Ebola virus epidemic in West Africa
Situation map of the outbreak in West Africa
|Date||December 2013 – present|
The most widespread epidemic of Ebola virus disease (commonly known as "Ebola") in history is currently ongoing in several West African countries. It has caused significant mortality, with reported case fatality rates of up to 70%[note 1] and specifically 57–59% among hospitalized patients. Ebola virus disease was first described in 1976 in two simultaneous outbreaks in sub-Saharan Africa; this is the 26th outbreak and the first to occur in West Africa. It began in Guinea in December 2013 and then spread to Liberia and Sierra Leone. A small outbreak of twenty cases occurred in Nigeria and one case occurred in Senegal; both Nigeria and Senegal are now declared disease-free. Several cases were reported in Mali, but this outbreak has also been declared over, and an isolated case has been reported in the United Kingdom. Imported cases in the United States and Spain led to secondary infections of medical workers but did not spread further. As of 29 April 2015[update], the World Health Organization (WHO) and respective governments have reported a total of 26,333 suspected cases and 10,907 deaths, though the WHO believes that this substantially understates the magnitude of the outbreak.
This is the first Ebola outbreak to reach epidemic proportions; past outbreaks were brought under control within a few weeks. Extreme poverty, a dysfunctional healthcare system, a mistrust of government officials after years of armed conflict, and the delay in responding to the outbreak for several months have all contributed to the failure to control the epidemic. Other factors include local burial customs that include washing of the body after death and the spread to densely populated cities.
As the disease progressed, many hospitals, short on both staff and supplies, became overwhelmed and 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". Hospital workers, who work closely with the highly contagious body fluids of the diseased, have been especially vulnerable to catching the disease. In August 2014, the WHO reported that ten percent of the dead have been healthcare workers. In September 2014, it was estimated that the countries' capacity for treating Ebola patients was insufficient by the equivalent of 2,122 beds; by December there were a sufficient number of beds to treat and isolate all reported Ebola cases, although the uneven distribution of cases was resulting in serious shortfalls in some areas. On 28 January 2015, the WHO reported that for the first time since the week ending 29 June 2014, there had been fewer than 100 new confirmed cases reported in a week in the three most-affected countries. The response to the epidemic then moved to a second phase, as the focus shifted from slowing transmission to ending the epidemic. On 8 April 2015, the WHO reported a total of only 30 confirmed cases, the lowest weekly total since the third week of May 2014.
The World Health Organization has been criticised for its delay in taking action to address the epidemic. By September 2014, Médecins Sans Frontières/Doctors Without Borders (MSF), the non-governmental organization (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." 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" and the Director-General, Margaret Chan, called the outbreak "the largest, most complex and most severe we've ever seen". In March 2015, the United Nations Development Group reported that due to a decrease in trade, closing of borders, flight cancellations, and foreign investment and tourism activity fuelled by stigma, the epidemic has resulted in vast economic consequences in both the affected areas and even throughout African nations that experienced low or no cases of Ebola. In April 2015, the Pulitzer Prize for feature photography was awarded to Daniel Berehulak for his photojournalism of the Ebola outbreak.
|Articles related to the|
|Ebola virus epidemic in
|Ebola virus disease
Timeline of the epidemic
Responses to the epidemic
|Nations with widespread transmission|
|Guinea • Liberia • Sierra Leone|
|Nations with isolated cases|
|Formerly affected nations|
|Mali • Nigeria • Senegal • Spain • United States • United Kingdom|
|List of Ebola outbreaks
1976 Zaire outbreak
2014 DR Congo outbreak
- 1 Epidemiology
- 1.1 Outbreak
- 1.2 Countries with widespread transmission
- 1.3 Countries with successfully contained spread
- 1.4 Countries with limited local cases
- 1.5 Countries with medically evacuated cases
- 1.6 Separate outbreak in the Democratic Republic of the Congo
- 2 Virology
- 3 Transmission
- 4 Containment and control
- 5 Treatment
- 6 Experimental treatments, vaccines and testing
- 7 Outlook
- 8 Economic effects
- 9 Responses
- 10 Timeline of reported cases and deaths
- 11 See also
- 12 References
- 13 External links
Researchers generally believe that a one-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. 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. 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.
On 25 March 2014, 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. By late May, the outbreak had spread to Conakry, Guinea's capital, a city of about two million inhabitants. On 28 May, the total number of cases reported had reached 281 with 186 deaths.
In Liberia, the disease was reported in four counties by mid-April 2014 and cases in Liberia's capital Monrovia were reported in mid-June. 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. 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.
The first death in Nigeria was reported on 25 July 2014: a Liberian-American with Ebola flew from Liberia to Nigeria and died in Lagos soon after arrival. As part of the effort to contain the disease, possible contacts were monitored – 353 in Lagos and 451 in Port Harcourt. 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.
On 29 August 2014, 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. This person subsequently recovered, and on 17 October 2014, the WHO officially declared that the outbreak in Senegal had ended.
In August and September 2014, two Spanish health care workers contracted Ebola in Liberia 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. 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; they both 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. In a separate outbreak in November, Mali reported seven cases with five deaths in Bamako.
In mid-November, the WHO reported that while all cases and deaths continued 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". One year into the outbreak, the total number of cases exceeded 20,000 on 29 December 2014.
On 28 January 2015, the WHO reported that for the first time since the week ending 29 June 2014, there had been fewer than 100 new confirmed cases reported in a week in the three most-affected countries. A combined total of 99 confirmed cases were reported from the three countries in the week to 25 January: 30 in Guinea, 4 in Liberia, and 65 in Sierra Leone. The response to the epidemic then moved to a second phase as the focus shifted from slowing transmission to ending the epidemic. Efforts have now moved from rapidly building infrastructure to ensuring that capacity for case finding, case management, safe burials, and community engagement is used as effectively as possible.
On 31 March 2015, one year since the outbreak was first reported, the total number of cases exceeded 25,000 with over 10,000 deaths according to the latest WHO report. The 8 April 2015 WHO Ebola Situation Report stated that a total of 30 confirmed cases were reported in the week to 5 April; this is the lowest weekly total since the third week of May 2014.
