West African Ebola virus epidemic

West African Ebola virus epidemic

Simplified Ebola virus epidemic situation map
Date	Main epidemic December 2013 – January 2016, with flare-ups still ongoing[1]
Casualties
Note: current estimates suggest that the number of cases might have been substantially underreported, by up to 70 percent.[2] Country Cases Deaths Last update On 24 April 2016 by WHO Liberia 10,675 4,809 12 new cases/4 deaths 24 April 2016[3] Sierra Leone 14,122 3,955 outbreak ended 17 March 2016[4] Guinea 3,814 2,543 10 new cases/8 deaths reported 24 April 2016[3] Nigeria 20 8 outbreak ended 19 October 2014[5] Mali 8 6 outbreak ended 18 January 2015[6] United States 4 1 outbreak ended 21 December 2014[7] Italy 1 0 outbreak ended 20 July 2015[8] United Kingdom 1 0 outbreak ended 10 March 2015[9] Senegal 1 0 outbreak ended 17 October 2014[5] Spain 1 0 outbreak ended 2 December 2014[10] Total 28,657 11,325 as of 24 April 2016

The most widespread epidemic of Ebola virus disease in history began in 2013 and has continued for over two years, resulting in significant loss of life and social disruption across the region of West Africa. As of 2016, although the epidemic is no longer out of control, flare-ups of the disease are likely to continue for some time.^[11]

The outbreak began in Guinea in December 2013 and then spread to Liberia and Sierra Leone,^[12] with minor outbreaks elsewhere. It has caused significant mortality, with reported case fatality rates of up to 70%^{[12][13][14][note 1]} and specifically 57–59% among hospitalized patients.^[15] Small outbreaks occurred in Nigeria and Mali,^[6][16] and isolated cases occurred in Senegal,^[17] the United Kingdom and Sardinia.^[14] Imported cases in the United States and Spain led to secondary infections of medical workers but did not spread further.^[18][19] As of 24 April 2016 , the World Health Organization and respective governments have reported a total of 28,657 suspected cases and 11,325 deaths, ^[3] though the WHO believes that this substantially understates the magnitude of the outbreak.^[20][21]

The WHO has warned that further small outbreaks of the disease may occur in the future, and vigilance should be maintained.^[22] A flare-up in January 2016 in Sierra Leone resulted in one death, one patient being treated, and over 100 people being quarantined.^[23][24] As of April 2016, the flare-up in Sierra Leone has been declared over, but new flare-ups have been reported in Guinea^[25] and Liberia.^[26][27]

Overview

Ebola virus disease (commonly known as "Ebola") was first described in 1976 in two simultaneous outbreaks in South Sudan and Democratic Republic of the Congo. The current outbreak is the first Ebola outbreak to occur in the West African subcontinent,^[28] and is also 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 distrust of government officials after years of armed conflict, and the delay in responding to the outbreak for several months all contributed to the failure to control the epidemic. Other factors included local burial customs of washing the body after death and the unprecedented spread of Ebola to densely populated cities.^{[29][30][31][32][33]}

As the outbreak spread, 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 have been causing "an additional death toll [that is] likely to exceed that of the outbreak itself".^[34][35] Hospital workers, who worked closely with the highly contagious body fluids of the diseased, were especially vulnerable to catching the disease. In August 2014, the WHO reported that ten percent of the dead had been healthcare workers.^[36] 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.^[37] 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.^[38] On 8 April 2015, the WHO reported a total of only 30 confirmed cases,^[39] and the weekly update for 29 July reported only seven new cases.^[40] On 7 October 2015, all three of the most seriously affected countries recorded their first joint week without any new cases,^[41] however, as of late 2015, while the large-scale epidemic had ended, sporadic new cases were still continuing to emerge, frustrating hopes that the epidemic could be declared over.^[42]

On 8 August 2014, the World Health Organization declared the outbreak a public health emergency of international concern.^[43] The WHO has been widely criticised for its delay in taking action to address the epidemic.^[44] By September 2014, Médecins Sans Frontières/Doctors Without Borders (MSF), the non-governmental organization 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."^[45] 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 its Director-General, Margaret Chan, called the outbreak "the largest, most complex and most severe we've ever seen".^[46] 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 had resulted in vast economic consequences in both the affected areas in West Africa and even in other African nations with no cases of Ebola.^[47] On 31 July 2015, the WHO announced "an extremely promising development" in the search for an effective vaccine for Ebola disease. While the vaccine has shown 100% efficacy in individuals, more conclusive evidence is needed on its capacity to protect populations through herd immunity.^[48][49]

In August 2015, after substantial progress in reducing the scale of the epidemic, the WHO held a meeting to work out a "Comprehensive care plan for Ebola survivors" and identify research needed to optimize clinical care and social well-being. Saying "the Ebola outbreak has decimated families, health systems, economies, and social structures", the WHO called the aftermath "an emergency within an emergency." Of special concern is recent research that shows some Ebola survivors experience so-called Post-Ebola Syndrome, with symptoms so severe that survivors may require medical care for months and even years.^[50][51] As the main epidemic was coming to an end in December 2015, the United Nations announced that 22,000 children had been orphaned, losing one or both parents to Ebola.^[52]

Epidemiology

Outbreak

  Widespread outbreak

  Limited outbreak

  Isolated cases: Guinea, Liberia

  Medically evacuated cases

  Ebola-free after prior cases

Researchers generally believe that a one-year-old boy,^[53] 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.^[54][55] Researchers have long believed that bats are involved in the spread of the virus and the boy's home was in the vicinity of a large colony of Angolan free-tailed bats, however the Ebola virus was not found in any of the bats that were captured and tested.^[56] 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.^[57][58] Although Ebola represents a major public health issue in sub-Saharan Africa, no cases had ever been reported in West Africa^{[note 2]} and the early cases were diagnosed as other diseases more common to the area. Thus, the disease had several months to spread before it became recognized as Ebola.^[55][57]

Monthly aggregate Ebola cases in the West Africa epidemic 2014–15

Monthly aggregate Ebola deaths

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 under investigation. In Guinea, a total of 86 suspected cases, including 59 deaths had been reported as of 24 March.^[59] By late May, the outbreak had spread to Conakry, Guinea's capital, a city of about two million people.^[59] On 28 May, the total number of cases reported had reached 281 with 186 deaths.^[59]

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.^[60][61] 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.^[62] 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.^[63][64]

As the epidemic progressed, a small outbreak occurred in Nigeria that resulted in 20 cases and another in Mali with seven cases. Four other countries (Senegal, Spain, the United Kingdom and the United States of America) also reported a case or cases imported from a West African country with widespread and intense transmission.^[65][66][67] 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. The response to the epidemic then moved from rapidly building infrastructure to a second phase as the focus shifted to ending the epidemic.^[50]

On 31 March 2015, one year after the first report of the outbreak, the total number of cases exceeded 25,000 with over 10,000 deaths.^[68] Liberia was officially declared Ebola-free on 9 May,^[69] however new cases were reported in late June and early July after three months of being disease-free.

