Ebola virus epidemic in West Africa

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Ebola virus epidemic in West Africa
2014 ebola virus epidemic in West Africa.svg
Situation map of the outbreak in West Africa
Date December 2013 – present[1]
Casualties
See notes for 19 October on Timeline Section

An epidemic of Ebola virus disease (EVD) is ongoing in certain West African countries. Caused by Ebola virus, this epidemic is the most severe outbreak of EVD since the identification of ebolaviruses in 1976.[6][7] It has caused significant mortality, with a case fatality rate (CFR) reported as 71%.[8] It began in Guinea in December 2013 and then spread to Liberia and Sierra Leone.[8] A small outbreak of twenty cases occurred in Nigeria, and one case occurred in Senegal. Following a 42-day waiting period, both countries were declared disease-free as of 20 October 2014.[9] [10] Cases of secondary infections of medical workers in the United States and Spain have occurred,[11][12] neither of which has yet spread to the general population. As of 22 October 2014, the World Health Organization (WHO) reported a total of 9,964 suspected cases and 4,881 deaths (5,488 cases and 2,945 deaths having been laboratory confirmed),[2] though the WHO believes that this substantially understates the magnitude of the outbreak[13] with true figures numbering 2.5 times as many cases as have been reported.[14] On 14 October, during a news conference in Geneva, the assistant director-general of the WHO stated that there could be as many as 10,000 new EVD cases per week by December 2014.[15]

Some African countries have encountered difficulties in their efforts to control the epidemic. [16] In some areas, people have become suspicious of both the government and hospitals, some of which have been attacked by angry protesters who believe either that the disease is a hoax or that the hospitals are responsible for the disease. Many of the areas seriously affected by the outbreak are areas of extreme poverty with limited access to the soap and running water needed to help control the spread of disease.[17] Other factors include reliance on traditional medicine and cultural practices that involve physical contact with the deceased, especially death customs such as washing and kissing[18] the body of the deceased.[19][20][21] Some hospitals lack basic supplies and are understaffed, increasing the chance of staff catching the virus themselves. In August, the WHO reported that ten percent of the dead have been health care workers.[22] By the end of August, the WHO reported that the loss of so many health workers was making it difficult for them to provide sufficient numbers of foreign medical staff.[23] In September, the WHO estimated that the countries' capacity for treating EVD patients was insufficient by the equivalent of 2,122 beds.

By September 2014, Médecins Sans Frontières/Doctors Without Borders (MSF), the largest NGO working in the affected countries, had grown increasingly critical of the international response. Speaking on 3 September, the president of MSF spoke out concerning the lack of assistance from the United Nations member countries saying, "Six months into the worst Ebola epidemic in history, the world is losing the battle to contain it."[24] A United Nations spokesperson stated, "They could stop the Ebola outbreak in West Africa in 6 to 9 months, but only if a 'massive' global response is implemented."[25] The Director-General of the WHO, Margaret Chan, called the outbreak "the largest, most complex and most severe we've ever seen" and said that it is "racing ahead of control efforts".[25] In a 26 September statement, the WHO said, "The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times."[26]

Epidemiology[edit]

Outbreak[edit]

Researchers believe that a 2-year-old boy who died on 6 December 2013 in the village of Meliandou, Guéckédou Prefecture, Guinea, was the index case of the current Ebola virus disease epidemic. Reports suggest that his family hunted bats of the Ebola-harboring species Hypsignathus monstrosus and Epomops franqueti for bushmeat, which may have been the original source of the infection.[27][28] His mother, sister, and grandmother then became ill with similar symptoms and also died. People infected by those victims spread the disease to other villages.[1]

Although Ebola represents a major public health issue in sub-Saharan Africa, no cases had ever been reported in West Africa and the early cases were diagnosed as other diseases more common to the area. Thus, the disease had several months to spread before it was recognized as Ebola.[1][29]

On 19 March, the Guinean Ministry of Health acknowledged a local outbreak of an undetermined viral hemorrhagic fever that had sickened at least 35 people and killed 23. "We thought it was Lassa fever or another form of cholera but this disease seems to strike like lightning. We are looking at all possibilities, including Ebola, because bushmeat is consumed in that region and Guinea is in the Ebola belt."[30] By 24 March, MSF had set up an isolation facility in Guéckédou.[31]

On 25 March, the World Health Organization (WHO) reported that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts, with suspected cases in the neighbouring countries of Liberia and Sierra Leone being investigated. In Guinea, a total of 86 suspected cases, including 59 deaths (case fatality ratio: 68.5%), had been reported as of 24 March.[32]

On 31 March WHO reported 112 suspected and confirmed cases including 70 deaths. Two cases were reported from Liberia of people who had recently traveled to Guinea, and suspected cases in Liberia and Sierra Leone were being investigated.[32] On 30 April, Guinea's Ministry of Health reported 221 suspected and confirmed cases including 146 deaths. The cases included 26 health care workers with 16 deaths. By late May, the outbreak had spread to Conakry, Guinea's capital, a city of about two million inhabitants.[32] On 28 May, the total number of cases reported had reached 281 with 186 deaths.[32]

In Liberia, the disease was reported in Lofa and Nimba counties in late March.[33] The Ministry of Health and Social Welfare recorded possible cases in Margibi and Montserrado counties in mid-April.[34] The first cases in Liberia's capital Monrovia were reported in mid-June.[35][36]

The outbreak then spread into Sierra Leone and rapidly progressed. A study of the virus genomes determined that twelve Sierra Leone residents had become infected while attending a funeral in Guinea. They then carried the virus back home.[37] On 25 May, the first cases in the Kailahun District, near the border with Guéckédou in Guinea, were reported.[38] By 20 June, there were 158 suspected cases, mainly in Kailahun and the adjacent district of Kenema. Others were reported in the Kambia, Port Loko, and Western districts in the northwest of the country.[39] By 17 July, the total number of suspected cases in the country stood at 442, overtaking the number in Guinea and Liberia.[40] By 20 July, additional cases of the disease had been reported in the Bo District. The first case in Freetown, Sierra Leone's capital, was reported in late July.[41][42]

The first death in Nigeria was reported on 25 July:[43] a Liberian-American with Ebola flew from Liberia to Nigeria and died in Lagos soon after arrival.[44] As part of the effort to contain the disease, possible contacts were monitored – 353 in Lagos and 451 in Port Harcourt.[45] On 22 September, the WHO reported a total of 20 cases, including eight deaths. The WHO's representative in Nigeria officially declared it Ebola free on 20 October after no new active cases were reported in the follow up contacts.[4]

On 29 August, Senegalese Minister of Health Awa Marie Coll-Seck announced the first case in Senegal. The victim was subsequently identified as a Guinean national who had been exposed to the virus and had been under surveillance, but had travelled to Dakar by road and fallen ill after arriving.[46] This person subsequently recovered, and on 17 October, the WHO officially declared that the outbreak in Senegal had ended.[5]

The Ebola situation in Guinea, Liberia, and Sierra Leone as of 1 October 2014[47]

Two Spanish health care workers contracted Ebola and were transferred to Spain for treatment where they both died. In October, a nursing assistant who had been part of their health care team was diagnosed with Ebola, making this the first case of Ebola contracted outside of Africa. The nursing assistant recovered and was declared disease-free on 19 October. [48] There have been cases of Ebola in the United States of America as well. A Liberian man who had traveled from Liberia to be with his family in Texas was declared to have Ebola and subsequently died on 8 October. Two nurses who had cared for the patient contracted the disease and and as of 20 October remain in treatment.[49]

Countries with widespread transmission[edit]

Guinea[edit]

