The recent Ebola virus disease (EVD) epidemic in Guinea, Liberia and Sierra Leone demonstrated that the World Health Organization (WHO) is incapable to control outbreaks of infectious diseases in less developed regions of the world. This essay analyses the causes for the failure of the international response and proposes four measures to improve resilience, early detection and response to future outbreaks of infectious diseases.
Keywords: Ebola, epidemic, infectious diseases, WHO, International Health Regulations
Ebola virus has been raging through Western Africa for seventeen months by now. The number of new cases is declining but an end to the epidemic is not in sight. The World Health Organization registered about 27,500 cases thus far, of which 11,220 have died. It will probably take several more months until the largest EVD outbreak in history can be declared over. Guinea, Liberia, and Sierra Leone will suffer from the economic consequences for many years to come. Scientists and politicians now unanimously argue that international aid came too late and was for the most part ineffective. The WHO in particular has been facing intense criticism not having reacted appropriately to the outbreak. The horrendous images coming out of Western Africa and concern for their own safety have finally woken up the industrialized nations.
How, then, can we protect ourselves against future outbreaks of deadly microbial diseases?
2. Causes for the Catastrophe
On 26 December 2013, an 18-month-old boy named Émile fell ill with high fever and severe diarrhea in a village of the Guéckédou Prefecture in the south of Guinea. Today, we suspect that he might have been infected by a fruit bat or some other wild animal which carried the virus into that area. By the time Émile died, his sister, his mother and his grandmother had already been infected. As more and more people fell ill, the local health authorities suspected cholera or Lassa fever to be the cause, both of which are common in that region.
On 13 March 2014, the Guinean Ministry of Health called WHO and Doctors Without Borders (Médecins sans Frontières, MSF) for support. Eight days later, the message arrived from a special laboratory in Lyon (France): it is Ebola and, moreover, it is the most deadly strain “Zaire” [sic].
At this point in time, MSF had already begun to isolate patients and to trace contacts in Guéckédou. The reports had often mentioned “hiccups”—a clinical sign that does not fit cholera or Lassa fever, but is frequently observed with Ebola virus disease (EVD). In an EVD outbreak it is essential to isolate all patients and their contacts as early as possible, and MSF immediately sent a specialized team into the affected region.
At WHO in Geneva, however, the reports from Western Africa were received in a markedly more relaxed manner. The Director-General, Dr. Margaret Chan had, in the past, been accused of alarmism. During the “swine flu” pandemic, she had declared the highest alert level, in spite of the relatively harmless manifestations of the disease. Then, during the years that followed, Dr. Chan dissolved WHO’s epidemic and pandemic response unit and split its duties among other departments. This move fit into the strategic turnover that Dr. Chan had pursued since she had taken up office in 2006: WHO should focus on technical advice, and leave practical disease control with the member states.
Until the middle of May 2014 the number of new Ebola virus infections remained stable. During this eclipse of the epidemic, only nine patients were treated in Guinea. Liberia, alerted by the outbreak in the neighboring country, had successfully isolated about a dozen cases. There were no more reports of new cases for several weeks in these two countries.
Sierra Leone had engaged the US firm Metabiota from the start of the epidemic to search for EVD cases in the border regions to Guinea. However, the professional virus hunters did not find any trace of Ebola virus in over 160 samples. On the basis of this information, President Ernest Koroma declared his country “Ebola-free” up until the last week of May 2014. WHO adopted this assertion unchecked in its reports. This would later prove to be the most fatal mistake in the initial stages of the epidemic.
Today it is clear that Ebola virus had already spread in Sierra Leone very early in the epidemic. MSF was told during their investigations in March 2014 of suspected EVD cases beyond the borders in Sierra Leone and immediately issued warnings to the Ministry of Health and WHO office in Freetown. There, the preferred reaction was to believe the reassuring information of the American consulting firm. Up until 24 May, WHO described the situation in Liberia and Sierra Leone as “stable”.
Then, after three weeks of deceptive calm, the viral storm broke loose. On 25 May, Freetown confirmed the first EVD case and, within a few weeks, hundreds more followed. The hidden outbreak in Sierra Leone had sparked a smoldering wildfire in Guinea and Liberia. Because of the high number of unknown cases, the critical mass, which a virus needs for explosive dissemination, had been reached. At least 4600 people died between June and October 2014 alone.
Facing this dramatic situation, the WHO Director-General decided to wait another two months before she declared the EVD outbreak a Public Health Emergency of International Concern (PHEIC). The legal definition of the PHEIC had already been fulfilled in March 2014: an extraordinary event must constitute a public health risk to other states through the spread of disease and potentially require coordinated international response.
The tasks of WHO and its 194 member states in the face of an epidemic are laid down in the International Health Regulations (IHR) of 2005. After declaring a PHEIC, the Director-General appoints a specialized Emergency Committee and issues “temporary recommendations” as to how the epidemic should be tackled. If necessary, WHO has the right to check information provided by affected countries regarding the nature and the spread of an infectious agent through its own investigations. Although the recommendations are not legally binding, the declaration of a PHEIC exerts considerable political pressure both on the affected countries to cooperate and on other states to provide financial aid. Therefore, according to the original intention of the IHR, WHO should take on the coordination of the fight against the epidemic.
The no-longer-disputed fact that WHO reacted too late was based on a fatal misjudgment of the initial epidemic in Western Africa. EVD is, next to rabies, one of the infectious diseases with the highest lethalities. On the other hand, Ebola virus is only transmitted by close contact and those seriously ill with the disease can hardly move. For this reason, earlier EVD epidemics, which occurred in the remote villages of Equatorial Africa, had always burnt out after two to three months.
Dr. Chan and the WHO representatives of the three affected countries had good reason to hope that the Western African epidemic would pass quickly too. The governments of Conakry, Monrovia, and Freetown for their part had no interest in being burdened with travel and trade restrictions. Hence they delivered spuriously low case numbers to Geneva for months and declared the situation as being under control. The common interest of local governments and WHO representatives to play down the problem resulted in fatal negligence, for which the affected countries, and the rest of the world, had to pay a high price in the following months.
On 25 July, Nigeria confirmed its first EVD case. One week later, two American aid workers, who had become infected with the virus in Monrovia, were flown out to the USA. On 8 August 2014 Dr. Chan finally declared the EVD epidemic a Public Health Emergency of International Concern.
By that time very few still believed that WHO, after months of procrastination and misjudgments, could lead an international emergency deployment in Western Africa. UN Secretary General Ban Ki-moon told the WHO leader that he was going to appoint a new UN mission to coordinate the Ebola response. On September 19, the UN Mission for Ebola Emergency Response (UNMEER) was initiated. It is the first health mission outside of WHO in the history of the United Nations, giving a clear signal that the sole UN agency for health could not be relied on to manage a multi-national outbreak.
