August 10, 2014
Chronology of the Ebola Outbreak in West Africa
by
Paul Conton

I began this investigation expecting to find that the Sierra Leone Government, my government, was wholly responsible for the disaster unfolding in our country. The facts were indisputable: the outbreak had started in  the neighbouring republic of Guinea and our government had had two full months to prepare before the first case was discovered in Sierra Leone. And yet when Ebola entered, it swept through the country with ease, almost as if we were defenseless. From the start goverrnment figures were consistently lower than WHO's, and no one in authority would acknowledge the seriousness of the situation, even when we began to hear reports of entire villages decimated. Hundreds died, perhaps even thousands, no one knows. Eventually the goverrnment panicked at the scale of the emerging catastrophe, and once again we had to run to the international community for rescue. Once again our nation is threatened. Suitably patronizing and magnanimous, the world outside Africa is responding. Meanwhile, the Guinean government, although hard hit, has battled valiantly against the disease and has managed to contain it to some extent. In two short months, from May to July, our numbers of Ebola dead and crippled had risen from zero to far outstrip theirs. This was the difference between a sober-minded government and an incompetent one. This was how I saw it when I started this work.

Our chronology begins with a terse statement on the WHO website Ebola section (http://www.who.int/csr/don/archive/disease/ebola/en/), dated March 23, 2014:

“The Ministry of Health (MoH) of Guinea has notified WHO of a rapidly evolving outbreak of Ebola virus disease (EVD) in forested areas of south-eastern Guinea. As of 22 March 2014, a total of 49 cases including 29 deaths (case fatality ratio: 59%) had been reported.”

Evidently the outbreak had started some time before this and the authorities in Conakry and at the WHO were not aware of it initially. Within the next two days the figures shoot up to 86 cases and 60 deaths.

Locations of the Ebola Outbreak in West Africa

At this point the information on the website portrays a remarkably rapid response. The update of  March 26 reports that Ebola had been confirmed in eleven blood samples by three separate laboratories, in France, Germany and Senegal. This was the first laboratory confirmation of Ebola, although the clinical picture (ie signs and symptoms) showed many more cases. Given the time it would have taken to collect samples from the forested regions deep inside Guinea, take them to Conakry and then fly them out, it’s evident that medical investigations had been ongoing for many days if not weeks before the first WHO updates. Isolation facilities had already been established in Guekedou, Guinea by MSF. Significantly, as we will show later, this update also reports that, “Investigations on reported cases in Liberia and Sierra Leone along the border with Guinea are ongoing.”

By March 27 four cases of Ebola had been confirmed in Conakry, the capital, with another suspected case having died without lab confirmation. Again, this rapid movement, from isolated, forested regions deep inside Guinea to the coastal capital indicates that Ebola had in reality been raging for some time. From the start, WHO reports active collaboration between the labs set up within Guinea (by the Europeans) and the three labs outside Guinea, the Institut Pasteur Lyon, France, Institut Pasteur (IP) Dakar, Senegal and Bernhard-Nocht Institute of Tropical Medicine Hamburg, Germany.

All affected countries appeared keenly aware at this point of the possibility of a wider outbreak. On March 27 WHO reports:

“WHO has alerted countries bordering Guinea about the outbreak and to heighten surveillance for illness consistent with a viral haemorrhagic fever, especially along land borders. Both Sierra Leone and Liberia have reported suspected cases and deaths consistent with EHF to WHO among people who had travelled to Guinea before symptom onset. To date, WHO has received no reports of viral haemorrhagic fever from either country in individuals who have not travelled to Guinea. The three countries are sharing information with each other and with WHO daily. Liberia has reported 8 suspected cases of EHF, including 6 deaths, with travel histories to Guekedou district. Sierra Leone has reported 6 suspected cases, including 5 deaths. Investigations into these suspected cases are on-going.”

