Ebola virus epidemic in West Africa

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Ebola virus epidemic in West Africa
2014 ebola virus epidemic in West Africa simplified.svg
Situation map of the outbreak in West Africa
Date December 2013 – present[1]
Casualties

Reported cases/deaths

  • Note: the CDC estimates that actual cases in Liberia, Sierra Leone, and Guinea are two to three times higher than officially reported numbers.[2][3]
Country Cases Deaths Last update
20 December 2014
Liberia Liberia 7,819 3,346 14 December 2014[4]
Sierra Leone Sierra Leone 8,832 2,502 18 December 2014[5]
Guinea Guinea 2,413 1,550 16 December 2014[4]
Nigeria Nigeria 20 8 outbreak ended 20 October 2014[6]
Mali Mali 8 6 23 November 2014[7]
United States United States 4 1 16 November 2014[8]
Senegal Senegal 1 0 outbreak ended 17 October 2014[9]
Spain Spain 1 0 outbreak ended 2 December 2014[10]
Total 19,098 7,413 as of 18 December 2014

As of 2014, the most widespread epidemic of Ebola virus disease (commonly known as "Ebola") in history is currently ongoing in several West African countries.[11][12] It has caused significant mortality, with a reported case fatality rate of 70%.[13] It began in Guinea in December 2013 and then spread to Liberia and Sierra Leone.[14] A small outbreak of twenty cases occurred in Nigeria and one case occurred in Senegal, both now declared disease-free.[15] Several cases have been reported in Mali.[16] Imported cases in the United States and Spain have led to secondary infections of medical workers but have not spread further.[17][18] As of 18 December 2014, the World Health Organization (WHO) and respective governments have reported a total of 19,078 suspected cases and 7,413 deaths,[4][5] though the WHO believes that this substantially understates the magnitude of the outbreak.[2][19][20]

Some countries have encountered difficulties in their efforts to control the epidemic.[21] 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 seriously affected areas have extreme poverty with limited access to the soap and running water needed to help control the spread of this disease.[22] Other factors include reliance on traditional medicine and cultural practices that involve physical contact with the deceased, especially death customs such as washing the body of the deceased.[23][24][25] 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.[26] 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.[27] In September, the WHO estimated that the countries' capacity for treating Ebola patients was insufficient by the equivalent of 2,122 beds. By the end of October many of the hospitals in the affected area had become dysfunctional or had been closed, leading some health experts to state that the inability to treat other medical needs may be causing "an additional death toll [that is] likely to exceed that of the outbreak itself".[28][29]

By September 2014, Médecins Sans Frontières/Doctors Without Borders (MSF), the NGO with the largest working presence 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."[30] On 3 September, the United Nations’ senior leadership said it could be possible to stop the Ebola outbreak in 6 to 9 months, but only if a “massive” global response is implemented.[31] 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".[31] 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. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long."[32] In December, Ebola healthcare workers were collectively named Time magazine's "Person of the Year."[33]

Epidemiology[edit]

Outbreak[edit]

  Widespread outbreak: Guinea, Sierra Leone, Liberia
  Limited outbreak: (none currently)
  Isolated cases: Mali
  Medically evacuated cases
  Ebola-free after prior cases

Researchers generally believe that a 2-year-old boy, later identified as Emile Ouamouno, who died in December 2013 in the village of Meliandou, Guéckédou Prefecture, Guinea, was the index case of the current Ebola virus disease epidemic.[34][35] His mother, sister, and grandmother then became ill with similar symptoms, and also died. People infected by those initial cases spread the disease to other villages.[1][36] 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][35]

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 had been reported as of 24 March.[37] By late May, the outbreak had spread to Conakry, Guinea's capital, a city of about two million inhabitants.[37] On 28 May, the total number of cases reported had reached 281 with 186 deaths.[37]

In Liberia, the disease was reported in four counties by mid-April and cases in Liberia's capital Monrovia were reported in mid-June.[38][39] The outbreak then spread to Sierra Leone and progressed rapidly. 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 and 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 Nigeria Ebola-free on 20 October after no new active cases were reported in the follow up contacts.[46]

On 29 August, Senegalese Minister of Health 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.[47] This person subsequently recovered, and on 17 October, the WHO officially declared that the outbreak in Senegal had ended.[48]

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 Ebola case contracted outside of Africa. The nursing assistant recovered and was declared disease-free on 19 October.[49] There have been Ebola cases 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;[50] both of the nurses have subsequently recovered and tested Ebola-free on 27 October 2014. On 23 October, the first case of Ebola in Mali was confirmed, a two year-old girl who had returned from Guinea,[51][52] and further cases were reported in November.[16]

According to a WHO report released on 19 November 72% of patients in Guinea are recorded and isolated, while the figure for Sierra Leone and Liberia is still dire. During the week of 9 November only 20% of cases were in isolation or treatment in Liberia, and in Sierra Leone the figure was as low as 13%. Most of these cases not in treatment or isolation are not counted in the official reports, while patients at home were also excluded.[8]

In mid-November the WHO reported that while all cases and deaths continue to be under-reported, "there is some evidence that case incidence is no longer increasing nationally in Guinea and Liberia, but steep increases persist in Sierra Leone".[53] The decline in Liberia cases is contradicted in the latest reports from WHO with 439 new cases reported between 23 and 28 November. Sierra Leone also noted a sharp increase in new cases between 23 and 30 November according to the same reports with an increase of 713 new cases in that week.[7][54]

By the end of November the total number of cases exceeded 17,000 since the outbreak started nearly a year ago.[54] One year into the outbreak the total number of cases exceeded 19,000 on 18 December. Sierra Leone has reported a surge in numbers with 8,759 cases reported.[55][56][13]

Countries with widespread transmission[edit]

Ebola outbreak in West Africa – outbreak distribution map as of 17 December 2014

Guinea[edit]

On 25 March, the World Health Organization (WHO) reported an outbreak of Ebola virus disease in four southeastern districts with a total of 86 suspected cases, including 59 deaths. MSF was helping the Ministry of Health of Guinea in establishing Ebola treatment centers in the epicenter of the outbreak.[37] 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.[37]

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.[57]

On 19 October, the WHO reported that although disease transmission remained intense, of the three districts affected, transmission remained the lowest in Guinea.[58] In mid-November it was reported that, while all cases and deaths continued to be under-reported, there was some evidence that case incidence was no longer increasing.[53] However, on 7 December, the WHO reported that the trend in Guinea since early October had been slightly increasing, with between 75 and 148 confirmed cases reported in each of the past 7 weeks.