Countries with widespread transmission
On 25 March 2014, the WHO reported an outbreak of Ebola virus disease in four southeastern districts with a total of 86 suspected cases, including 59 deaths. Médecins Sans Frontières (MSF) assisted the Ministry of Health of Guinea by establishing Ebola treatment centers in the epicenter of the outbreak. 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.
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.
On 19 October 2014, the WHO reported that although disease transmission remained intense, of the three districts affected, transmission remained the lowest in Guinea. 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. 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 previous seven weeks.
According to the WHO, 60% of the Ebola cases in Guinea are related to the practice of traditional burial rituals. Speaking on 27 January, Guinea's Grand Imam El Hadj Mamadou Saliou Camara, the country's highest cleric, said, "There is nothing in the Koran that says you must wash, kiss or hold your dead loved ones," and he called on citizens to do more to stop the virus by practicing safer burying rituals that do not compromise tradition.
On 11 February, Guinea recorded a rise in cases for the second week in a row. Health authorities said that the rise in cases was related to the fact that they "were only now gaining access to faraway villages" where violence had previously prevented them from entering. On 14 February, violence broke out and an Ebola treatment center near the center of the country was destroyed. According to Guinea Red Cross teams, they have been attacked an average of 10 times a month over the last year. On 24 February, MSF reported that acceptance of Ebola education in Guinea remained low and that an increase in violent attacks against their workers may force them to leave. On 28 March, a 45-day "health emergency" was declared in 5 regions of the country in response to the virus. On 20 April, it was reported that the court system in Guinea sentenced 11 individuals to life in prison after having murdered a team of Ebola educators.
In Liberia, the disease was reported in Lofa and Nimba counties in late March 2014. 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. Schools and universities were closed, and the worst-affected areas in the country were placed under quarantine.
With only 50 physicians in the entire country—one for every 70,000 Liberians—Liberia already faced a health crisis even before the outbreak. In September the US CDC reported that some hospitals had been abandoned while those which were still functioning lacked basic facilities and supplies. In October, the Liberian ambassador in Washington was reported as saying that he feared that his country may be "close to collapse". By 24 October, all of the 15 Liberian districts had reported Ebola cases.
In November the rate of new infections in Liberia appeared to be declining and the state of emergency was lifted. The drop in cases was believed to be related to an integrated strategy combining isolation and treatment with community behaviour change including safe burial practices, case finding and contact tracing.
In January 2015, the MSF field coordinator reported that Liberia was down to only five confirmed cases. In March, after two weeks of not reporting any new cases, three new cases were confirmed. On 8 April, a new health minister was named in an effort to end Ebola in Liberia. The last known case of Ebola died on 27 March, and the country is conducting the 42-day countdown to be officially declared free of the disease. On 26 April, Doctors Without Borders handed ELWA - 3, an Ebola treatment facility, back to the government of Liberia. On 30 April, the U.S. shut down a special Ebola treatment unit in Liberia. On 1 May, it was reported that the last person who died of Ebola was due to unprotected sex, health officials indicated.
The first person reported infected in the spread to Sierra Leone was a tribal healer who had been treating Ebola patients from across the nearby border with Guinea and died on 26 May 2014. According to tribal tradition, her body was washed for burial and this appears to have led to infections in women from neighbouring towns. 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. On 30 July, the government began to deploy troops to enforce quarantines. By 15 October, the last district in Sierra Leone untouched by the disease had declared Ebola cases.
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. On 4 November, it was reported that thousands violated quarantine in search for food in the town of Kenema. 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." 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. 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.
On 9 December, news reports described the discovery of "a grim scene": piles of bodies, overwhelmed medical personnel and exhausted burial teams in the remote Eastern Kono District. On 15 December, the CDC indicated that their main concern was Sierra Leone where the epidemic had given no evidence of halting and cases continued 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." On 17 December, President Koroma launched "Operation Western Area Surge" and workers went door-to-door in the capital city looking for possible cases. The operation led to a surge in the number of cases, with 403 new cases reported between 14 to 17 December.
According to the 21 January 2015 WHO Situation Report, case incidence was rapidly decreasing in Sierra Leone, but on 5 February, it was reported that there was a rise in weekly cases for the first time this year. The U.N. indicated that the sharp drop in cases had "flattened out" raising concern about the spread of the virus, and on 5 March, a report indicated cases in Sierra Leone continued to rise.
A 5 April WHO report again disclosed a downward trend in cases with confidence that it will continue. Sierra Leone had reported zero cases on 3 days during the week to 5 April with no reports of unsafe burials over the same period.
Countries with successfully contained spread
In March 2014, the Senegal Ministry of Interior closed the southern border with Guinea, 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. 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.
On 28 August 2014, 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. On 10 September, it was reported that the student had recovered but health officials would continue to monitor his contacts for 21 days. No further cases were reported. and on 17 October, the WHO officially declared that the outbreak in Senegal had ended.
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 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. On 27 January, Senegal opened its land border with Guinea.
The first case in Nigeria was a Liberian-American, Patrick Sawyer, who flew from Liberia to Nigeria's commercial capital Lagos on 20 July 2014. 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. On 6 August 2014, 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." On 19 August, it was reported that the doctor who treated Sawyer, Ameyo Adadevoh, had also died of Ebola disease.
On 22 September 2014, 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. 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".
On 9 October 2014, 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. Complimenting Nigeria's successful efforts to control the outbreak, "the usually measured WHO declared the feat 'a piece of world-class epidemiological detective work'."
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 and died on 12 August. 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.
In October 2014, a nursing assistant, Teresa Romero, who had cared for these patients became unwell and on 6 October tested positive for Ebola, making this the first confirmed case of Ebola transmission outside Africa. On 19 October, it was reported that Romero had recovered, and on 2 December the WHO declared Spain Ebola-free following the passage of 42 days since Teresa Romero was found to be cured.
On 30 September 2014, 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. Thomas Duncan died on 8 October. Two additional cases stemmed from Thomas Eric Duncan, when Nina Pham and Amber Vinson tested positive for Ebola on October 10 and 14 and ended when they were declared Ebola free on October 24 and 22, respectively.
