http://www.nytimes.com/2014/11/13/health/mali-reports-a-second-larger-ebola-outbreak.html 2014-11-12 19:24:18 Mali Reports a Second, Larger Ebola Outbreak Authorities are trying to trace those who came into contact with an imam who fell ill in Guinea and traveled to Mali for treatment at a clinic that failed to diagnose the virus. === Mali The first case in the new outbreak was a 70-year-old religious figure, a grand imam, who fell ill in Guinea and traveled to Mali for better treatment at a major private clinic in Bamako, Mali’s capital. He died there on Oct. 27, and because of his importance, his body was washed at a large Bamako mosque before being returned to Guinea for burial. But the Pasteur Clinic, where he was treated, failed to diagnose Ebola as the underlying cause of the It was only realized how infectious he was after a nurse at the clinic fell ill and died, and when the chief W.H.O. representative in Mali heard from his counterparts in Guinea that the imam’s family members were dying. “It was a real failure by the clinic,” said Dr. Ibrahima Soce Fall, the W.H.O. Mali team leader, in a telephone interview. Now the clinic is closed and under quarantine — as is the mosque, another small Malian clinic where the imam was treated, and the large family compound where the nurse lived. Health experts are trying to trace everyone the imam and the nurse were in contact with. The task will be complex, since the imam fell ill nearly a month ago on Oct. 17 in Kourémalé, a town in Guinea near the border. The consequences for Mali were not recognized until Nov. 10, when doctors ordered an Ebola test on the dying Bamako nurse. So far, 28 staff members at the Pasteur Clinic — which is not related to the Pasteur Institute in France or any of its African offshoots — have been quarantined, as have 50 people who had contact with the nurse. A friend who visited the imam at the clinic has also died of unknown causes and is considered a suspect case, although no blood samples are available to test, the W.H.O. said. “We’re still working on the contact tracing,” Dr. Fall said. The mosque is worrisome, he said, because it is unclear who may have come into contact with the body there. No one has fallen ill there so far. The imam traveled in a private car, not on public transportation, and three members of his family who were in the car are now ill or dead in Guinea. Teams with advisers from the W.H.O. and other health agencies are working at the clinic, the mosque, and the border. Malian authorities have not closed the border. Closing it is considered impractical — it is 500 miles long with many gravel roads crossing it. Also, it is a hangover from the divisions of French colonialism and separates many extended families that are used to traveling back and forth. In addition, Mali has a longstanding tradition of welcoming both strangers and those with clan connections — a principle known as diatiguiya (pronounced JAH-tih-GEE) — and closing the border was unthinkable, many Malians said. The new outbreak is frustrating for health authorities because they were feeling triumphant about their success in containing the country’s first case: a 2-year-old Guinean girl, Fanta Condé, who died in the town of Kayes in northwest Mali on Oct. 24. The authorities had quarantined 108 people who were briefly in contact with Fanta on buses from Guinea, at a family compound in Bamako and at the hospital in Kayes where she died. None had fallen ill — not even the three family members who brought her from Guinea on Oct. 19 — and all 108 were due to be released from quarantine by Friday. When the new, unrelated cluster was first suspected on Monday, Dr. Rana Hajjeh, who directed the Centers for Disease Control and Prevention team in Mali that worked on the Fanta Condé case, mentioned it in an email and described it as “Murphy’s Law” — that is, the principle that anything that can go wrong will go wrong, and at the worst possible time. In Guinea, the imam’s first wife has died, as has his daughter. In the daughter’s case, the death took place Monday and Ebola was suspected, but the family declined offers of a safe burial. The imam’s brother, second wife and son are ill and in Ebola treatment centers.