The 8 April 2015 WHO Ebola Situation Report stated that a total of 30 cases were reported and^[50][70] the WHO weekly update for 29 July reported a total of only seven cases, the lowest total in more than a year.^[40] In October the WHO recorded the first week without any new cases,^[41] and as of late 2015, while the large-scale epidemic appeared to have ended, sporadic new cases continued to be reported.^[42][71]

On 14 January 2016, after all the previously infected countries had been declared Ebola-free, the WHO said in a statement, "all known chains of transmission have been stopped in West Africa," but they cautioned that further small outbreaks of the disease may occur in the future, and vigilance should be maintained.^[22] The next day, Sierra Leone confirmed its first new case since September 2015.^[11] On 28 March it was reported that the Director-General of WHO had terminated the Public Health Emergency of International Concern in regards to the Ebola EVD outbreak.^[72]

Countries that have experienced widespread transmission

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

Guinea

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.^[59] On 31 March, the U.S. Centers for Disease Control and Prevention 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.^[59]

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.^[73]

In February 2015, Guinea recorded a rise in cases for the second week in a row.^[74] 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.^[75] On 14 February, violence erupted and an Ebola treatment center near the center of the country was destroyed. Guinea Red Cross teams said they had been attacked an average of 10 times a month over the previous year,^[76] and MSF reported that acceptance of Ebola education in Guinea remained low and that an increase in violent attacks against their workers might force them to leave.^[77]

Guinea's resistance to the interventions of health officials has remained greater than those of Sierra Leone and Liberia, causing concerns as the efforts to stop the epidemic progress. In mid-March there were 95 new cases and on 28 March, a 45-day "health emergency" was declared in 5 regions of the country.^[77][78] On 22 May, the WHO again reported a rise in cases;^[79] the rise is believed to be due to funeral transmissions.^[80] On 25 May, six individuals were placed in prison isolation after they were found to be travelling with a corpse who had died of the disease.^[81] On 1 June, it was reported that violent protests in a north Guinean town at the border with Guinea-Bissau had caused the Red Cross to withdraw workers.^[82]

In late June the WHO reported, "Weekly case incidence has stalled at between 20 and 27 cases since the end of May, whilst cases continue to arise from unknown sources of infection, and to be detected only after post-mortem testing of community deaths."^[83] On 29 July, a sharp decline in cases was reported,^[40] with only one case left by the end of the week.^[84] The number of cases plateaued at 1 or 2 cases per week after the beginning of August. No new cases had occurred since 16 September^[85] but on 16 October, two new cases were detected, one of them in Forécariah.^[86] On 28 October a further three cases were reported in the Forécariah Prefecture by the WHO.^[87] On 6 November, a report indicated Tana village to be the last known place with Ebola in the country.^[88] On 11 November, WHO indicated no Ebola cases were reported in Guinea. It is the first time since the epidemic began that no cases have been reported in any country.^[89] On 15 November, the last quarantined individuals were released,^[90] and on 17 November, the last Ebola patient in Guinea has recovered, a 3-week-old baby. The 42-day countdown toward Guinea being declared Ebola-free started on 17 November the day after the last EVD patient in Guinea received a second consecutive EVD-negative blood test.^[91][92][93] The baby was discharged from the hospital on 28 November.^[94] After the expiration of a 42-day waiting period, the WHO declared Guinea Ebola-free on 29 December 2015.^[95][96] This is an important milestone; two years ago in Guinea in December 2013 the outbreak began.^[95]

On 17 March 2016, the government of Guinea reported 2 people had tested positive for Ebola virus in Korokpara.^[25] It was also reported that they are from the village where members of one family died recently from vomiting (and diarrhea).^[97] On 19 March, it was reported that another individual had died due to the virus, at the treatment centre in Nzerekore.^[98] The country's government has quarantined an area around the home where the cases took place. This region of Guinea is where the first case was registered on December 2013, at the beginning of the Ebola outbreak.^[99] On 22 March, it was reported that medical authorities in Guinea have quarantined 816 people as possibly having had contact with the prior cases (more than one hundred individuals are considered high risk^[100]);^[101] on the same day Liberia ordered its border with Guinea closed.^[102] Macenta prefecture, 200 kilometers from Korokpara, has registered the fifth fatality due to the Ebola virus disease in Guinea.^[103] On 29 March it was reported that about 1000 contacts have been identified (142 are high risk),^[104] and on 30 March, 3 more confirmed cases were reported from the sub-prefecture of Koropara in Guinea.^[105] On 1 April it was reported that possible contacts, which number in the hundreds, have been vaccinated with an experimental vaccine, in a "ring vaccination" approach.^[106]

On 5 April it was reported that there were nine new cases of Ebola since the virus resurfaced. Of these nine cases eight have died.^[107]

Sierra Leone

Kenema Hospital, Sierra Leone

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.^[108] 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.^[109] On 30 July, the government began to deploy troops to enforce quarantines.^[110] By 15 October, the last district in Sierra Leone untouched by the disease had declared Ebola cases.^[111]

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.^[112] On 4 November, it was reported that thousands violated quarantine in search for food in the town of Kenema.^[113] 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."^[114] 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.^[65] 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.^[115]

Ebola crisis: More UK aid arrives in Sierra Leone

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.^[116] On 15 December, the Centers for Disease Control 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 Centers for Disease Control, "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."^[117] On 17 December, President Koroma launched "Operation Western Area Surge" and workers went door-to-door in the capital city looking for possible cases.^[118][119] The operation led to a surge in the number of cases, with 403 new cases reported between 14 and 17 December.^[118][120]

According to the 21 January 2015 WHO Situation Report, case incidence was rapidly decreasing in Sierra Leone,^[121][122] but in February and March it was reported that there was a rise in the number of cases^{[123][124][125][126]} A 5 April WHO report again disclosed a downward trend^[127] and the WHO weekly update for 29 July reported a total of only three new cases, the lowest total in more than a year.^[40] On 17 August, the country had its first week with no new cases,^[128] and one week later the last patients were released.^[129] However, a new case was reported on 1 September when a patient from Sella Kafta village in Kambia District tested positive for the disease after her death.^[130] Eventually, her case resulted in three more cases among her contacts.^[131]

On 14 September, the National Ebola Response Center confirmed the death of a 16-year-old in a village in the Bombali district.^[132] It is suspected that she contracted the disease from the semen of an Ebola survivor who was discharged in March 2015.^[133] On 27 September, a new 42-day countdown began to declare the country Ebola-free.^[134] On 7 November 2015, the WHO declared Sierra Leone to be free of Ebola transmission;^[135] the country has increased its vigilance with the Guinean border.^[136] Sierra Leone entered a 90-day period of enhanced surveillance which was scheduled to conclude on 5 February 2016, but due to a new case in mid-January it did not.^[137]

On 14 January, it was reported there had been a fatality linked to the Ebola virus. The case occurred in the Tonkolili district.^[138] Prior to this case WHO had advised, "we anticipate more flare-ups and must be prepared for them ... massive effort is underway to ensure robust prevention, surveillance and response capacity across all three countries by the end of March.”^[139] On 16 January, it was reported that the woman who died of the virus may have exposed several individuals; the government announced that 100 people had been quarantined.^[140] On the same day, WHO released a statement, indicating that originally the 90-day enhanced surveillance period was to end on 5 February. Investigations indicate the female case was a student at Lunsar in Port Loko district, who had gone to Kambia district on December the 28th until returning symptomatic. Bombali district was visited by the individual, for consultation with an herbalist, later going to a government hospital in Magburaka. WHO indicates there are 109 contacts, 28 of which are high risk, furthermore, there are three missing contacts.The source or route of transmission which caused the fatality is still unknown.^[141] A second new case was confirmed on 20 January. The patient had contact with the previous death.^[142] WHO confirmed the carer for the individual who died of the virus is a relative, of 38 years of age. WHO spokesman Tarik Jasarevic added that the relative became symptomatic on Wednesday.^[143] On 22 January, it was reported that the 2nd Ebola case, a caregiver, is responding to treatment.^[144] On 26 January, WHO confirmed officially that the outbreak is not yet over, per WHO director Dr. Margaret Chan.^[11] On 26 January, it was reported that Ebola restrictions have halted market activity in Kambia district, amid protests.^[145] On 7 February, it was reported that 70 individuals were released from quarantine,^[146] and on 8 February the last Ebola patient was released on Monday.^[147] On 17 February, WHO indicated that 2600 Ebola survivors had accessed a health assessment and eye examination.^[4]

On 4 February 2016, the last known case tested negative for Ebola for a second consecutive time. Sierra Leone then entered a second 42-day countdown to declare the country Ebola-free.^[148][149] On 17 March 2016, the WHO announced that the Sierra Leone flare-up was over, and no other chains of transmission were known to be active at that time.^[150] Sierra Leone has now entered a period of 90 days of heightened surveillance which is scheduled to end on 15 June 2016.

