After being confined to her country, Liberia, for close to seven consecutive months, embroiled in a battle to contain the deadly Ebola virus that had ravaged the nation, President Ellen Johnson Sirleaf stepped out of her cocoon in February, 2015, and ventured out in the world to personally thank President Obama, the United States Congress, the American people, her friends and the Europeans, for hearing her plea and coming to her aid in responding to the unprecedented Ebola epidemic that took the lives of over four thousand people in Liberia. She was embraced and celebrated because, at that time, new Ebola cases and case fatalities were on the decline since August 2014, when the first peak of 2000 cases was recorded. So her visit was indeed something to celebrate, a huge relief, a breath of much need fresh air.

At the Commission on the Status of Women beginning on March 8 th, International Women’s Day, followed by an opening ceremony at the United Nations on March 9 th, recognizing and celebrating the accomplishments of women worldwide, the platform line up included Hilary Rodham Clinton, her daughter Chelsea Clinton, Melinda Gates, the wife of Bill Gates, President Sirleaf and many other women of international repute. With the slogan, Stepping It Up for Gender Equality, Planet 50-50 by 2030, the challenges still to be overcome in achieving full equality for women in all aspects of life globally, were also addressed. Several days later at York College in Jamaica (Queens), New York, Ellen Sirleaf was again celebrated and also congratulated for, as one presenter said, “Liberia is Ebola free.” That statement was premature because Liberia had not been declared Ebola free by the World Health Organization (WHO), although the country had reported no new cases and the last Ebola patients had been discharged from all Ebola Treatment Units (ETU) throughout the country on March 5th. However, the forty two days countdown to zero new cases nationwide was in effect. Only after reaching the forty two day mark (two cycles of twenty one days) with no new cases reported, would Liberia be declared Ebola free.

Basking all the accolades, President Sirleaf left New York and returned to Liberia on Friday, March 13 th. Exactly one week later, on March 20 th, a newly confirmed Ebola case was reported. Ebola has struck Liberia again! This time, sexual contact is presumed to be the hidden culprit in this new Ebola virus transmission, according to a statement from the Ministry of Information and case reports from the National Ebola Response Team. Countdown to zero has ceased. The cycle must begin all over again!

The story goes like this. A man, I refer to as Joe Blow, who had a date with death during the height of the Ebola epidemic in Liberia, miraculously recovered and was certified Ebola free after a second negative Ebola test post recovery. He is a declared survivor. It is not yet confirmed, exactly when he was certified Ebola free. On March 7, 2015, Joe had a rendezvous with his lover, a woman I call Lorpu. They met in Douala Market, New Kru Town, on the outskirts of the Monrovia and travelled by commercial motorbike to his house, his arms wrapped tightly around her on the bike. Ecstatic, to see each other, they had a sexual encounter, an explosion of heat, passion and ecstasy. What is significant here is that Joe was advised to abstain from sex for ninety days after his full recovery from Ebola or use condoms if he did because, research has shown, male Ebola survivors harbor the Ebola virus for 90 days in the seminal vesicle or semen, after certified recovery and can dislodge Ebola virus particles with each ejaculation! The problem is, he did not listen to the advice and chose to have sex anyway!

On Saturday March 14, 2015, Lorpu, in her mid-forties, who runs a small cook shop (local community restaurant) in the Caldwell area not far from Douala Market, felt sick. She had a severe, unrelenting headache. The next day, Sunday March 15th, she met Joe and they had sex again, despite her severe headaches. By Monday March 16th though unwell, she traveled by motorbike to Douala Market to buy food supplies to prepare for the next day. She sold her cooked food at Sims Community Public School on Tuesday, with the aid of her daughter and brother’s girlfriend, because she felt very ill. Two days later, on the evening of March 19 th, her brother took her on a commercial motorbike to Redemption Hospital in New Kru Town, with a highly elevated temperature (over 102 F) and multiple symptoms (nausea, vomiting, generalized weakness, loss of appetite, joint pain, muscle pain, headache, cough and red eyes. Before going to the hospital, Lorpu had previously medicated herself with unknown drugs from a local drug store in her area, as is commonly done in Liberia, expecting relief of her symptoms, which only worsened. Significant in her history, however, is that epidemiologically, she had had no known direct contact with an Ebola patient, nor had she traveled to an Ebola affected area outside her community.

Triage nurses, wearing full protective gear (personal protective equipment or PPE), attended the patient in the emergency room (ER) at Redemption Hospital. They suspected Ebola virus disease (EVD) and transferred her speedily to MSF (Medicins sans Frontiers) transit unit (MSFTU) at the hospital. Her symptoms intensified after admission, with several episodes of profuse vomiting, diarrhea, excruciating headache, muscle and joint pain. Malaria (similar symptoms to Ebola) was ruled out, with a confirmed negative result, while the EVD test was confirmed positive on March 20, 2015 by CDC (Centers for Disease Control). Lorpu was taken to ELWA 3 (Eternal Love Winning Africa, a religious enterprise established in the late 1950s, that includes a hospital and radio station), the larger Ebola Treatment Unit run by MSF.