At the beginning of September, Ellen Johnson Sirleaf, President of Liberia and respected Nobel Peace Prize winner, wrote a personal letter to the leaders of Australia, Brazil, China, Germany, India, Japan, Cuba, Russia, South Africa, and the USA. Shortly after that, President Barack Obama announced the greatest humanitarian aid program in history: 3000 soldiers were to construct treatment centers in Liberia for a total of 1700 EVD patients. China and Germany also pledged to build treatment centers in Monrovia.
However, progress in international response was sluggish. By August, the few operational treatment centers in Western Africa had been overwhelmed by patients. At the same time, officials in Washington, Paris, and Berlin discussed protective equipment, disinfectants, tent constructions, liability issues and medevac procedures for potentially infected aid workers.
In Berlin, an interagency working group led by the chancellery dealt with the many technical, logistical and legal questions (The suggestion made by the author of this article (A. Kekulé, Report for the German Federal Foreign Office, 17 September 2014) to immediately train German aid workers with MSF in Brussels and Western Africa and to construct treatment centers in tents according to the MSF concept, was dismissed as impractical at that time). In recognition of an eminent lack of resources, the federal government finally commissioned the German Red Cross to construct and run an Ebola treatment center in Monrovia, with technical support provided by the German Army (Bundeswehr). In contrast to the rather improvised MSF camps, the made-in-Germany treatment center was to be equipped with proper electricity and water supply systems, solid walls, stormproof roofs and concrete foundations. On 23 December 2014, the facility was eventually finished. The necessary personnel, who received a perfect preparation in a purpose-built German training center, were supposed to follow until mid-January. At this point, the MSF 250 bed facility in Monrovia was half-empty because the epidemic had been declining since October. Furthermore, the USA and China had created their own treatment centers with several hundred beds. As a consequence, not a single EVD patient has ever been treated in the German facility.
3. Lessons Learned
From the mistakes and the limited successes of the response to the EVD epidemic in Western Africa, we are able to gain five essential insights:
3.1. Naturally Occurring Outbreaks do not Happen Suddenly
The West African EVD epidemic started long before little Émile became infected. Current genetic research suggests that Ebola virus had been present in the Western African rainforest for more than ten years before the current present outbreak (Scientists from the Bernhard Nocht Institute in Hamburg found signs of Ebola virus infections in the East of Sierra Leone as early as 1982. However, because detection methods were not reliable in those days, these findings were not investigated further). The migration of Equatorial African fruit bats, which are regarded as a possible source of the epidemic, had been observed for some time. With better preparation and sensitive epidemic surveillance in place, Western Africa could have been warned about Ebola virus.
3.2. The Fight against Epidemics Starts with Humans
In the remote regions of the Equatorial African rainforest, where Ebola virus has been present for a long time, people with uncommon fevers are treated by an old woman in a hut outside the village, who everyone avoids during that time: without scientific knowledge, people have developed an appropriate method of isolation (From a virologist’s point of view this makes perfect sense, because older people are more likely to have contracted and survived EVD, and could therefore have become immune). In Western Africa, the people have learned how to protect themselves against EVD-like illnesses: avoid any contact with the sick and the dead, as well as with strangers. Tens of thousands of local community health workers carried this message to the most remote villages. This simple rule of behavior is the main reason why new infections have dropped since October 2014.
The statisticians of the US Centers for Disease Control and Prevention (CDC) and WHO did not take this learning process into account when they predicted at the end of September 2014 that in Liberia and Sierra Leone, alone, the number of EVD cases would rise up to 1.4 million by mid-January 2015 (The CDC estimated 550,000 recorded cases and a factor of 2.5 for underreporting. Extrapolating the calculations of WHO, which published a prognosis only until November 2014, up to 500,000 cases were to be expected by end of February 2015). (The author of this article vehemently disputed those figures at that time. Considering that the affected people would autonomously change their behavior, he predicted that the case numbers would start to drop from November 2014 onwards and that by January 2015 the epidemic would largely be under control (A. Kekulé, Report for the Commission on Civil Protection at the German Federal Ministry of the Interior, 13 October 2014)). On the basis of these pessimistic forecasts, many countries, including Germany, devised long-term aid programs, with the result that most of the treatment centers were only completed when the epidemic had already abated.
Knowledge of culture and living conditions of the affected populations is essential in the fight against epidemics. The fact that WHO, as part of its restructuring policies, decided to let go of almost all its anthropologists, was a grave mistake.
3.3. Treatment Centers are the Most Effective Form of Emergency Aid
The behavioral learning process takes time, especially where religious and ethnic customs are involved. During the initial phase of an epidemic, the pathogenicity of the organism determines how quickly it spreads. In highly contagious virus diseases, every patient infects a large number of other individuals. The average number of persons infected by one patient is the basic reproduction number,R0 (“R-naught”). For measles, one of the most contagious diseases, R0 is approximately 15. EVD, in contrast, is only transmitted through contact with bodily fluids. At the beginning of the epidemic, when the population did not yet know how to protect itself, R0 had a value of about 2. In order to stop the spread of a disease, the value of R0 must be brought below 1. As long as no vaccine is available, there is only one way to accomplish this task: the infected must be isolated immediately and efficiently.
For this purpose, mobile Ebola Treatment Centers (ETCs) have proved their usefulness during earlier outbreaks. The current epidemic showed that isolation at home (which would be an alternative in highly developed countries) is not feasible under basic living conditions. In addition, it has become clear that simple infusions, to replenish the water and salt losses from fever and diarrhea, can save many patients.
For the isolate-and-treat strategy to work, sufficient capacity must be constructed very quickly. During the most intensive phase of the Western African epidemic, the ETCs were so overcrowded that they could hardly administer infusions. The patients understood quickly that they would only be isolated, but not treated. Understandably, many EVD patients preferred to stay, and to die, at home. Thousands of infected hid away from the aid workers, some even fled from the treatment centers.
3.4. In an Emergency, Only Things Will Work That Have Worked Already Before
Médecins sans Frontières had more than ten years of experience with outbreaks of EVD and similar diseases. Therefore, it was no coincidence that a MSF specialist thought of Ebola early, having heard only of some clinical symptoms, and reacted appropriately. The plans and the packing lists for ETCs were in the drawer and experienced personnel were available (although not in sufficient numbers). The International Federation of Red Cross and Red Crescent Societies (IFRC) was also able to utilize its earlier experience with EVD and opened its first ETC on 23 September in Sierra Leone, which was still early enough to help hundreds of patients.
The mobile field laboratories, which were provided mainly by the EU and the USA, proved to be successful. The first unit of the European Mobile Laboratory (EMLab) program, managed by the Bernhard Nocht Institute in Hamburg, started operations in Guéckédou in the first days of April 2014.
In contrast, the aid organization Samaritan’s Purse, which had no experience with Ebola outbreaks, had to close its ETC in Liberia after two aid workers became infected. The effort led by the United States was similarly ill-planned: 2800 soldiers built 17 ETCs in Liberia, but there was no medical staff to run the centers. The only US facility that ever came into operation is a small, high-tech hospital in Monrovia, designed exclusively for the treatment of aid workers.