Liberia[edit]

An Ebola treatment unit in Liberia

In Liberia, the disease was reported in Lofa and Nimba counties in late March.[59] 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.[60] Schools and universities were closed,[61][62] and the worst-affected areas in the country were placed under quarantine.[63]

With only 50 physicians in the entire country—one for every 70,000 Liberians—Liberia already faced a health crisis even before the outbreak.[64] In September the US CDC reported that some hospitals had been abandoned while those which were still functioning lacked basic facilities and supplies.[65] In October, the Liberian ambassador in Washington was reported as saying that he feared that his country may be "close to collapse".[64] By 24 October, all of the 15 Liberian districts had reported Ebola cases.[58][66]

On 29 October, the WHO announced that the rate of new infections in Liberia was declining, but urged continued vigilance against a reversal of this trend.[67] A report by CDC released on 14 November, based on data collected from Lofa county, indicates that there has been a genuine reduction in new infections. This is credited to an integrated strategy combining isolation and treatment with community behaviour change including safe burial practices, case finding and contact tracing. This strategy might serve as a model to implement in other affected areas to accelerate control of Ebola.[68]

On 10 November MSF announced that isolation units in some parts of the country now have adequate capacity. However Ebola hotspots are expected to emerge in towns and villages in Liberia, and the international response should be modified to a flexible approach that allows a rapid response to new outbreaks and gets the regular healthcare system safely up and running again.[69] On 13 November, the Liberian president announced the lifting of the state of emergency in the country following the decrease in the number of new cases.[70] On December 14, elections were postponed again due to Ebola; "we think that it is important for us to be able to ensure that elections are held in ways that are credible so that the results are accepted by everybody in the country so that we avoid crisis," one government source indicated.[71] On December 15, Liberia started treating patients with serum therapy; as one medical source said, "this will empower local health care systems to become more self-sufficient and better serve their patients during this current epidemic."[72] On December 16, the German Red Cross opened a new treatment center in Monrovia. One source indicated, "the rate of new infections is very stable at the moment, but we don't know what will happen in the following days or weeks ... we are working with high pressure so that our treatment center can operate soon. We want to be ready if the number of cases rises again."[73]

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.[74] 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.[75] On 30 July, the government began to deploy troops to enforce quarantines.[76] By 15 October, the last district in Sierra Leone untouched by the disease had declared Ebola cases.[77]

During the first week of November, it was reported that the situation was "getting worse" due to intense transmission in Freetown as a contributing factor. According to the Disaster Emergency Committee, food shortages resulting from aggressive quarantines were making the situation worse.[78] On 4 November, it was reported that thousands violated quarantine in search for food in the town of Kenema.[79] With the number of cases continuing to increase, a MSF coordinator reported the situation in Sierra Leone as "catastrophic", saying: "There are several villages and communities that have been basically wiped out... Whole communities have disappeared but many of them are not in the statistics."[80] In mid-November the WHO reported that, while there was some evidence that cases were no longer increasing in Guinea and Liberia, steep increases persisted in Sierra Leone.[53] Although the international community had responded to the emergency by building and equipping treatment centres, they were not able to function effectively because of lack of staff, poor coordination, government mismanagement and inefficiency.[81]

On 9 December, Sierra Leone authorities placed the remote Eastern Kono District in a two week lock-down following the alarming rate of infection and deaths there. The lock-down followed the WHO discovery of what news reports described as "a grim scene: piles of bodies, overwhelmed medical personnel and exhausted burial teams" in the only hospital in the area. Using a local proverb equated to "the tip of the iceberg" to describe fears of what remained to be discovered, the WHO reported fear of a major outbreak in the area saying, "We are only seeing the ears of the hippo".[82] The district with 350,000 inhabitants buried 87 bodies in 11 days, with 25 patients dying in the 5 days before the WHO arrived.[83] During the week ending 7 December, the number of cases in Sierra Leone surpassed those of Liberia. However, Sierra Leone has reported only 1,768 deaths, far below Liberia's 3,177 dead, likely due to the fact that Sierra Leone reports only laboratory confirmed cases. [84] On 12 December, Sierra Leone banned all public festivities for Christmas or New Year, because of the outbreak.[85] On 15 December, the CDC indicated the main problem now is Sierra Leone where the epidemic has given no proof of halting, and cases continue to rise exponentially; during the second week of December Sierra Leone reported nearly 400 cases, more than three times the number of cases reported by Guinea and Liberia combined. According to the CDC, "the risk we face now [is] that Ebola will simmer along, become endemic and be a problem for Africa and the world, for years to come." [86] On December 17, in Sierra Leone, treatment centers filled as health workers went through the streets of the capital city looking for any possible patients, literally going door-to-door, after the government launched an operation to contain the Ebola virus. President Koroma indicated on television that travel within the country had been restricted, "operation Western Area Surge" had begun and public gatherings would be controlled.[87][88] "Operation Western Area Surge" led to a surge in the number of cases, with 403 new cases reported between 14 to 17 December.[56][89]

Countries with successfully contained spread[edit]

Senegal[edit]

In March, the Senegal Ministry of Interior closed the southern border with Guinea,[90] but on 29 August the Senegal health minister announced Senegal's first case, a university student from Guinea who was being treated in a Dakar hospital.[47] The case was a native of Guinea who had traveled 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.[47]

On 28 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.[47] On 10 September, it was reported that the student had recovered but health officials would continue to monitor his contacts for 21 days.[91] No further cases were reported.[92] and on 17 October, the WHO officially declared that the outbreak in Senegal had ended.[9]

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.[93]

Nigeria[edit]

Nigerian states with Ebola cases (Lagos, Port Harcourt)
Nigerian health care workers at a training event, August 2014

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.[94] 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."[95]

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.[96][97]

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." According to the WHO, 19 cases and 7 deaths had been confirmed, along with the imported case, who also died. Four of the dead were health care workers who had cared for Sawyer. In all, 529 contacts had been followed and of that date they had all completed a 21 day mandatory period of surveillance.[98] The WHO's representative in Nigeria officially declared Nigeria to be Ebola free on 20 October after no new active cases were reported in the follow up contacts, stating it was a "spectacular success story".[46]

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.[99] Complimenting Nigeria's successful efforts to control the outbreak, "the usually measured WHO declared the feat 'a piece of world-class epidemiological detective work'."[100]

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.[101] 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.[102]

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.[103] A second test confirmed the diagnosis,[104] making this the first confirmed case of Ebola transmission outside Africa. On 19 October, it was reported that Romero had recovered and was officially declared to be Ebola free.[49]

On 2 December the WHO have declared Spain Ebola free after 42 days have passed since Teresa Romero was cured of Ebola on 21 October.[105]

United States[edit]