A fourth case of Ebola was identified on 23 October 2014 when Dr. Craig Spencer, a physician who had treated Ebola patients in West Africa, himself tested positive for Ebola. This case had no relation to the cases originating from Thomas Eric Duncan. He recovered and was released from hospital on 11 November.
On 23 October 2014, 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. All contacts were followed for 21 days, with no further spread of the disease reported.
On 12 November 2014, 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. A nurse and a doctor who had treated the imam subsequently fell ill with Ebola and died. 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. 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. On 16 December, Mali released the final 13 individuals who were being quarantined and 24 days later (18 January 2015) without new cases the country was declared Ebola-free.
Countries with limited local cases
On 29 December 2014, a British aid worker who had just returned to Glasgow from Sierra Leone via Casablanca Airport and London Heathrow Airport was diagnosed with Ebola in Glasgow. She was transferred to the specialist high-level isolation unit at the Royal Free Hospital in London where she was treated with blood plasma from Ebola survivors. She was declared to be free of infection and released from hospital on 24 January 2015. On 10 March, the U.K. was declared Ebola-free by WHO.
Countries with medically 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. With the exception of a single isolated case in Spain, no secondary infections have occurred as a result of these medical evacuations.
A French volunteer health worker working for MSF in Liberia contracted Ebola and was flown to France on 18 September 2014. After successful treatment at Bégin Military Teaching Hospital, she was discharged on 4 October.
On 1 November, a United Nations employee who had contracted 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.
On 4 October 2014, a Ugandan pediatrician, Michael Mawanda working in Sierra Leone, was flown to Germany for treatment at the University Hospital in Frankfurt. He was released on 19 November after seven weeks of intensive treatment.
On 9 October 2014, a Sudanese doctor working with the United Nations UNMIL peacekeeping force in Liberia was transported to the St Georg Hospital in Leipzig for treatment. He died on 14 October, becoming the first person on German soil to die of Ebola.
On 24 November 2014 the Italian Health Ministry announced that an Italian doctor later identified as Fabrizio Pulvirenti, working for Emergency in Lakka, Sierra Leone, contracted Ebola. On 25 November a military plane carrying Pulvirenti landed at Pratica di Mare military airport, from which he was transferred to the Lazzaro Spallanzani National Institute for Infectious Diseases in Rome. On 10 December, the infectious disease unit of the hospital reported that the patient's conditions improved and he was discharged on 2 January 2015.
A United Nations UNMIL Peacekeeper who contracted the disease in Liberia arrived in the Netherlands on 6 December 2014 according to the Health Ministry. The Nigerian soldier was treated at the University Medical Centre in Utrecht. This is the third peacekeeper who contracted the disease. The first two cases were fatal. On 19 December, it was reported that the Nigerian UN peacekeeper was cured of Ebola; on 23 December, the peacekeeper was released and returned to Liberia.
On 6 October 2014, 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. On 20 October, it was announced that she had been successfully treated and had been discharged.
On 18 November 2014 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. Baez was able to step off the plane unaided. On December 6 it was announced that he had recovered and left the country.
An isolation unit at the Royal Free Hospital, London, received its first case on 24 August 2014. 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.
On 11 March 2015, a U.K. military worker tested positive for Ebola and was flown home for treatment at Royal Free Hospital in London. On 17 March, it was reported that another U.K. worker had been sent back to the United Kingdom from Sierra Leone due to fear of having contracted the virus. Cpl Anna Cross, the U.K. military worker tested positive for Ebola, was the first person in the world to be treated with the experimental Ebola drug MIL 77 and was released from hospital after making a full recovery. The doctors treating her confirmed it is too soon to speculate if the drug helped in her recovery.
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. On 17 November 2014 Dr. Martin Salia, evacuated from Sierra Leone to the US, died of the Ebola virus, aged 44 years. On 12 March, a U.S. health worker was diagnosed positive in Sierra Leone, and was therefore medically evacuated to Bethesda, Maryland. The individual was said to be in serious condition, which was changed to critical, and 10 or more Americans were evacuated from Sierra Leone to the U.S. due to exposure. On 26 March 2015 the NIH have upgraded the medically evacuated health worker who is currently being treated in Bethesda, Maryland from critical to serious. A further 16 volunteers are being monitored for possible exposure.
Separate outbreak in the Democratic Republic of the Congo
In August 2014, the WHO reported an outbreak of Ebola virus in the Boende District, part of the northern Équateur province of the Democratic Republic of the Congo (DRC), where 13 people were reported to have died of Ebola-like symptoms. Genetic sequencing revealed that this outbreak was the Zaire Ebola species, which is indigenous to the DRC; there have been seven previous Ebola outbreaks in the country since 1976. The virology results and epidemiological findings indicate no connection to the epidemic in West Africa.
The index case was initially reported to have been a woman from Ikanamongo Village who became ill with symptoms of Ebola after she had butchered a bush animal. However more recent findings suggested that there may have been several previous cases, and it was reported that the pigs in the village may have been infected with Ebola some time before the first human case occurred. The WHO declared the outbreak over on 21 November 2014, with a total of 66 cases with 49 deaths.
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. 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. However, further studies have shown that the current outbreak is likely caused by an Ebola virus lineage that has spread from Central Africa via an animal host within the last decade, with the first viral transfer to humans in Guinea.
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. Five members of the research team became ill and died from Ebola before the study was published in August 2014.