Liberia

An Ebola treatment unit in Liberia

In Liberia, the disease was reported in both Lofa and Nimba counties in late March 2014.^[151] 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.^[152] Schools and universities were closed,^[153][154] and the worst-affected areas in the country were placed under quarantine.^[155]

With only 50 physicians in the entire country—one for every 70,000 Liberians—Liberia was already in a health-care crisis.^[156] In September the US CDC reported that some hospitals had been abandoned while those still functioning lacked basic facilities and supplies.^[157] In October, the Liberian ambassador in Washington was reported as saying that he feared that his country may be "close to collapse".^[156] By 24 October, all of the 15 Liberian districts had reported Ebola cases.^[5][158]

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.^[159][160]

In January 2015, the MSF field coordinator reported that Liberia was down to only five confirmed cases.^[161] In March, after two weeks of not reporting any new cases, three new cases were confirmed.^[162] On 8 April, a new health minister was named in an effort to end Ebola in Liberia. On 26 April, Doctors Without Borders handed ELWA – 3, an Ebola treatment facility, back to the government of Liberia.^[163] On 30 April, the US shut down a special Ebola treatment unit in Liberia.^[164] The last known case of Ebola died on 27 March,^[165] and the country was officially declared Ebola-free on 9 May 2015 after 42 days without any further cases being recorded. The WHO congratulated Liberia saying, "Reaching this milestone is a testament to the strong leadership and coordination of Liberian President Ellen Johnson Sirleaf and the Liberian Government, the determination and vigilance of Liberian communities, the extensive support of global partners, and the tireless and heroic work of local and international health teams."^[69] As of May 2015, the country remained on high alert against recurrence of the disease.^{[166][167][168]}

After three months with no new reports of cases, on 29 June Liberia reported that the body of a 17-year-old boy who had been treated for malaria tested positive for Ebola. The WHO said the boy had been in close contact with at least 200^[169] people, who they were following, and that "the case reportedly had no recent history of travel, contact with visitors from affected areas, or funeral attendance." A second case was confirmed on 1 July.^[170][171] After a third new case was confirmed on 2 July and it was discovered that all three new cases had shared a meal of dog meat, researchers looked at the possibility that the dog meat may have been involved in the transfer of the virus.^[172][173] Testing of the dog's remains were negative for the Ebola virus.^[174] By 9 July two more cases were discovered, bringing the total number of new cases to five, all from the same area.^[175] On 14 July a woman died due to the virus in the county of Montserrado, bringing the total to 6.^[176] On 20 July, the last patients were discharged,^[177] and on 3 September 2015, Liberia was declared Ebola-free again.^[178]

After two months of going Ebola-free, on 20 November a new case was confirmed when a 15-year-old boy was diagnosed with Ebola^[179][180] and two family members subsequently tested positive as well.^[181][182] Health officials were concerned because the child had not recently travelled or been exposed to someone with Ebola and the WHO stated, "we believe that this is probably again, somehow, someone who has come in contact with a virus that had been persisting in an individual, who had suffered the disease months ago." Two members of the US CDC were sent to the country to help to ascertain the cause of the new cases.^[183] The infected boy died on 24 November,^[184] and on 3 December the two remaining cases were released after recovering from the virus.^[185] The 42-day countdown toward Liberia being declared Ebola-free, for the third time, started on 4 December 2015 and ended on 14 January 2016 when Liberia was declared Ebola-free.^[186] On 16 December, WHO reaffirmed that the cases in Liberia were the result of re-emergence of the virus in a previously infected person,^[187] and there is speculation that the boy may have been infected by an individual who became infectious once more due to pregnancy which may have weakened her immune system.^[188] On 18 December, the WHO indicated that it still considers Ebola in West Africa a public health emergency, though progress has been made.^[189] After having completed the 42 day time period, Liberia was declared free from the virus on 14 January 2016, effectively ending the outbreak started in neighbouring Guinea 2 years ago. Liberia will however have a 90-day period of heightened surveillance which was scheduled to conclude on 13 April 2016,^[190] but on 1 April it was reported that a new Ebola fatality has occurred in Liberia,^[191] and on 3 April a second case was reported in Monrovia.^[192] On 4 April it was reported that 84 individuals were under observation due to contact with the 2 confirmed cases of the virus.^[193] On 7 April Liberia confirmed three new cases since the virus resurfaced. A total of 97 contacts, including 15 Healthcare workers are currently being monitored.^[194] The index case of the new flare up was reported to be the wife of a patient who died from the virus in Guinea. She traveled to Monrovia after the funeral of her husband but succumbed the disease.^[195]

On 29 April, WHO reported that Liberia had discharged the last patient and had begun the 42 day countdown to be declared Ebola-free once more. According to WHO tests indicate the flare-up was likely due to contact with a prior Ebola-survivor's infected body fluids.^[196]

West African countries with limited local cases

Senegal

In March 2014, the Senegal Ministry of Interior closed its southern border with Guinea,^[197] 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.^[198] 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.^[198]

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.^[198] On 10 September, it was reported that the student had recovered but health officials would continue to monitor his contacts for 21 days.^[199] No further cases were reported.^[200] and on 17 October 2014, the WHO officially declared that the outbreak in Senegal had ended.^[5]

The WHO have officially commended the Senegalese government, and in particular the President Macky Sall and the Minister of Health Dr Awa Coll-Seck, for their 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 Centers for Disease Control for their assistance.^[201]

Nigeria

The first case in Nigeria was a Liberian-American, who flew from Liberia to Nigeria's most populated city of Lagos on 20 July 2014. On 6 August 2014, the Nigerian health minister told reporters that one of the nurses that attended to the Liberian died from the disease. Five newly confirmed cases were being treated at an isolation ward.^[202]

On 22 September 2014, the Nigeria health ministry announced, "As of today, there is no case of Ebola in Nigeria." According to the WHO, 20 cases and 8 deaths had been confirmed, including the imported case, who also died. Four of the dead were health care workers who had cared for the index case.^[203]

The WHO's representative in Nigeria officially declared Nigeria to be Ebola free on 20 October 2014, after no new active cases were reported in the follow up contacts, stating it was a "spectacular success story".^[204]

Mali

Malian regions with Ebola cases (Kayes and Bamako), as of November 2014

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 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.^[205][206] All contacts were followed for 21 days, with no further spread of the disease reported.^[207]

On 12 November 2014, Mali reported deaths from Ebola in an outbreak unconnected 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.^[208] A nurse and a doctor who had treated the imam subsequently fell ill with Ebola and died.^[209][210] 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.^[211] 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.^[212] On 16 December, Mali released the final 13 individuals who were being quarantined^[213] and 24 days later (18 January 2015) without new cases the country was declared Ebola-free.^[6]

Other countries with limited local cases

United Kingdom

On 29 December 2014, Pauline Cafferkey, a British aid worker who had just returned to Glasgow from Sierra Leone was diagnosed with Ebola.^[214] She was treated and declared to be free of infection and released from hospital on 24 January 2015.^[9][215] On 8 October, she was readmitted for complications caused by the virus^[216] and was in "serious" condition according to a hospital report. On 14 October her condition was listed as "critical"^[217] and 58 individuals were being monitored and 25 received an experimental vaccination, due to close contact.^[218][219] On 21 October, it was reported that she had been diagnosed with meningitis caused by the virus persisting in her brain.^[220] On 12 November she was released from hospital after a full recovery.^[221] However, on 23 February Ms. Cafferkey was admitted for a third time, "under routine monitoring by the Infectious Diseases Unit...for further investigations" according to a spokesperson.^[222][223]