On 30 September, the United States Centers for Disease Control and Prevention (CDC) declared its first case of Ebola virus disease. The CDC disclosed that Thomas Eric Duncan became infected in Liberia and traveled to Texas on 20 September. On 26 September he fell ill and sought medical treatment but was sent home with antibiotics. He returned to the hospital by ambulance on 28 September and was placed in isolation and tested for Ebola.[106][107] Thomas Duncan died on 8 October.[108] Two additional cases stemmed from Thomas Eric Duncan, when Nina Pham and Amber Vinson tested positive for Ebola on October 10th and 14th[109][110] and ended when they were declared Ebola free on October 24th and 22nd, respectively.[111][112]

A fourth case of Ebola was identified October 23rd 2014 when Dr. Craig Spencer, a physician who had treated Ebola patients in West Africa, himself tested positive for Ebola.[113] This case had no relation to the cases originating from Thomas Eric Duncan. He was declared Ebola free on November 7th, 2014.[114] Spencer was released from the hospital on November 11.[115] He was cheered and applauded by medical staff members, and hugged by the Mayor of New York, Bill de Blasio as he walked out of the hospital. The Mayor also declared: “New York City is Ebola free".[116]

Countries with limited local transmission[edit]

Mali[edit]

Mali regions with Ebola cases (Kayes, Bamako)

On 23 October, the first case of Ebola disease in Mali was confirmed in the city of Kayes; a two year-old girl who had arrived with a family group from Guinea. Her father had worked for the Red Cross in Guinea and had also worked in a private health clinic; he died earlier in the month, likely from an Ebola infection which he had contracted in the private clinic. It was later established that a number of family members had also died of Ebola. A family group returned to Mali after the father's funeral via public bus and taxi, a journey of more than 1,200 kilometres (750 mi). On 23 October, the girl tested positive for Ebola but died the next day.[117][118] All contacts were followed for 21 days, with no further spread of the disease reported.[119]

On 12 November, Mali reported deaths from Ebola in an outbreak which is not connected with the first case in Kayes. The first probable case was an imam who had fallen ill on 17 October in Guinea and was transferred to the Pasteur Clinic in Mali's capital city Bamako for treatment. He was treated for kidney failure but was not tested for Ebola; he died on 27 October and his body was returned to Guinea for burial.[120] A nurse and a doctor who had treated the imam subsequently fell ill with Ebola and died.[121][122] The next three cases were related to the imam as well: a man who had visited the imam while he was in hospital, his wife, and his son. On 22 November, the final case related to the imam was reported: a friend of the Pasteur Clinic nurse who had died from the Ebola virus.[123] On 12 December, the last case in treatment recovered and was discharged, "so there are no more people sick with Ebola in Mali”, according to a Ministry of Health source.[124] On 16 December, Mali released the final 13 individuals that were being quarantined, therefore the country will be declared free of the virus on 18 January.[125]

Countries with medically evacuated cases[edit]

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. With the exception of a single isolated case in Spain, no secondary infections have occurred as a result of these medical evacuations.

France[edit]

A French volunteer health worker, working for MSF in Liberia, contracted Ebola and was flown to France on 18 September. After successful treatment at Bégin Military Teaching Hospital near Paris, she was discharged on 4 October.[126]

On 1 November 2014, a United Nations employee suffering from Ebola was evacuated from Sierra Leone to France for treatment. On 23 November it was announced that the person, whose identity was not disclosed, had recovered from the disease.[127]

Germany[edit]

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.[128]

On 4 October, a Ugandan doctor working in Sierra Leone was flown to Germany for treatment at the University Hospital in Frankfurt.[129] The doctor was released on 19 November after seven weeks of intensive treatment. The doctor suffered multiple organ failure and received intensive treatment "including organ replacement procedures."[130]

On 9 October, a Sudanese doctor working with the United Nations UNMIL peacekeeping force in Liberia[131] was transported to the St Georg Hospital in Leipzig for treatment.[132] He died on 14 October, becoming the first person on German soil to die of Ebola.[133]

Italy[edit]

On 24 November the Italian Health Ministry announced that an Italian doctor working for Emergency in Lakka, Sierra Leone, contracted Ebola.[134] On 25 November a military plane carrying the 50-year-old doctor landed at Pratica di Mare military airport, from which he was transferred to the Lazzaro Spallanzani National Institute for Infectious Diseases in Rome. The doctor was reportedly still not showing symptoms and in good health on arrival.[135] On November 29, it was reported the condition of the doctor, the first Italian to contract Ebola, has worsened according to Lazzaro Spallanzani hospital. The hospital has "declined" to indicate which experimental drug it has given the patient.[136] On December 10, the infectious disease unit of the hospital reported that the patient's conditions improved, as he was reported as not feverish and able to positively interact with the hospital staff.[137] On December 18, according to the Lazzaro Spallanzani National Institute for Infectious Diseases in Rome, Italy, it was indicated in their latest press bulletin that "the clinical condition of the patient is enhanced ... the patient breathes, he walks and eats independently". The next report is scheduled for Monday, December 22, according to the press officer, Lorella Saloe.[138]

Netherlands[edit]

A United Nations UNMIL Peacekeeper who contracted the disease in Liberia has arrived in the Netherlands on 6 December according to the Health Ministry.[139] The Nigerian soldier will be treated at the University Medical Centre in Utrecht. This is the third peacekeeper who contracted the disease. The first two cases were fatal.[140] On December 19, it was reported that the Nigerian UN peacekeeper is cured of Ebola; he will be transferred to the military hospital in Utrecht. The soldier was the first Ebola patient that the country of the Netherlands had taken in. "Until today the patient was in strict isolation nursed in the night by specially trained medical staff ... Specific laboratory testing, performed by Erasmus MC and Bernhard Nor Institut in Hamburg, confirm that the man (is) no longer contagious", a hospital source indicated. "The attending medical (doctor) of the UMC Utrecht said ... this hospital is part of the Ministry of defence", the source concluded. Edith Schippers, current Health Minister to the Netherlands, had indicated on December 6 that at the behest of WHO, they would treat the peacekeeper.[141]

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.[142][143] 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.[144]

Switzerland[edit]

On 18 November a Cuban doctor, Felix Baez, tested positive for Ebola in Sierra Leone. He arrived in Geneva on Friday 21 Nov for treatment at the Geneva University Hospital. Dr Baez was able to step off the plane unaided.[145] On November 25, it was reported, Dr. Baez was being treated with ZMab, an experimental drug related to ZMapp.[146] On December 6 it was announced that he had recovered and left the country.[147]

United Kingdom[edit]