3.5. Epidemic Control Must Be Fast and Flexible
Epidemics jump from one location to another at lightning speed and countermeasures must be able to follow. MSF’s camp-type treatment units and the mobile field laboratories were successful because they could be moved quickly and, if necessary, expanded in a modular way. The UK, like all other governmental bodies, could only put its aid program into practice very late. They invested in mobile tent construction, similar to those of MSF, which were then handed over to the management of non-governmental aid organizations. From 5 November until 15 December, at a time when the epidemic was still at its height in Sierra Leone six successful UK treatment centers went operational in that country.
4. Four Things that Should Be Done Now
On the basis of the experiences in Western Africa, four important measures for the protection against future epidemics are to be recommended:
4.1. Integration of Epidemic Preparedness into International Development Policy
Ebola virus was able to spread in Western Africa so massively because the national health services and infrastructures failed. Due to a lack of information, people did not know for a long time how to protect themselves. Well-run education systems and health services, as well as functioning infrastructures, are the best protection against epidemics.
However, the path towards this ambitious goal is long and costly. A faster and more effective intervention would be the integration of epidemic prevention into all areas of development aid. In regions particularly affected by outbreaks many small and simple measures can be implemented that contribute to the protection against dangerous pathogens.
4.2. Early Warning System for Emerging Pathogens
Newly-emerging pathogens almost always jump from animals to humans. Ebola virus came from fruit bats or some other, yet unknown reservoir. SARS coronavirus came from palm civets, HIV-1 from chimpanzees and influenza A virus from waterfowl (While fruit bats are regarded as the most likely animal host of Ebola virus, this has not been proven yet. Severe Acute Respiratory Syndrome is a viral lung disease that claimed over 1000 victims during an international outbreak in 2003). Ebola virus may have circulated in Western Africa for many years before the actual outbreak. Equipped with simple laboratory tools and a mobile telephone, hospitals in endangered regions could act as sensors for a global surveillance system (“Global System for Early Warning and Response” (A. Kekulé, presentation at the Global Working Group, German Federal Foreign Office, 2005)). After the tsunami of 2004, an earthquake warning system was established in the Indian Ocean. The EVD outbreak in Western Africa alerts us that similar alarm bells for the global threat of pandemics are urgently needed.
4.3. African Center for Disease Control and Prevention
The prevention, early detection and control of outbreaks are managed by specialized centers for disease control in almost every continent. The CDC in Atlanta, which may well be seen as the most appropriate blueprint for such an organization, operates with 15,000 employees and an annual budget of US$ 6.9 billion. Other regions of the world are overseen by similar, albeit much smaller, disease control institutions, e.g., the Chinese Center for Disease Control and Prevention (CCDC) in Beijing or the European Centre for Disease Prevention and Control (ECDC) in Sweden. Australia has invested in decentralized academic centers to lead research and response in similar areas to the US CDC rather than building up a single state-owned institution.
For Africa, however, neither a common center for disease control nor a decentralized network equivalent exists. Taking into account that the rural regions of this continent are supposed to be home to many of the most dangerous pathogens on earth, an African Center for Disease Control and Prevention (“ACDC”) is urgently needed.
The idea of an African CDC was brought up already in 2013, at the African Union Special Summit on HIV, AIDS, Tuberculosis and Malaria in Abuja, Nigeria. However, it was not seriously followed thereafter, due to both financial and political restraints. However, now, in the aftermath of the Ebola outbreak, the ACDC concept has been revived.
The present idea is that an ACDC should copy the concept of the European ECDC: A small coordinating and advisory office, with its own laboratories and field intervention task forces. However, help for Africa and protection of the rest of the world does not come cheaply. In contrast to Europe, where many states have powerful national disease control facilities (such as Robert Koch Institute in Berlin, Public Health England in London and the Pasteur Institute in Paris), almost no specialized expertise exists in African countries. Therefore, an African CDC should run its own, state-of-the-art laboratories and intervention teams.
4.4. Medical Response Unit
The fast setup of ETCs, in sufficient numbers, is crucial for the early containment of an outbreak. In Western Africa neither WHO, the international community of states, nor single countries were able to implement this. In recognition of this shortcoming, suggestions for an international Medical Response Unit, which could be deployed quickly in case of an outbreak, were made (“Humanitarian Intervention Troup” (Alexander Kekulé, 18 September 2014); “White Coat Corps” (Ban Ki-moon, 25 September 2014); “White Helmet Troup” (Frank-Walter Steinmeier, 20 October 2014)).
The necessary technical equipment is not a challenge. Mobile units in tents or containers have proved to be superior to fixed buildings. Corresponding resources could be made available by the UN Disaster Assessment and Coordination (UNDAC), the European Commission Humanitarian Aid and Civil Protection (ECHO), the IFRC and national military and disaster aid units. The provision of consumable materials (e.g., protection suits, disinfectants) should be secured through supply contracts or stockpiling, respectively.
In addition, ETCs need access to simple lab equipment for the determination of basic parameters, in particular electrolytes (salt concentrations in blood and urine). Also plasma extraction (plasmapheresis) devices are important because antibodies from the blood of convalescent patients could potentially be used as a therapy for the newly-infected.
A far greater challenge than equipment is the personnel. For a treatment center with 100 beds, around 30 international and 300 local aid workers are required. In contrast to IFRC, MSF and other non-governmental organizations, states have no access to pools of field workers who are already trained and can be deployed quickly. As well, government-led missions involving voluntary personnel face considerable legal problems in most countries (liability in case of infection, leave from the workplace, etc.).
For the Medical Response Unit proposed here, four main components are necessary:
An international operational command. It develops and practices scenario-based, generic plans for medical crises and acts as a coordinator in case of an outbreak.
An interdisciplinary roster of experts. In case of an outbreak, consultants, trainers and field leaders can be called up from this pool.
A network of cooperating organizations providing technical and logistical support (e.g., UNDAC, ECHO, IFRC, national military and technical aid units).
National voluntary aid worker pools from relevant professions. These should be adequately prepared through continuous education (disaster medicine, languages, etc.) and, when necessary, through special field training.
The Medical Response Unit should as a rule act in conjunction with aid organizations in the affected region, which in particular provide the necessary field staff. Such public-private cooperative efforts have proven very effective during the Western African outbreak.
5. Rapid Outbreak Intervention Cannot Be Led by WHO
The shortcomings of WHO during the EVD crisis can only be partially blamed on particular persons. More important is a structural problem which cannot be solved in the medium term. The yearly budget of the global health guardians, which has remained unchanged for years, stagnates at a meager US$ 2 billion (as a comparison: the US health authority CDC alone has access to US$ 6.9 billion yearly). Of this budget, assessed contributions of the member states account only for 23 percent. The rest comes from voluntary donations, which usually are tied to specific projects. The dependency on voluntary donations made the agency highly susceptible to political interference. According to the demands of the industrial states, which contribute comparatively large amounts, ailments of civilization like coronary heart disease, diabetes and obesity have lately been pushed to the top of the WHO agenda. In the case of an outbreak, the concerned country and regional offices set the pace of the WHO response, in accordance with the demands of the national governments.
