By Lexi Elo
One year after the first Ebola cases started to surface in Guinea, a “mysterious” disease began silently
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spreading in a small village in Guinea on 26 December 2013 but was not identified as Ebola until 21 March 2014. The index case in West Africa’s Ebola epidemic was an 18-month-old boy who lived in [pro_ad_display_adzone id=”10″]
Meliandou, Guinea. He developed an illness characterised by fever, black stools, and vomiting on 26 [pro_ad_display_adzone id=”10″]
December 2013 and died two days later.
As weeks went by, (precisely January 2014), several members of the boy’s immediate family had [pro_ad_display_adzone id=”10″]
developed a similar illness followed by rapid death. In the weeks that followed, members of the boy’s extended family, who attended funerals or took care of sick relatives, also took I’ll and died. By then, the virus had spread to four sub-districts via additional transmission chains.
A pattern of unprotected exposure, more cases and deaths, more funerals, and further spread had been established. As the month progressed, cases spread to the prefectures of Macenta, Baladou, Nzerekore, and Farako as well as to several villages and cities along the routes to these destinations.
While the country’s Ministry of Health issued its first alert to the unidentified disease on 13 March 2014, the Institute Pasteur in Lyon, France, a WHO Collaborating Centre on March 21, confirmed that the causative agent was a filovirus, narrowing the diagnosis down to either Ebola virus disease or Marburg haemorrhagic fever. When WHO publicly announced the outbreak on its website on 23 March, 49 cases and 29 deaths were officially reported.
Factors fueling undetected spread
In Guinea, it took nearly three months for health officials and their international partners to identify the Ebola virus as the causative agent. By that time, the virus was firmly entrenched and its spread was primed to explode. By 23 March 2014, a few scattered cases had already been imported from Guinea into Liberia and Sierra Leone, but these cases were not detected, investigated, or formally reported to WHO.
The outbreaks in these two countries likewise smouldered for weeks, eventually becoming visible as chains of transmission multiplied, spilled into capital cities, and became so numerous they could no longer be traced.
According to a latest WHO report titled “Ebola in West Africa: 12 months on”, West African countries, which had never experienced an Ebola outbreak, were poorly prepared for this unfamiliar and unexpected disease at every level, from early detection of the first cases to orchestrating an appropriate response. Clinicians had never managed cases and no laboratory had ever diagnosed a patient specimen.
While no government had ever witnessed the social and economic upheaval that can accompany an outbreak of this disease, populations could not understand what hit them or why. The West African outbreaks demonstrated how swiftly the virus could move once it reached urban settings and densely populated slums.
The primary aim of rapid patient isolation was to interrupt chains of transmission. With so many people infected, the primary aim must also include aggressive supportive care, especially rehydration and correction of electrolyte imbalances, which improves the chances of survival.
Guinea, Liberia, and Sierra Leone, had recently emerged from years of civil war and unrest that left basic health infrastructures severely damaged or destroyed and created a cohort of young adults with little or no education. Road systems, transportation services, and telecommunications are weak in all three countries, especially in rural settings. These weaknesses greatly delayed the transportation of patients to treatment centres and of samples to laboratories, the communication of alerts, reports, and calls for help, and public information campaigns.
Recent studies estimate that population mobility in these countries is seven times higher than elsewhere. To a large extent, poverty drives this mobility as people travel daily looking for work or food. Many extended West African families have relatives living in different countries.
Population mobility created two significant impediments to control. First, as noted early on, cross-border contact tracing is difficult. Populations readily cross porous borders but outbreak responders do not. As the situation in one country began to improve, it attracted patients from neighbouring countries seeking unoccupied treatment beds, thus reigniting transmission chains.
Prior to the outbreaks, the three countries had a ratio of only one to two doctors per nearly 100,000 population. That meagre workforce has now been further diminished by the unprecedented number of health care workers infected during the outbreaks. Nearly 700 were infected by year end and more than half of them had died.
Though the number of infected health care workers was highest at the start of the outbreaks, infections in doctors and nurses began to spike again in the last quarter of the year. The reasons for this spike are currently being investigated.