An isolation unit at the Royal Free Hospital, London, received its first case on 24 August. William Pooley, a British nurse, was evacuated from Sierra Leone by the Royal Air Force on a specially-equipped C-17 aircraft. He was released from hospital on 3 September.[148][149]

United States[edit]

A number of people who contracted Ebola virus disease while working in the affected areas have been medically evacuated to the United States for treatment; most recovered, but one has died.[150] On 17 November 2014 Dr. Martin Salia, evacuated from Sierra Leone to the US, died of the Ebola virus, aged 44 years.[151]

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

In August 2014, the WHO reported an outbreak of Ebola virus in the Boende District, Democratic Republic of the Congo (DRC).[152] They confirmed that the virus is of the Zaire Ebola species, which is common in the DRC ("Zaire" is the former name of the DRC). 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.[153][154]

In August, 13 people were reported to have died of Ebola-like symptoms in the remote northern Équateur province.[154] The initial case was reported to have been a woman from Ikanamongo Village who became ill with symptoms of Ebola after she had butchered a bush animal that her husband had killed.[154] However, more recent findings suggest that there may have been several previous cases, and an investigation is ongoing.[155] According to the WHO, as of 28 October 2014, there had been 66 cases with 49 deaths including eight healthcare workers. Twenty days had passed since the last reported case was discharged and no new contacts were being followed.[156] The government of Congo declared the outbreak over on 15 November 2014, after 42 days without any new cases.[157] This was confirmed by WHO on 21 November.[158]

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 species responsible for the ongoing epidemic in West Africa.[159][160]

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 species endemic to Guinea might be the cause, rather than being imported from central to West Africa.[35] 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.[159][161]

In a study done by Tulane University, 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.[159] Five members of the research team became ill and died from Ebola before the study was published in August.[159]

Transmission[edit]

The life cycles of the Ebolavirus

It is not entirely clear how an Ebola outbreak starts.[162] 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.[163]

Human-to-human transmission occurs only via direct contact with blood or bodily fluids from an infected person who is showing signs of infection or by contact with objects recently contaminated by an actively ill infected person.[164] 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.[165] Semen and possibly other body fluids (e.g., breast milk) may be infectious in survivors for months.[166][167]

One of the primary reasons for spread is the poorly-functioning health systems in the part of Africa where the disease occurs.[168] 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.[162]

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.[169] 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.[170]

Difficulties in attempting to contain the outbreak include its multiple locations across country borders.[171] 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.[57] 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 has made transmission harder to track and break.[27]

Containment and control[edit]

Nigerian doctors receive training in how to use protective clothing by the World Health Organization.

On 28 August the WHO published a roadmap of the steps required to bring the epidemic under control and to prevent further transmission of the disease within West Africa; the coordinated international response is working to realise this plan.[172] Key elements required to prevent transmission are contact tracing and follow-up as well as social mobilisation and public awareness.

Surveillance and contact tracing[edit]

Contact tracing is an essential method of preventing the spread of the disease. This requires effective community surveillance so that a possible case of Ebola can be registered and accurately diagnosed as soon as possible, and subsequently finding everyone who has had close contact with the case and tracking them for 21 days. However, this requires careful record-keeping by properly trained and equipped staff.[173] 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."[174] There is a massive ongoing effort to train volunteers and health workers, sponsored by USAID.[175] According to WHO reports 25,926 contacts from Guinea, 35,183 from Liberia and 104,454 from Sierra Leone are listed and being traced as of 23 November.[7]

Community awareness[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.[176] These include avoiding contact with infected people and regular hand washing using soap and water.[177] 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."[178]

A number of organisations have enrolled local people to conduct public awareness campaigns among the communities in West Africa.[179] "...what we mean by social mobilization is to try to convey the right messages, in terms of prevention measures, adapted to the local context – adapted to the cultural practices in a specific area,” said Vincent Martin, FAO’s representative in Senegal.[180]

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.[23][24][25][41] An August 2014 study found that nearly two thirds of Ebola cases in Guinea are believed to be due to burial practices.[181] In November, WHO released a protocol for safe and dignified burial of people who die from Ebola virus disease which encourages inclusion of family and clergy, giving specific instructions for Muslim and Christian burials.[182]

Denial in some affected countries has also made containment efforts difficult.[183] Language barriers and the appearance of medical teams in protective suits has sometimes increased fears of the virus.[184] In Liberia, a mob attacked an Ebola isolation centre, stealing equipment and "freeing" patients while shouting "There's no Ebola."[185] Red Cross staff were forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives.[186] 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.[187]

Travel restrictions and quarantines[edit]

There is serious concern that the disease may spread further within West Africa or elsewhere in the world.

West Africa[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.[188] This has subsequently been replaced by a series of simple checkpoints for hand-washing and measuring body temperature on major roads throughout the region, manned either by local volunteers or by military.[189][190]

International[edit]

Many countries have considered imposing restrictions on travel to or from the region. On 2 September, WHO Director-General Margaret Chan advised against this, 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".[26] 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."[30]

In early August, airports in Guinea, Liberia and Sierra Leone began screening departing passengers for symptoms of Ebola. A study of the effectiveness of this has concluded that it has probably prevented 3 cases of Ebola per month from leaving the affected countries.[191][192]

Returning health workers[edit]

There is concern that people returning from affected countries, such as health workers and reporters, may be incubating the disease and become infectious after arriving. A number of agencies have issued guidelines for returning workers; examples are CDC,[193] MSF,[194] Public Health England,[195] and Public Health Ontario.[196] Generally these recommend a risk assessment based on the likelihood of exposure. People in the low risk category are recommended to self-monitor for 21 days for symptoms which may indicate Ebola; there are more stringent requirements for those judged to be at higher risk.