On 25 March, the World Health Organization (WHO) reported that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts. In Guinea, a total of 86 suspected cases, including 59 deaths (case fatality ratio: 68.5%), had been reported as of 24 March.[32] On 31 March, the U.S. Centers for Disease Control and Prevention (CDC) sent a five-person team to assist Guinea's Ministry of Health and the WHO as they led an international response to the Ebola outbreak.[32]

Thinking that the virus was contained, MSF closed its treatment centers in May leaving only a small skeleton staff to handle the Macenta region. However, high numbers of new cases reappeared in the region in late August. According to Marc Poncin, a coordinator for MSF, the new cases were related to persons returning to Guinea from neighbouring Liberia or Sierra Leone.[50]

It has been reported that some people in this area believe that health workers have been purposely spreading the disease to the people, while others believe that the disease does not exist. Riots recently broke out in the regional capital, Nzérékoré, when rumors were spread that people were being contaminated when health workers were spraying a market area to decontaminate it.[51]

On 18 September, it was reported that the bodies of a team of Guinean health and government officials, accompanied by journalists, who had been distributing Ebola information and doing disinfection work, were found in a latrine in the town of Womey near Nzérékoré.[52] The workers had been murdered by residents of the village after they initially went missing after a riot against the presence of the health education team. Government officials said "the bodies showed signs of being attacked with machetes and clubs" and "three of them had their throats slit."[53]

WHO estimated on 21 September that Guinea's capacity to treat EVD cases falls short by the equivalent of 40 beds.[16] On 13 October, France indicated it would build more treatment centers.[54] On 18 October, Egypt sent three tons of medical aid, consisting of medicine and medical equipment.[55]

Liberia[edit]

Ebola treatment unit in Liberia

In Liberia, the disease was reported in Lofa and Nimba counties in late March.[33] In July, the health ministry implemented measures to improve the country's response.[56] On 27 July, Ellen Johnson Sirleaf, the Liberian president, announced that Liberia would close its borders, with the exception of a few crossing points such as the airport, where screening centres would be established.[57] Football events were banned,[58] schools and universities were closed,[59][60] and the worst-affected areas in the country were to be placed under quarantine.[61]

In August, President Sirleaf declared a national state of emergency, noting that it might require the "suspensions of certain rights and privileges".[62] The National Elections Commission announced that it would be unable to conduct the scheduled October 2014 senatorial election and requested postponement,[63] one week after the leaders of various opposition parties had publicly taken different sides on the question.[64] In late August, Liberia's Port Authority cancelled all "shore passes" for sailors from ships coming into the country's four seaports.[65] As of 8 September, Ebola had been identified in 14 of Liberia's 15 counties.[66]

With only 50 physicians in the entire country—one for every 70,000 Liberians—Liberia already faced a health crisis even before the outbreak.[67] In September the US CDC reported that some hospitals had been abandoned while those which were still functioning lacked basic facilities such as running water, rubber gloves, and sanitizing supplies.[68] The WHO estimated that Liberia's capacity to treat EVD cases fell short by the equivalent of 1,550 beds.[16] In September, a new 150-bed treatment clinic was opened in Monrovia. At the opening ceremony six ambulances were already waiting with potential patients. More patients were waiting by the clinic after making their way on foot with the help of relatives.[69]

In October, the Liberian ambassador in Washington was reported as saying that he feared that his country may be "close to collapse".[67] On 12 October, Liberian nurses threatened a strike over wages.[70] On 14 October, another 100 U.S. troops arrived, bringing the total to 565 to aid in the fight against the disease.[71] On 16 October, U.S. President Obama authorized, via executive order, the use of National Guard and reservists to Liberia.[72] A report of 15 October indicates that Liberia needs 80,000 more body bags and about 1 million protective suits for the next six months.[73] On October 20, the Liberian ambassador to Canada indicated it was time to try the ZMapp drug on the infected in Liberia.[74]

Sierra Leone[edit]

Kenema Hospital, Sierra Leone

The first person reported infected in the spread to Sierra Leone was a tribal healer. She had treated one or more infected people and died on 26 May. According to tribal tradition, her body was washed for burial and this appears to have led to infections in women from neighbouring towns.[75] On 11 June, Sierra Leone shut its borders for trade with Guinea and Liberia and closed some schools in an attempt to slow the spread of the virus.[76] On 30 July, the government began to deploy troops to enforce quarantines.[77]

On 29 July, well-known physician Sheik Umar Khan, Sierra Leone's only expert on hemorrhagic fever, died after contracting Ebola at his clinic in Kenema. Khan had long worked with Lassa fever, a disease that kills over 5,000 a year in Africa. He had expanded his clinic to accept Ebola patients. Sierra Leone's president, Ernest Bai Koroma, celebrated Khan as a "national hero".[75]

In August, awareness campaigns in Freetown, Sierra Leone's capital, were delivered over the radio and through loudspeakers.[78] Also in August, Sierra Leone passed a law that subjected anyone hiding someone believed to be infected to two years in jail. At the time the law was enacted, a top parliamentarian criticised failures by neighbouring countries to stop the outbreak.[79]

In an attempt to control the disease, Sierra Leone imposed a three-day lockdown on its population from 19 to 21 September. During this period 28,500 trained community workers and volunteers went door-to-door providing information on how to prevent infection, as well as setting up community Ebola surveillance teams.[80] On 22 September, government officials said that the three-day lockdown had obtained its objective and would not be extended. Eighty percent of targeted households were reached in the operation. A total of around 150 new cases were uncovered, although reports from remote locations had not yet been received.[81]

WHO estimated on 21 September that Sierra Leone's capacity to treat EVD cases falls short by the equivalent of 532 beds.[16] There have been reports that political interference and administrative incompetence have hindered the flow of medical supplies into the country.[82] On 4 October, Sierra Leone recorded 121 fatalities, the largest number in a single day.[83] On 8 October, Sierra Leone burial crews went on strike.[84] On 12 October, it was reported that the U.K. would begin providing military support to Sierra Leone.[85]

The last district in Sierra Leone untouched by the Ebola virus has declared Ebola cases. According to Abdul Sesay, a local health official, 15 suspected deaths with two confirmed cases of the deadly disease were reported on 16 October in the village of Fakonya. The village is 60 miles from the town of Kabala in the center of a mountainous region of the Koinadugu district. All of the districts in this country now have confirmed cases of Ebola.[86]

Countries with limited local transmission[edit]

Spain[edit]

On 5 August 2014, the Brothers Hospitallers of St. John of God confirmed that Brother Miguel Pajares, who had been volunteering in Liberia, had become infected. He was evacuated to Spain on 6 August, and died on 12 August.[87] On 21 September it was announced that Brother Manuel García Viejo, another Spanish citizen who was medical director at the San Juan de Dios Hospital in Lunsar, had been evacuated to Spain from Sierra Leone after being infected with the virus. His death was announced on 25 September.[88] Both of these cases were treated at the Hospital Carlos III in Madrid.[89]

In October, a nursing assistant, later identified as Teresa Romero, who had cared for these patients became unwell and on 6 October tested positive for Ebola.[90] A second test confirmed the diagnosis,[91] making this the first confirmed case of Ebola transmission outside Africa. There are currently 50 contacts being monitored, with seven kept in isolation at Hospital Carlos III in Madrid. [92] [93] On 9 October, the Spanish Health ministry quarantined three more people. [94] On 12 October, Romero began to show some improvement. According to some reports, the improvement may be attributed to Romero's having received the experimental drug ZMab which is similar to ZMapp, which has been used to treat several Ebola patients. However, according to information released by Spain's Centre for Health and Emergency Alerts, the nurse did not receive ZMab due to concerns over possible side-effects.[95][96] On 19 October, it was reported that Romero had recovered and was officially declared to be Ebola free.[97]

