Kailahun district in eastern Sierra Leone was one of the country's first hot spot in the Ebola outbreak, at its peak reporting more than 80 new cases per week in late June 2014. With the assistance of WHO and partners, combined with the close involvement of community leaders, the district has managed to beat the disease and has reported no new cases for several weeks. There is no room for complacency however. Community teams and health workers are on high alert and are ready to react quickly to any possible new infection.
Kailahun district borders the area of Guinea where the first cases of Ebola were confirmed at the end of March 2014. The risk of infectious diseases spreading across the border has always been high, as communities are culturally connected and there is a lot of free movement between the two countries. Almost as soon as the outbreak was reported in Guinea, WHO started working closely with the Ministry of Health of Sierra Leone to prepare for possible imported cases of Ebola from Guinea, including organizing training in border areas in April and May.
In spite of these efforts, the disease was carried across the border and, on 25 May, Sierra Leone notified WHO of its first confirmed case. Three days later, Kailahun district already had 7 confirmed cases. The virus then spread so fast that local health capacities in Kailahun were quickly overwhelmed and needed urgent assistance.
WHO immediately established an office in the city. In June, Médecins Sans Frontières (MSF) established an Ebola treatment centre and WHO helped deploy a mobile laboratory from Public Health Canada to test blood and swab samples inside the MSF treatment centre.
"The outbreak in Sierra Leone was still restricted to Kailahun area at the time I arrived in mid-June," says Dr Zabulon Yoti, WHO team leader who has a long track record of working on many other haemorrhagic fever outbreaks. "There was lots of community resistance. Some areas were not allowing response teams in. My first priority was to help build a broader response structure with full involvement of local leaders and communities."
By mid-July, the situation had escalated. MSF reported more than 90 confirmed cases in the first 4 weeks since opening the treatment centre. "The disease was ahead of us, we did not know where transmission chains were," says Dr Yoti.
"In 12 days that July, we buried more than 50 bodies in makeshift graveyards close to the Ebola treatment centre," said Jose Rovira, a WHO logistics expert who trained 20 volunteers there from the National Red Cross and Ministry of Health in safe burials of deceased Ebola patients, "and this number did not include people who died in their homes."
The response structure started to take shape as more chiefdom leaders joined the fight. "Initially only 4 out of 14 chiefdom leaders were part of the District Ebola Taskforce. We went to see all the others to convince them to join the fight," recalls Dr Yoti. "We also included the head of the interreligious council so mosques and churches would also spread the appropriate messages."
With financial support from United Nations Populations Fund (UNFPA), the District Ebola Taskforce recruited, trained and equipped 20 volunteers with mobile phones in each of the 14 chiefdoms. Some 300 volunteers were charged with contact tracing and alerting response teams on any suspect cases or deaths. These volunteers were selected by chiefdom leaders from local community health workers, health promoters or teachers.
"We started to receive alerts from communities; at the peak we had more than 20 per day, half of them for burials, the other half reporting suspect cases," says Dr Yoti. But with only 4 vehicles available, there was a backlog in dealing with all the calls.
Turning the tide against Ebola
By the beginning of August, the number of confirmed cases started to level off and the majority of new cases were coming from registered contacts.
"What was really important is that we started to know where transmission chains were located and we were able to link cases to one another," says Dr Yoti.
In just weeks, the number of new cases started to fall -- from 80 reported cases in the last week of June to just 10 new infections in the second week of August.
From September to November, the progress was sustained. New cases were quickly identified and identified, and contacts were listed and monitored for 21 days. "From being hunted by the virus at the beginning, we started to hunt it down, cutting each transmission chain we found," says Dr Yoti.
In total, 645 people are known to have contracted the virus in Kailahun and 228 of them have died. However the toll is most likely higher as many infections in the early phase were not reported.
At time of publishing, the last confirmed case was reported on 12 December . Today in Kailahun, the only patients in the treatment centre have come from other districts.
Lessons learned from Kailahun approach
The Kailahun approach has since been successfully applied to the neighbouring district of Kenema, also heavily affected by the Ebola outbreak.
"This is a classical Ebola situation where partners all come together to ensure they contain the disease within the district," says Sierra Leone Chief Medical Officer Dr Brima Kargbo.
"There were good interpersonal relationships between all the players including the District Medical Health Teams, WHO, MSF, Save the Children, World Vision, UNFPA and, importantly, the local nongovernmental organizations," says Dr Victoria Mukasa, WHO Infection Prevention and Control specialist, who spent more than 2 months in the district.
Dr James Squire, District Medical Officer in Kailahun, who was heading the response from the beginning, singles out key interventions: "The 2 most important things that helped to overcome the outbreak were the early establishment of response structures that we did with assistance of WHO and full involvement of community leaders."
"The decrease of cases in Kailahun is very good news, but it does not mean the epidemic is over - outreach and contact tracing activities play a major role at this stage and all actors involved should continue to monitor the situation very closely," says David Nash, MSF Project Coordinator in Kailahun. "However, the acceptance of the community and the acknowledgment that Ebola is real has been of huge importance in order to come to this point."