On March 30, Sierra Leone and Liberia revised downwards their number of suspected cases, to 2 and 3 respectively, all of these recent travelers to Guinea.

Contact tracing was very strong in Guinea from the outset, with 400 contacts reported being tracked in the April 1 update.

Especially in its early stages, Ebola has symptoms that are similar to those of many other diseases, and it must be confirmed by sophisticated laboratory testing of blood samples. Initially, samples from Liberia, which did not have an Ebola testing lab of its own were being sent to Conakry. Liberia reported its first lab-confirmed case of Ebola in Week 2, in the WHO April 1 update, based on samples sent to Conakry. At some point after this, the Sierra Leonean laboratory became involved in the testing of  Liberian samples. Based in Kenema, eastern Sierra Leone, the Sierra Leonean laboratory was initially set up to test for Lassa fever, which is endemic in Sierra Leone. At some point over the years, this lab became involved in highly secretive work relating to Ebola. Not much is known in Sierra Leone about this work or the internal organization of the lab. It is not funded by the Sierra Leone government, and apparently most of the lab's top scientific personnel are non-Sierra Leonean. From various public records the lab receives support, directly or indirectly, from the US Department of Defense and is involved in research into the uses of Ebola as a weapon and defenses against Ebola's use by bioterrorists.

The WHO update of April 5 says (MOHSW here refers to the Liberian Ministry of Health and Social Welfare):

"At the request of the MOHSW and WHO, the Metabiota Laboratory in Kenema, Sierra Leone, will install Real-Time Zaire ebolavirus-specific PCR, a pan-filo PCR, Lassa virus PCR, yellow fever and Marburg virus PCRs among other assays. This technology is being transferred from its laboratory in Kenema, Sierra Leone. Metabiota will also provide training to laboratory staff in Liberia."

“Metabiota” is not a name that would be readily recognized in Sierra Leone. The lab facility in Kenema is widely known as the Lassa Fever laboratory, or now, the Ebola lab. A search of the internet reveals that Metabiota is a small, shadowy US based company founded in 2008 or 2012 (it changed names along the way) that promises revolutionary new approaches to disease testing but that does not appear to have much of a track record. The company announced 2.4 million dollars of venture capital funding in March of this year.

This decision to put Metabiota in charge of lab testing in Liberia (and to effectively do the same in Sierra Leone) appears in hindsight to be more than a little curious, even foolhardy, even bizarre. This was a small, new organization with little experience in the region. Testing for the various strains of the Ebola virus is a sophisticated, highly specialized business. Even with all the right equipment the results can still be difficult to interpret, and experience is required. Metabiota was a new, for-profit organization with investors to satisfy. As far as I can tell from their documentation, they do not even have an independent laboratory of their own. By contrast, the Guineans were using the world-famous Institut Pasteur, founded by Louis Pasteur and credited with 10 Nobel prize winners and Germany's largest institution for research in tropical medicine, the Bernard Nocht Institute, federally funded.

So the Liberians began using their new US laboratory, installed "at the request of the MOHSW and WHO" in the middle of the crisis. WHO reports on April 17 that , “The MOHSW commissioned a new ebolavirus laboratory on 16 April in collaboration with Metabiota.” All the while, the crisis had been eating into Guinea, with 109 lab-confirmed cases from six districts and many more clinical cases. All the lab testing was being done by two European installed labs within the country (one in Gueckedou and one in Conakry) and by the three partner labs mentioned earlier, all Europe centered. Meanwhile, two suspected cases of viral hemorrhagic fever in Sierra Leone were confirmed as Lassa Fever, not Ebola, by the lab in Kenema on April 7.

The Guinean authorities were working hard to contain the disease, with significant help from international partners.They would eventually trace several thousand contacts of confirmed cases, one of the key steps to eliminating transmission of the disease. By April 25 this work looked as though it might be starting to pay off. WHO reported that the epidemiological situation had improved considerably, with four affected districts not recording any new cases for more than 21 days, the figure taken as the incubation period of the disease.