United States[edit]

On 30 September, the United States Centers for Disease Control and Prevention (CDC) declared its first case of Ebola disease. A CDC spokesperson said, "The patient is a man who became infected in Liberia and traveled to Texas, where he was hospitalized with symptoms that were confirmed to be caused by Ebola." The patient, later named as Thomas Eric Duncan, arrived in Dallas on 20 September. On 26 September, he fell ill and sought medical treatment. Despite telling a nurse that he had arrived in the US from West Africa, he was sent home with antibiotics. The hospital later cited a flaw in their health records system as the reason for his having been released.[98] He returned to the hospital by ambulance on 28 September and was placed in isolation.[99][100] On 1 October, the Dallas county health department reported that contacts of the infected patient were under watch and would be monitored for 21 days[101] and four relatives of the patient were placed legally under strict quarantine until 19 October, the end of the 21-day incubation period.[102] The patient, Thomas Duncan, died on 8 October.[103] On 19 October, the four relatives, as well as 44 other people who had had contact with Duncan were released from quarantine free of Ebola virus.[104]

On 12 October, the CDC confirmed that a health worker who had treated Duncan had tested positive for the Ebola virus, making this the first known transmission of the disease in the United States. Speaking on NBC News' Meet the Press, the director of the National Institute of Allergy and Infectious Diseases (NIAID) said there was clearly "an inadvertent breach of protocol" that led to the infection of the health care worker.[105] Nurses at the hospital who were assigned to care for Duncan said they did not receive the proper training or personal protective equipment.[106] On 14 October, a second health worker at Dallas Health Presbyterian Hospital tested positive for Ebola.[107] Nina Pham, the first nurse infected, was transferred to a facility at the National Institutes of Health (NIH) in Bethesda, Maryland on 16 October,[108] while the second, Amber Vinson, has been transferred to Emory University Hospital in Atlanta, Georgia.[109]

Countries with contained spread[edit]

Senegal[edit]

In March, the Senegal Ministry of Interior closed the southern border with Guinea,[110] but on 29 August the Senegal health minister announced Senegal's first case, a university student from Guinea who was being treated in Dakar. The WHO was informed on 30 August.[46] According to the WHO, the case was a native of Guinea who had traveled by road to Dakar, arriving on 20 August. On 23 August, he sought medical care for symptoms including fever, diarrhoea, and vomiting. He received treatment for malaria, but did not improve and left the facility. Still experiencing the same symptoms, on 26 August he was referred to a specialized facility for infectious diseases, and was subsequently hospitalized.[46]

On 27 August, authorities in Guinea issued an alert informing medical services in Guinea and neighbouring countries that a person who had been in close contact with an Ebola infected patient had escaped their surveillance system. The alert prompted testing for Ebola at the Dakar laboratory, and the positive result launched an investigation and triggered urgent contact tracing.[46] On 10 September, it was reported that the student had recovered but health officials would continue to monitor his contacts for 21 days.[111] No further cases were reported, and on 22 September, the WHO announced that Senegal would be declared disease-free after the required waiting period of 42 days.[112] On 17 October, the WHO officially declared that the outbreak in Senegal had ended.[5]

The WHO have officially commended the Senegalese government, and in particular the President Macky Sall and the Minister of Health Dr Awa Coll-Seck, for their quick response in quickly isolating the patient and tracing and following up 74 contacts as well as for their public awareness campaign. This acknowledgement was also extended to MSF and the CDC for their assistance.[113]

Nigeria[edit]

Health care workers in Nigeria receiving training

The first case in Nigeria was a Liberian-American, Patrick Sawyer, who flew from Liberia to Nigeria's commercial capital Lagos on 20 July. Sawyer became violently ill upon arriving at the airport and died five days later. In response, the Nigerian government observed all of Sawyer's contacts for signs of infection and increased surveillance at all entry points to the country.[114] On 6 August, the Nigerian health minister told reporters, "Yesterday the first known Nigerian to die of Ebola was recorded. This was one of the nurses that attended to the Liberian. The other five [newly confirmed] cases are being treated at an isolation ward."[115]

On 9 August, the Nigerian National Health Research Ethics Committee issued a statement waiving the regular administrative requirements that limit the international shipment of any biological samples out of Nigeria[116] and supporting the use of non-validated treatments without prior review and approval by a health research ethics committee.[116] Besides increased surveillance at the country’s borders, the Nigerian government says that they have also made attempts to control the spread of disease by improving tracking, providing education in order to avert disinformation and increase accurate information, and teaching appropriate hygiene measures.[citation needed]

On 19 August, it was reported that the doctor who treated Sawyer, Ameyo Adadevoh, had also died of Ebola disease. Adadevoh was posthumously praised for preventing the index case (Sawyer) from leaving the hospital at the time of diagnosis, thereby playing a key role in curbing the spread of the virus in Nigeria.[117][118]

Also on 19 August, the Commissioner of Health in Lagos announced that Nigeria had seen twelve confirmed cases, and that four had died (including the index case) while another five, including two doctors and a nurse, were declared disease-free and released.[citation needed] On 22 September, the Nigeria health ministry announced, "As of today, there is no case of Ebola in Nigeria. All listed contacts who were under surveillance have been followed up for 21 days."[119]

On 9 October, the European Centre for Disease Prevention and Control (ECDC) acknowledged Nigeria's positive role in controlling the effort to contain the Ebola outbreak. "We wish to thank the Federal Ministry of Health, Abuja, Nigeria, and the staff of the Ebola Emergency Centre who coordinated the management of cases, containment of outbreaks and treatment protocols in Nigeria." Nigeria's quick responses, including intense and rapid contact tracing, surveillance of potential contacts, and isolation of all contacts were of particular importance in controlling and limiting the outbreak, according to the ECDC.[120] Complimenting Nigeria's successful efforts to control the outbreak, "the usually measured WHO declared the feat 'a piece of world-class epidemiological detective work'."[121]

The WHO's representative in Nigeria officially declared Ebola free on 20 October after no new active cases were reported in the follow up contacts, stating it was a "spectacular success story".[4]

Countries with medically evacuated cases[edit]

World situation map of the outbreak including local and evacuated cases

A number of people who had become infected with Ebola virus disease have been medically evacuated to treatment in isolation wards in Europe or the US. These are mostly health workers with one of the NGOs in the area. Germany is currently the only country which has agreed to treat non citizens.[122]

France[edit]

A French volunteer health worker, working for MSF in Liberia, contracted EVD and was flown to France on 18 September. After successful treatment at a military hospital near Paris, she was discharged on 4 October.[123]

According to the FujiFilm company, the woman was treated with their drug favipiravir. This fact has not yet been confirmed by the French health authorities.[124]

Germany[edit]

Germany set up an isolation ward to care for six patients at the University Medical Center Hamburg-Eppendorf. On 27 August, a Senegalese epidemiologist working for the WHO in Sierra Leone became the first patient. On 4 October he was discharged after being declared noninfectious.[125]

The WHO requested that a Ugandan doctor working in Sierra Leone who had contracted the disease be treated in Germany. The request was granted by Germany and he was flown to the country on 3 October. The patient is being treated in an isolation unit at the University Hospital in Frankfurt. The doctor was working for an Italian NGO in Sierra Leone, according to Stefan Gruettner, the State Health Minister of Hessen.[126]

On 9 October, a third patient was medevaced to Leipzig, Germany. The 56-year-old Sudanese man, who worked as a UN employee in Liberia, was transferred to St Georg Hospital in Leipzig.[127] He died on 14 October, becoming the first person on German soil to die of Ebola.[128]

Norway[edit]