With the International Health Regulations (IHR) of 2005, the main responsibility for epidemic control was transferred from WHO onto the member states. This made sense in the light of the SARS epidemic of 2003, which had been the reason for the 2005 revisions of the IHR, because mainly rich countries were affected. On the same grounds, the PHEIC essentially provides measures for the border protection of highly developed states (e.g., restrictions of air and maritime traffic). For the containment of outbreaks within developing countries, however, WHO has no effective policy in place.
To ensure effectiveness and speed as well as financial and political independence, the Medical Response Unit must be established outside WHO; for example, as a continuation of the UNMEER program of the United Nations or an interdisciplinary unit within the European Commission. In regard of its geographic vicinity and colonial heritage, Europe has both special security demands and special responsibilities for Africa.
The four measures proposed here could be funded by the Pandemic Emergency Facility (PEF), a novel financial instrument currently developed by the World Bank as a reaction to the EVD epidemic. In addition, the industrialized countries should guarantee, by national legislation, that voluntary aid workers are properly insured and their employers are compensated for their absence.
The world can count itself lucky that Ebola virus did not spread any further, in particular after the satellite outbreak in Nigeria. A virus only slightly more contagious could have caused a worldwide pandemic, claiming millions of victims. With the globalization of travel and goods, the war between man and microbes has exacerbated to a level that is unprecedented in history. In this “New Age of Pandemics”, the Western African EVD outbreak was just the beginning. At risk, from now on, is no less than the survival of humanity. In this war, at the outmost border of the human species, epidemic control in developing countries is our last line of defense.
Conflicts of Interest
The author declares no conflict of interest.
The Emergence of Ebola as a Global Health Security Threat: From ‘Lessons Learned’ to Coordinated Multilateral Containment Efforts
Sarathi Kalra,Dhanashree Kelkar,1Sagar C. Galwankar,1Thomas J. Papadimos,2Stanislaw P. Stawicki,Bonnie Arquilla,3Brian A. Hoey,Richard P. Sharpe,Donna Sabol, and Jeffrey A. Jahre
St Luke's University Health Network, Bethlehem, Pennsylvania, USA
1University of Florida, Jacksonville, Florida, USA
2The Ohio State University College of Medicine, Columbus, Ohio, USA
3SUNY Downstate Medical Center, Brooklyn, New York, USA
Address for correspondence: Prof. Stanislaw P. Stawicki, E-mail: firstname.lastname@example.org
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Copyright : © Journal of Global Infectious Diseases
This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC.
First reported in remote villages of Africa in the 1970s, the Ebolavirus was originally believed to be transmitted to people from wild animals. Ebolavirus (EBOV) causes a severe, frequently fatal hemorrhagic syndrome in humans. Each outbreak of the Ebolavirus over the last three decades has perpetuated fear and economic turmoil among the local and regional populations in Africa. Until now it has been considered a tragic malady confined largely to the isolated regions of the African continent, but it is no longer so. The frequency of outbreaks has increased since the 1970s. The 2014 Ebola outbreak in Western Africa has been the most severe in history and was declared a public health emergency by the World Health Organization. Given the widespread use of modern transportation and global travel, the EBOV is now a risk to the entire Global Village, with intercontinental transmission only an airplane flight away. Clinically, symptoms typically appear after an incubation period of approximately 11 days. A flu-like syndrome can progress to full hemorrhagic fever with multiorgan failure, and frequently, death. Diagnosis is confirmed by detection of viral antigens or Ribonucleic acid (RNA) in the blood or other body fluids. Although historically the mortality of this infection exceeded 80%, modern medicine and public health measures have been able to lower this figure and reduce the impact of EBOV on individuals and communities. The treatment involves early, aggressive supportive care with rehydration. Core interventions, including contact tracing, preventive initiatives, active surveillance, effective isolation and quarantine procedures, and timely response to patients, are essential for a successful outbreak control. These measures, combined with public health education, point-of-care diagnostics, promising new vaccine and pharmaceutical efforts, and coordinated efforts of the international community, give new hope to the Global effort to eliminate Ebola as a public health threat. Here we present a review of EBOV infection in an effort to further educate medical and political communities on what the Ebolavirus disease entails, and what efforts are recommended to treat, isolate, and eventually eliminate it.
Keywords: Containment, Ebolavirus, Epidemic, Outbreak, Global response, Government response system, Global Health Security Agenda, Virus transmission
There have been multiple Ebola transmission events[1,2,3] and more than 20 Ebola outbreaks since the 1970s.[4,5] In August 2014, the largest, most sustained, and widespread Ebola outbreak in history was declared a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO).[6,7] The WHO was initially notified of the outbreak in March 2014, after a febrile illness cluster associated with a high case fatality rate in the area of Gueckedou, Guinea, attracted international attention, and was subsequently identified as the viral zoonosis Ebola (EBOV), formerly known as Zaire Ebolavirus (ZEBV).[7,9,10,11] This deadly member of the family Filoviridae, an enveloped, negative single-stranded RNA virus, is the most virulent of the five family members. The other members of the Ebolavirus family are Sudan (SUDV), Tai Forest (TAFV), Bundibugyo (BDBV), and Reston (RESV) sub-types.[13,14] The sequencing data showed that the 2014 outbreak in West Africa was due to infections with a strain of ZEBV, which differed from the viral strains identified in the earlier outbreaks.[15,16] For the sake of clarity and uniformity, we will refer to Ebolavirus as EBOV throughout the remainder of this manuscript, unless the mention of specific viral subtype is mandated.