Italy

On 12 May 2015, it was reported that a nurse who had been working in Sierra Leone had been diagnosed with Ebola after returning home to the Italian island of Sardinia. He was treated at Spallanzani Hospital, the national reference center for Ebola patients.^[224] On 10 June it was reported that he had recovered and was disease-free and he was released from hospital.^[225]

Spain

On 5 August 2014, the Brothers Hospitallers of Saint 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.^[226] 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.^[227]

In October 2014, a nursing assistant, Teresa Romero, who had cared for these patients became unwell and on 6 October tested positive for Ebola,^[228][229] making this the first confirmed case of Ebola transmission outside of 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.^[230]

United States

On 30 September 2014, the United States Centers for Disease Control and Prevention declared its first case of Ebola virus disease. The US 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.^[231][232] Thomas Duncan died on 8 October.^[233] Two additional cases stemmed from Thomas Eric Duncan, when two nurses that had treated him tested positive for Ebola on 10 and 14 October^[234][235] and ended when they were declared Ebola free on 24 and 22 October, respectively.^[236][237]

A fourth case of Ebola was identified on 23 October 2014 when a physician who had treated Ebola patients in West Africa, himself tested positive for Ebola.^[238] This case had no relation to the cases originating from Thomas Eric Duncan. He recovered and was released from hospital on 11 November.^[239]

Countries with medically evacuated cases

A number of people who had become infected with Ebola were medically evacuated for treatment in isolation wards in Europe or the US. They were mostly health workers with one of the NGOs in West Africa. With the exception of a single isolated case in Spain, no secondary infections occurred as a result of the medical evacuations. The United States accepted four evacuees and three were flown to Germany.^{[240][241][242]} France,^[243][244] Italy,^[245] the Netherlands,^[246] Norway,^[247][248] Switzerland,^[249] and the United Kingdom received two (and five who were exposed) patients.^[250][251]

Unrelated 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.^[252] 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.^[252][253]

The index case was initially reported to have been a woman from Ikanamongo Village, who became ill with the symptoms of Ebola after she had butchered a bush animal.^[252][254] 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.^[255] The WHO declared the outbreak over on 21 November 2014, with a total of 66 cases with 49 deaths.^[256][257]

Virology

Ebola virus particles using electron micrograph

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.^[258][259] 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.^[55] However, further studies have shown that the current outbreak is likely caused by an Ebola virus lineage that spread from Central Africa via an animal host within the last decade, with the first viral transfer to humans in Guinea.^[258][260]

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 provided information about the origin and transmission of the Ebola virus that sets this outbreak apart from previous outbreaks. The researchers found 341 genetic changes that make the outbreak distinct from previous outbreaks.^[258] Five members of the research team became ill and died from Ebola before the study was published in August 2014.^[258]

Ebola virus particles

In a report released in August 2014, researchers 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 had changed. This tracking 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 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.^{[261][262][263][264][265]}

In January 2015, researchers in Guinea reported mutations in the virus 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.^[266] According to Alfson et al., a recent study suggests that accelerating the rate of mutation of the Ebola virus could make the virus less capable of infecting humans. In the animal study the virus became practically non-viable, consequently increasing survival.^[267][268]

Transmission

Animal to human transmission

The life cycles of the Ebolavirus

It is not entirely clear how an Ebola outbreak starts.^[269] 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 (however, despite considerable research, infectious ebolaviruses have never been recovered from bats).^[270][271] 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.^[272] 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 had contact with an insectivorous bat from a colony of Angolan free-tailed bats near the village.^[273]

On 12 January, Nature reported the virus’s natural host can be found by studying how bush-meat hunters interact with the ecosystem.^[274]

Human to human transmission

Based on a limited number of studies it is believed that 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.^[275] Other possible methods of transmission are currently being studied.^[276] 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.^[277] One study suggested that the virus can live up to 7 days in a deceased individual.^{[278][279][280]} A 7 January article by NEJM indicated that male and female individuals had similar risks of contracting the virus. Females did have a higher survival rate than males (who spent half a day longer than females in the community while already symptomatic with the virus.)^[281]

Airborne transmission

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 said that while the study raised issues "it would be rare; as the study points out, it has never been demonstrated in humans."^[282]

Sexual transmission

According to information distributed by the WHO in September 2014, "No formal evidence exists of sexual transmission, but sexual transmission from convalescent patients cannot be ruled out. There is evidence that live Ebola virus can be isolated in seminal fluids of convalescent men for 82 days after onset of symptoms. Evidence is not available yet beyond 82 days."^[279] In April 2015, following a report that the Ebola virus had been detected in a semen sample six months after a man's recovery, the WHO issued a statement saying, "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."^[283][284]

The WHO based their new recommendations on a March 2015 case in which a Liberian woman who had no contact with the disease other than having had unprotected sex with a man who had had the disease in October 2014 was diagnosed with Ebola. While no evidence of the virus was found in his blood, his semen revealed Ebola virus RNA closely matching the strain that infected the woman, however "doctors don’t know if there was any fully formed (and therefore infectious) virus in the guy’s semen." It is known that a male's testes are protected from the body's immune system to protect the developing sperm, and it is thought that it may be that this same protection may allow the Ebola virus to survive in the male testes for an unknown time.^[285]

On 14 September 2015, the body of a girl that had died in Sierra Leone tested positive for Ebola^[132] and it was suspected that she may have contracted the disease from the semen of an Ebola survivor who was discharged in March 2015.^[133] According to some news reports, a new study to be published in the New England Journal of Medicine indicates the possibility that the virus may remain in the semen of survivors for up to six months.^[286] According to Thorson et al., the virus can continue in semen for 82 days and maybe longer. Furthermore, EBOV RNA has been found up to 284 days post onset of the viral symptoms. In one case a female individual had no detectable virus on day 19, however RT-PCR was positive for sweat until day 30, and conjunctival and vaginal swabs until the 28th day after onset of the virus. The study continues that there is evidence that indicates viral constancy in semen, though such evidence is weak in vaginal fluids. The WHO indicates testing after 3 months, abstinence, or condom use 6 months or more after recovery. ^[287] The U.S. National Library of Medicine indicates that studies have shown for males who had four to six months of recovery, 26 of 40 were still positive with the virus, while individuals who were 9 months post-symptomatic showed 26% were positive. PubMed Health additionally indicates that there have been rare reports of the virus being contracted sexually, which could mean it is not transmitted via this route with ease, even though there is a large number of Ebola survivors.^[288]

Containment difficulties

One of the primary reasons for spread is the poorly-functioning health systems in the part of Africa where the disease occurs.^[289] 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.^[269]

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.^[290] 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 [Centers for Disease Control] 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.^[291]

Difficulties in attempting to halt transmission have also included the multiple disease outbreaks across country borders.^[292] 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.^[73] 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.^[293] On 9 December, a study indicated that a single individual introduced the virus into Liberia, causing the most cases of the virus in that country.^[294]

Containment and control

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

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.^[295] 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.^[296] 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."^[297] There is a massive ongoing effort to train volunteers and health workers, sponsored by USAID.^[298] 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.^[66] According to Ilesanmi et al., it is important to have a public awareness campaign to inform the affected community about the importance of contact tracing, so that true information can be obtained from the community.^[299]

Community awareness

To reduce the spread, the World Health Organization recommended raising community awareness of the risk factors for Ebola infection and the protective measures individuals can take.^[300] These include avoiding contact with infected people and regular hand washing using soap and water.^[301] 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."^[302] One study showed that once people had heard of the Ebola virus disease, hand washing with soap and water improved, though socio-demographic factors influence hygiene.^[303]