On 6 October, MSF announced that one of their workers, a Norwegian national, had become infected in Sierra Leone. On 7 October the woman, Silje Lehne Michalsen, was admitted to a special isolation unit at Oslo University Hospital. [129][130] On 20 October, it was announced that she had been successfully treated and had been discharged. It was reported that Michalsen had received an unspecified drug as part of her treatment plan.[131] After discharge Michalsen remarked, "For three months I saw the total absence of an international response. For three months I became more and more worried and frustrated."[130]

Switzerland[edit]

On 22 September a Swiss health worker was flown by a private airline to Geneva. The nurse was bitten by an Ebola-infected child on 20 September in Sierra Leone. The unidentified male nurse will remain in isolation for 21 days at Geneva's University Hospital. The health ministry says it is unlikely that he was infected but are monitoring him as a potential Ebola patient until the incubation period has passed.[132]

United Kingdom[edit]

An isolation unit at the Royal Free Hospital received its first case on 24 August. William Pooley, a British nurse, was evacuated from Sierra Leone. He was released on 3 September.[133][134]

United States[edit]

A number of American citizens who contracted Ebola virus disease while working in the affected areas have been evacuated to the United States for treatment; none have died.

Among these citizens is Ashoka Mukpo, an NBC News freelancer who contracted the Ebola virus while reporting on the disease in Liberia. Mukpo was flown to the Nebraska Medical Center for treatment on 6 October. On 22 October, the hospital stated that Mukpo had recovered from the virus.

Separate outbreak in the Democratic Republic of the Congo[edit]

Democratic Republic of Congo – 2014
DRC Ebola Map.png
DRC Ebola area as of 6 September 2014[135]
Casualties

In August 2014, the WHO reported an outbreak of Ebola virus in the Boende District, Democratic Republic of the Congo.[136] They confirmed that the current strain of the virus is the Zaire Ebola species, which is common in the country. The virology results and epidemiological findings indicate no connection to the current epidemic in West Africa. This is the country's seventh Ebola outbreak since 1976.[137][138]

In August, 13 people were reported to have died of Ebola-like symptoms in the remote northern Équateur province, a province that lies about 1,200 km (750 mi) north of the capital Kinshasa.[138] The initial case was a woman from Ikanamongo Village who became ill with symptoms of Ebola after she had butchered a bush animal that her husband had killed. The following week, relatives of the woman, several health-care workers who had treated the woman, and individuals with whom they had been in contact came down with similar symptoms.[138] On 26 August, the Équateur Province Ministry of Health notified the WHO of an outbreak of Ebola.[138] According to the WHO, as of 19 October 2014 there have been 66 cases with 49 deaths including eight healthcare workers, and 1,120 contacts are being monitored with 1,116 cleared.[2]

In a show of African solidarity, Congo will train more than 1,000 volunteers in the capital city of Kinshasa to help Ebola-ravaged West Africa.[139]

Virology[edit]

Ebola virus disease is caused by four of five viruses classified in the genus Ebolavirus. Of the four disease-causing viruses, Ebola virus (formerly and often still called the Zaire virus), is the most dangerous and is the strain responsible for the ongoing epidemic in West Africa.[37][140]

Since the discovery of the viruses in 1976 when outbreaks occurred in Sudan and the Democratic Republic of Congo (then called Zaire), Ebola virus disease has been confined to areas in Central Africa, where it is endemic. With the current outbreak, it was initially thought that a new strain endemic to Guinea might be the cause, rather than being imported from central to West Africa.[29] However, further studies have shown that the current outbreak is likely caused by an Ebola virus lineage that has spread from Central Africa into West Africa, with the first viral transfer to humans in Guinea.[37][141]

In a study done by the Broad Institute and Harvard University, in partnership with the Sierra Leone Ministry of Health and Sanitation, researchers may have provided information about the origin and transmission of the Ebola virus that sets this outbreak apart from previous outbreaks. For this study, 99 Ebola virus genomes were collected and sequenced from 78 patients diagnosed with the Ebola virus during the first 24 days of the outbreak in Sierra Leone. From the resulting sequences, and three previously published sequences from Guinea, the team found 341 genetic changes that make the outbreak distinct from previous outbreaks. It is still unclear whether these differences are related to the severity of the current situation.[37] Five members of the research team became ill and died from Ebola before the study was published in August.[37]

Transmission[edit]

The life cycles of the Ebolavirus

It is not entirely clear how an Ebola outbreak starts.[142] The initial infection is believed to occur after an Ebola virus is transmitted to a human by contact with an infected animal's body fluids. Evidence strongly implicates bats as the reservoir hosts for ebolaviruses. Bats drop partially eaten fruits and pulp, then land mammals such as gorillas and duikers feed on these fallen fruits. This chain of events forms a possible indirect means of transmission from the natural host to animal populations.[143]

Human-to-human transmission occurs only via direct contact with blood or bodily fluids from an infected person or by contact with objects contaminated recently by an actively ill virus carrier.[144] When adequate infection control measures are utilized, the potential for widespread Ebola infections is considered most unlikely as the disease is typically only spread by direct contact with the secretions from someone who is showing signs of infection.[144] Airborne transmission has not been documented during Ebola outbreaks. The time interval from infection with the virus to onset of symptoms is two to twenty-one days. Because dead bodies are still infectious, the handling of the bodies of Ebola victims can only be done while observing proper barrier/ separation procedures.[145] Semen and possibly other body fluids (e.g., breast milk) may be infectious in survivors for months.[146][147]

Health care workers receive training in how to use protective clothing.

One of the primary reasons for spread is the poorly-functioning health systems in the part of Africa where the disease occurs.[148] The risk of transmission is increased among those caring for people infected. Recommended measures when caring for those who are infected include medical isolation via the proper use of boots, gowns, gloves, masks and goggles, and sterilizing equipment and surfaces.[142] However, even with proper isolation equipment available, working conditions such as no running water, no climate control, and no floors may continue to make direct care more difficult. Two American health workers who had contracted the disease and later recovered said that to the best of their knowledge their team of workers had been following "to the letter all of the protocols for safety that were developed by the CDC and WHO", including a full body coverall, several layers of gloves, and face protection including goggles. One of the two, a physician, had worked with patients, but the other was assisting workers to get in and out of their protective gear, while wearing protective gear herself.[149]

Successfully addressing one of the "biggest danger(s) of infection" faced by medical staff requires their learning how to properly suit up with, and later remove, personal protective equipment. In Sierra Leone, the typical training period for the use of such safety equipment lasts approximately 12 days.[150]

Difficulties in attempting to contain the outbreak include its multiple locations across country borders.[151] Dr Peter Piot, the scientist who co-discovered the Ebola virus, has stated that the present outbreak is not following its usual linear patterns as mapped out in previous outbreaks. This time the virus is "hopping" all over the West African epidemic region.[50] Furthermore, past epidemics have occurred in remote regions, but this outbreak has spread to large urban areas, which has increased the number of contacts an infected person may have and made transmission harder to track and break.[23]

Prevention[edit]

Contact tracing[edit]

Contact tracing is an essential method of preventing the spread of the disease. It involves finding everyone who has had close contact with an Ebola case and tracking them for 21 days. However, this requires careful record-keeping by properly trained and equipped staff.[152] WHO Assistant Director-General for Global Health Security, Keiji Fukuda, said on 3 September, "We don’t have enough health workers, doctors, nurses, drivers, and contact tracers to handle the increasing number of cases."[153] There is a massive ongoing effort to train volunteers and health workers. According to reports, 20,419 people from Sierra Leone and 18,699 from Liberia are listed and being traced as of 17 October. Figures for Guinea are not known.[154][155]

Travel restrictions and quarantines[edit]