By April 28, WHO was reporting mainly on Guinea with Liberia having remained stable on 5 or 6 confirmed cases since April 8 and Sierra Leone having no confirmed case.

In its May 2 update, the WHO reported that the number of suspected cases in Liberia had been revised downward from 35 on April 23 to 13 on May 1 due to a reclassification of some of the cases, apparently using the American testing methods that had been transferred from Sierra Leone to Liberia. At this point Liberia was still reporting only 6 confirmed cases. There had been no new clinical cases since April 6, before the Metabiota lab was installed, and the disease looked as though it was winding down. The WHO update reports that the new classification method would be used for new EVD cases “should they occur.” Only 2 districts of Guinea were now a cause for concern: the capital, Conakry, and Gueckedu, the origin, close to the border with Liberia and Sierra Leone, but according to the update the number of new cases was decreasing in Gueckedou

Over the next several weeks the picture presented was one of steady improvement in the situation. The outbreak appeared to be ending. There was one ominous note on April 25 repeated and amplified on May 8:

"As of 7 May, no cases of EVD have been confirmed in Sierra Leone. From 16 March to 7 May 2014, the Ministry of Health and Sanitation (MOHS) of Sierra Leone has tested 106 patients presenting with a VHF-like illness for EVD and Lassa fever. No cases of EVD have been detected using ebolavirus PCR assays while 10 patients have been confirmed with a Lassa fever virus infection. Lassa fever is endemic in Sierra Leone"

This surely should have sparked alarm, but apparently it did not. 106 samples collected and tested. For what reason? The patients must have had symptoms consistent with viral hemorrhagic fever. All 106 tested negative for Ebola. Really? At a time when the disease was raging in Guinea and all the signs now indicate it was also raging in Sierra Leone and Liberia. In the same period Guinea had tested 191 and 115 had tested positive. All 106 in Sierra Leone negative. Astounding! During the same period of time, the lab in Liberia, using the same imported American technology, was similarly unable to find Ebola.

Table: Cumulative lab-confirmed Ebola cases.

* Table gives cumulative laboratory-confirmed Ebola cases from the last WHO update before the date indicated, except for week 8, May 20, where the update for May 23 was used.

lab-confirmed Ebola cases

On May 12, Guinea and Liberia had had no new cases for days, in most areas well beyond the incubation period, and Sierra Leone was still reporting zero. It looked as though the crisis had passed.

In its May 15 update WHO reported no new cases in Conakry since April 26, with only Gueckedou now seemingly the area to be watched.

As late as May 24 WHO reports the situation in Sierra Leone and Liberia stable with no new cases, but worryingly, a cluster of 8 new cases had arisen in Guinea, some in a previously unaffected district (Telimele) and some in a district thought to have shaken off the disease(Macenta). The pattern continues over the next updates and WHO appears surprised by its occurring in affected districts that had not reported cases for more than 42 days, generally taken as signalling the end of an outbreak. It blames the new occurrences partly on "persistent community resistance in some communities in Gueckedou, Macenta, and Conakry."

On May 28 cases from Sierra Leone suddenly spring up in the WHO updates and mushroom in the coming weeks, followed by a similar pattern in Liberia. The chart below and table above depict the cumulativCumulative lab-confirmed Ebola casese number of laboratory confirmed Ebola cases by country over the course of this outbreak. Liberia's situation does not look as bad as it actually is, because Liberia has a large number of probable and suspected cases that never went through lab confirmation. Liberia's actual position may in fact be more dire than Sierra Leone's. Looking at the neighbouring Guinean situation, it's hard to believe that Ebola was not present in the other two countries long before May 28. Ebola was present, eating its way into our nations. If it had been detected early it could have been contained, as the Guineans managed to do, although they themselves have been affected by re-infection from Sierra Leone and Liberia.The failure to detect early caused the disease to mushroom in all three countries.