Infections in at least some health care workers, who rigorously followed safe procedures while caring for Ebola patients in a hospital or clinic, are known to have acquired their infection in the community. As of mid-December, MSF had more than 3,400 staff working in the affected countries. Of these staff, 27 became infected with Ebola and 13 of them died. Investigations by MSF found that the vast majority of these infections occurred in the community, and not in its treatment facilities, which have an outstanding reputation for safety.
The Nigerian story
The importation of Ebola into Lagos, Nigeria on July 20, 2014, marked the first time the virus entered a new country via air travellers. These events theoretically placed every city with an international airport at risk of an imported case.
The imported case, which provoked intense media coverage and public anxiety, brought home the reality that all countries are at some degree of risk as long as intense virus transmission is occurring anywhere in the world – especially given the radically increased interdependence and interconnectedness that characterize this century.
In both cities (Port Harcourt and Lagos), all the ingredients for an explosion of new cases were in place. That explosion never happened, thanks to Nigeria’s strong leadership and effective coordination of an immediate and aggressive response.
As in Senegal, an emergency operations centre was established, supported by the WHO country office. Also like Senegal, Nigeria had a first-rate virology laboratory, affiliated with the Lagos University Teaching Hospital that was staffed and equipped to promptly diagnose a case of Ebola virus disease.
The government generously allocated funds and dispersed them quickly. Isolation facilities were built in both cities, as were designated Ebola treatment facilities. House-to-house information campaigns and messages on local radio stations, in local dialects, were used to ease public fears. Infrastructures and cutting-edge technologies in place for polio eradication, were repurposed to support the Ebola response, putting GPS systems to work for real-time contact tracing and daily mapping of transmission chains. Contact tracing reached 100% in Lagos and 99.8% in Port Harcourt.
In what WHO described as a “spectacular success story”, Nigeria held the number of cases to 19, with 7 deaths. World-class epidemiological detective work eventually linked all cases back to either direct or indirect contact with air traveller from Liberia. WHO declared Liberia free of Ebola virus transmission on 20 October 2014.
Addressing EVD spread
The situation in West Africa has been far more challenging, with cases reported in all or most parts of the three countries, including their capital cities. The demands of addressing this broad geographical dispersion of cases outstripped international response capacity at nearly every level, ranging from worldwide supplies of personal protective equipment to the number of foreign medical teams able to staff newly built treatment centres.
During 2014, the outbreaks in West Africa behaved like a fire in a peat bog that flares up on the surface and is stamped out, but continues to smoulder underground, flaring up again in the same place or somewhere else. Unlike other humanitarian crises, like an earthquake or a flood, which are static, the Ebola virus was constantly – and often invisibly – on the move.
The Ebola outbreak demonstrated the lack of international capacity to respond to a severe, sustained, and geographically dispersed public health crisis. Governments and their partners, including WHO, were overwhelmed by unprecedented demands driven by culture and geography as well as logistical challenges. Together, these and other factors, including the behaviour of the virus, created a volatile situation that evaded conventional control measures and constantly delivered surprises.
Faced with so much suffering and so many unmet needs, many partners in the outbreak response courageously took on responsibilities that went beyond their traditional areas of work and expertise. Some, including MSF, the US CDC, the International Federation of Red Cross and Red Crescent Societies (IFRC), the World Food Programme, and UNICEF built upon their well-established roles during health and humanitarian crises to expand their areas of engagement.
MSF, which provided the bulk of clinical care since the beginning of the outbreaks, used its treatment centres to collaborate in clinical trials of experimental therapies and also provided funding. The World Food Programme extended its unparalleled logistical capacities to support response operations that went well beyond the delivery of food.
Hundreds of CDC staff, including epidemiologists with extensive experience in outbreak containment, were deployed to support surveillance, contact tracing, data management, laboratory testing, and health education. UNICEF worked to promote child health and safe childbirth in addition to taking the lead on social mobilization.
Manufacturers of essential supplies, like personal protective equipment, were also stretched to the limits of their production capacity, while WHO was left to ensure that donated supplies from existing stockpiles were of the right quality to protect staff during an outbreak caused by an especially contagious and lethal virus. Unfortunately, when the outbreak started, no gear specifically designed to protect against Ebola virus infection existed, and this problem raised some uncertainties throughout the year.