On 8 August, a cordon sanitaire, a disease-fighting practice that forcibly isolates affected regions, was established in the triangular area where Guinea, Liberia, and Sierra Leone are separated only by porous borders and where 70 percent of the known cases had been found.[156] By September, the closure of borders had caused a collapse of cross-border trade and was having a devastating effect on the economies of the involved countries. A United Nations spokesperson reported that the price of some food staples had increased by as much as 150% and warned that if they continue to rise widespread food shortages can be expected.[citation needed]

On 2 September, WHO Director-General Margaret Chan advised against travel restrictions, saying that they are not justified and that they are preventing medical experts from entering the affected areas and are "marginalizing the affected population and potentially worsening [the crisis]". UN officials working on the ground have also criticized the travel restrictions, saying the solution is "not in travel restrictions but in ensuring that effective preventive and curative health measures are put in place".[22] MSF, also speaking out against the closure of international borders, called it "another layer of collective irresponsibility" and added, "The international community must ensure that those who try to contain the outbreak can enter and leave the affected countries if need be. A functional system of medical evacuation has to be set up urgently."[24]

Deaths of healthcare workers[edit]

In August, it was reported that healthcare workers represented nearly 10 percent of the cases and fatalities, significantly impairing the ability to respond to the outbreak in an area which already faces a severe shortage of doctors.[157] In the hardest hit areas there have historically been only one or two doctors available to treat 100,000 people, and these doctors are heavily concentrated in urban areas.[23] Healthcare providers caring for people with Ebola, and family and friends in close contact with people with Ebola, are at the highest risk of getting infected because they may come in direct contact with the blood or body fluids of the sick person. In some places affected by the current outbreak, care may be provided in clinics with limited resources, and workers could be in these areas for several hours with a number of Ebola infected patients.[158] According to the WHO, the high proportion of infected medical staff can be explained by a lack of the number of medical staff needed to manage such a large outbreak, shortages of protective equipment or improperly using what is available, and "the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe".[23]

Among the fatalities is Samuel Brisbane, a former advisor to the Liberian Ministry of Health and Social Welfare, described as "one of Liberia's most high-profile doctors".[159] In July, leading Ebola doctor Sheik Umar Khan from Sierra Leone died in the outbreak. His death was followed by two more deaths in Sierra Leone: Modupe Cole, a senior physician at the country's main referral facility,[160] and Sahr Rogers, who worked in Kenema.[161][162][163] In August, a well-known Nigerian physician, Ameyo Adadevoh, died. She was posthumously praised for preventing the Nigerian index case from leaving the hospital at the time of diagnosis, thereby playing a key role in curbing the spread of the virus in Nigeria.[117]

By 12 October, the WHO reported 427 workers had been infected and 236 had died. Liberia has been especially hard hit with almost half the total cases (201 with 95 deaths) reported. Sierra Leone registered 129 cases with 96 fatalities, thus indicating a death toll of 73.6% in Sierra Leone. Guinea reported 76 infected cases with 34 deaths. In Nigeria 11 healthcare workers were also infected and 5 deaths were recorded. One infected case in Spain was reported, as well as two in the United States.[107][164]

Community[edit]

In order to reduce the spread, the World Health Organization recommends raising community awareness of the risk factors for Ebola infection and the protective measures individuals can take.[165] These include avoiding contact with infected people and regular hand washing using soap and water.[166] A condition of extreme poverty exists in many of the areas that have experienced a high incidence of infections. According to the director of the NGO Plan International in Guinea, "The poor living conditions and lack of water and sanitation in most districts of Conakry pose a serious risk that the epidemic escalates into a crisis. People do not think to wash their hands when they do not have enough water to drink."[167]

Containment efforts have been hindered because there is reluctance among residents of rural areas to recognize the danger of infection related to person-to-person spread of disease, such as burial practices which include washing of the body of one who has died.[19][20][21][41] A 2014 study found that nearly two thirds of cases of Ebola in Guinea are believed to be due to burial practices.[168]

Denial in some affected countries has also made containment efforts difficult.[169] Language barriers and the appearance of medical teams in protective suits has sometimes increased fears of the virus.[170] There are reports that some people believe that the disease is caused by sorcery and that doctors are killing patients.[171] In late July, the former Liberian health minister, Peter Coleman, stated that "people don't seem to believe anything the government now says."[57]

Acting on a rumor that the virus was invented to conceal "cannibalistic rituals" (due to medical workers preventing families from viewing the dead), demonstrations were staged outside of the main hospital treating Ebola patients in Kenema, Sierra Leone. The demonstrations were broken up by the police and resulted in the need to use armed guards at the hospital.[172] In Liberia, a mob attacked an Ebola isolation centre, stealing equipment and "freeing" patients while shouting, "There's no Ebola."[173] Red Cross staff were forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives.[174] On 18 September in the town of Womey in Guinea, suspicious inhabitants wielding machetes murdered at least eight aid workers and dumped their bodies in a latrine.[175]

Treatment[edit]

Ebola virus disease in West Africa
WHO ebola response map.jpg
New cases and total cases of Ebola virus disease in Guinea, Liberia, and Sierra Leone as of 12 October 2014[164]

No proven Ebola virus-specific treatment exists as of August 2014.[176] Treatment is primarily supportive in nature and includes minimizing invasive procedures, balancing fluids and electrolytes to counter dehydration, administration of anticoagulants early in infection to prevent or control disseminated intravascular coagulation, administration of procoagulants late in infection to control bleeding, maintaining oxygen levels, pain management, and the use of medications to treat bacterial or fungal secondary infections.[177][178][179][180][181] Early treatment may increase the chance of survival.[182]

Level of care[edit]

Local authorities have not had resources to contain the disease, with health centres closing and hospitals overwhelmed.[183] In late June, the Director-General of MSF said, "Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible."[151] Adequate equipment has not been provided for medical personnel,[184] with even a lack of soap and water for hand-washing and disinfection.[185]

In late August, MSF called the situation "chaotic" and the medical response "inadequate". They reported that they had expanded their operations but were unable to keep up with the rapidly increasing need for assistance which had forced them to reduce the level of care they were able to offer: "It is not currently possible, for example, to administer intravenous treatments." Calling the situation "an emergency within the emergency", MSF reported that many hospitals have had to shut down due to lack of staff or fears of the virus among patients and staff, which has left people with other health problems without any care at all. Speaking from a remote region, a MSF worker said that a shortage of protective equipment was making the medical management of the disease difficult and that they had limited capacity to safely bury bodies.[186]

By September, treatment for Ebola patients had become unavailable in some areas. Speaking on 12 September, WHO Director-General Margaret Chan said, "In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centers. Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia."[187] According to a WHO report released on 19 September, Sierra Leone is currently meeting only 25% of its need for patient beds, and Liberia is meeting only 20% of its need.[188]

Current bed capacity in countries with active cases as of 12 Oct 2014.[2]
Countries Existing beds Planned beds Percentage of existing/Planned beds
Guinea 160 260 61%
Liberia 620 2,690 23%
Sierra Leone 346 1,198 29%
Total 1,126 4,148 27%

Healthcare settings[edit]

WHO workers gear up to go into Ebola isolation ward in Lagos, Nigeria ~ 2014.