The ongoing genome sequencing in Sierra Leone has provided valuable information in the study of the Ebola virus. Researchers have tracked the spread of Ebola in Sierra Leone from the group first infected, the 13 women who had attended the funeral of a traditional healer where they contracted the disease, giving a unique opportunity to track how the virus has changed. This tracking has provided "the first time that the real evolution of the Ebola virus can be observed in humans.” The research showed that the outbreak in Sierra Leone was sparked by at least two distinct viruses which had been introduced from Guinea at about the same time. It is not clear whether the traditional healer was infected with both variants, or if perhaps one of the women attending the funeral was independently infected. As the Sierra Leone epidemic progressed, one virus lineage disappeared from patient samples, while a third lineage appeared. The discovery that the genome is changing fairly rapidly has raised concerns related to diagnostic testing, vaccines, and the effectivness of medications such as the drug ZMapp. In January 2015, researchers in Guinea also reported that the virus is going through considerable change in the samples that they were looking at. They reported: "We've now seen several cases that don't have any symptoms at all, asymptomatic cases. These people may be the people who can spread the virus better, but we still don't know that yet. A virus can change itself to less deadly, but more contagious and that's something we are afraid of." Also, while extremely unlikely, researchers remain concerned that the virus could morph into an airborne disease given the time.
It is not entirely clear how an Ebola outbreak starts. 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. As primates in the area were not found to be infected and fruit bats do not live near the location of the initial zoonotic transmission event in Meliandou, Guinea it is suspected that the index case occurred after a child played with an insectivorous bat from a colony of Angolan free-tailed bats near the village.
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. Airborne transmission has not been documented during Ebola outbreaks, however in February 2015 a group of researchers published a paper suggesting, "it is very likely that at least some degree of Ebola virus transmission currently occurs via infectious aerosols". Commenting on the study, an infectious disease specialist, William Schaffner, said that while the study raised issues "it would be rare; as the study points out, it has never been demonstrated in humans."
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. One study suggested that the virus can live up to 7 days in a deceased individual. Semen and possibly other body fluids (e.g., breast milk) may be infectious in survivors for months.
One of the primary reasons for spread is the poorly-functioning health systems in the part of Africa where the disease occurs. 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.
One of the biggest dangers of infection faced by medical staff requires their learning how to properly suit up and remove personal protective equipment. Full training for wearing protective body clothing can take 10 to 14 days. Even with proper isolation equipment available, working conditions such as lack of running water, climate control, and flooring have made direct care difficult. Two American health workers who 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. Difficulties in attempting to halt transmission have also included the multiple disease outbreaks across country borders. 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. 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. On 15 April, a WHO statement indicated, "for greater security and prevention of other sexually transmitted infections, Ebola survivors should consider correct and consistent use of condoms for all sexual acts beyond three months until more information is available." On the same day it was reported that the virus has been detected in semen, 6 months after recovery. On 28 April, it was reported that WHO will try to isolate all patients with the virus in West Africa towards the end of May.
Containment and control
In August 2014, the WHO published a road map 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. Key elements required to prevent transmission are contact tracing and follow-up as well as social mobilisation and public awareness.
Surveillance and contact tracing
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. 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." There is a massive ongoing effort to train volunteers and health workers, sponsored by USAID. According to WHO reports, 25,926 contacts from Guinea, 35,183 from Liberia and 104,454 from Sierra Leone were listed and being traced as of 23 November 2014.
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. These include avoiding contact with infected people and regular hand washing using soap and water. 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."
A number of organisations have enrolled local people to conduct public awareness campaigns among the communities in West Africa. "...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.
Denial in some affected countries has also made containment efforts difficult. Language barriers and the appearance of medical teams in protective suits has sometimes increased fears of the virus. In Liberia, a mob attacked an Ebola isolation centre, stealing equipment and "freeing" patients while shouting "There's no Ebola." Red Cross staff were forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives. In September 2014 in the town of Womey in Guinea, suspicious inhabitants wielding machetes murdered at least eight aid workers and dumped their bodies in a latrine.
An August 2014 study found that nearly two thirds of Ebola cases in Guinea were believed to be due to burial practices including washing of the body of one who has died. 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. In the 21 January 2015 WHO road map update it was reported that 100% of districts in Sierra Leone and 71% of districts in Guinea have a list of key religious leaders who promote safe and dignified burials. Speaking on 27 January 2015, Guinea's Grand Imam, the country's highest cleric, gave a very strong message saying, "There is nothing in the Koran that says you must wash, kiss or hold your dead loved ones," and he called on citizens to do more to stop the virus by practicing safer burying rituals that do not compromise tradition.
Travel restrictions and quarantines
There is serious concern that the disease may spread further within West Africa or elsewhere in the world.
On 8 August 2014, 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. 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.
Many countries have considered imposing restrictions on travel to or from the region. On 2 September 2014, 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". 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."
As of February 2015, countries still maintaining entry restrictions for Ebola affected countries are Antigua and Barbuda, Australia, Bahrain, Belize, Botswana, Brazil, Cameroon, Cape Verde, Cayman Islands, Central African Republic, Chad, Ivory Coast, Dominican Republic, Equatorial Guinea, Gabon, Gambia, Guyana, Haiti, India, Iraq, Jamaica, Kenya, Maldives, Mauritius, Mongolia, Oman, Panama, Rwanda, Sao Tome and Principe, Saudi Arabia, Senegal, Seychelles, Singapore, South Africa, Sri Lanka, Saint Kitts and Nevis, Suriname, Trinidad and Tobago and the United States.
Returning health workers
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, MSF, Public Health England, and Public Health Ontario. 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.
No proven Ebola virus-specific treatment presently exists, however there are measures that can be taken that will improve a patient's chances of survival. 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. This is often followed by severe vomiting and diarrhoea. 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.
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 should be hydrated with intravenous therapy (IV); however, administration of intravenous fluids is difficult in the African environment. Inserting an IV needle while wearing three pairs of gloves and goggles which may be fogged is difficult and once in place, the site and line must be constantly monitored. Without sufficient staff to care for patients, needles may become dislodged or pulled out by a delirious patient. A patient's electrolytes must be closely monitored to determine correct fluid administration, and many areas do not have access to laboratory services.