Regarding the current EBOV outbreak, it is hypothesized that the index case most likely originated via animal — human contact (e.g., ingestion of undercooked ‘bush meat’, animal bite, or inadvertent contact with body fluids or blood from an animal). Following the index transmission event, the predominant mode of the subsequent viral transmission is human-to-human. This is consistent with the previous observations and characteristics of human-to-human transmission. Late in the spring of 2014, the number of reported cases declined, causing medical investigators to believe that the course of this outbreak followed the trajectory of previous outbreaks and that the outbreak's ‘burnout’ phase had begun. However, within a period of a few months, sporadic cases were being diagnosed beyond Guinea, including Liberia, Sierra Leone, Senegal, Mali, Nigeria, and most recently in the United States and Spain.[9,20,21,22,23,24] Some of the reported cases were clearly associated with transmission following a history of travel to the affected regions of Africa.[9,20,21,23] In West Africa, the number of new EBOV cases was increasing at an accelerating rate, with a number of factors contributing to this phenomenon, including poorly functioning healthcare, under-developed water and waste management systems; a degree of international complacency; population movement within the affected geographic areas (including rural-to-urban migrations);[27,28] increasing urban population density; local cultural factors (e.g., burial customs); widespread poverty; and a lack of responsiveness from the local and national governments.[6,31,32] To make things worse, there was a shortage of physicians in West Africa. For example, before the outbreak, fewer than a 100 physicians were providing healthcare for 4.3 million people in Liberia. The fact that numerous healthcare workers were themselves becoming infected with Ebola (including over a 100 healthcare workers who died as of late August 2014) further complicated the already critical situation.[35,36] At the time of this manuscript's initial submission (November 14, 2014) the Ebola outbreak has been contained in Nigeria and Senegal, and there have been no further reported cases in the United States or Spain.[37,38] However, a new outbreak in Mali has just been announced.[39,40]
It has been noted that the global response to the current epidemic was initially slow, disorganized, financially constrained, and poorly planned and executed.[6,41] As it confronts the possibility of as many as 10,000 new cases per week, the international medical community must realize that the confluence of circumstances and factors beyond human control may not always be in the society's favor, as it may have been within the last decade, with Influenza H1N1, Influenza H5N1, Hantavirus, or the Severe Acute Respiratory Syndrome (SARS).[43,44] In the face of easy movement across relatively porous borders (intercontinental travel) in an age of super highways, fast rail, and air travel, all ‘corners’ of the planet have become reachable in a matter of hours, making cities such as Lagos, New York, Tokyo or New Delhi, with populations exceeding 12 million, easily vulnerable.[45,46,47,48] In fact, a recently ‘imported’ case of Ebola in New York City should serve as a wakeup call and a global stimulus for both local and global coordinated action.
Until late August, most of the scientific journals and media reports advocated that the risk of Ebola is very low in the United States. Although it remains so, a recent diagnosis of a patient in Dallas, Texas, with Ebolavirus disease (EVD), who had traveled from Liberia and ultimately died despite intensive efforts, has made Western countries wary.[51,52] It is important to note that initial care in the first documented US case of Ebola may have been delayed due to poor recognition of the patient's disease symptoms. The diagnosis of two healthcare workers from the same hospital and the possible threat of spread of infection to people who had been in close contact with these subsequent cases has threatened a chain of transmission events.[54,55,56] This chain included a number of potentially exposed individuals on a commercial airline flight from Ohio to Texas on which an individual possibly experiencing early symptoms of Ebola may have traveled.[54,55,56]
The initial documented episodes of filovirus hemorrhagic fever were seen in the late1960s, in nonhuman primates, which were being transported to Germany for vaccine development.[57,58] At that time, workers of the vaccine industry who handled non-human primates were also affected. In 1976, reappearance of hemorrhagic fever outbreaks were noted to affect people in south Sudan and Zaire, which were caused by a distinct species of the Filoviridae family.[60,61] The Ebolavirus is named after the Ebola river, a tributary of the Congo River and an area where the first documented modern case of infection was identified, in 1976. Of interest, some researchers have suggested that EBOV outbreaks may be related to certain confluences of environmental and climatic conditions. The frequency of the recognizable outbreaks has been on the rise since 1990, involving many locations in sub-Saharan Africa.[64,65] The 2014 event has been the largest documented outbreak of Ebola thus far. Nearly 14,100 cases have been reported worldwide, killing almost 5,200 people — an overall mortality of 37% [Table 1]. The outbreak has been most intense in Guinea, Liberia and Sierra Leone, which together account for over 99% of all cases and nearly all the recorded deaths.
The 2014 outbreak: Report of Ebola cases by country (data as of November 12, 2014)
Fruit bats are considered to be the primary reservoirs of filoviruses [Figure 1] and are thought to contribute to the viral transmission, to both non-human primates and humans. According to the Centers for Disease Control (CDC), the modes of Ebola transmission include the following — contact with blood or body fluids of a person who is sick with or has died from Ebola, coming in contact with contaminated objects like needles and touching infected animals, their blood or other body fluids, or bush meat. Reproduction rate (R0) of EBOV is low (1 to 4). Ebolavirus rarely spreads through the respiratory route. Of interest, persistence of the Ebola viral RNA in convalescing individuals has been reported, likely due to replicating intracellular nucleocapsids.
Diagram demonstrating the pathogenesis of Ebolavirus infection. Phase I can be characterized as the transfer of EBOV from an animal carrying the virus to a human, usually via small cutaneous lesions. Similar principles apply in human-to-human transmission...
The pathophysiology of Ebola is not yet fully understood, however, most studies report that the incubation period varies depending on the type of exposure (i.e., six days for percutaneous and ten days for contact exposure).[71,72] The WHO Ebola response team's findings have documented that the mean incubation period was 11.4 days, which did not vary by country. Following viral transmission, symptoms usually appear in approximately eight to ten days (range, 2-21 days).
After EBOV enters the human body, macrophages and dendritic cells are generally considered as the first cells to be infected [Figure 1]. The virus then proliferates rapidly within these cells, releasing multiple new copies into the extracellular fluid.[74,75] Spread of the virus into the regional lymph nodes amplifies the viral load in the body, causing further viral dissemination to the lymphoid and vascular tissues. Subsequently, a systemic inflammatory response is initiated, resulting in cytokine and chemokine release from the infected macrophages and other cells. This constellation of innate host responses is considered to be responsible for the prodromal symptoms.[74,75]
The coagulation defects are attributable to the synthesis of the cell surface tissue factor from viral infected macrophages. The ensuing hepatic injury also leads to decreased synthesis of coagulation factors from the liver. The appearance of hemorrhagic symptoms is associated with a worse prognosis, as outlined in the subsequent paragraphs.
CLINICAL FEATURES AND DIAGNOSTIC TESTING
The clinical presentation of Ebola patients progresses from non-specific ‘flu-like’ symptoms to multiorgan failure. The mean time from the onset of symptoms to hospitalization is approximately five days. After admission, the mean length of stay in the hospital, the mean time to death, and the mean time to discharge are 6.4 days, 4.2 days, and 11.8 days, respectively. With regard to the symptoms, the fevers may be mild during the initial phase of illness, but may evolve to become more abrupt and high-grade, with associated chills and rigors. Non-specific prodromal symptoms are almost always present comprising mainly of malaise, weakness, anorexia, severe headache, and pain in the truncal and lower back muscles. High fever with relative bradycardia mimicking the presentation of typhoid fever has also been reported.[79,80] Progressive, diffuse, erythematous, nonpruritic, maculopapular rash around the face, neck, trunk, and arms usually appears by the end of the first week.
As the disease progresses, gastrointestinal symptoms such as diarrhea, nausea, vomiting, and abdominal pain begin to develop. Although bleeding is not seen in the early phase, there may be a gradual appearance of petechiae, ecchymoses, prolonged bleeding from the venipuncture sites, and mucosal hemorrhage, as the disease progresses. Patients who recover from Ebola infection have been reported to show clinical improvement by the middle of the second week. As outlined in Figure 2a-d, the clinical outcomes may depend on the appearance and the subsequent management of the symptoms and signs associated with increased mortality (i.e., impending septic shock, hemorrhagic manifestations, and multiorgan failure).