A number of organisations enrolled local people to conduct public awareness campaigns among the communities in West Africa.^[304] "...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.^[305]

Denial in some affected countries also made containment efforts difficult.^[306] Language barriers and the appearance of medical teams in protective suits sometimes increased fears of the virus.^[307] In Liberia, a mob attacked an Ebola isolation centre, stealing equipment and "freeing" patients while shouting "There's no Ebola."^[308] Red Cross staff were forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives.^[309] In 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.^[310]

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.^{[31][32][33][53][63][311]} In November, WHO released a protocol for safe and dignified burial of people who die from Ebola virus disease. It encouraged inclusion of family and clergy, and gave specific instructions for Muslim and Christian burials.^[312] 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 had a list of key religious leaders who promote safe and dignified burials.^[313] 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.^[314]

During the height of the epidemic most schools in the three most affected countries were shut down and remained closed for several months. During the period of closure UNICEF and its partners established strict hygiene protocols to be used when the schools were reopened in January 2015. They met with thousands of teachers and administrators to work out hygiene guidelines. Their efforts included installing handwashing stations and distributing millions of bars of soap and chlorine and plans for taking the temperature of children and staff at the school gate. Their efforts were complicated by the fact that less than 50% of the schools in these three countries have access to running water. In August 2015, UNICEF released a report that stated, "Across the three countries, there have been no reported cases of a student or teacher being infected at a school since strict hygiene protocols were introduced when classes resumed at the beginning of the year after a months-long delay caused by the virus."^[315] According to Fallah et al., recent evidence indicated that infected people that lived in low socioeconomic areas were more likely to transmit the virus to other SES communities, in contrast to individuals in higher SES areas who were infected as well.^[316] According to Buli et al., in Guinea a satisfactory knowledge has not altered the level of comprehensive knowledge about the virus. As a consequence, the high level of misinterpretation was responsible for a low comprehensive knowledge about the virus; 82% of individuals believed that Ebola was the result of a virus (36.2% thought that a higher power had caused it).^[317] According to Onyeonoro et al., in this case a prompt response by the government and proactive public health measures resulted in the quick control of the outbreak.^[318]

Travel restrictions and quarantines

A quarantine travel pass for people providing help to those infected with Ebola

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

West Africa

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.^[319] This was subsequently 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 the military.^[320][321]

International

Many countries 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 were not justified and that they prevent medical experts from entering the affected areas and that they were "marginalizing the affected population and potentially worsening the crisis". UN officials working on the ground 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".^[322] MSF also spoke out against the closure of international borders, called them "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."^[45]

In December 2015, during the 8th meeting of the World Health Organization Emergency Committee in relation to the Ebola Virus Disease the committee spoke out against further travel restrictions saying, "The Committee remains deeply concerned that 34 countries still enact inappropriate travel and transport measures and highlights the need to immediately terminate any such measures due to their negative impact, particularly on recovery efforts." ^[323]

In December 2015, the CDC indicated that it no longer would make the recommendation for US citizens going to Sierra Leone to be extra careful. However, the CDC did further indicate that individuals traveling to the country should take precaution with sick people and body fluids. Additionally, individuals traveling to the country should avert contact with animals.^[324]

Returning health workers

There was concern that people returning from affected countries, such as health workers and reporters, may have been incubating the disease and become infectious after arriving. Guidelines for returning workers were issued by a number of agencies, including the Centers for Disease Control,^[325] MSF,^[326] Public Health England,^[327] and Public Health Ontario.^[328]

Treatment

Practising taking blood in Ebola safety suits

No proven Ebola virus-specific treatment presently exists,^[329] however measures can be taken to improve a patient's chances of survival.^[330] 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.^[331] In past outbreaks it has been noted that some patients may experience the loss of blood through bleeding internally and/or externally, however data published in October 2014 showed that bleeding had been a rare symptom in this outbreak.^[332] Another study published in October 2014 suggested that a person's genetic makeup may play a major role in determining how an infected person's body reacts to the disease, with some infected people experiencing mild or no symptoms while some progress to a very severe stage that includes massive bleeding.^[333]

Without fluid replacement, such extreme loss of fluids leads to dehydration, which may lead to hypovolaemic shock—a condition in which 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 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 that may be fogged is difficult, and once in place, the IV 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 did not have access to laboratory services.^[334]

According to the WHO, the main reason that most patients in American and European hospitals survived was due to the use of IV fluids along with constant measuring of blood chemistry. However, at the height of the epidemic facilities had little to offer in terms of equipment, staffing, and laboratory services. Treatment centers were overflowing with patients while others waited to be admitted and dead patients were so numerous that it was difficult to arrange for safe burials. Based on many years of experience in Africa and several months of experience working with the present epidemic, MSF took a conservative approach. While using IV treatment for as many patients as they could manage, they argued that improperly managed IV treatment is not helpful and may even kill a patient when not properly managed. They also said that they were concerned about further risk to already overworked staff.^[334] 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.^[335] Paul Farmer of Partners in Health, an NGO that as of January 2015 had only recently begun to treat Ebola patients, strongly supported 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 suggested that every treatment facility should have a team that specializes in inserting IVs, or better yet, peripherally inserted central catheter (PICC) lines.^[334]

Prognosis

Ebola virus disease has a high case fatality rate (CFR-risk of death in those infected), which in past outbreaks has varied between 25 percent and 90 percent of those who have contracted the disease. The previous 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.^[336] The current epidemic has caused significant mortality, with reported case fatality rates of up to 70%.^{[12][13][14][15]} Care settings that have access to medical expertise may increase survival by providing maintenance of hydration, circulatory volume, and blood pressure.^[332]

The disease affects males and females equally and the majority of those that contract Ebola disease are between 15 and 45 years of age.^[12] 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.^[332] 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."^[337] In September 2015 the WHO organization issued pregnancy guidance information entitled, "Interim Guidance on Ebola Virus Disease in Pregnancy."^[338][339]

It has been suggested that the loss of human life was not limited to Ebola victims alone. Many hospitals had to shut down leaving people with other medical needs without care. A spokesperson for the UK-based health foundation the Wellcome Trust said in October 2014 that "the additional death toll from malaria and other diseases [is] likely to exceed that of the outbreak itself".^[34] Doctor Paul Farmer stated "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."^[35] As the epidemic began to come to a close in 2015, a report from Sierra Leone showed that the fear and mistrust of hospitals generated by the epidemic had resulted in giving birth at health centres falling by 11%, and those receiving care before or after birth falling by about a fifth. Consequently, the deaths of women during or just after childbirth rose by almost a third and those of newborns by a quarter between May 2014 and April 2015 compared with the previous year.^[340]

Research suggests that many Ebola infections are asymptomatic, meaning that people have been infected with Ebola but show no symptoms of the disease. For example, two studies done on previous outbreaks showed that 71% of seropositive individuals did not have the disease in one outbreak and another study reported that 46% of asymptomatic close contacts of patients with Ebola were seropositive.^[341] On 22 January, WHO issued Clinical Care for survivors of Ebola Virus Disease interim guidance. The guidance covers specific issues like musculoskeletal pain which is reported in up to 75% of survivors. The pain is symmetrical and more pronounced in the morning, with the larger joints most affected. There is also possibly periarticular tenosynovitis, which affects the shoulders. WHO guidelines advise to distinguish non-inflammatory arthralgia from inflammatory arthritis. In regards to ocular problems, sensitivity to light and blurry vision have been indicated among survivors. Among the aftereffects of EVD, uveitis and optic nerve disease could appear after the individual is discharged. Ocular problems could threaten sight in survivors, and therefore treatment must be quick. When treating, WHO recommends immediate treatment if uveitis is suspected; this consists of prednisone (corticosteroid). Hearing loss by Ebola survivors has been reported 25% of the time. Treatment in the case of acute labyrinthitis (inner ear disorder) should be given within 10 days of onset of symptoms. Prochlorperazine, a vestibular sedative, may be administered for vertigo.^[342]