Although there is currently no cure or treatment for the disease medical experts are divided over whether aggressive treatment with IV fluids must be given to Ebola patients. Some believe that aggressive treatment with IV fluids is medically possible and even "a moral obligation". According to the WHO, the main reason that most patients in American and European hospitals have survived is the use of IV fluids along with constant measuring of blood chemistry. Dr. Robert A. Fowler, a specialist leading the WHO Ebola team, states that the “early, liberal use of intravenous fluid and electrolyte replacement,” should be standard care in all Ebola treatment centers. Paul Farmer of Partners in Health, an NGO that has only recently begun to treat Ebola patients, strongly supports IV therapy for all Ebola patients stating, “What if the fatality rate isn’t the virulence of disease but the mediocrity of the medical delivery?" Farmer has suggested that every treatment facility should have a team that specializes in inserting IVs, or better yet, peripherally inserted central catheter (PICC) lines. Based on many years of experience in Africa and several months of experience working with the present epidemic, MSF takes a more conservative approach. While using IV treatment for as many patients as they can manage, they argue that improperly managed IV treatment is not helpful and may even kill a patient. They also state that they are concerned about the further risk for staff. While experts have studied the mortality rates of different treatment settings, given the wide differences in variables that affect outcome adequate information has not yet been gathered to make a definitive statement about what may constitute the optimal care in the West African setting.
Some Ebola survivors have reported lingering health effects. A WHO consultant states “Many of the survivors are discharged with the so-called Post-Ebola Syndrome. We want to ascertain whether these medical conditions are due to the disease itself, the treatment given or chlorine used during disinfection of the patients. This is a new area for research; little is known about the post Ebola symptoms.”
Ebola virus disease has a high case fatality rate (CFR-risk of death in those infected) which varies between 25 percent and 90 percent of those who have contracted the disease. The average case fatality rate is about 50%, however it is known that the Zaire species, which is responsible for the current outbreak, carries a higher death rate. Care settings that have access to medical expertise may increase survival by providing maintenance of hydration, circulatory volume, and blood pressure.
The disease affects males and females equally and the majority of those that contract Ebola disease are between 15 and 45 years of age. 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. 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."
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". 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." On 9 April, WHO indicated that virus survivors were having eye and joint problems.
Level of care
In June 2014 it was reported that local authorities did not have resources to contain the disease, with health centres closing and hospitals overwhelmed. There were also reports that adequate personal protection equipment was not being provided for medical personnel. 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."
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 had 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.
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." According to a WHO report released on 19 September, Sierra Leone was currently meeting only 35% of its need for patient beds, and Liberia was meeting only 20% of its need. The WHO 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 were a sufficient number of beds in treatment facilities to treat and isolate all reported Ebola cases, although the uneven distribution of cases was resulting in serious shortfalls in some areas. Similarly, all affected countries had sufficient and widespread capacity to bury all reported deaths; however, because not all deaths are reported, it was possible that some areas still had insufficient burial capacity. They reported that every district now had access to a laboratory to confirm cases of Ebola within 24 hours from sample collection, and that all three countries had reported that more than 80% of registered contacts associated with known cases of EVD were being traced, although contact tracing was still a challenge in areas of intense transmission and in areas of community resistance.
|Countries||Existing beds||Planned beds||Percentage of
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. In January 2015, a new treatment and research center was built by Rusal and Russia in the city of Kindia in Guinea. It is one of the most modern medical centers in Guinea. Also in January, MSF admitted its first patients to a new treatment centre in Kissy, an Ebola hotspot on the outskirts of Freetown, Sierra Leone. The center has a maternity unit for pregnant women with the virus.
Although the WHO does not advise caring for Ebola patients at home, in some cases it became a necessity when no hospital treatment beds were available. For those being treated at home, the WHO advised informing the local public health authority and acquiring appropriate training and equipment. UNICEF, USAID and the NGO Samaritan's Purse began to take measures to provide support for families that were forced to care for patients at home by supplying caregiver kits intended for interim home-based interventions. The kits included protective clothing, hydration items, medicines, and disinfectant, among other items. 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. In October the WHO and non-profit partners launched a program in Liberia to move infected people out of their homes into ad hoc centres that could provide rudimentary care.
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.
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." By October there were reports that protective outfits were beginning to be in short supply and manufacturers began to increase their production, but the need to find better types of suits has also been raised.
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". On 12 December 2014, USAID announced the result of the first selection in a press release.
On 17 December 2014, 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. On 19 March, Google developed a tablet that can be cleaned with chlorine; it was created to help medics treating patients with the virus. The device will be used in Sierra Leone. It is charged wirelessly and can transmit information to servers outside of the area.
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. In August 2014, 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. By 22 February 2015, the WHO reported a total of 854 health workers had been infected and 496 had died. One infected case in Spain has been reported, as well as three in the United States, two in Mali with one death, and 11 in Nigeria, including five deaths. Of the three most heavily affected areas Liberia has been especially hard hit with 372 and 180 deaths reported. Guinea reported 170 infected cases with 89 deaths. Sierra Leone registered 295 cases with 221 fatalities on 17 February 2015.
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 outbreak care may be provided in clinics with limited resources, and workers can be in these areas for several hours with a number of Ebola infected patients. 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".
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". In July 2014, 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, and Sahr Rogers, who worked in Kenema. In August, a well-known Nigerian physician, Ameyo Adadevoh, died. Mbalu Fonnie, a licensed nurse midwife and nursing supervisor with over 30 years of experience at the Kenema hospital in Sierra Leone, died after contracting Ebola while caring for a fellow nurse who was pregnant and had Ebola. Fonnie was a co-author of a study that analyzed the genetics of the Ebola virus; five others contracted Ebola and died while working on the study as well.
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 2014 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."
Experimental treatments, vaccines and testing
There is as yet no known effective medication, vaccine, or treatment. However, should an effective vaccine be developed only moderate levels of coverage are needed to control epidemics (e.g. 20% coverage of a highly effective vaccine would likely be adequate ) . 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.
As of February 2015[update] a number of experimental treatments are undergoing clinical trials. One of these, Favipiravir (Avigan), was successful in initial trials and authorities in Guinea have approved its wider use. On 1 February 2015, a clinical drug trial in Liberia was halted due to lack of patients. Health authorities have also reported that the falling number of patients may affect the plans for the testing of the experimental drug ZMapp and two vaccines as well. On 22 April, it was reported that TKM-Ebola-Makona had worked by protecting three highly infected monkeys from the virus.