Neurological symptoms, including confusion, loss of consciousness or coma were more frequently seen in patients who died. Values shown on the y-axis represent percentages. Source: WHO Ebola Response Team. Ebolavirus disease in West Africa — The...
A number of miscellaneous symptoms — including difficulty breathing, chest pain, cough, and sore throat — were more frequently seen among non-survivors. Source: WHO Ebola Response Team. Ebola virus disease in West Africa — The...
Hematological symptoms, including injection site bleeding, vaginal bleeding, hematuria, epistaxis, and bleeding from the gums were more frequently seen in patients who died. Values shown on the y-axis represent percentages. Source: WHO Ebola Response...
On the basis of the observed patient outcomes, the WHO Ebola Outbreak Team has compared the signs and symptoms that were more likely to be present in patients who died. Neurological symptoms (i.e., confusion, coma, unconsciousness); hematological symptoms (i.e., bleeding gums, bloody nose, bleeding from venipuncture sites, vaginal bleeding); and other selected symptoms (i.e., chest pain, cough, difficulty breathing, and sore throat), were associated with greater observed mortality. Except for difficulty in swallowing, the presence of gastrointestinal symptoms (i.e., diarrhea, abdominal pain, loss of appetite) did not appear to be associated with increased mortality [Figure 2c]. A detailed summary of the clinical symptoms and signs in survivors and non-survivors is provided in Figure 2a-d. Of note, Towner et al. demonstrated that patients who died were found to have higher viral loads.
Gastrointestinal signs/symptoms of Ebola. Except for difficulty swallowing, gastrointestinal symptoms (i.e., loss of appetite, abdominal pain, and diarrhea) were seen at approximately similar rates in survivors and non-survivors of Ebola. Values shown...
Various derangements in the hematological profile characterized by leukopenia, thrombocytopenia, elevated transaminases, proteinuria, and elevated prothrombin, and thromboplastin times can be seen, and are associated with worse prognosis. The confirmatory diagnosis for Ebola involves detection of the viral antigens or RNA in the blood or other body fluids. Until recently, testing could only be performed in specialized laboratories, and relied on detection of the RNA sequence by reverse-transcription polymerase chain (RT-PCR) reaction or viral antigens by an enzyme-linked immunosorbent assay (ELISA) within three to ten days of onset of symptoms. However, newer rapid diagnostic methods are quickly evolving,[82,83] and are expected to be available for deployment in the near future.
In the past, mortality associated with Ebola infection was as high as 50-80%.[84,85,86] More recently, the mortality rate of Ebolavirus is reported to be between 20 and 60% [Table 1], due mainly to the prompt and more effective clinical management of infected patients. Most of the care that is being offered to infected patients is comprised of supportive measures such as hydration, nutritional support, and replacement of electrolytes.[87,88] As of now, there is no specific immunization or treatment for the Ebolavirus disease that has been validated in humans,[89,90] although survivors may exhibit immunity. Of interest, both nurses who became infected while caring for the Dallas, Texas patient, were declared free of the virus.[92,93] Passive immunity associated with plasma transfusion from an Ebola survivor, Dr Kent Brantley, may have played a role in one of those cases and has some support in the historical experiences from a 1995 Ebola outbreak in Kikwit, Democratic Republic of Congo.
Other than the above-mentioned supportive therapy, there is no proven treatment for Ebola. Some have suggested that anti-retroviral agents may have some effectiveness against EBOV, but at this time these claims remain both unproven and controversial. As mentioned previously, passive immunity may be helpful in attenuating the severity of the disease, as suggested by the relatively quick recovery of one of the Dallas, Texas nurses following plasma transfusion from an Ebola survivor. An experimental drug called ZMapp (Mapp Biopharmaceutical, San Diego, California, USA), is also based on the concept of passive immunotherapy, and combines three humanized monoclonal anti-EBOV antibodies that are synthesized in Nicotiana benthamiana plants. Administration of ZMapp in rhesus macaque primates who were inoculated with virulent Ebola strains may have attenuated the disease severity. The drug has also shown some promise after it was administered, with permission from the US Food and Drug Administration (FDA), to several infected individuals; however, its scarcity and lack of substantiating data make it challenging for the agent to reach those most in need. Another drug, TKM-Ebola (Tekmira Pharmaceuticals, British Columbia, Canada), has also been approved for selective use by the FDA, along with ZMapp. Finally, Brincidofovir (Chimerix, Durham, North Carolina), a broad-spectrum antiviral drug, has been shown to have in vitro activity against Ebola, and has reportedly been administered to patients with EVD in the United States.
There are currently two notable Ebola vaccine efforts. The first is cAd3-ZEBOV developed by GlaxoSmithKline and tested by the US National Institute of Allergy and Infectious Diseases (NIAID).[102,103] The second is the rVSV tested by the New Link Genetics Corporation after being licensed from the Public Health Agency of Canada.[103,104] Both vaccines demonstrated promising rates of efficacy in nonhuman primates, but the translation of these results to human subjects has not yet been accomplished.
PERSONAL PROTECTIVE EQUIPMENT FOR HEALTH WORKERS
With regard to healthcare worker protection and prevention of healthcare-related transmission of Ebola, many opportunities for improvement have been identified, based on the previous outbreaks.[84,105,106,107] It is critical that the medical community learns from the previous mistakes so that emphasis in the fight against Ebola can shift toward preparing healthcare systems and organizations, establishing better disease surveillance systems, and restoring the trust in health services across affected communities.[108,109]
Patients infected with EBOV, who seek emergency care, expose ‘front-line’ healthcare workers to significant risk of contracting the infection.[36,110,111] Considering the highly contagious nature of the body fluids from individuals with symptomatic infection, dealing with Ebola mandates that healthcare workers follow standard safety precautions rigorously in order to safeguard themselves and the people with whom they interact. The critical nature of the personal protective equipment (PPE) in cases of Ebola and the risk of transmission despite taking apparently adequate precautions is exemplified by the two cases of patient-to-nurse viral transmission in Dallas, Texas, one case in Spain, and the recently diagnosed case in New York City. It is important to note that special circumstances requiring heightened vigilance regarding personal protection equipment may arise when caring for patients with Ebola, including the performance of emergency surgery in this population.
An example of the personal protective equipment used by healthcare workers when caring for patients with Ebola is shown in Figure 3. Detailed illustrated guidelines have been provided by the WHO regarding the use of protective equipment and handling of potentially infectious Ebola samples. Any biological specimens or samples obtained from EBOV patients should be collected using adequate personal protective equipment, using closed vacuum containers. The samples should be transported in leak-proof containers and kept separately from other patient samples. For blood work of patients suspected with EBOV, under no circumstances should manual pipetting and open centrifugation be considered. After the laboratory tests are concluded, disinfectants with a higher potency (preferably, 10% chlorine solution) to kill the virus should be used. Elimination of all infectious materials should be conducted according to the prevailing/approved local protocols, rules, and regulations.[116,117] It is important to note that the actual approach to biohazardous waste disposal has to take into consideration specific economic-based realities and circumstances across different geographic areas. Pertaining to this, it is critical that adequate training of the medical transportation personnel is conducted, to ensure safe and transmission-free transit of the infected patients and/or infectious materials.