A number of Ebola Treatment Centres have been set up in the area, supported by international aid organisations and staffed by a combination of local and international staff. Each treatment centre is divided into a number of distinct and rigorously separate areas. For patients, there is a triage area, and low- and high-risk care wards. For staff, there are areas for preparation and decontamination. An important part of each centre is an arrangement for safe burial or cremation of bodies, required to prevent further infection.[189][190]

Although the WHO does not advise caring for Ebola patients at home, it is an option and even a necessity when no hospital treatment beds are available. For those being treated at home, the WHO advises informing the local public health authority and acquiring appropriate training and equipment.[191][192] UNICEF, USAID and the NGO Samaritan's Purse have begun to take measures to provide support for families that are forced to care for patients at home by supplying caregiver kits intended for interim home-based interventions. The kits include protective clothing, hydration items, medicines, and disinfectant, among other items.[193][194] Even where hospital beds are available, it has been debated whether conventional hospitals are the best place to care for Ebola patients, as the risk of spreading the infection is high.[195] The WHO and non-profit partners have launched a program in Liberia to move infected people out of their homes into ad hoc centres that will provide rudimentary care.[196]

Protective clothing[edit]

Preparing to enter an Ebola treatment unit

The Ebola epidemic has caused an increasing demand in protective clothing. It is assumed that a health worker uses seven suits per bed per day. A full set of protective clothing includes a suit, goggles, mask, socks and boots, and an apron. Boots and aprons can be disinfected and reused, but everything else must be destroyed. Health workers change garments frequently, discarding gear that has barely been used. This not only uses a great deal of time but also exposes them to the virus because for health care workers wearing protective clothing, one of the most dangerous times for catching Ebola is while suits are being removed.[197] The protective clothing set that MSF uses cost about $75 apiece. Staff who have returned from deployments to West Africa say the clothing is so heavy that it can be worn for only about 40 minutes at a stretch. A physician working in Sierra Leone has said, "After about 30 or 40 minutes, your goggles have fogged up; your socks are completely drenched in sweat. You're just walking in water in your boots. And at that point, you have to exit for your own safety...Here it takes 20-25 minutes to take off a protective suit and must be done with two trained supervisors who watch every step in a military manner to ensure no mistakes are made, because a slip up can easily occur and of course can be fatal." [198] [199] According to some reports, protective outfits are beginning to be in short supply and manufacturers have started to increase their production,[200] but the need to find better types of suits has also been raised.[201]

USAID published an open competitive bidding for proposals that address the challenge of developing "... new practical and cost-effective solutions to improve infection treatment and control that can be rapidly deployed (1) to help health care workers provide better care and (2) transform our ability to combat Ebola".[202]

Experimental treatments[edit]

A researcher working with the Ebola virus while wearing a BSL-4 positive pressure suit to avoid infection

The unavailability of treatments in the most-affected regions has spurred controversy, with some calling for experimental drugs to be made more widely available in Africa on a humanitarian basis, and others warning that making unproven drugs widely available would be unethical, especially in light of past experimentation conducted in developing countries by Western drug companies.[203][204] As a result of the controversy, on 12 August an expert panel of the WHO endorsed the use of interventions with as-yet-unknown effects for both treatment and prevention of Ebola, and also said that deciding which treatments should be used and how to distribute them equitably were matters that needed further discussion.[205]

The WHO has recognised that transfusion of whole blood or purified serum from Ebola survivors is the therapy with the greatest potential to be implemented immediately although there is little information on its efficacy.[206] At the end of September, WHO issued an interim guideline for this therapy.[207] During September, there were reports of blood from survivors of the disease being offered for sale on the black market. Health professionals have warned that patients buying blood on the black market could expose themselves to a number of risks, including infection with HIV or hepatitis.[208]

A number of experimental treatments are being considered for use in the context of this outbreak, and are currently or will soon undergo clinical trial:[209]

  • ZMapp, a combination of monoclonal antibodies. The limited supply of the drug has been used to treat 7 individuals infected with the Ebola virus.[210] Although some of them have recovered, the outcome is not considered to be statistically significant.[211] ZMapp has proved highly effective in a trial involving rhesus macaque monkeys.[212] Texas A&M stated on 8 October that it was ready to mass-produce the drug, pending final approval.[213]
  • TKM-Ebola, an RNA interference drug.[214] The drug started Phase 1 trial in early 2014 and has since has received limited approval from the FDA for emergency use.[215] The drug disrupts the virus replication process, "allowing the body’s immune system to catch up with the virus and destroy it".[216]
  • Favipiravir (Avigan), a drug approved in Japan for stockpiling against influenza pandemics. The drug appears to be useful in a mouse model of the disease[217][218] and a clinical trial is being planned for Ebola patients in Guinea, due November.[219] The French Health ministry has authorized its use.[220] Treatments that use small interfering RNAs protected macaque monkeys that were exposed to the virus.[221]
  • BCX4430 is a broad-spectrum antiviral drug developed by BioCryst Pharmaceuticals and currently being researched as a potential treatment for Ebola by USAMRIID.[222] The drug has been approved to progress to Phase 1 trials, expected late in 2014.[223] BCX4430 attempts to disrupt viral replication or the pathogenic mechanism. Stated simply, "it tries to stop ... the virus by directly acting on the virus".[224]
  • Brincidofovir, another broad-spectrum antiviral drug, has been granted an emergency FDA approval as an investigational new drug for the treatment of Ebola after it was found to be effective against Ebola virus in in vitro tests.[225] It has subsequently been used to treat the first patient diagnosed with Ebola in the USA after he had recently returned from Liberia.[226] On 16 October, it was cleared to start clinical trials. The drug is based on injectable antiviral Cidofovir.[227]
  • JK-05 is a is a broad-spectrum small molecule antiviral drug, and its pharmacological mechanism inhibits the RNA polymerase of the Ebola virus.[228][229] The drug can selectively inhibit virus replication by inhibiting the RNA polymerase of the Ebola virus, meaning that it blocks an enzyme that the virus needs to replicate its genes.[230][231]

Experimental preventative vaccines[edit]

  • In September, an experimental vaccine, now known as the cAd3-ZEBOV vaccine, commenced simultaneous Phase 1 trials, being administered to volunteers in Oxford and Bethesda. The vaccine was developed jointly by GlaxoSmithKline and the NIH. During October the vaccine is being administered to a further group of volunteers in Mali. If these trials are completed successfully, the vaccine will be fast tracked for use in West Africa. In preparation for this, GSK is preparing a stockpile of 10,000 doses.[232][233]
  • A second vaccine candidate, rVSV-ZEBOV, developed by the Public Health Agency of Canada is ready to undergo Phase 1 trials, expected October.[234] It will not be mass-produced until 2015, pending trials.[235] However, On October 18, Canada indicated it was ready to send shipments of the vaccine to WHO, which in turn would determine how best to use it in the affected West African countries.[236]

Outlook[edit]

Since the beginning of the outbreak, there has been serious difficulty in getting reliable estimates both of the number of people affected, and of the geographical extent of the outbreak.[237] The three countries which are most affected, Sierra Leone, Guinea and Liberia, are among the poorest in the world, with extremely low levels of literacy, few hospitals or doctors, poor physical infrastructure, and poorly functioning government institutions.[238] One effect of the epidemic has been to weaken the institutions which already exist as healthcare and government workers become overwhelmed by the workload, in some cases abandoning their posts, or succumb to infection. Since the symptoms of EVD resemble other diseases such as malaria which are common in the area, even diagnosis is uncertain unless a blood sample can reach one of the few testing centres which are equipped to perform PCR or ELISA tests. WHO, MSF and the CDC have warned that the official counts of EVD cases and deaths are not consistent with field observations, and are likely to understate the extent of the epidemic by a factor of 2.5.[12][14][239]

Statistical measures[edit]

Calculating an accurate case fatality rate (CFR) is difficult for an ongoing epidemic due to differences in testing policies, the inclusion of probable and suspected cases, and the inclusion of new cases that have not run their course. In late August, the WHO made an initial CFR estimate of 53% though this included suspected cases.[240][241] On 23 September, the WHO released a revised and more accurate CFR of 70.8%, derived using data from patients with definitive clinical outcomes.[8]