Experimental preventative vaccines
Several Ebola vaccine candidates had been developed in the decade prior to 2014, and had been shown to protect nonhuman primates (usually macaques) against lethal infection, but none has yet been approved for clinical use in humans. In response to this epidemic, the clinical trial process has been accelerated; two of the potential vaccines cAd3-EBOZ and VSV-ZEBOV progressed to mass trials early in 2015. Part of the trial will incorporate a ring vaccination strategy designed to test if vaccines might be useful for stamping out hot spots in outbreak settings. As of 7 March, large scale vaccine trials have started in Guinea and Liberia. On 25 March, it was reported that the vaccine raised no safety concerns; the rVSV-ZEBOV vaccine candidate invoked an anti-viral response in all the subjects. On 8 April, two new vaccines by Merck, that in initial form caused joint pain, have been reintroduced and have passed initial tests.
Potential diagnostic tests
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.
As of February 2015[update] a number of diagnostic tests are under trial:
- Diagnostics-in-a-Suitcase, based on Recombinase Polymerase Amplification (RPA). The new equipment, about the size of a laptop and solar-powered, allows testing to be done in remote areas; testing commenced in Guinea during January 2015.
- In December 2014, the FDA approved LightMix (R) Ebola Zaire rRT-PCR Test for emergency use on patients with symptoms of Ebola.
- Massachusetts Institute of Technology has developed a 10-minute Ebola test using Matrix Multiplexed Diagnostic (MMDx) technology. This still has to complete testing to gain FDA approval.
- Corgenix Medical Corp announced on 26 February that health regulators had approved its rapid Ebola test for emergency use. The ReEBOV Antigen Rapid Test involves putting a drop of blood on a paper strip and waiting for at least 15 minutes for a reaction.
- On 29 March, a new rapid Ebola virus diagnostic kit/test was developed by British military scientists and NHS in Sierra Leone.
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. 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.
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 August 2014, the WHO made an initial CFR estimate of 53% though this included suspected cases. In September and December 2014, WHO released revised and more accurate CFR figures, using data from patients with definitive clinical outcomes, of 70.8% and 71% respectively. The CFR among hospitalized patients, based on three intense-transmission countries, is between 57% and 59%.
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; if the rate is greater than 1, the infection will continue to spread in a population with exponential growth of cases. During the first 9 months of the current outbreak, the reproduction number was estimated to be between 1.5 and 2.5. If the reproduction number had continued to be approximately 1.5, as it was estimated to be in September 2014, the total number of infected individuals would have been 100,000 by the end of January 2015.
Projections of future cases
On 28 August 2014, 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. 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." It includes an assumption that some country or countries will pay the required cost of their plan, estimated at half a billion dollars.
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 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".
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. 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", and according to an editorial in the New England Journal of Medicine, eventually to other parts of Africa and beyond.
A report on 23 September by CDC analyses the impact of under-reporting – 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. 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.
A study published in December 2014 found that transmission of the Ebola virus occurs principally within families, in hospitals and at funerals. The data, gathered during three weeks of contact tracing in August, showed that the third person in any transmission chain often knew both the first and second person. The authors estimated that between 17 percent and 70 percent of cases in West Africa are unreported – far fewer than had been estimated in prior projections. The study concludes that the epidemic is not as difficult to control as feared, if rapid, vigorous contact tracing and quarantines are employed.
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 periodically through 2014.
In addition to the loss of life, the outbreak is having a number of significant economic impacts.
- In August it was reported that many airlines had suspended flights to the area. Markets and shops have closed due to travel restrictions, a cordon sanitaire, or fear of human contact, which leads to loss of income for producers and traders.
- Movement of people away from affected areas has disturbed agricultural activities. The UN Food and Agriculture Organisation (FAO) has warned that the outbreak could endanger harvest and food security in West Africa. On 17 December, 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.
- Tourism is directly impacted in affected countries. For example on 26 April, in Lagos, Nigeria it was reported that 75% of hotel business had been lost due to fears of the outbreak. Additionally it was reported that the country lost N8 Billion Over Ebola outbreak.  Other countries in Africa which are not directly affected by the virus have also reported adverse effects on tourism. On 6 January 2015, it was reported that Gambia's tourism had fallen below 50 percent. Ghana experienced a drop in tourism due to the virus, though it never had an Ebola case. On 8 March, it was reported that perceived Ebola threats have impacted Kenya leading to low tourism numbers. Zimbabwe reported a decrease in tourism due to the virus in a March 29 report. On 4 April, it was reported that Ebola was part of the reason for "crippled" air-travel to Senegal. On 15 April it was reported that Zambia and Tanzania tourism were also affected by the virus fears.
- Foreign mining companies have withdrawn non-essential personnel, deferred new investment, and cut back operations. In December it was reported that the iron ore mining company African Minerals had started the shutdown of its Sierra Leone operations because it was running low on income. On 10 March, it was reported that Sierra Leone had begun to diversify away from mining, due to the country's recent problems.
- The outbreak is straining the finances of governments, with Sierra Leone using Treasury bills to fund the fight against the virus. On 27 January, Oxfam, which works for disaster relief, indicated that a "Marshall Plan" was needed so that other countries can begin to help financially those who have been worst hit by the virus, stating "failure to help these countries after surviving Ebola will condemn them to a double disaster." According to (UNDG), West Africa could lose $3.6 billion per year between 2014 and 2017, due to trade and closing of borders. On 25 March, Liberia's positive (economic) growth forecast was cut by more than 50 percent. On 6 April, it was reported that the Liberia economy is forecast to grow by as little as three percent in 2015. On 15 April, the President of Sierra Leone stated, "there was a considerable slowdown in the economy; loss of revenue to government, loss of revenue to individuals and businesses and the country was more or less isolated." On 17 April it was reported that the West African countries affected the most by the epidemic asked for an $8 billion "Marshall Plan" to rebuild their economies. On 29 April, Minister Konneh of Liberia indicated that the nation's projected Growth Domestic Product (GDP) dropped from 5.9 to 1 percent due to the Ebola outbreak.
