe – 10, Montserrado – 1)
– 5 currently admitted in FJ Grant hospital have stabilized.

One new case identified during active case search within the Down town community, Greenville, Sinoe county, who presented with similar symptoms recovered 2 days ago.

21 specimens collected so far: 7 oral swabs, 7 whole blood, 3 urine, 2 cardiac fluid, 1 rectal swab;
– 7 oral swabs, 6 whole blood, and 2 cardiac fluid tested negative for EVD;
– chemistry analysis of 3 urine specimens has yielded no common pattern and inconclusive;
– laboratory tests to exclude cholera and shigellosis is on-going; and
– aliquots 11 specimens shipped to CDC-Atlanta for toxicological testing.

52 contacts have been listed; age range of contacts: 6-15 years (8), 23-65 years (40), and 4 adults; 32 are female and 20 male.

[The figures listed are available at the URL of the source, above. – Mod.SH]
Figure 1 [graph]: Distribution of cases of unexplained cluster of health events, Greenville, Sinoe County and Monrovia, Montserrado county, 23-29 Apr 2017
Figure 2 [graph]: Age distribution of cases of unexplained cluster of health events, Greenville, Sinoe county and Monrovia, Montserrado county, 23-29 Apr 2017
Figure 3 [graph]: Trend of events, unexplained cluster of health events, Greenville, Sinoe county and Monrovia, Montserrado county, 23-29 Apr 2017
[Map of geographic distribution of cases]

Probable risk factors
The event is driven by possible predisposing risk factors such as:
– attending and participating in funeral events — wake keeping, funeral, burial, and re-pass within the community of the deceased (Teah town);
– the risk of consuming the same food or drink that is probably contaminated; and
– environmental exposure.

– Establishing a full list of all attendees from outside and within Sinoe county who participated in the funeral events.
– Further laboratory testing is still ongoing to identify other potential causative agents of event.
– Inadequate disclosure of information related to the funeral event by family members and residents in Sinoe county.
– Lack of motivational package for community health volunteers (CHVs) involved with contact tracing & interpersonal communication.

Public health actions
– the national level National Epidemic Preparedness and Response Committee meets regularly to provide guidance and support to Sinoe CHT [County Health Team];
– the national level team is coordinating with the Montserrado CHT on follow up of people who participated at the funeral in Greenville;
– the health system remains resilient as people are still visiting the hospital normally to receive care; and
– in addition, all clinics remain opened with encouraging turn out while the implementation of African vaccines campaign ongoing.

Surveillance and contact tracing
– active case search ongoing in the affected and circumscribed communities in Sinoe county and follow of people who participated in the funeral in other counties;
– outbreak case definition developed to facilitate active case search;
– data from field investigations being analyzed to inform further laboratory tests;
– investigation and compilation of outbreak line list for all cases including contacts; and
– surveillance has been heightened at district and community levels including community engagement and sensitization.

Case management
– case management of patients currently admitted at the FJ Grante Hospital is ongoing; and
– isolation space has been identified in JFK hospital for any case in Montserrado county.

Social mobilization and community engagement
– county level advocacy meetings and community engagement ongoing;
– the district health team has also embarked on mass public awareness;
– publicity awareness conducted in 3 communities in Greenville district (Seebeh, Dioh town, Bannah), and 4 communities in bordering districts, (Kpanyan, Pannama, Tubmanville, Kabada, Saywon town), and Butaw district;
– publicity awareness team using the moving stage with PA system to reinforce social mob activities in Greenville city; and
– psychosocial team visited all hot spot communities to counsel bereaved families, give feedback and reinforce social mobilization activities.

Laboratory investigation
– all samples tested were negative for Ebola virus disease (EVD): 17 specimens (7 oral swabs, 3 cardiac fluids, and 7 venous blood specimens, all collected from a total of 12 suspected cases) tested negative for EVD; 3 urine specimens were tested at Redemption Hospital laboratory, the results were variable and therefore it was not possible to deduce any pattern; 1 rectal swab testing ongoing, preliminary results to be shared as soon as available;
– toxicological investigations: aliquots 11 specimens shipped to CDC-Atlanta for toxicological testing; efforts continuing to send samples to South Africa (WHO) and France (MSF) for further testing;
– water (tested in-country, in Sinoe): water samples tested negative for coliforms; and
– food sampling: food (cake, sugar, seasons, powder milk, garlic, pepper) samples collected and preserved at National Reference Laboratory (NRL) for further analysis.

Dead body management
– except for the corpse in Monrovia, all dead bodies were safely disposed by the burial team in Sinoe county; and
– WHO is accelerating process to urgently deploy a pathologist to conduct autopsy on the corpse in Monrovia.

Water sanitation and hygiene
– hand hygiene practices have been re-enforced at health facilities and communities in the affected areas; and
– the social mobilization team along with the DHO [district health officer], DSO [district surveillance officer], GCHVs [general community health volunteers] are carrying out the awareness on hand hygiene practices, no touch policy, and encouraging community members to take their sick relatives to the hospital. Posters on hand hygiene are also distributed to community members.

Psychosocial support
– psychosocial support provided to the bereaved families and to the 4 self-discharged patients in Greenville.

Planned activities/recommendations
Action points for county
– proper investigation of unexplained events;
– re-enforce infection prevention and control measures in all health facilities;
– visit and discuss with spiritual healer who was reported to be treating cases that attended the funeral;
– conduct rapid analysis of the field investigation data and share results with central MOH for decision;
– more control samples to be collected by field investigation team within the next 24 hours;
– ensure that the required specimen collection kits are available;
– community engagement and reinforce hand washing within affected communities;
– continue to engage community leaders, spiritual leaders and school authorities, and sensitize the public to minimize fear and panic; and
– inquire about unusual animal deaths in the communities.

Action points for national
– establish isolation space at the JFK hospital for any case in Montserrado linked to the event in Sinoe county;
– accelerate the process of deploying a pathologist to carry out autopsy on the remaining corpse in Monrovia;
– establish list of all persons (based in Montserrado county) who attended the funeral in Greenville, Sinoe county;
– provide situational reports to all stakeholders and press releases to the public daily;
– conduct daily operational and National Epidemic Preparedness and Response Committee meetings to monitor and support the response in Sinoe county; and
– liaise with all CHTs to follow up people from other counties (Grand Bassa, Grand Kru, Grand Gedeh, Maryland, Rivercess, and Montserrado) who attended the funeral in Greenville.

communicated by:
ProMED-mail rapporteur Mary Marshall

[Although the case numbers have not changed since the last ProMED-mail post (Undiagnosed disease – Liberia (03): (SI) fatal 20170429.5002799), this report provides additional details, including graphs and a map, about the occurrence with a description of the situation and anticipated plans and actions. The good news is that there have been no new cases, suggesting that the disease is not transmissible. It will be interesting to learn what the toxicological tests done at CDC might reveal. Those results are awaited with interest.

Maps of Liberia can be accessed at and – Mod.TY] Also see  Google Satellite Map – Liberia, Sinoe county.

See Also

Undiagnosed disease – Liberia (03): (SI) fatal 20170429.5002799
Undiagnosed disease – Liberia (02): (SI) fatal 20170427.5000144
Undiagnosed disease – Liberia: (SI) fatal, RFI 20170426.4997304

A ProMED-mail post
ProMED-mail is a program of the International Society for Infectious Diseases

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