A critical link to Ebola virus containment is Contact Tracing, tracking every contact like a military operation. Being the primary source of this new infection, Lorpu had 5 initial contacts, including family members (two daughters, age 17 and 15, her brother age 31, his son age 3 and girlfriend age 20, who live in the same impoverished household. Because she sells food prepared in her kitchen, to neighborhood schools, school children, staff and everyone in contact with them must now be listed as contacts, primary if in direct contact with her, secondary if in contact with her primary contacts. Sims Community Public School (SIMS) where she sells her food in the school yard has an enrollment of 1901 students plus staff of all categories, who buy her food daily. There are no school lunches or cafeteria here. Lorpu also sells at Savaco Community School (SCS), with an enrollment of 72 students, located directly adjacent to her rooming house. These students may also be primary and secondary contacts. Other areas of her business have not been determined. Given that the woman uses commercial motorbikes to buy and transport her food supplies, motorbike drivers and their passengers are also potential contacts.

Lorpu lives in a rooming house with 12 rooms, housing a total of 43 people. There are two additional attached houses, one with 6 rooms with 16 residents and the other with 6 tenants. Being a housing cluster with shared kitchen and one bathroom (without toilet) located outside the houses, interaction with each other is frequent. Therefore, we can expect that these residents were all in contact with Lorpu at varying periods during her illness and are listed as contacts.

It is common that poor families in Liberia live in communities, in housing clusters with one make- shift bathroom in a designated common area outside, surrounded by zinc sheets or thatch enclosure and is shared by all the residents. There is usually no toilet facility. Consequently, in the absence of toilets, the “flying toilet” is the community’s innovation. A flying toilet is a regular plastic bag used in markets for packaging goods. Local people use these bags as toilets when they defecate. The bag is then tied up and flung in the air or over fences, landing in areas some distance from where it originated. Hence, the toilet “flies.” Lorpu’s family and everyone in her community use flying toilets. Considering that she had diarrhea for several days at home, and used flying toilets, with flying toilets containing Ebola excrements, one never knows where, in whose yard or on whom they will land, yielding yet another potential source of Ebola contamination in the neighborhood. It is therefore essential that regulations be instituted and enforced, requiring all housing developments to have functioning toilets.

It is important to emphasize that as of March 20 th, 59 primary contacts have been identified, consisting of family members and residents in the three clustered houses. When school children (SIM Community Public school, 1901 students, Savaco Community School, 72 students, teachers, their friends and families, unknown motorbike drivers running to the schools and Douala market and their passengers are added to this mix , the number of contacts could far exceed 2000.

People on the Contact Tracing list have to be supported if they are expected to cooperate with health authorities and stay in voluntary quarantine, allowing them to be easily followed for the required 21 days. The home of the affected family has to be decontaminated and supplies such as mattresses replaced as quickly as possible. Others on the list, along with the family, must be given food and psychological support. The community must be engaged, educated and made aware of the implications of the new infection and their role in assisting health officials monitor contacts within their communities, by reporting anyone who manifests symptoms in the specified 21 day period and beyond.

As with HIV/AIDS, sexual intercourse could be the new hidden culprit of Ebola virus transmission in Liberia. Given the sexual proclivities of men in general, Liberian men in particular, it is likely that sexual contact post Ebola could be the source of new outbreaks in Liberia ! It is presumed that because of Sex, Liberia missed the 42 day mark to being Ebola free after 28 days of no new cases. Thus began the saga of the newly confirmed Ebola infection in Liberia on March 20, 2015, as Liberia was counting down to ZERO.

The triage nurses at Redemption Hospital must be commended for being alert, trained to recognize Ebola symptoms, acting swiftly and appropriately, by immediately transferring the patient to the Ebola Transit Unit. This action may have prevented further transmission and escalation of an outbreak in an already impoverished and densely populated area.

The National Ebola Response Team, in particular, the Case Management team led by Dr. Moses Massaquoi, National Case Manager and Contact Tracing team, ably managed by C. Sanford Wesseh, Assistant Minister of Health for Vital Statistics, mobilized quickly to get the situation under control, implementing an immediate, painstaking case investigation, contact listing and tracing for the required 21 days, along with community involvement to avoid panic. These are all essential elements in averting a widespread outbreak.

The current WHO guidelines as to when a country would be declared Ebola free should be reassessed. As long as the focus was on containment within two twenty one day cycles or forty-two consecutive days, based on the date the last patient was released after two consecutive negative tests, the potential for sexual transmission of the virus by a male survivor up to ninety days post certification of recovery was not emphasized, despite research pointing to this mode of transmission as a possibility. This in itself indicates the evolving nature of EVD and the necessity of inclusion of survivors, particularly male survivors, in the research agenda.

Editor’s Note: Dr. Moses Massaquoi, National Case Manager, Liberia’s Ebola Response Team / Country Director, Clinton Health Access Initiative Liberia, provided pertinent information that contributed to this story.

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