The basic reproduction number (R0) is a statistical measure of the number of people who are expected to be infected by one person who has the disease in question. If the rate is less than 1, the infection will die out in the long run; if the rate is greater than 1, the infection will continue to spread in a population.[242] The BRN of the current outbreak is estimated to be between 1.71 and 2.02.[8]

Projections of future cases[edit]

On 28 August, the WHO released its first estimate of the possible total cases (20,000) from the outbreak as part of its roadmap for stopping the transmission of the virus.[243] The WHO roadmap states "[t]his Roadmap assumes that in many areas of intense transmission the actual number of cases may be two- to fourfold higher than that currently reported. It acknowledges that the aggregate case load of EVD could exceed 20,000 over the course of this emergency. The Roadmap assumes that a rapid escalation of the complementary strategies in intense transmission, resource-constrained areas will allow the comprehensive application of more standard containment strategies within 3 months."[243] It includes an assumption that some country or countries will pay the required cost of their plan, estimated at half a billion dollars.[243]

When the WHO released its first estimated projected number of cases, a number of epidemiologists presented data to show that the WHO's projection of a total of 20,000 cases was likely an underestimate. On 31 August, the journal Science quoted Christian Althaus, a mathematical epidemiologist at the University of Bern in Switzerland, as saying that if the epidemic were to continue in this way until December, the cumulative number of cases would exceed 100,000 in Liberia alone.[244] According to a research paper released in early September, in the hypothetical worst-case scenario, if a BRN of over 1.0 continues for the remainder of the year we would expect to observe a total of 77,181 to 277,124 additional cases within 2014. The researchers believe this is unlikely but say that Ebola "must be regarded as a Public Health Emergency of International Concern".[245] On 9 September, Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine controversially announced that the containment fight in Sierra Leone and Liberia has already been "lost" and that the disease would "burn itself out".[246] Writing in The New York Times on 12 September, Bryan Lewis, an epidemiologist at the Virginia Bioinformatics Institute at Virginia Tech, said that researchers at various universities who have been using computer models to track the growth rate say that at the virus's present rate of growth, there could easily be close to 20,000 cases in one month, not in nine.[247]

On 8 September, the WHO warned that the number of new cases in Liberia was increasing exponentially, and would increase by "many thousands" in the following three weeks. In a 23 September WHO report, the WHO revised their previous projection, stating that they expect the number of Ebola cases in West Africa to be in excess of 20,000 by 2 November.[8] They further stated, that if the disease is not adequately contained it could become endemic in Guinea, Sierra Leone and Liberia, "spreading as routinely as malaria or the flu",[248] and according to an editorial in the New England Journal of Medicine, eventually to other parts of Africa and beyond.[249]

In a 23 September CDC report, a projection calculates a potential underreporting which is corrected by a factor of 2.5. With this correction factor, approximately 21,000 total cases are the estimate for the end of September 2014 in Liberia and Sierra Leone alone. The same report predicted that total cases, including unreported cases, could reach 1.4 million in Liberia and Sierra Leone by 20 January 2015 if no improvement in intervention or community behaviour occurred.[14]

On 2 September, an assessment of the probability of Ebola virus disease case importation in countries across the world was published in PLOS Currents Outbreaks.[250] The projections are based on simulations of epidemic spread worldwide. The analysis was updated with simulations based on new data on 6 October, and the updated results are available online.[251] On 14 October, during a news conference in Geneva, the assistant director-general of the WHO stated that there could be as many as 10,000 new Ebola cases per week by December 2014.[15]

Economic effects[edit]

In addition to the loss of life, the outbreak is having a number of significant economic impacts.

  • Markets and shops are closing, due to travel restrictions, a cordon sanitaire, or fear of human contact, leading to loss of income for producers and traders.[252]
  • Movement of people away from affected areas has disturbed agricultural activities.[253][254] The UN Food and Agriculture Organisation (FAO) has warned that the outbreak could endanger harvest and food security in West Africa.[255]
  • Tourism is directly impacted in affected countries.[256] Other countries in Africa which are not directly affected by the virus have also reported adverse effects on tourism.[257]
  • Many airlines have suspended flights to the area.[258]
  • Foreign mining companies have withdrawn non-essential personnel, deferred new investment, and cut back operations.[254][259][260]
  • The outbreak is straining the finances of governments, with Sierra Leone using Treasury bills to fund the fight against the virus.[261]
  • The IMF is considering expanding assistance to Guinea, Sierra Leone, and Liberia as their national deficits are ballooning and their economies contract sharply.[262]
  • On 8 October, the World Bank issued a report which estimated overall economic impacts of between $3.8 billion and $32.6 billion, depending on the extent of the outbreak and the speed with which it can be contained. The economic impact would be felt most severely in the three affected countries, with a wider impact felt across the broader West African region.[263][264]

Responses[edit]

In July, the World Health Organization convened an emergency meeting with health ministers from eleven countries and announced collaboration on a strategy to co-ordinate technical support to combat the epidemic. In August they published a roadmap to guide and coordinate the international response to the outbreak, aiming to stop ongoing Ebola transmission worldwide within 6–9 months, and formally designated the outbreak as a Public Health Emergency of International Concern.[265] This is a legal designation used only twice before (for the 2009 H1N1 (swine flu) pandemic and the 2014 resurgence of polio) which invokes legal measures on disease prevention, surveillance, control, and response, by 194 signatory countries.[266][267]

In September, the United Nations Security Council declared the Ebola virus outbreak in West Africa "a threat to international peace and security" and unanimously adopted a resolution urging UN member states to provide more resources to fight the outbreak; the WHO stated that the cost for combating the epidemic will be a minimum of $1 billion.[268][269] The Economic Community of West African States and the World Bank Group have pledged aid money, and the World Food Programme announced plans to mobilize food assistance for an estimated 1 million people living in restricted access areas. Several non-governmental organizations have provided assistance in the efforts to control the spread of the disease. The humanitarian aid organisation Médecins Sans Frontières (Doctors Without Borders) is the leading organization responding to the crisis. Currently it has five treatment centers in the area.[188] Samaritan's Purse is providing direct patient care in multiple locations in Liberia.[270] On 9 October the International Charter on Space and Major Disasters was activated, marking the first time that its charitably re-purposed satellite imaging assets have been deployed in an epidemiological role.[271]

Many nations and charitable organizations, foundations, and individuals have also pledged assistance to control the epidemic.

Timeline of cases and deaths[edit]

Data comes from reports by the Centers for Disease Control and Prevention[272] and the WHO.[273] All numbers are correlated with United Nations Office for the Coordination of Humanitarian Affairs (OCHA) if available.[274] The table includes suspected cases that have not yet been confirmed. The reports are sourced from official information from the affected countries' health ministries. The WHO has stated the reported numbers "vastly underestimate the magnitude of the outbreak", estimating there may be 2.5 times as many cases as officially reported.[13][14] Liberia was singled out in the 8 and 14 October reports from WHO, noting "There continue to be profound problems affecting data acquisition in Liberia... it is likely that the figures will be revised upwards in due course."[12]

The case numbers reported may include probable or suspected cases. Numbers are revised downward if a case is later found to be negative. (Numbers may differ from reports as per respective Government reports. See notes at the bottom for stated source file.)

