Les Roberts – Freetown, Sierra Leone – April 12, 2015
There are some amazing events that keep passing-by just beyond my comprehension, and I really want to explore them, but I know they will do little or nothing to stop the present outbreak, so I have to resist.
We were doing a sensitivity assessment in Bombali District this week, looking at the system for recording deaths. The idea is, you pick some villages at random, you go out and find out about the deaths there since New Year’s Day, and then you see how many of those deaths were recorded by the surveillance system. We did this in a village way off the beaten path on a road barely passable by car. It began as usual with a conversation with the Chief. Early on, in my asking about deaths, the 30 men and children hanging around got rather agitated and I was a little worried, briefly, that we might get beaten, but that passed. There were three deaths, and one was a little suspicious on the Ebola front as it was a middle-aged woman dying with a headache, no fever. Upon further probing, it turns out she had arrived from Freetown just a couple days before her demise. But, they insisted that she was without fever and that there was a safe burial team that buried her and she was Ebola negative… and the Chief could show me. He returned with some of her medical records and it turns out, she had been living in Freetown, was HIV+, had entered an ETU in December and been discharged after testing negative on the 12th, re-entered a different holding center almost six weeks later on January 19th, and was discharged with a letter showing her negative test for Ebola on the 21st. She died 10 or 11 days later. That delay would make me think that she got infected while in the holding center, except that the Viral Hemorrhagic Fever database (VHF) shows that when entering the facility in Freetown she had fever, vomiting, diarrhea, body pain, and severe fatigue. Thus, maybe she took a long time to have detectable virus in her blood? I don’t know. It is just an interesting case. Perhaps most disturbing is that the District Alert database and the CDC’s VHF database both show that she had a swab taken at her death, as should have happened, but there was no test result recorded. Thus, we may never know for sure if she is an Ebola case, but my counterpart in Bombali is trying to chase down that test result. Looking back on the agitated crowd, I think they thought she was EVD+ and they feared I would bring quarantine to the village. If they knew, they might have bribed the burial team to lose the sample… which would be useful to know in terms of fixing the present system. But the rest of the fascinating case, I just want to know about that out of curiosity and my fondness for historical records.
Likewise, on the same day that Bombali counterpart, Oleg Storozhenko, who is following up on the lab test, went to a tiny village with less than 150 people that experienced 48 cases of EVD in late 2014 with 42 of them dying. The Chief was very clear and up-front about it all. Someone came from outside and died. They had a funeral where people drank the body rinse water, and then lots more got sick… Of those 48 reported cases, it appears only 3 are recorded in the VHF. We asked a WHO colleague who was there all this time and he remembers the village being decimated but says record keeping was so bad that, yes, it is possible only 3 out of 48 got properly recorded. A part of me wants to go to the village and spend a couple days confirming the information to try and understand how a quarter of a village could be infected and why it stopped… and how the surveillance system missed them or mis-recorded them. But, that was five and six months ago, and it might not teach us much about improving our systems and services right now. So, I will try and block it from my mind and figure out how deaths are getting missed in the next District. It is painful to think about the lessons we are not learning.