A pictorial representation of the protective equipment used by healthcare personnel in the setting of direct contact with actively symptomatic individuals, their blood, or body fluids. Ebolavirus can be contracted by such contact and is capable of infecting...
More recently, potential technological solutions designed to reduce human exposure to EBOV were introduced. Among those, the most prominent one was the idea of a robotic device that could help assist in the care of Ebola patients by delivering supplies, disinfecting, and transporting hazardous specimens, among other functionalities.[119,120] Another important consideration is the possibility of creating volunteer teams of Ebola survivors, who could help in the direct care of the exposed and acutely ill cases so that the overall risk of viral exposure and acute illness would be minimized for other ‘front-line’ healthcare workers.[121,122,123]
SCREENING AND ACTIVE SURVEILLANCE
There is an ongoing debate about the screening of individuals from Ebola-affected countries, who are traveling abroad,[124,125,126,127] with some experts questioning the usefulness of routine traveler screening. Although there are no available statistics to support the effectiveness of screening methods used in the current Ebola epidemic, data from the SARS epidemic airport screening in Canada demonstrated that of the 677,494 who completed the screening questionnaire, 2,478 answered with a ‘yes’ to one or more questions, and among those, none went on to develop SARS. Six major airports installed thermal scanners and screened 467,870 people, of whom 95 suspected ‘positives’ were further assessed. None of them went on to develop SARS. The total cost of the program was 17 million Canadian dollars.[125,130]
From the Ebola case in Texas, it has been recognized that a delay in diagnosis was sufficient enough to create a ‘near-panic’ situation. Employing adequate screening protocols and ensuring that the ‘front-line’ personnel are familiar with pertinent policies is of special importance. In order to contain the spread of Ebola, it is of paramount importance to ensure that the medical staff in the Emergency Departments is prepared, that appropriate screening and isolation policies are in place, and that vigilance and clinical suspicion are sufficient enough to readily identify individuals who have recently traveled to EBOV-affected areas or who may have been in contact with an actively symptomatic Ebola patient, keeping in mind the pertinent incubation periods and other key information about the characteristics of the virus. Despite the significant resources needed to institute such efforts, the societal benefits of limiting or arresting the spread of Ebola outbreak(s) will far outweigh the costs of such concerted initiatives.[36,132]
Active surveillance is a public health approach that consists of the ongoing, systematic collection, analysis, and interpretation of key clinical data, closely integrated with a prompt dissemination of such data to officials responsible for control and prevention of disease. In case of Ebola, active surveillance consists of close supervision by health officials, with systematic collection of vital signs, and monitoring of key clinical symptoms associated with the early course of clinical infection. The use of active surveillance is critical for containing the outbreaks of Ebola, especially in the densely populated urban settings where human-to-human transmission predominates. It has been recommended that the coordinated response to Ebola outbreaks should include sufficiently funded national and regional interdisciplinary surveillance response systems that incorporate early warning capabilities.
QUARANTINE AND ISOLATION
By definition, quarantine is a procedure wherein a healthy person exposed to a communicable disease undergoes a period of close observation in order to prevent disease transmission during the incubation period, and isolation is the restriction of an infected person during their time of communicability.[137,138] The use of quarantine is highly controversial and is usually viewed as an unjust measure, always invoking the consideration of fairness and distributive justice. Herein lies the clash between personal liberty and the public's health. The use of quarantine and isolation of the infectious individual was a basic pillar of public health in seaports in centuries past. However, its use as an effective tool since the latter part of the twentieth century has come into question. There is probably less resistance by professionals and politicians in this Ebola epidemic to the isolation of infected patients, as compared to the use of quarantine for healthy exposed individuals, although it must be acknowledged that isolation itself can be an emotionally traumatic experience. In a modern, free society, the use of quarantine and isolation is likely to face legal challenges by the affected individuals.[143,144]
There have been calls from many professionals to ‘honor’ workers returning from the Ebola front in West Africa, while at the same time they criticize the intervention of public officials/politicians to pursue the quarantine of those same workers. What is ironic is that during the SARS outbreak in 2003, the decision was made by scientific experts that quarantine should be put into place because no one knew, at least initially, how the disease was effectively spread and how quickly it could spread across the globe. After the SARS outbreak, there was great concern about how and why quarantine measures were put into place, with Bensimon et al. stating that, “It is, therefore, incumbent on us to recognize and legitimize a broader notion of effectiveness (of quarantine) — one that transcends the dominant conception that it derives from a set of proven and verifiable data to one that gives a voice to nonscientific, nontechnical perspectives, experiences, preferences, and cultural commitments. Such efforts are essential and not accidental”.
However, in the current Ebola outbreak, as opposed to the SARS event, with regard to the United States, the public health authorities/scientific experts, who know much more about the modes of transmission, effectiveness of counter measures, and the number of individuals one person could infect (1 to 4), and so on, did not make the call to ‘quarantine’ the exposed, but healthy, individuals.[147,148] In this case it was the political leaders who ordered/recommended the quarantine (New York and New Jersey) instead of the scientific establishment. The governors were the non-technical voices that many citizens felt needed to be heard. There is a basis to state that the fear of Ebola in 2014 seems to be greater than that of SARS in 2003. However, there is evidence from quarantines carried out for the SARS epidemic that quarantine is the most effective, ‘when it is voluntary, home-based, and accompanied by extensive outreach, communication, and education efforts’. This outbreak is not the first, nor will it be the last, to pit individual civil liberties against the utilitarianism of the general public's health. To add further perspective to the above argument, it appears thus far that Nigeria was able to contain the outbreak by utilizing an immediate and aggressive response to the very first report of Ebola on its soil, while Guinea and Sierra Leone have experienced a resurgence of cases amid claims of complacency. Faced with the most recent outbreak in Mali, government officials are responding with quarantine orders for dozens of potentially exposed individuals.
ETHICAL AND CULTURAL ISSUES
There have been a lot of controversies related to Ebola in the context of cultural and religious influences.[84,153,154] As much as it is important for containing the infection, the fact that a patient's life has come to an end needs to be dealt with equal empathy. Preparing for a funeral in a respectful yet safe way can be done following a few guidelines. First, it is acceptable to bury patients who died from Ebola without washing the bodies. Second, it is acceptable to offer prayers for people who have died from Ebola and bury them while avoiding direct contact with the body and limiting the burial attendance to family and close friends. Third, religious leaders should be intimately involved in the process of containing the outbreak and should work with the local authorities and the community so that appropriate and safe actions are taken with regard to disposition of the bodies.[153,155] Finally, governments need to do more to clamp down on the illegal practices of bribing health facility workers in order to recover highly infectious bodies of relatives so that a private burial (as opposed to a cremation or burial in designated public sites) can take place.