From numerous internet references, it's not hard to piece together a rough outline of the Metabiota story in Sierra Leone: The US Department of Defense contracted the company to assist in the Ebola outbreak. On March 24, just as the outbreak is being announced by the WHO, two officials from the company, Dr Joseph Fair and Dr Jean Paul Gonzalez, take leave of Sierra Leone's ambassador to the US, Bockarie Stevens. Ambassador Stevens is very supportive of their mission and hopeful that they will eliminate Ebola. The scientists are leaving with a substantial quantity of reagents and other materials that are essential in and specific to the testing of the various types of Ebola. Metabiota is using a new type of test, real-time testing, possibly invented by the company itself, as opposed to more conventional methods. The Kenema lab, which had been in existence for years testing for Lassa fever, appears to be using the conventional method. Somehow Metabiota gains sway over the testing procedures at Kenema, to the extent that only a few days after the arrival of the two officials in Sierra Leone, they are invited by the WHO to set up the lab in Liberia.

For eight  critical weeks as the outbreak rages in Guinea these two labs fail to detect a single case of Ebola, even though six cases of Ebola in Liberia had previously been confirmed by the Guinean European labs.There must have been some disagreement at the Kenema lab with the scientists who favoured the conventional method. Tulane University and Harvard University were the leaders in a consortium of American institutions that had been working at the lab on Lassa Fever for several years. One could speculate on professional rivalry between Tulane and the newcomers, Metabiota.  At some point it was resolved that both methods would be used to test incoming samples (http://mysierraleoneonline.com/sl_portal/site/news/detail/2525 ). Only after this, on May 28, was it possible to confirm that Sierra Leone indeed had cases of Ebola. Only after this could all the Ebola-specific measures be implemented by government. On July 23 there was the much discussed decision reported on the Sierra Leone Ministry of Health Facebook page that Tulane University should stop Ebola testing. The conflict between the two testing methods and two groups appears to still not have been fully resolved. It was discussed during a meeting of Sierra Leone's Ebola Emergency Operations Center aired on national television on Monday August 11. Metabiota appears still to be testing samples for Ebola at the lab in Kenema.

This article does not seek to absolve the Sierra Leone government of blame. National governments have to be held responsible for the health of their citizens. The ministries of health of both Sierra Leone and Liberia should have resisted efforts to engage an untested private company on such a critical mission and should have been more skeptical of its results. The Sierra Leone health authorities, if they had been doing their jobs, should surely have picked up that there was an alarming pattern of deaths in Kailahun, and that this could only, or at least most likely, have been due to Ebola. But the WHO-approved labs were telling the government here and in Monrovia that there was no Ebola. We have heard many times during this epidemic talk of "fragile countries", "weak health systems", "poor infrastructure", etc. If WHO gives its blessing to. indeed appoints, a laboratory to do sophisticated lab tests beyond the capabilities of these "weak" national governments then WHO shares responsibility for the results of those tests. It would be extremely interesting to find out who paid for these tests, how much was paid and who authorized payment. I have no means of doing that. It would be extremely interesting to find out more about Metabiota, and what exactly they have been doing at the Kenema lab, and how exactly they came to set up the Liberian lab in the middle of this crisis. I suspect strong commercial and professional rivalry between the American interests that dominate in Kenema and the European labs that were working with the Guineans, but I don't have details. I have read all the internet accounts of US Department of Defense funding for Ebola warfare research, although I make no claims here of anything other than technical incompetence in the lab tests.


I do appreciate that there are some organizations, even commercial enterprises, that are doing important work in the area of Ebola research, work that will hopefully lead to a vaccine and/or cure. And in order for these things to happen, at some point there needs to be human testing of the new medicines. These areas need to be entered into with  great caution and under the strictest supervision.  Not to do so, to allow fledgling companies seeking profit to enter these areas with abandon, invites the kind of disaster we see unfolding in West Africa. 

2014 Paul  Conton