Despite all this support from multiple sources, capacity was insufficient for most of the year or not available where it was needed most. The problem of insufficient capacity was greatest for foreign medical teams needed to run treatment centres. Many WHO staff sent to the field to serve as coordinators ended up donning protective gear and treating patients as well. With response teams overwhelmed and resources stretched so thin, these laudable efforts to fill in the gaps raised some important questions.
The importance of preparedness
The successful experiences in Senegal, Nigeria, and Mali demonstrated the importance of preparedness and having the capacities in place to mount a rapid and comprehensive emergency response. Given the devastation caused by Ebola virus disease in Guinea, Liberia, and Sierra Leone, countries worldwide are on high alert for imported cases and many have elaborate preparedness plans in place.
Experiences in the United States of America (USA) and Spain showed that conventional control measures, including isolation and exhaustive tracing and monitoring of contacts, can halt further spread quickly following locally-acquired infections.
Throughout the year, small teams at WHO headquarters systematically gathered intelligence, using a dedicated internet search engine, about possible Ebola cases in non-affected countries. Staff in WHO country offices and partners, including nongovernmental agencies, working in the field provided another source of alerts to possible cases.
The system has a translation facility that lets it pick up rumours and hints suggesting an Ebola case in any language. Staff in WHO country offices and partners, including nongovernmental agencies, working in the field provided another source of alerts to possible cases.
From mid-October to year end, the system picked up more than 183,000 alert signals. These were rapidly screened by epidemiologists, who selected a subset for further examination, risk assessment, or investigation and verification. More than 150 signals required further investigation, with the peak seen in August. Based on the number of rumours tracked, worldwide vigilance for imported cases was judged high.
While any country with an international airport was theoretically at risk of an imported case, the need for preparedness was considered greatest in countries with weak public health infrastructures and little or no diagnostic capacity to detect cases early. When investigating possible cases, WHO paid especially close attention to rumours in countries that share borders or have extensive travel and trade relations with the three hardest-hit countries.
Training courses, workshops, and simulation exercises have been undertaken for groups of countries, while visits have been made to more than 70 countries in all regions to review capacities first-hand, develop action plans, and provide direct support. All regions have also developed their own Ebola task forces and have regional response plans in place. Emergency operation centres and rapid response teams are likewise in place.
Most experts warn countries to expect additional imported cases as 2015 progresses. Given the high level of worldwide vigilance, chances are good, especially in countries with well-developed health systems, that these cases will be detected early – before they have a chance to spark multiple new chains of transmission.
What needs to happen in 2015
As 2014 progressed, the world learned a great deal from the largest and longest Ebola outbreak in history, and these lessons have shaped a more strategic approach going forward. The epidemic in West Africa – the largest and longest in the nearly four-decade history of this disease – yielded greater clinical understanding of the pathology of Ebola virus disease and ways to improve survival rates jumped ahead. We have gained much greater understanding at the operational level: what specific packages of control interventions will have the greatest impact on getting transmission down?
Scientific research about the disease escalated dramatically, as has research and development to develop new medical products for prevention, treatment and possibly cure. The four biggest lessons from 2014: countries with weak health systems and few basic public health infrastructures in place cannot withstand sudden shocks, whether these come from a changing climate or a runaway virus. Under the weight of Ebola, health systems in Guinea, Liberia and Sierra Leone collapsed. People stopped receiving – or stopped seeking – health care for other disease, like malaria, that cause more deaths yearly than Ebola.
The severity of the disease, compounded by fear within and beyond the affected countries, caused schools, markets, businesses, airline and shipping routes, and borders to close. Tourism shut down, further deepening the blow to struggling economies. What began as a health crisis snowballed into a humanitarian, social, economic and security crisis. In a world of radically increased interdependence, the consequences were felt globally.
The evolution of the crisis underscored a point often made by WHO: fair and inclusive health systems are a bedrock of social stability, resilience and economic health. Failure to invest in these fundamental infrastructures leaves countries with no backbone to stand up under the weight of the shocks that this century is delivering with unprecedented frequency.