- The IMF is considering expanding assistance to Guinea, Sierra Leone, and Liberia as their national deficits are ballooning and their economies contract sharply. On 17 December 2014, 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". On December 22, a Cambridge University study linked IMF policies with weak Ebola response in the three west African countries. On December 31, a U.N. commission asked the IMF to cancel the debt owed by Ebola-hit countries. On 30 January, the IMF reported it was near a deal for debt forgiveness. On 9 February, Britain indicated it would contribute 50 million dollars to help west Africa, via an IMF fund. On 23 February, the IMF gave Guinea $37 million to fight the virus. On 27 February, the IMF gave Liberia $36 million for virus economic relief. On 2 March, Sierra Leone received $187 million for recovery purposes, becoming the third country to receive monetary relief. On 24 March, Sierra Leone received $102 million in extra debt relief for the outbreak. On 21 April, the IMF indicated that falling commodity prices, among other factors, are hindering recovery for the three virus-hit countries.
- 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. 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. On December 30, the World Bank projected Ebola could cost $4 billion to fight the virus. Growth in 2014 in Sierra Leone, fell to 4.0 percent from 11.3 percent projected before the virus. On 14 February, the World Bank indicated it would provide funding for agriculture in Ebola-hit countries. On 26 February, Liberia received $3 million for psychosocial support from virus impact. On 16 March, the World Bank approved a monetary package for Guinea fisheries. On 13 April, Dr. Kim (World Bank) indicated talks in regards to the Ebola-hit countries about universal health care access.
Following the first known case in December 2013 in the village of Meliandou, Guinea, the disease spread to neighboring villages causing about 70 deaths. The deaths were attributed to other diseases endemic to the area; it was not properly identified as Ebola until March 2014. The initial response by MSF, WHO and CDC seemed effective in April and May, but, in fact, failed. By 21 June, according to MSF, the epidemic was “out of control.”
In July, WHO 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. 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.
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 would be a minimum of $1 billion.
During October, WHO and UNMEER announced a comprehensive 90-day plan to control and reverse the Ebola epidemic. The immediate objective was to isolate at least 70% of Ebola cases and safely bury at least 70% of patients who died from Ebola by 1 December 2014 (the 60-day target). The ultimate goal was 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). Many nations and charitable organizations cooperated to realise the plan. A WHO situation report in mid-December indicated that the international community was on track to meet the 90-day target. On 26 April, the U.N. appointed a new head for the emergency mission to West Africa in charge of the Ebola crisis.
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. In October, the Associated Press reported that in an internal draft document the WHO admitted that "nearly everyone" involved in the Ebola response failed to notice factors that turned the outbreak into the biggest on record, and they had missed chances to stop the spread of Ebola due to "incompetent staff, bureaucracy and a lack of reliable information". Peter Piot, co-discoverer of the Ebola virus, has called the WHO regional office in Africa "really not competent." On 19 April, WHO admitted very serious failings in handling the crisis and indicated reforms for any future crisis; "we did not work effectively in coordination with other partners, there were shortcomings in risk communications and there was confusion of roles and responsibilities" further indicated a statement released by the organization. Furthermore, WHO said it was a "reminder that the world, including WHO, is ill prepared for a large sustained disease outbreak".
Timeline of reported cases and deaths
Data comes from reports by the World Health Organization Global Alert and Response Unit[Resource 1] and the WHO'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. As an example, Sierra Leone has had cases grow at a much faster rate, while simultaneously at an insoluble lower reported death rate versus those in Guinea and Liberia. 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."
Characterizations of rate of growth
On October 23, 2014, 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). A study estimated during the first nine months of the outbreak the disease was transmitted onwards to approximately 1.7–2 people for each case.
Understanding the data and its limitations
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 be revised 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.
|26 Apr 2015||26,277||10,884||3,584||2,377||≥10,322||≥4,608||12,371||3,899||[note 2]|
|19 Apr 2015||26,044||10,808||3,565||2,358||10,212||4,573||12,267||3,877||[note 3]|
|12 Apr 2015||25,791||10,689||3,548||2,346||≥10,042||≥4,486||12,201||3,857||[note 4]|
|5 Apr 2015||25,515||10,572||3,515||2,333||9,862||4,408||12,138||3,831||[note 5]|
|29 Mar 2015||25,178||10,445||3,492||2,314||9,712||4,332||11,974||3,799||[note 6]|
|22 Mar 2015||24,872||10,311||3,429||2,263||9,602||4,301||11,841||3,747||[note 7]|
|15 Mar 2015||24,666||10,179||3,389||2,224||9,526||4,264||11,751||3,691||[note 8]|
|8 Mar 2015||24,282||9,976||3,285||2,170||≥9,343||≥4,162||11,619||3,629||[note 9]|
|1 Mar 2015||23,934||9,792||3,219||2,129||≥9,249||4,117||11,466||3,546||[note 10]|
|22 Feb 2015||23,694||9,589||3,155||2,091||9,238||4,037||11,301||3,461||[note 11]|