COLLABORATIVE GLOBAL EFFORTS: STEPS FOR THE FUTURE
As Ebola has managed to spread outside of West Africa, it is imperative to diligently contain the infection in all affected localities.[27,157] During earlier Ebola outbreaks, a combination of core interventions has been effective in containing the disease — exhaustive case and contact tracing, preventive interventions, and an effective and timely response to patients and the community.[27,157,158,159] However, given the massive scale of the current EBOV outbreak, new and more effective approaches are required. On account of the magnitude of the current events, it will be very difficult to effectively and simultaneous implement all of the above-mentioned measures in very under-resourced medical systems. This is further exacerbated by the delayed and underfunded early international response and increased mobility of patients and/or their contacts, who can readily reach large population centers through improved highways, rail systems, and air travel. Finally, there is a relative lack of trust by local populations toward the authorities, which is further exacerbated by the incompatibility between local social customs, the biology of the virus, and the rules of outbreak containment.[84,153,154] The traditional outbreak approaches used during earlier, smaller Ebola outbreaks will probably not work and will require massive International supplementation. The global community will need to augment local roads, hospitals, supply medical and support personnel, pharmaceuticals, and accelerate vaccine efforts.[32,36,103,161,162,163,164] This needs to be accompanied by a social/media thrust to explain this disease to the affected inhabitants and to ‘win their hearts and minds.’ In other words, while significant scientific and medical initiatives are needed to stop the outbreak, these efforts will likely be less effective without population-based education and trust-building efforts. Finally, population-based prevention and treatment strategies are desperately needed, involving (among other things) the development of new pharmaceutical agents and vaccines, better diagnostic point-of-care tools that are both rapid and inexpensive, the encouragement of out-of-the-box thinking with regard to enhanced surveillance methods, as well as the concept of readily deployable international rapid medical response teams.[103,157,165] It is incumbent on the international medical community to not only establish a rapid and effective global response capability to large-scale epidemics and natural disasters, but also to realize the necessity and acceptance of the concept of Global Responsibility and Security for all nations that cannot fend off calamities on their own.[162,166]
Failure to act in a timely and coordinated fashion as a global community has brought us to a position where we simply must act together or face the full wrath of an out-of-control Ebola outbreak. Although strategic actions needed for the management of an epidemic remain the same for any disease, there are a few essential issues in the context of the Global Health Security Agenda [Table 2] that need to be addressed in order to effectively combat Ebola. Although the likelihood of Ebola becoming an epidemic in high-income countries is very low, there are many reasons for supporting the ongoing efforts in countries of West Africa, the most prominent among which are the duty to provide humanitarian assistance to the people affected, the obligation of global justice and fairness, and the ethical code of conduct inherent to the above. Equally important is the need to minimize Ebola's spread to other potentially vulnerable geographic areas including the densely populated regions in other parts of Africa, East Asia, and the Central and South Americas.[169,170] Some have suggested, for example, that an Ebola outbreak in Central America and Asia may be as difficult to manage as the current outbreak in West Africa,[169,170] with some government officials openly concerned about lack of resources to effectively deal with Ebola. In fact, some countries in Central America are already reacting to the possibility of Ebola importation, by imposing travel bans and restrictions.
Key elements of the global health security agenda
EBOLA: ECONOMICS OF THE OUTBREAK
The Human Development Index ranked Liberia, Guinea, and Sierra Leone one hundred and seventy-fifth, one hundred and seventy-ninth, and one hundred and eighty-third, from a total of 187 countries, in 2014. Even as Guinea is exceptionally and chronically underdeveloped, Liberia and Sierra Leone have had recent civil wars. Over 20% of the populace lives in poverty and these countries are woefully understaffed in regard to medical personnel. In recent times, a World Bank Report indicated that if Ebola spreads to nearby countries, the global cost of this epidemic may reach $32 billion over the next two years. With a forecast of 550,000-1,400,000 cases by early next year these countries will suffer immeasurably. The outbreak may cost Sierra Leone as much as $163 million (3.3% of its Gross National Product, or GDP), with a loss of up to 8.9% of GDP, in 2015. Liberia may expend as much as $234 million (12% of GDP), and Guinea will spend approximately $142 million (2.3% of GDP) as a result of this outbreak.
Agriculture, which constitutes a significant portion of the regional economy, will be most specifically affected, reducing not only farm productivity, but also threatening local food security. Sierra Leone reported that its economy has deflated by approximately 30% because of Ebola. Additionally, a significant proportion of the GDP of Guinea, Liberia, and Sierra Leone is attributable to mining operations and services, all of which will experience a negative impact from the Ebola epidemic. The World Bank report leaves the reader with a serious warning-if 800 SARS deaths between 2002 and 2004 cost an estimated $40 billion, what will happen, not only to the West African, but also to the World's economy, if the total cases exceed the predicted 1,400,000 mark in 2015, or the outbreak spreads to other geographic regions?[157,158,159] Contrast the possible aftershocks to the estimated $1 billion needed right now to contain the current outbreak of Ebola.
Despite our growing knowledge of Ebola and outbreak dynamics, many unanswered questions and controversies remain. For example, it is not known what the optimal decontamination procedures should be. Likewise, there is lack of agreement on what constitutes the best personal protective equipment when treating patients suffering from Ebola infection. Furthermore, we do not yet have a complete picture of the virus’ ability to survive extracorporeally under a variety of physical conditions.[178,179] Better understanding is needed of why there is a variable host response to the infection, with some patients experiencing a more severe clinical course than others. Finally, should patients with Ebola be treated at local hospitals or should they be transferred to highly specialized referral centers that are better equipped to handle the logistics and complexities of the care involved?[180,181,182]
Successfully combating the current outbreak of Ebola involves coordinated global action. Aggressive investment for early containment efforts is the wisest and the least expensive of all approaches and the global community should come together at this time of crisis to implement a uniform, well-coordinated strategy to prevent catastrophic human and economic losses that may result from inaction. One of the reasons the current outbreak has been more difficult to contain than the earlier Ebola outbreaks is the spread of the disease to areas of high population density, as opposed to the previously seen rural area incidents, where isolation is easier. This may also be a harbinger of what may happen if the virus were to spread to other developing countries with large cities, where millions of low-income residents live in very densely populated areas (i.e., Bangkok in Thailand, Cairo in Egypt, Dhaka in Bangladesh, Lagos in Nigeria, or Mumbai in India). As part of the global health security strategy, the key preventive interventions must include meticulous infection control in healthcare settings, creating awareness and community support for implementation of containment measures, rigorous enforcement of the existing public health protocols, and ample resources to investigate and document any new chain of transmission. Although isolation of suspected cases is likely to be ineffective or impossible under many circumstances, voluntary quarantine and active surveillance can prove helpful. Given all of the above considerations, the time is now for humanity to act as one unified front, against Ebola.
Source of Support: Nil.
Conflict of Interest: None declared.
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