Preparedness, including a high level of vigilance for imported cases and a readiness to treat the first confirmed case as a national emergency, made a night-and-day difference. Countries like Nigeria, Senegal and Mali that had good surveillance and laboratory support in place and took swift action were able to defeat the virus before it gained a foothold.
Also, no single control intervention is, all by itself, sufficiently powerful to bring an Ebola epidemic of this size and complexity under control. All control measures must work together seamlessly and in unison. If one measure is weak, others will suffer. Aggressive contact tracing will not stop transmission if contacts are left in the community for several days while test results are awaited.
Good treatment may encourage more patients to seek medical care, but will not stop community-wide transmission in the absence of rapid case detection and safe burials. In turn, the powers of rapid case detection and rapid diagnostic confirmation are diminished in the absence of facilities for prompt isolation. As long as transmission occurs in the community, medical staff following strict protocols for infection prevention and control in clinics will be only partially protected.
Finally, community engagement is the one factor that underlies the success of all other control measures. It is the linchpin for successful control. Contact tracing, early reporting of symptoms, adherence to recommended protective measures, and safe burials are critically dependent on a cooperative community. Having sufficient facilities and staff in place is not enough. In several areas, communities continued to hide patients in homes and bury bodies secretly even when sufficient treatment beds and burial teams were available. Experience also showed that quarantines will be violated or dissolve into violence if affected communities are given no incentives to comply.
As 2015 began, a revised response that builds on accumulated experiences was mapped out by WHO. This new response plan adopts what has been shown to work but also sets out new strategies designed to seize all opportunities for getting the number of cases down to zero. Apart from low levels of community understanding and cooperation, contact tracing is considered the weakest of all control measures. Its poor performance likewise needs to be addressed with the greatest urgency.
As the year evolved, outbreak responders learned the importance of tailoring response strategies to match distinct needs at district and sub-district levels. An understanding of transmission dynamics at the local level usually reveals which control measures are working effectively and which ones need improvement. Doing so requires better district-level data and, above all, better coordination. The outbreaks will not be contained by a host of vertical programmes operating independently. Again, all control measures must work seamlessly and in unison.
At year end, as cases flared up in new areas or moved from urban to rural settings, a clear need emerged for rapid response teams and for agile and flexible strategies that can change direction – and location – quickly. In WHO’s assessment, all three countries now have sufficient numbers of treatment beds and burial teams, but these are not always located where they are most needed. As was also learned during 2014, transporting patients over long distances for treatment does not work, either for families and communities or in terms of its impact on transmission.
As long as logistical problems persist, community confidence in the response will remain low. People cannot be expected to do as they are told if the effort leaves them visibly worse off – quarantined without food, sleeping in the same room with a corpse for days – instead of better off. These problems are compounded by poor road systems and weak telecommunications in all three countries. In Liberia, for example, health officials in rural areas are lucky if they have an hour or two of internet connectivity per week. This weakness defeats rapid communication of suspected cases, test results and calls for help, thus ensuring that response efforts continue to run behind a virus that seizes every opportunity to infect more people.
As the response decentralizes to the subnational level, fully functional emergency operations centres, with local government health teams integrated and playing a leadership role, must be established in each county, district and prefecture in the three countries. These centres will drive the step-change in field epidemiology capacity needed to achieve high-quality surveillance, rapid and complete case-finding, and comprehensive contact tracing – the fundamental requirements for getting to zero.
A decentralised response also demands urgent attention to well-known gaps and failures in collecting, collating, managing and rapidly sharing information on cases, laboratory results and contacts. Understanding and tackling the drivers of transmission in each area call for enhanced case investigation and analytical epidemiology. Tools for collecting and sharing this information need to be standardized and put into routine use by governments and their partners.
Another major problem is the unacceptably large difference in case fatality rates between people who receive care in affected countries (71%) and foreign medical staff (26%) who were evacuated for specialized treatment in well-resourced countries. Getting case fatality down in affected countries is an ethical imperative.