Post-Ebola Syndrome

There are at least 17,000 people who have survived infection from the Ebola virus in West Africa; some survivors have reported lingering health effects.^[343] In early November a WHO consultant reported, "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."^[344][345]

In February 2015, a Sierra Leone physician said about half of the recovered patients she saw reported declining health and that she had seen survivors go blind.^[346][347] In May 2015 a senior consultant to the WHO said that the reports of eye problems were especially concerning because "there are hardly any ophthalmologists in West Africa, and only they have the skills and equipment to diagnose conditions like uveitis that affect the inner chambers of the eye."^[51]

The medical director of a hospital in Liberia reported that he was seeing health problems in patients who had been in recovery for as long as nine months. Problems he was seeing included chronic pain, sometimes so severe that walking was difficult; eye problems, including uveitis; and headaches as the most common physical symptoms. "They’re still very severe and impacting their life every day. These patients will need medical care for months and maybe years." A physician from the Kenema hospital in Sierra Leone reported similar health difficulties.^[51]

In December 2014, a British aid worker who had just returned from Sierra Leone was diagnosed with Ebola. She was treated with survivors' blood plasma and experimental drugs and declared free of disease in January 2015. However, in October 2015 she again became critically ill and was diagnosed with meningitis. In this unprecedented case it is thought that the virus remained in her brain replicating at a very low level until it had replicated to a degree capable of causing the clinical illness of meningitis. The woman was treated and in November 2015 it was reported that she had recovered.^[220][221]

Studies

An observational study done roughly 29 months after the outbreak on survivors of the 2007 Bundibugyo Ebola virus outbreak in Uganda found that long-term sequelae (consequences) persisted for more than two years after Ebola virus disease. Symptoms included eye pain, blurred vision, hearing loss, difficulty swallowing, difficulty sleeping, arthralgias, memory loss or confusion, and "various constitutional symptoms controlling for age and sex".^[341]

From August through December 2014, a total of 10 patients with Ebola were treated in U.S. hospitals; of these patients, 8 survived. In March 2015, the U.S. CDC interviewed the survivors; they all reported having had at least one adverse symptom during their recovery period. The symptoms ranged from mild (for instance hair loss) to more severe complications requiring rehospitalization or treatment. The most frequently reported symptoms were lethargy or fatigue, joint pain, and hair loss. Sixty-three percent reported having eye problems including two who were diagnosed with uveitis, 75% reported psychological or cognitive symptoms, and 38% reported neural difficulties. Although most symptoms resolved or improved over time, only one survivor reported complete resolution of all symptoms.^[348]

A study published in May 2015 discussed the case of Ian Crozier, a Zimbabwe-born physician and American citizen who became infected with Ebola while he was working at an Ebola treatment center in Sierra Leone. He was transported to the US and was successfully treated at Emory University Hospital. However, after discharge Crozier began to experience symptoms including low back pain, bilateral enthesitis of the Achilles tendon, paresthesias involving his lower legs, and eye pain, which was diagnosed as uveitis. His eye condition worsened and a specimen of aqueous humor was obtained from his eye which tested positive for Ebola. The authors of the study concluded "Further studies to investigate the mechanisms responsible for the ocular persistence of Ebola and the possible presence of the virus in other immune-privileged sites (e.g., in the central nervous system, gonads, and articular cartilage) are warranted." The authors also noted that 40% of participants in a survey of 85 Ebola survivors in Sierra Leone reported having "eye problems", though the incidence of actual uveitis was unknown.^[349]

Another study which was released in August 2015 looked at the health difficulties that have been reported by survivors. Calling the set of symptoms "post-Ebolavirus disease syndrome (PEVDS)", the research found symptoms which included "chronic joint and muscle pain, fatigue, anorexia, hearing loss, blurred vision, headache, sleep disturbances, low mood and short-term memory problems." The research suggests that "implementation of specialized health services to treat and follow-up survivors" is needed.^[350]

Level of care

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

In June 2014 it was reported that local authorities did not have resources to contain the disease, with health centres closing and hospitals becoming overwhelmed.^[351] There were also reports that adequate personal protection equipment was not being provided for medical personnel.^[352] 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."^[292]

In late August, MSF called the situation "chaotic" and the medical response "inadequate." They reported that they had expanded their operations, but couldn't keep up with the rapidly increasing need for assistance, which had forced them to reduce the level of care: "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.^[353]

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."^[354] 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.^[355]

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.^[37]

Healthcare settings

Ebola treatment centre built by the UK in Kerry Town, Sierra Leone, in 2014

A number of Ebola Treatment Centres were 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.^[356][357] 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.^[358][359] 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.^[360][361]

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.^[362][363] 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.^[364][365] Even where hospital beds were available, it was debated whether conventional hospitals are the best place to care for Ebola patients, as the risk of spreading the infection is high.^[366] 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.^[367] According to Youkee et al., health facilities with poor levels of preventing infection have been involved as sites of amplification during viral outbreaks.^[368]

Protective clothing

Examining equipment

The Ebola epidemic 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.^[369]

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."^[370][371] By October there were reports that protective outfits were beginning to be in short supply and manufacturers began to increase their production,^[372] but the need to find better types of suits has also been raised.^[373]

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".^{[374][375][376]} On 12 December 2014, USAID announced the result of the first selection in a press release.^[377]

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," said one source.^[378] In March, Google developed a tablet that can be cleaned with chlorine.^[379] It is charged wirelessly and can transmit information to servers outside of the working area.^[380] According to a 2015 article by Fisher et al., it is recommended that the mucous membrane be covered with a powered air-purifying respirator that includes a face shield, or helmet. This in turn must be used with a disposable hood that completely covers the neck, and also should comprise using goggles to protect conjunctival membranes. In terms of a mask, a fluid-resistant medical mask, duckbill-type, should be used. WHO recommends using 2 pairs of gloves with the outer pair worn on top/over the gown. Using 2 pairs of gloves may reduce the risk of sharp injuries, however, there is no evidence that using more than recommended will give additional protection. WHO also recommends the use of a coverall which generally is appraised via its resistance to nonenveloped DNA virus. When a gown (coverall) is worn, it should continue beyond the shoe covers.^[381] According to guidelines released on August 2015 by the CDC, updates are in place to improve the PAPR doffing method to make the steps easier, and affirm the importance of cleaning the floor where doffing has been done. Additionally a designated doffing assistant is recommended to help in this process.The order in which boot covers are removed should now follow guidelines that indicate removal after the coverall or gown. Finally, a trained observer will read to the HCW each step in donning and doffing, but must not physically assist in doffing.^[382]

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

Healthcare workers

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.^[293] 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.^[383] 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".^[293] In August 2014, healthcare workers represented nearly 10 percent of the cases and fatalities—significantly impairing the ability to respond to an outbreak in an area already facing a severe shortage.^[384] By 1 July 2015, the WHO reported a total of 874 health workers had been infected and 509 had died.^[385]

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".^[386] In July 2014, leading Ebola doctor Sheik Umar Khan from Sierra Leone died in the outbreak.^{[108][387][388]} In August, a well-known Nigerian physician, Ameyo Adadevoh, died.^[389] 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.^[390]

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."^[391] According to an October 2015 report by the CDC, Guinean HCWs have 42.2 times higher Ebola infection than non-HCWs, and male HCWs were more affected than their female counterparts. The report indicates that 27% of Ebola infections among HCWs in Guinea happened to doctors. The CDC report also says that the Guinea Ministry of Health states males represent 46% of the health workforce, and 67% of EVD infections among HCWs (non-doctors) happened among males. The CDC further indicates that HCWs in Guinea were less likely to report contact with an infected individual than non-healthcare workers.^[392]