Ebola cases and deaths by country and by date – 1 August to most recent WHO /Gov update
Date Total Guinea Liberia Sierra Leone Nigeria Senegal United States Spain Refs
Cases Deaths  % Daily
growth
Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths
19 Oct 2014 9,964 4,881 +1.2% 1,540 904 4,693 2,709 3,706 1,259 20 8 1 0 3 1 1 0 [note 1][2][3]
17 Oct 2014 9,693 4,811 +1.7% 1,501 886 4,607 2,689 3,560 1,227 20 8 1 0 3 1 1 0 [note 2][275][154][155][5]
12 Oct 2014 8,997 4,493 +1.4% 1,472 843 4,249 2,458 3,252 1,183 20 8 1 0 2 1 1 0 [note 3][164]
7 Oct 2014 8,386 3,988 +2.1% 1,350 778 4,076 2,316 2,937 885 20 8 1 0 1 1 1 0 [note 4][276][277]
5 Oct 2014 8,033 3,865 +1.7% 1,298 768 ≥3,924 ≥2,210 2,789 ≥879 20 8 1 0 1 0 [note 5][12][276]
1 Oct 2014 7,492 3,439 +1.3% 1,199 739 ≥3,834 ≥2,069 2,437 623 20 8 1 0 1 0 [note 6][278]
28 Sep 2014 7,192 3,286 +1.8% 1,157 710 ≥3,696 ≥1,998 2,317 570 20 8 1 0 1 0 [note 7] [279][280][281]
25 Sep 2014 6,808 3,159 +1.7% 1,103 668 ≥3,564 ≥1,922 2,120 561 20 8 1 0 [note 8] [282][283][284]
23 Sep 2014 6,574 3,043 +2.4% 1,074 648 ≥3,458 ≥1,830 2,021 557 20 8 1 0 [note 9][285][286]
21 Sep 2014 6,263 2,900 +2.0% 1,022 635 ≥3,280 ≥1,707 1,940 550 20 8 1 0 [note 10][287][288]
17 Sep 2014 5,762 2,746 +2.5% 965 623 ≥3,022 ≥1,578 1,753 537 21 8 1 0 [note 11][289][290][291]
14 Sep 2014 5,339 2,586 +2.3% 942 601 ≥2,720 ≥1,461 1,655 516 21 8 1 0 [note 12][292][293][294]
10 Sep 2014 4,848 2,376 +3.3% 899 568 2,415 1,307 1,509 493 22 8 3 0 [note 13][295][296]
7 Sep 2014 4,391 2,177 +2.1% 861 557 2,081 1,137 1,424 476 22 7 3 0 [note 14][297][298]
3 Sep 2014 4,001 2,059 +2.4% 823 522 1,863 1,078 1,292 452 22 7 1 0 [299]
31 Aug 2014 3,707 1,808 +2.9% 771 494 1,698 871 1,216 436 21 7 1 0 [note 15] [241][300]
25 Aug 2014 3,071 1,553 +3.0% 648 430 1,378 694 1,026 422 19 7 [301]
20 Aug 2014 2,615 1,427 +2.7% 607 406 1,082 624 910 392 16 5 [13]
18 Aug 2014 2,473 1,350 +4.7% 579 396 972 576 907 374 15 4 [302]
16 Aug 2014 2,240 1,229 +1.7% 543 394 834 466 848 365 15 4 [303]
13 Aug 2014 2,127 1,145 +3.6% 519 380 786 413 810 348 12 4 [304]
11 Aug 2014 1,975 1,069 +3.2% 510 377 670 355 783 334 12 3 [305]
9 Aug 2014 1,848 1,013 +1.2% 506 373 599 323 730 315 13 2 [306]
6 Aug 2014 1,779 961 +1.9% 495 367 554 294 717 298 13 2 [307]
4 Aug 2014 1,711 932 +2.1% 495 363 516 282 691 286 9 1 [308]
1 Aug 2014 1,603 887 - 485 358 468 255 646 273 4 1 [309]
Notes:
Date is the "as of" date from the reference. A single source may report statistics for multiple "as of" dates.
Total cases and deaths before 1 July 2014 are calculated.
Numbers with ± are deltas from a previous report. The deltas may not be consistent.
Numbers with a ↓ indicate cases that were eliminated.
Liberia:
29 Mar: LI data is confused. Earlier, there were 8 suspected cases and 6 deaths (no confirmed cases). Seven suspected cases were tested by 29 Mar, and five were not Ebola. That should take suspected cases to 3, but a total was not stated; it also implies deaths should be at most 3. The report states only 2 suspected deaths were tested, and one was not Ebola.[344]
21 Apr: reduced deaths by 2: one in Guinea total and one case discarded. 26 samples negative for Ebola.[335]
24 Apr: stated it was reviewing its 27 suspected cases and may toss all of them;[334]
2 May: reclassification complete.[333]
Sierra Leone: cases were reported, but by 3 May there were no cases.[332] Early reports are marked with parens "()".
7 Apr: 2 suspected cases of EVD were confirmed as Lassa Fever.[340]
15 Apr: Of 12 suspected cases, 11 were tested for Ebola but came up negative.[36]
Mali: 4 possible cases were reported on 7 April,[340][341] but they were not EVD.[36]
  1. ^ 19 October as per WHO for all except Liberia 19 October as per Gov.
  2. ^ 17 October data are based on official information reported by Ministries of Health up to the end of 17 October for all governments. Liberian and Sierra Leone as per Gov. Guinea as per OCHA. Rest stat as per WHO 17 Oct report
  3. ^ 12 October as per WHO Spain and US as per news reports
  4. ^ WHO report is for 7 Oct and not 8 Oct, updated with 7 Oct dates for Sierra Leone
  5. ^ 5 October 275 of the additional deaths reported this week from Sierra Leone are the result of a retrospective analysis of hospital records. Data are based on official information reported by Ministries of Health up to the end of 5 October for Guinea and Sierra Leone, and 4 October for Liberia. Liberian numbers are likely an underestimate and may be adjusted upwards at a later date.
  6. ^ 1 October as per reports WHO. Liberia subject to change.[278]
  7. ^ 28 September Liberia and Guinea reports as per respective WHO[279] and Sierra Leone as per government[280](2304 cases and 622 deaths according to WHO report). Nigeria and Senegal stat. Note US case only dated 29 September but been in US since 28 September
  8. ^ 25 September Liberia and Sierra Leone reports as per respective governments[282][283] and OCHA for Guinea.[284] Nigeria and Senegal stat.
  9. ^ 23 Sept Liberia, Guinea,Nigeria and Senegal as per WHO report.[285] Modified with Sierra Leone death toll as per Gov which is lower than WHO death toll (605).[286]
  10. ^ 21 September Liberia, Guinea as per WHO report.[287] modified with Sierra Leone death toll as per Gov which is lower than WHO death toll (597)[288]
  11. ^ 17 September Guinea and Senegal as per OCHA report.[289] Updated with Liberia numbers as per Gov.[290] Updated with Sierra Leone per Gov (OCHA report states 18 September but totals are as per SL gov on 17 September) [291] Nigeria and Senegal stat.
  12. ^ 14 September Guinea as per WHO report.[292] Updated with Liberia numbers as per Gov.[293] Updated with Sierra Leone death toll as per Gov[294]
  13. ^ 10 Sept From Primary Source OCHA[295] and Liberia government.[296] Nigeria and Senegal stat
  14. ^ 7 Sept WHO[297] report Sierra Leone death rate suspected added up double in report.[298]
  15. ^ 31 Aug WHO[241] SL death toll wrong.[300]

References[edit]

  1. ^ a b c Grady, Denise; Fink, Sheri (9 August 2014). "Tracing Ebola's Breakout to an African 2-Year-Old". The New York Times. ISSN 0362-4331. Retrieved 14 August 2014. 
  2. ^ a b c d e f g h i j WHO (22 Oct 2014). "Ebola Response Roadmap Situation Report". who.int. Retrieved 22 Oct 2014. 
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