The US Centers for Disease Control and Prevention recommends monitoring of exposed people for 21 days but does not require quarantine, in which they are kept away from others. However, in October some states in the United States made a decision to ignore the CDC guidelines and issued orders for a mandatory 21-day quarantine.[197] In compliance with the new orders, Kaci Hickox, a nurse who was returning after working with Doctors Without Borders, was quarantined in a tent in the parking lot of a New Jersey hospital, one of the states that had adopted the stricter quarantine rules.[198][199][200] After threat of a legal action, Hickox was allowed to return to her home in Maine, where she again faced mandatory quarantine.[201] Hickox again took legal measures to allow her to follow the recommended CDC guidelines rather than an enforced state mandatory quarantine. The court ruled for Hickox saying, "The court is fully aware of the misconceptions, misinformation, bad science and bad information being spread from shore to shore in our country with respect to Ebola. The court is fully aware that people are acting out of fear and that this fear is not entirely rational."[202]

Speaking on lengthy quarantines for health care workers, US President Barack Obama said that "subjecting returning health-care workers to lengthy quarantines is motivated by fear, not science, and will be counterproductive because it will dissuade people from joining the fight against the disease in West Africa."[203] National Institute of Health expert Anthony Fauci has also urged against these mandatory quarantines, warning that they would further discourage American healthcare workers from traveling to affected areas.[204][205] The United Nations is concerned about travel restrictions placed on medical workers returning from West Africa and has issued a statement disapproving of the excessive quarantine of medical personnel.[206]

Treatment[edit]

No proven Ebola virus-specific treatment presently exists,[207] however there are measures that can be taken that will improve a patient's chances of survival.[208] Ebola symptoms may begin as early as two days or as long as 21 days after one is exposed to the virus. They usually begin with a sudden influenza-like stage characterized by feeling tired, fever, and pain in the muscles and joints. Later symptoms may include headache, nausea, and abdominal pain.[209] This is often followed by severe vomiting and diarrhoea.[209]

Without fluid replacement, such extreme loss of fluids leads to dehydration which may lead to hypovolaemic shock, a condition which occurs when there isn't enough blood for the heart to pump through the body. If a patient is alert and is not vomiting, oral rehydration fluids may be given, but patients who are vomiting or are delirious must be treated with intravenous fluids. In past outbreaks it has been noted that some patients may experience the loss of blood through bleeding internally and/or externally, however early data suggests that bleeding has been a rare symptom in this particular outbreak.[210]

Prognosis[edit]

Ebola virus disease has a high risk of death in those infected which varies between 25 percent and 90 percent of those who have contracted the disease. The case fatality rate (CFR), in previous Ebola infections is 50%, however it is known that the Zaire species, which is responsible for the current outbreak, carries a higher death rate.[211] Care settings that have access to medical expertise may increase survival by providing maintenance of hydration, circulatory volume, and blood pressure.[210]

The disease affects males and females equally and the majority of those that contract Ebola disease are between 15 and 45 years of age.[14] For those over 45 years of age, a fatal outcome has been more likely in the current epidemic, as has also been noted in past outbreaks.[210] Only rarely do pregnant women survive. A midwife who works with MSF in a Sierra Leone treatment center states that she knew of "no reported cases of pregnant mothers and unborn babies surviving Ebola in Sierra Leone."[212]

It has been suggested that the loss of human life is not limited to Ebola victims alone. Many hospitals have shut down leaving people with other medical needs without care. A spokesperson for the UK-based health foundation the Wellcome Trust said in October that "the additional death toll from malaria and other diseases [is] likely to exceed that of the outbreak itself".[28] Doctor Paul Farmer states "Most of Ebola's victims may well be dying from other causes: women in childbirth, children from diarrhoea, people in road accidents or from trauma of other sorts."[29]

Level of care[edit]

Local authorities have not had resources to contain the disease, with health centres closing and hospitals overwhelmed.[213] 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."[171] Adequate equipment has not been provided for medical personnel,[214] with even a lack of soap and water for hand-washing and disinfection.[215]

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.[216]

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."[217] According to a WHO report released on 19 September, Sierra Leone is currently meeting only 35% of its need for patient beds, and Liberia is meeting only 20% of its need.[218] The WHO has set a goal to isolate and treat 100% of Ebola cases and provide safe burials by 1 January 2015.

In early December the WHO reported that at a national level there was now a sufficient number of beds in treatment facilities to treat and isolate all reported Ebola cases, although the uneven distribution of cases is resulting in serious shortfalls in some areas. Similarly, all affected countries now have sufficient and widespread capacity to bury all reported deaths; however, because not all deaths are reported, it is possible that some areas still have insufficient burial capacity. Every district now has access to a laboratory to confirm cases of Ebola within 24 hours from sample collection. All three countries report that more than 80% of registered contacts associated with known cases of EVD are being traced, although contact tracing is still a challenge in areas of intense transmission and in areas of community resistance. [219]

Current bed capacity in countries with active cases as of 14 Dec 2014.[13]
Countries Existing beds Planned beds Percentage of
existing/planned beds
Guinea 230 695 37%
Liberia 650 1,219 53%
Sierra Leone 615 2,020 30%
Total 1,525 3,934 39%

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.[220][221]

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.[222][223] 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.[224][225] 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.[226] 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.[227]

Protective clothing[edit]

Médecins Sans Frontières and American CDC staff preparing to enter an Ebola treatment unit in Liberia

The Ebola epidemic has caused an increasing demand in protective clothing. 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.[228]

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."[229][230] According to some reports, protective outfits are beginning to be in short supply and manufacturers have started to increase their production,[231] but the need to find better types of suits has also been raised.[232]

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".[233][234][235][236] On December 17, a team at Johns Hopkins developed a prototype breakaway hazmat suit. The project has been awarded a grant from the U.S. Agency for International Development (USAID) to develop. The prototype has a small, battery-powered cooling pack on the worker's belt; "you'll have air blowing out that is room temperature but it's 0% humidity ... the Ebola worker is going to feel cold and will be able to function inside the suit without having to change the suit so frequently," indicated one source.[237]

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.[238] 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.[27]

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.[239] 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".[27]

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".[240] In July, leading Ebola doctor Sheik Umar Khan from Sierra Leone died in the outbreak. 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".[74] His death was followed by two more deaths in Sierra Leone: Modupe Cole, a senior physician at the country's main referral facility,[241] and Sahr Rogers, who worked in Kenema.[242][243][244] 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.[96]

Basing their choice on "the person or persons who most affected the news and our lives, for good or ill, and embodied what was important about the year", in December the editors of Time magazine named the Ebola health workers as Person of the Year. Editor Nancy Gibbs said, "The rest of the world can sleep at night because a group of men and women are willing to stand and fight. For tireless acts of courage and mercy, for buying the world time to boost its defenses, for risking, for persisting, for sacrificing and saving, the Ebola fighters are Time's 2014 Person of the Year."[33]

By 14 December, the WHO reported 649 workers had been infected and 365 had died. Liberia has been especially hard hit with over half the total cases (365 with 177 deaths) reported. Sierra Leone registered 142 cases with 109 fatalities, thus indicating a death toll of 79.5% in Sierra Leone. Guinea reported 125 infected cases with 72 deaths. One infected case in Spain was reported, as well as three in the United States. In Nigeria 11 healthcare workers were also infected and 5 deaths were recorded. Mali reported 2 with 1 death to date.[13]

Experimental interventions[edit]

Experimental treatments[edit]