Experimental treatments, vaccines and testing

Researcher working on the Ebola virus

There is as yet no known confirmed medication or treatment for Ebola virus disease. 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.^{[393][394][395]} A number of experimental treatments are undergoing clinical trials.^{[396][397][398][399]} During the epidemic some patients received experimental blood transfusions from Ebola survivors, but a later study found that the treatment did not provide significant benefit.^[400]

The effectiveness of potential treatments for disease is usually assessed in a randomized controlled trial which compares the outcome of those who received treatment to those who received a placebo (dummy treatment). However, randomized controlled trials are considered unethical when a disease is frequently fatal, as is the case with Ebola. In December 2015, a study was released that found that the amount of viral load found in a patient's blood in the week after the onset of symptoms is a strong indication of the patient's likelihood to die or survive the disease. The researchers suggest that this information may help to assess the efficacy of proposed treatments more accurately in nonrandomized clinical trials.^[401]

Ebola control is hindered by the fact that current diagnostic tests require specialised equipment and highly trained personnel. Since there are few suitable testing centres in West Africa, this delays diagnosis. As of February 2015 a number of diagnostic tests are under trial.^[402] In September 2015, a new chip-based testing method that can detect Ebola accurately was reported. The new device allows for the use of portable instruments that can provide immediate diagnosis.^[403][404]

Several Ebola vaccine candidates had been developed in the decade prior to 2014, and had been shown to protect nonhuman primates against infection, but none had yet been approved for clinical use in humans.^[405] Several trials are ongoing.^{[406][407][408]}

On 31 July 2015, researchers announced that a vaccine trial in Guinea had been completed that appeared to give protection from the virus. The vaccine, formally called rVSV-ZEBOV but more commonly known as VSV-EBOV,^[409] has shown 100% efficacy in individuals, but more conclusive evidence is needed on its capacity to protect populations through what is called herd immunity. The technique used in the vaccine trial is called ring vaccination, which was used in the 1970s to eradicate smallpox. Ring vaccination controls an outbreak by vaccinating all suspected infected individuals in the area around the outbreak.^{[48][49][410]} If VSV-EBOV is approved, it would be the first licensed Ebola vaccine available. Dr. Jeremy Farrar indicated, the "vaccine...could still play an important role in containing any additional flare ups of this outbreak... being available to help prevent future epidemics.”^[411] A pharmaceutical company has begun the process for approval of VSV-EBOV to the WHO Emergency Use Assessment and Listing.^[412] According to a 2015 review article by Sridhar the Ebola outbreak demonstrated the lack of a vaccine in such an emergency as the ongoing outbreak. About 15 different vaccines are in development (preclinical). These include DNA vaccines, virus-like particles and viral vectors (vesicular stomatitis virus, human adenovirus, and vaccinia virus). An unheard-of 7 vaccines (ChAd3, MVA-BNFilo, Ad26, MVA-EBOZ, rAd5, rVSV and VLP) have been placed into development. Additionally, there are two phase III studies with two different vaccines. The author indicates that a vaccine would need durable efficacy and be effective in children. A prime-boost vaccination plan like Ad/MVA before multiple booster vaccinations of rVSV may be a strategy that could be followed, or as an alternative a post-exposure vaccination to EVD might be a better idea, the author suggests. The review further indicates that a second point is identifying immunological correlates of protection, as currently there is no human protection. It is possible that immunological correlates change depending on the type of vaccine. Correlates of immunity to a virus are measurable signs that an individual is immune (is protected against becoming infected). The third point is licensing the vaccines, since traditional models do not apply. Ebola, which is unpredictable (due to outbreaks), would cause phase III clinical trials which note efficacy to be challenging. The FDA allows licensing of vaccines via the ‘animal rule’, where the vaccine must show efficiency in animal models, plus phase I and II clinical trials indicating safety for humans. The article notes that one single dose of rVSV is able to achieve antibody titres. The review article points out that challenges remain in developing vaccines that give long-lasting efficacy and coming up with the best ways for vaccine deployment, and linking the immunological record with efficiency data to ascertain the correlates of protection.^[413]

Outlook

Since the beginning of the outbreak, considerable difficulty has existed in getting reliable estimates both of the number of people affected, and of the geographical extent of the outbreak.^[414] The three most affected countries, 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.^[415] According to Santermans et al., a recent study yielded results of the spatial and temporal evolution of the viral outbreak. With the use of heat maps it was determined that the outbreak did not uniformly unfold over the affected community areas. Growth in the regions of Guinea, Liberia and Sierra Leone was very different over time, indicating that monitoring the outbreak at district level was important. Visual inspection of incidence curves alone could not render the needed results/data; growth rates with a two-dimensional heatmap were used. Finally, the study showed that precisely accurate predictions of growth are improbable, coupled with knowledge about the disease (as it has now had cases via sexual transmission) that is not fully adequate at this time.^[416]

Statistical measures

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.^[417][418] 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.^[12][13][14] The CFR among hospitalized patients, based on the three intense-transmission countries, was between 57% and 59% in January 2015.^[15]

The basic reproduction number R₀ is a statistical measure of the average number of people expected to be infected by one person who has a disease. If the rate is less than 1, the infection dies out. If the rate is greater than 1, the infection continues to spread—with exponential growth of cases.^[419] In September 2014 the estimated basic reproduction numbers were 1.71 (95% CI, 1.44 to 2.01) for Guinea, 1.83 (95% CI, 1.72 to 1.94) for Liberia, and 2.02 (95% CI, 1.79 to 2.26) for Sierra Leone.^{[12][420][421]} In October 2014, WHO noted that exponential increase of cases continued in the countries with the most intense transmission (Guinea, Liberia and Sierra Leone).^[422]

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.^[295] The WHO roadmap stated "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."^[295] The report included an assumption that some country or countries would pay the required cost of their plan, estimated at half a billion dollars.^[295]

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.^[423][424] 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".^[425]

On 23 September 2014, the WHO revised their previous projection, stating that they expected the number of Ebola cases in West Africa to be in excess of 20,000 by 2 November 2014.^[12] They further stated, that if the disease was not adequately contained it could become endemic in Guinea, Sierra Leone and Liberia, "spreading as routinely as malaria or the flu",^[426] and according to an editorial in the New England Journal of Medicine, eventually to other parts of Africa and beyond.^[427]

In a report released on 23 September 2014, the Centers for Disease Control analysed the impact of under-reporting which required 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.^[20] However, at a congressional hearing on 19 November, the director of the Centers for Disease Control said that the number of Ebola cases was no longer expected to exceed 1 million, moving away from the worst scenario that had been previously predicted.^[428]

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 were unreported – far fewer than had been estimated in prior projections. The study concluded that the epidemic would not be as difficult to control as feared if rapid, vigorous contact tracing and quarantines were employed.^[429]

Economic effects

In addition to the loss of life, the outbreak has caused a number of significant economic impacts. 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 fueled by stigma, the epidemic resulted in vast economic consequences in both the affected areas and even throughout African nations that experienced low or no cases of Ebola.^[47] A September 2014 report in the Financial Times journal suggested that the economic impact of the Ebola outbreak could kill more people than the disease itself.^[430] According to Bowles et al., in regards to Ebola and economic activity in the country of Liberia 8% of automotive firms, 8% of construction firms, 15% of food and 30% of restaurants in the study have closed due to the Ebola outbreak. Montserrado county experienced 20% firm closure. According to the author this indicates a decrease in the Liberian economy nationwide during the Ebola outbreak, as well as an indication that the county of Montserrado was hit hardest economically. The capital city Monrovia has suffered construction and restaurant unemployment the most, while outside the capital food and beverage sectors have suffered economically. The study indicates a recuperation in the economy from the end of the viral outbreak could restart in some sectors faster than other sectors. The study goes on to say that if the large decrease in economic activity persists a focus on economic recovery in addition to support for the healthcare system in Liberia will be needed. The World Bank suggests that $1.6 billion of productivity in all three affected west African countries in 2015 will be lost. Employment and the economy are believed to have a consequence on health in the long-term. There is cross-country interaction between income per capita and the rate of mortality. In Liberian counties that were less affected by the outbreak, the number of individuals employed fell by 24%. In the capital, Montserrado has seen a 47% decline in employment per firm in contrast to prior to the Ebola outbreak.^[431]