Innovation needs to be encouraged, publicized, tested and funnelled into control strategies whenever appropriate. Mali used medical students with training in epidemiology to rapidly increase the number of contact tracers. Guinea drew on its corps of young and talented doctors to strengthen its outbreak response, with training provided by WHO epidemiologists. These staff know the country and its culture best. They will still be there long after foreign medical teams leave.
Much debate has focused on the importance of strengthening health systems, which were weak before the outbreaks started and then collapsed under their weight. In large parts of all three countries, health services have disintegrated to the point that essential care is either unavailable or not sought because of fear of Ebola contagion.
As some have argued, cases will decrease fastest when a well-functioning health system is in place. That argument also points to the need to restore public confidence – which was never high – in the public health system. Targeted drug-delivery campaigns that aimed to treat and prevent malaria were well-received by the public and are a step in the right direction, but much more needs to be done.
Although virtually no good systems for civil registration and vital statistics are still functioning in the three countries, indirect evidence suggests that childhood deaths from malaria have eclipsed Ebola deaths. Liberia, for example, had around 3500 malaria cases each month prior to the outbreak, with around half of these cases, mainly young children, dying. An immediate strengthening of health systems could reduce these and many other deaths, while also restoring confidence that health facilities can protect health and heal disease.
Others argue that efforts must stay sharply focused on outbreak containment. As this argument goes, response capacity is limited and must not be distracted. This argument favours a step-wise approach that initially concentrates on strengthening those health system capacities, like surveillance and laboratory services, that can have a direct impact on outbreak containment.
For its part, WHO sees a need to change past thinking about the way health systems are structured. As the Ebola epidemic has shown, capacities to detect emerging and epidemic-prone diseases early and mount an adequate response need to be an integral part of a well-functioning health system. Outbreak-related capacities should not be regarded as a luxury or added as an afterthought. Otherwise, the security of all health services is placed in jeopardy.
Step up research
Research aimed at introducing new medical products needs to continue at its current accelerated pace. Executives in the R&D-based pharmaceutical industry have expressed their view that all candidate vaccines must be pursued “until they fail”. They have further agreed that the world must never again be taken by surprise, left to confront a lethal disease with no modern control tools in hand.
New tools will likely be needed to get to zero. For example, vaccines to protect health care workers may make it easier to increase the numbers of foreign and national medical staff. Better therapies – and improved prospects of survival – may encourage more patients to promptly seek medical care, greatly increasing their prospects of survival.
As cases decline, robust and reliable point-of-care diagnostic tests will boost efforts to break transmission chains. Rapid diagnostic tests can support efficient patient triage and reduce the time that contacts or suspected cases are held in facilities alongside confirmed cases, where they are at risk of infection. Such tests could also facilitate the screening of patients at regular health care facilities, thus reducing the risk of transmission from undiagnosed cases to unprotected medical staff.
All new control tools must be introduced carefully and in ways that guard against both unrealistic public expectations and unfounded fears. For example, vaccines may not confer full protection; the duration of protection could be brief; a booster shot may be needed. Not all experimental therapies can be easily and safely administered in resource-constrained settings.
Such tools may also be needed for the future. Researchers have identified at least 22 African countries that have the ecological conditions and social behaviours that put them at risk of future outbreaks of Ebola virus disease.
Research is also needed to determine how areas that have achieved zero transmission can be protected from re-reinfection. Some success stories look real and robust, but these are only pockets of low or zero transmission in a broad cloak of contamination. At every opportunity, strategies devised for the emergency response should be made to work to build basic health capacities as well. Some success stories can serve as models.
Given the fear and stigma associated with Ebola, people who survive the disease, especially women and orphaned children, need psychosocial support and counselling services as well as material support. They may need medical support as well. A number of symptoms have been documented in what is increasingly recognized as a “post-Ebola syndrome”.
Efforts are now under way to understand why these symptoms persist, how they can best be managed, whether they are caused by the disease, and whether they might be linked to treatment or the heavy use of disinfectants. WHO staff have developed an assessment tool that is being used to investigate these issues further.
One overarching question hangs in the air. The virus has demonstrated its tenacity time and time again. Will national and international control efforts show an equally tenacious staying power?