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

There is as yet no known effective medication or vaccine. The director of the US National Institute of Allergy and Infectious Diseases has stated that the scientific community is still in the early stages of understanding how infection with the Ebola virus can be treated and prevented.[245] 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.[246][247] 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.[248]

A number of experimental treatments are being considered for use in the context of this outbreak, and are currently or will soon undergo clinical trials,[249] but it will still be some time before sufficient quantities have been produced for widespread trials.[245] On 13 November, MSF announced that trials of three possible treatments - serum, brincidofovir and favipiravir (see below) - would start during November in Ebola treatment centres.[250] On December 17, it was reported in a new study in the Nature Press journal Emerging Microbes and Infections, that researchers at the Icahn School and National Institutes of Health (NIH) indicated 53 promising drug compounds have been identified to possibly treat Ebola. The team used technology to go through a library of almost 3,000 U.S. Food and Drug Administration compounds that are used to treat other ailments. The drugs could prevent Ebola from infecting human cells by 50%; it is possible Ebola could be treated similarly to what has been developed for the viruses HIV and hepatitis C.[251]

  • Serum Transfusion - Identified as a promising method since the early 1970s days of Ebola research,[252] 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 in the short term, although there is little information on its efficacy.[253] The first clinical trial of this therapy, involving 70 patients, started at the ELWA 2 treatment Centre in Liberia during December with funding from the Gates Foundation in coordination with national health authorities and WHO. Further trials are scheduled to start in late December or early January in Guinea and Sierra Leone.[254]
  • ZMapp, a combination of monoclonal antibodies. The limited supply of the drug has been used to treat 7 individuals infected with the Ebola virus.[255] Although some of them have recovered, the outcome is not considered to be statistically significant.[256] ZMapp has proved highly effective in a trial involving rhesus macaque monkeys.[257] Texas A&M University stated on 8 October that it was preparing to mass-produce the drug, in its Center for Innovation in Advanced Development and Manufacturing, pending final approval.[258]
  • TKM-Ebola, an RNA interference drug.[259] A Phase 1 clinical trial involving healthy volunteers was started in early 2014 but suspended because of concern over side effects; however the FDA has approved emergency use to treat patients actually infected with the virus.[260][261] On December 4, it was reported that TKM-Ebola is "on a partial clinical hold because the U.S. Food and Drug Administration"[262] has concerns in regards to the safety data it has put forth.
  • Favipiravir (Avigan), a drug approved in Japan for use against influenza; the drug appears to be useful in a mouse model of Ebola disease,[263][264] and a clinical trial is being planned for Ebola patients in Guinea, due November. The drug has been tried on four Ebola patients who subsequently recovered, but this outcome is not statistically significant.[265]
  • BCX4430 is a broad-spectrum antiviral drug developed by BioCryst Pharmaceuticals and currently being researched as a potential treatment for Ebola by USAMRIID.[266] The drug has been approved to progress to Phase 1 trials, expected late in 2014.[267]
  • Brincidofovir, another 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.[268] On 16 October, it was cleared to start clinical trials.[269] A November 17 report indicated that Chimerix sent its experimental drug to west Africa, so it can be evaluated in clinical studies of patients with the Ebola virus.[270]
  • JK-05 is an antiviral drug developed by the Chinese company Sihuan Pharmaceutical along with the Chinese Academy of Military Medical Sciences. In tests on mice, JK-05 shows efficacy against a range of viruses, including Ebola. It is claimed to have a simple molecular structure, which should be readily amenable to synthesis scale-up for mass production. The drug has been given preliminary approval by the Chinese authorities to be available for Chinese health workers involved in combating the outbreak, and Sihuan are preparing to conduct clinical trials in West Africa.[271][272]

Experimental preventative vaccines[edit]

  • In September, an experimental vaccine, now known as the cAd3-ZEBOV vaccine, commenced Phase 1 trials, being administered to volunteers in Oxford, Bethesda and Mali. The vaccine was developed jointly by GlaxoSmithKline and the NIH. During November it was reported that the initial results were promising and it is hoped that it will be possible to offer the vaccine, initially to health workers, from January 2015.[273] In preparation for this, GSK is preparing a stockpile of 10,000 doses.[274][275] On December 4, it was reported that scientists at Oxford University had begun the first tests (clinical) of a new Ebola vaccine method, a booster made by Bavarian Nordic that may bolster the effects of the GlaxoSmithKline injection. Furthermore, "if a single dose of an Ebola vaccine is sufficient, it makes absolute sense to use that. But it also makes sense at this early stage of trials to see if a second booster vaccine can greatly increase the levels of immune responses produced," sources indicated.[276] On December 19, it was reported that trials of GlaxoSmithKline's Ebola vaccine will be moving into the second phase on February, after a meeting of national regulators indicated more time was needed to review the available information. "Reviewing countries requested additional documentation from the manufacturer of the vaccine, GlaxoSmithKline, before authorization of the trials," a WHO source indicated in a press release. Still there are several unresolved questions in regards to the use of experimental vaccines, such as whether patients might need one or two injections.[277]
  • A second vaccine candidate, rVSV-ZEBOV, has been developed by the Public Health Agency of Canada, with development subsequently taken over by Merck Inc.[278] On 29 October, the Wellcome Trust announced the start of multiple trials in healthy volunteers in Europe, Gabon, Kenya, and the USA.[279] On 2 December, researchers announced early results from the trials indicating no serious side effects.[280] However, on 11 December, the trial was temporarily halted, due to some side effects in four of the 59 participants, including joint pains in the hands and feet. The trial may resume on 5 January, if the symptoms are found to be "benign and temporary", according to the University of Geneva Hospital.[281][282]
  • A third vaccine candidate, consisting of a prime-boost regimen of an adenovirus vaccine component from Crucell (Johnson & Johnson) and a modified vaccinia Ankara component from Bavarian Nordic is being prepared for clinical trials in early 2015.[283] Johnson & Johnson have announced their commitment to accelerate the development of the vaccine and will produce more than 1 million doses of the vaccine during 2015.[284]
  • A fourth vaccine candidate, made by the government of China has been approved to begin clinical trials, the official government news agency Xinhua indicated on Thursday. The vaccine is made by the Academy of Military Medical Sciences, a military research unit. Chinese biotechnology firm Tianjin CanSino Biotechnology Inc is involved. Trials will begin this month. "This follows American and Canadian vaccines to become the third Ebola vaccine to enter clinical trials," one source indicated. It is based on the 2014 mutant gene and targets the strain plaguing west Africa.[285][286]

Potential diagnostic tests[edit]