|15 Feb 2015||23,218||9,365||3,108||2,057||≥9,007||≥3,900||11,103||3,408||[note 12]|
|8 Feb 2015||22,859||9,162||3,044||1,995||≥8,881||≥3,826||10,934||3,341||[note 13]|
|1 Feb 2015||22,460||8,966||2,975||1,944||8,745||3,746||10,740||3,276||[note 14]|
|25 Jan 2015||22,057||8,795||2,917||1,910||8,622||3,686||10,518||3,199||[note 15]|
|18 Jan 2015||21,689||8,626||2,871||1,876||8,478||3,605||10,340||3,145||[note 16]|
|11 Jan 2015||21,261||8,414||2,806||1,814||8,331||3,538||10,124||3,062||[note 17]|
|4 Jan 2015||20,726||8,229||2,775||1,751||8,171||3,499||9,780||2,943||[note 18]|
|Date||Total||Nigeria||Senegal||United States||Spain||Mali||United Kingdom||Refs|
|1 Mar 2015||35||15||20||8||1||0||4||1||1||0||8||6||1||0|||
|22 Feb 2015||35||15||20||8||1||0||4||1||1||0||8||6||1||0|||
|15 Feb 2015||35||15||20||8||1||0||4||1||1||0||8||6||1||0|||
|8 Feb 2015||35||15||20||8||1||0||4||1||1||0||8||6||1||0|||
|1 Feb 2015||35||15||20||8||1||0||4||1||1||0||8||6||1||0|||
|25 Jan 2015||35||15||20||8||1||0||4||1||1||0||8||6||1||0|||
|18 Jan 2015||35||15||20||8||1||0||4||1||1||0||8||6||1||0|||
|11 Jan 2015||35||15||20||8||1||0||4||1||1||0||8||6||1||0|||
|4 Jan 2015||35||15||20||8||1||0||4||1||1||0||8||6||1||0|||
|29 Dec 2014||35||15||20||8||1||0||4||1||1||0||8||6||1||0||[note 19]|
|28 Dec 2014||20,206||7,905||2,707||1,709||8,018||3,423||9,446||2,758||20||8||1||0||4||1||1||0||6||6|||
|14 Dec 2014||18,590||7,288||2,415||1,525||7,819||3,346||8,356||2,417||20||8||1||0||4||1||1||0||6||6||[note 20]|
|30 Nov 2014||17,145||6,412||2,164||1,325||7,653||3,157||7,312||1,915||20||8||1||0||4||1||1||0||8||6||[note 21]|
|18 Nov 2014||15,353||5,790||2,047||1,214||7,082||2,963||6,190||1,598||20||8||1||0||4||1||1||0||6||6||[note 22]|
|2 Nov 2014||13,042||5,198||1,731||1,041||6,525||2,697||4,759||1,450||20||8||1||0||4||1||1||0||1||1||[note 23]|
|19 Oct 2014||9,936||4,899||1,540||926||4,665||2,705||3,706||1,259||20||8||1||0||3||1||1||0||-||-||[note 24]|
|12 Oct 2014||8,973||4,484||1,472||843||4,249||2,458||3,252||1,183||20||8||1||0||1||0||1||0||-||-||[note 25]|
|28 Sep 2014||7,191||3,286||1,157||710||3,696||1,998||2,317||570||20||8||1||0||1||0||-||-||-||-|||
|14 Sep 2014||5,349||2,585||942||601||2,720||1,461||1,655||516||21||7||1||0||-||-||-||-||-||-|||
|31 Aug 2014||3,685||1,801||771||494||1,698||871||1,216||436||21||7||1||0||-||-||-||-||-||-|||
|16 Aug 2014||2,240||1,229||543||394||834||466||848||365||15||4||-||-||-||-||-||-||-||-|||
|9 Aug 2014||1,848||1,013||506||373||599||323||730||315||13||2||-||-||-||-||-||-||-||-|||
|30 Jul 2014||1,440||826||472||346||391||227||574||252||3||1||-||-||-||-||-||-||-||-|||
|23 Jul 2014||1,201||672||427||319||249||129||525||224||-||-||-||-||-||-||-||-||-||-|||
|14 Jul 2014||982||613||411||310||174||106||397||197||-||-||-||-||-||-||-||-||-||-|||
|2 Jul 2014||779||481||412||305||115||75||252||101||-||-||-||-||-||-||-||-||-||-|||
|17 Jun 2014||528||337||398||264||33||24||97||49||-||-||-||-||-||-||-||-||-||-|||
|27 May 2014||309||202||281||186||12||11||16||5||-||-||-||-||-||-||-||-||-||-|||
|12 May 2014||260||182||248||171||12||11||-||-||-||-||-||-||-||-||-||-||-||-|||
|1 May 2014||239||160||226||149||13||11||-||-||-||-||-||-||-||-||-||-||-||-|||
|14 Apr 2014||194||121||168||108||8||2||-||-||-||-||-||-||-||-||-||-||-||-|||
|31 Mar 2014||130||82||122||80||8||2||-||-||-||-||-||-||-||-||-||-||-||-|||
|22 Mar 2014||49||29||49||29||-||-||-||-||-||-||-||-||-||-||-||-||-||-|||
- The mortality rate (death/case ratio) recorded in Liberia up to 26th August 2014 was 70%. However, the general estimated case fatality rate (70.8%) for this ongoing epidemic differs from the ratio of the number of deaths divided by that of cases due to the estimation method used. Current infections have not run their course, and the estimate may be poor if reporting is biased towards severe cases.
- 26 April : All governments as per WHO. Liberia dated 23 April 2015
- 19 April : All governments as per WHO.
- 12 April : All governments as per WHO. Liberia dated 11 April 2015
- 5 April : All governments as per WHO.
- 29 March : All governments as per WHO.
- 22 March : All governments as per WHO.
- 15 March : All governments as per WHO.
- 8 March : All governments as per WHO. Liberia dated 5 March 2015
- 1 March : All governments as per WHO.
- 22 February : All governments as per WHO.
- 15 February : All governments as per WHO.Liberia dated 12 February 2015
- 9 February : All governments as per WHO.Liberia dated 7 February 2015
- 1 February : All governments as per WHO.
- 25 January : All governments as per WHO.
- 18 January : All governments as per WHO.
- 11 January : All governments as per WHO.
- 4 January : All governments as per WHO. Liberia as per Government.
- 29 December: All governments as per WHO. United Kingdom case dated 29 December.
- 14 December: Guinea as per WHO. Sierra Leone and Liberia as per government report.
- 28 November: Guinea governments as per WHO. Sierra Leone and Liberia as per Government report.
- 18 November: All governments as per WHO. Sierra Leone deaths as per Government report. Liberia dated 17 November
- 2 November: All governments as per WHO and Sierra Leone as per Gov.
- 19 October as per WHO for all except Liberia 18 October.
- 12 October as per WHO Spain and US as per news reports
- 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.
- Meltzer, Martin I.; Atkins, Charisma Y.; Santibanez, Scott et al. (26 September 2014). "Estimating the Future Number of Cases in the Ebola Epidemic — Liberia and Sierra Leone, 2014–2015". Morbidity and Mortality Weekly Report (United States: Centers for Disease Control and Prevention).
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WHO2015_05_01was invoked but never defined (see the help page).
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