One issue which hinders control of Ebola is that diagnostic tests which are currently available require specialised equipment and highly trained personnel. Since there are few suitable testing centres in West Africa, this leads to delay in diagnosis. In December, a conference in Geneva will aim to work out which diagnostic tools could be to identify Ebola reliably and more quickly. The meeting, convened by the WHO and the non-profit Foundation for Innovative New Diagnostics, seeks to identify tests that can be used by untrained staff, do not require electricity or can run on batteries or solar power and use reagents that can withstand temperatures of 40 °C.[287]

On 29 November, a new 15-minute Ebola test was reported that if successful, "not only gives patients a better chance of survival, but it prevents transmission of the virus to other people." The new equipment, about the size of a laptop and solar-powered, allows testing to be done in remote areas. The equipment is currently being tested in Guinea.[288]

Outlook[edit]

Since the beginning of the outbreak, there has been considerable difficulty in getting reliable estimates both of the number of people affected, and of the geographical extent of the outbreak.[289] 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.[290]

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 succumbing to infection. Since the symptoms of Ebola 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 Ebola cases and deaths are not consistent with field observations, and are likely to understate the extent of the epidemic.[2][18][291]

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.[292][293] On 23 September, the WHO released a revised and more accurate CFR of 70.8% (with 95% confidence intervals of 68.6%-72.8%), derived using data from patients with definitive clinical outcomes.[14] The latest 1014 estimate was released in December. On 7 December, the WHO reported a CFR for the current epidemic of cases with a "recorded definitive outcome" at 76%.[294]

The basic reproduction number R0 is a statistical measure of the average 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.[295] For the current outbreak, R0 is estimated to be between 1.5 and 2.5.[14][296] According to the WHO Ebola response team, "once infection has become established, the number of people still at risk declines, so the reproduction number falls from its maximum value of R 0 to a smaller, net reproduction number, R t. When R t falls below 1, infection cannot be sustained. Estimates of R 0 and R t help in evaluating the magnitude of the effort required to control the disease, the way in which transmission rates have fluctuated.Many factors contribute to the R0, such as how long you're infectious and how many virus particles are needed to make another person sick."[297] With the Ebola virus, the way the virus is transmitted keeps its R0 low, Ebola isn't spread through the air,it requires close contact with some bodily fluid, blood or vomit, that have the virus. R0 of 2 means one person infects two individuals, who infect four, 8, 16, 32, 64— and so on.The R0 is assimilated over time when an individual is infectious. For example with HIV, this could be years, but for Ebola, that time is a week.Therefore, even though they have about the same R0s, Ebola has an "infections per unit of time" greater than HIV's.[298]

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.[172] The WHO roadmap states "this 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 Ebola 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 three months."[172] It includes an assumption that some country or countries will pay the required cost of their plan, estimated at half a billion dollars.[172]

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.[299][300] On 9 September, Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine in Germany, controversially announced that the containment fight in Sierra Leone and Liberia has already been "lost" and that the disease would "burn itself out".[301]

On 23 September, 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.[14] 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",[302] and according to an editorial in the New England Journal of Medicine, eventually to other parts of Africa and beyond.[303]

A report on 23 September by CDC analyses the impact of underreporting - which requires correction of case numbers by a factor of up to 2.5. With this correction factor, approximately 21,000 total cases were estimated 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 the end of January 2015 if no improvement in intervention or community behaviour occurred.[2] However at a congressional hearing on 19 November the director of CDC said that the number of Ebola cases is no longer expected to exceed 1 million, moving away from the worst-scenario that had been previously predicted.[304]

The Laboratory for the Modeling of Biological and Socio-Technical Systems (MoBS) at Northeastern University has published an online model which assesses the progression of the epidemic in West Africa and its international spread based on simulations of epidemic spread worldwide. The analysis is considered as a live paper that is constantly updated with new data, projections and analysis; it has been updated twice in September, October and November, with the latest update on 24 November.[305][306]

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, which leads to loss of income for producers and traders.[307]
  • Movement of people away from affected areas has disturbed agricultural activities.[308][309] The UN Food and Agriculture Organisation (FAO) has warned that the outbreak could endanger harvest and food security in West Africa.[310] On December 17, it was reported that Ebola continues its attack on Guinea, Liberia and Sierra Leone; the disease is posing a greater threat to food security. United Nations agencies are warning that more than 1 million people could be food insecure by March. "With all the quarantines and movement limitations placed on them ... there’s an absolute lack of labor force in this area", one source indicated. The UN agency must "re-establish the farm system in the three countries," the source concluded.[311]
  • Tourism is directly impacted in affected countries.[312] Other countries in Africa which are not directly affected by the virus have also reported adverse effects on tourism.[313][314][315]
  • Many airlines have suspended flights to the area.[316]
  • Foreign mining companies have withdrawn non-essential personnel, deferred new investment, and cut back operations.[309][317][318]
  • The outbreak is straining the finances of governments, with Sierra Leone using Treasury bills to fund the fight against the virus.[319]
  • The IMF is considering expanding assistance to Guinea, Sierra Leone, and Liberia as their national deficits are ballooning and their economies contract sharply.[320] On December 17, it was reported that the International Monetary Fund (IMF) had been asked to provide debt relief to the three worst Ebola-hit countries, which will spend $100 million by this year's end. "They can't afford to have millions of dollars flowing out of their economies now when every day counts in fighting this frightening disease," one source was quoted as saying, adding, "yet the IMF, which has made a $9 billion surplus from its lending over the last three years, is considering offering loans, not debt relief and grants, in response".[321]
  • 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.[322][323] On December 2, it was reported that the epidemic would cost about $2 billion across the west African region, causing robust economies to slow down to a stall.[324]

Responses[edit]

In July, the World Health Organization, a United Nations agency which coordinates international response to disease outbreaks, 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.[325] 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.[19][326]

There has been heavy criticism of the WHO from some aid agencies because its response has been perceived as slow and insufficient, especially during the early stage of the outbreak.[327] In October, the Associated Press reported that in a leaked preliminary draft report the WHO admitted to mistakes saying that they had missed chances to stop the spread of Ebola "thanks to incompetent staff, a lack of information, and bureaucracy due to 'politically motivated appointments'." Peter Piot, co-discoverer of the Ebola virus, has called the WHO staff "really not competent.”[328]

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.[329][330]

During October, WHO and UNMEER announced a comprehensive 90-day plan to control and reverse the Ebola epidemic. The immediate objective is to isolate at least 70% of Ebola cases and safely bury at least 70% of patients who die from Ebola by 1 December 2014 (the 60-day target) - this has become known as the 70:70:60 program. The ultimate goal is to have capacity in place for the isolation of 100% of Ebola cases and the safe burial of 100% of casualties by 1 January 2015 (the 90-day target).[331] Many nations and charitable organizations are cooperating to realise this plan.[332] A WHO situation report in mid-December indicated that the international community was on track to meet the 90-day target.[333]

Timeline of reported cases and deaths[edit]

Data sources[edit]

Data comes from reports by the World Health Organization Global Alert and Response Unit[Resource 1] and the Organization's Regional Office for Africa.[Resource 2] All numbers are correlated with United Nations Office for the Coordination of Humanitarian Affairs (OCHA) if available.[Resource 3] 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 3 times as many cases as officially reported.[2][334][19] As an example, Sierra Leone has grown cases at a much faster rate, while simultaneously at an insoluble lower reported death rate versus those in Guinea and Liberia.[335] And 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."[18]

Characterizations of rate of growth[edit]

On October 23 WHO noted at a press conference that exponential increase of cases continued in the countries with the most intense transmission (Guinea, Liberia and Sierra Leone).[336] A study estimated during the first 9 months of the outbreak the disease was transmitted onwards to approximately 1.7-2 people for each case.[14]

Understanding the data and its limitations[edit]

Each row of the table represents the best available information cross-checked from multiple sources on the day it was reported. The data may be inaccurate for the following reasons:

  • Each data source or report may or may not include suspected cases that have not yet been confirmed.
  • Each source or report may or may not include probable cases.
  • Case numbers may be revised downward if a probable or suspected 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.)
  • The reports usually refer to cumulative data totals since the start of the 2014 epidemic. When new data becomes available or old data is revised the correction could apply either to the past or the present.
  • The number of deaths may revise downwards if it is later found from testing those deaths were not from Ebola.
  • There are variable delays in gathering, correcting and reporting the data from multiple sources.

It is not possible to infer the rate of growth or decline in the spread of the disease from the cumulative data or the graphs; they simply reflect a timeline of the available data as reported on any given date. The real-world spread could be slowing while reported cumulative cases rise at a faster rate due to improved reporting, or the real-world spread could be increasing with flat cumulative data due to lack of reporting.

Graphs[edit]

Tables[edit]

Major Ebola virus outbreaks by country and by date – 17 October to most recent WHO / Gov update
Note: These reflect official confirmations only. The actual numbers are estimated to be higher.[2][334][19]
Date Total Guinea Liberia Sierra Leone Sources
Cases Deaths Cases Deaths Cases Deaths Cases Deaths
14 Dec 2014 18,590 7,288 2,415 1,525 7,819 3,346 8,356 2,417 [note 1][13][89][55]
9 Dec 2014 18,150 6,933 2,339 1,454 7,797 3,290 8,014 2,189 [note 2][337][338][84]
7 Dec 2014 17,954 6,776 2,292 1,428 7,765 3,222 7,897 2,100 [note 3][219][339][84]
30 Nov 2014 17,129 6,397 2,164 1,325 7,653 3,157 7,312 1,915 [note 4][54][340][341]
28 Nov 2014 16,869 6,319 2,155 1,312 7,635 3,145 7,109 1,862 [note 5][342][343]
23 Nov 2014 15,929 5,988 2,134 1,260 7,196 3,029 6,599 1,699 [note 6][7][344][345]
18 Nov 2014 15,319 5,775 2,047 1,214 7,082 2,963 6,190 1,598 [note 7][346][347]
16 Nov 2014 15,113 5,727 1,971 1,192 7,069 2,964 6,073 1,571 [note 8][8][348]
11 Nov 2014 14,383 5,492 1,919 1,166 6,878 2,812 5,586 1,514 [note 9][6][349]
9 Nov 2014 14,068 5,476 1,878 1,142 6,822 2,836 5,368 1,498 [note 10][350][351]
4 Nov 2014 13,200 5,275 1,760 1,054 6,619 2,766 4,821 1,455 [note 11][15][351]
2 Nov 2014 13,014 5,191 1,731 1,041 6,524 2,700 4,759 1,450 [note 12][352][353][354]
30 Oct 2014 12,647 5,087 1,675 1,022 6,485 2,636 4,487 1,429 [note 13][355][356][357]
24 Oct 2014 11,868 5,026 1,598 981 6,253 ≥2,704 4,017 1,341 [note 14][66][358][359]
19 Oct 2014 9,911 4,890 1,540 926 ≥4,665 ≥2,705 3,706 1,259 [note 15][58]
17 Oct 2014 9,668 4,802 1,501 886 ≥4,607 ≥2,689 3,560 1,227 [note 16][9][360][361][362]

Notes[edit]

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 ≥ may not be consistent due to under reporting.
  1. ^ 14 December: Guinea as per WHO.Sierra Leone and Liberia as per government report.
  2. ^ 9 December: All governments as per WHO.Sierra Leone deaths as per Government report.
  3. ^ 7 December: All governments as per WHO.Sierra Leone deaths as per Government report.
  4. ^ 28 November: Guinea governments as per WHO. Sierra Leone and Liberia as per Government report.
  5. ^ 28 November: All governments as per WHO. Sierra Leone deaths as per Government report.
  6. ^ 23 November: All governments as per WHO except Sierra Leone deaths as per Government report and Liberia as per Gov (WHO report only till 22 Nov for Lib.)
  7. ^ 18 November: All governments as per WHO. Sierra Leone deaths as per Government report. Liberia dated 17 November
  8. ^ 16 November: All governments as per WHO. Sierra Leone deaths as per Government report. Liberia dated 15 November
  9. ^ Guinea and Sierra Leone up to the end of 11 November, and the Ministry of Health of Liberia up to the end of 10 November. Sierra Leone deaths as per Government report
  10. ^ All totals as per WHO report for 9 Nov except Sierra Leone deaths as per Government report
  11. ^ All totals as per WHO report for 4 Nov except Guinea, dated 3 Nov 2014 and Sierra Leone as per Government report
  12. ^ 2 November Liberian and Sierra Leone as per Gov. Guinea as per OCHA.
  13. ^ 30 October Liberian and Sierra Leone as per Gov. Guinea as per OCHA.
  14. ^ Liberia and Sierra Leone countries date as per governments. Guinea as per OCHA. All cases dates 24 October. Death toll for Liberia as per latest WHO report.
  15. ^ 19 October as per WHO for all except Liberia 18 October.
  16. ^ 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
  17. ^ 12 October as per WHO Spain and US as per news reports

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External links[edit]

Resources[edit]

  1. ^ "Disease Outbreak News (DONs)". Global Alert and Response (GAR). WHO.    Website content changes frequently.
  2. ^ "Disease Outbreak News". Regional Office for Africa. WHO.    Website content changes frequently.
  3. ^ "West and Central Africa". HumanitarianResponse.info. OCHA.