Another study by Stanturf et al. indicates that the economic effect of the Ebola outbreak will be felt for years due to social vulnerability. Economic effects caused by the Ebola outbreak are being felt nationwide in Liberia, such as a termination to an expansion in the mining business. Initial scenarios had estimated $25 billion in economic loss, however more recent World Bank estimates are much lower (about 12% of the combined GDP of the 3 worst hit countries). The authors of the paper go on to state that social vulnerability has multiple factors and a classification created from multiple variables instead of single indicators such as food insecurity or lack of hospitals. Rural Liberians are not food secure and do not have easy access to medical facilities. In spite of the fact that civil violence has been stopped since 2003 and donor funding has come into Liberia from international sources, reconstruction of Liberia has been very slow and non-productive; water delivery systems, sanitation facilities and centralized electricity are practically non-existent, even in Monrovia. Even before the outbreak medical facilities did not have potable water, lighting or refrigeration. The authors also indicate that lack of food and other economic effects will probably continue in the rural population long after EVD has ended.^[432]

• In August 2014 it was reported that many airlines had suspended flights to the area.^[433] Markets and shops had closed due to travel restrictions, a cordon sanitaire, or fear of human contact, which leads to loss of income for producers and traders.^[434]
• Movement of people away from affected areas disturbed agricultural activities.^[435][436] The UN Food and Agriculture Organisation (FAO) warned that the outbreak could endanger harvest and food security in West Africa.^[437] They warned that with all the quarantines and movement limitations placed on them, more than 1 million people could be food insecure by March 2015.^[438] By 29 July, the World Bank had given 10,500 tons of maize and rice seed to the 3 hardest-hit countries to assist them to rebuild their agricultural systems.^[439]
• Tourism was directly impacted in affected countries.^[440] In April 2014, Nigeria reported that 75% of hotel business had been lost due to fears of the outbreak;^[441] the limited Ebola outbreak cost Nigeria ₦8 billion.^[442][443] Countries in Africa that were not directly affected by the virus also reported adverse effects on tourism.^{[444][445][446]} For example, in 2015, it was reported that Gambia's tourism had fallen below 50 percent,^[447][448] Elmina Bay in Ghana had an 80% decrease in U.S. tourism,^[449] and Kenya,^[450] Zimbabwe,^[451] Senegal, Zambia, and Tanzania also reported a drop.^[452]
• Some foreign mining companies withdrew all non-essential personnel, deferred new investment, and cut back operations.^{[436][453][454]} In December 2014, 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.^[455] In March 2015, it was reported that Sierra Leone had begun to diversify away from mining, due to the country's recent problems.^[456]

In January 2015, Oxfam, which works for disaster relief, indicated that a "Marshall Plan", a reference to the massive plan to rebuild Europe after World War II, was needed so that other countries could begin to financially assist those who had been worst hit by the virus.^[457] The request was repeated in April 2015 when the West African countries affected the most by the epidemic asked for an $8 billion "Marshall Plan" to rebuild their economies. Speaking at the World Bank and International Monetary Fund, Liberian president Ellen Johnson Sirleaf said the large amount was needed for recovery because "Our health systems collapsed, investors left our countries, revenues declined and spending increased."^[458]

The International Monetary Fund (IMF) has been criticised for its lack of assistance in the efforts to combat the epidemic. In December 2014, a Cambridge University study linked IMF policies with the financial difficulties that prevented a strong Ebola response in the three most heavily affected countries,^[459] and they were urged by both the UN and NGOs who had worked in the affected countries to grant debt relief rather than only granting low-interest loans. According to one advocacy group, "...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".^[460][461] On 30 January 2015, the IMF reported it was near a deal for debt forgiveness.^[462] On 22 December, it was reported that the IMF had given Liberia an additional $10 million due to the economic impact of the Ebola virus outbreak.^[463]

In October 2014, a World Bank report estimated overall economic impacts of between $3.8 billion and $32.6 billion, depending on the extent of the outbreak and speed of containment. The report expected that economic impact would be most severe in the three affected countries, with a wider impact across the broader West African region.^[464][465] On 13 April 2015, the World Bank said that they would soon announce a major new effort to rebuild the economies of the three hardest-hit countries.^[466] On 23 July, a World Bank poll warned "we are not ready for another Ebola outbreak".^[467] On 15 December, the World Bank indicated that by 1 December of this year, it had marshalled $1.62 billion in financing for Ebola outbreak response.^[468]

On 6 July 2015, Secretary-General Ban Ki-moon announced he would host an Ebola recovery conference to raise funds for reconstruction. The three countries hit hardest by Ebola need about $700 million to rebuild their health services in the next two years.^[469] On 10 July, it was announced that the countries most affected by the Ebola epidemic will receive $3.4 billion to rebuild.^[470][471] On 29 September, the leaders of both Sierra Leone and Liberia indicated at the U.N. the start of the "Post-Ebola Economic Stabilization and Recovery Plan".^[472] On 24 November, it was reported that due to the decrease in commodity prices and the Ebola outbreak in West Africa, China’s investment in the continent declined 43 per cent in the first 6 months of 2015.^[473] On 25 January, the International Monetary Fund projected a GDP growth of 0.3% for Liberia. The country of Liberia indicated it would cut spending by 11 percent due to a stagnation in the mining district, which will cause a domestic revenues drop of $57 million.^[474]

Responses

In July 2014, the 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.^[43] This is a legal designation used only twice before (for the 2009 H1N1 (swine flu) pandemic and the 2014 resurgence of polio) that invokes legal measures on disease prevention, surveillance, control, and response, by 194 signatory countries.^[475][476]

In September 2014, 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.^[477][478] In October, WHO and the UN Mission for Ebola Emergency Response announced a comprehensive 90-day plan to control and reverse the Ebola epidemic. 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).^[479] Many nations and charitable organizations cooperated to realise the plan.^[480] A WHO situation report in mid-December indicated that the international community was on track to meet the 90-day target.^[481]

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.^[38] In May 2015, Dr. Margaret Chan indicated, "demands on WHO were more than ten times greater than ever experienced in the almost 70-year history of this Organization".^[482][483] On 23 March, the WHO director-general indicated that "the world remains woefully ill-prepared to respond to outbreaks that are both severe and sustained."^[484]

Criticism of WHO

WHO

There has been significant criticism of the WHO from some aid agencies because its response was perceived as slow and insufficient, especially during the early stages of the outbreak.^[44][485] In October 2014, 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".^[486] Peter Piot, co-discoverer of the Ebola virus, called the WHO regional office in Africa "really not competent."^[487] In April 2015, the 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".^[488] In May 2015, an independent panel indicated "deep and substantial" change would be needed by WHO;^[489] on the same topic, the German chancellor Angela Merkel unveiled a strategy to improve WHO at the G7 meeting.^[490][491] In November 2015 the WHO was again criticized by a panel of global health experts that convened to review the course of the epidemic and make recommendations. A WHO spokesperson said the organization welcomed the report and that they are reviewing the recommendations carefully, as well as those provided by other groups. The article published in The Lancet indicates that the panel's ten recommendations try to prevent small outbreaks from turning into large outbreaks, and demand encouragement of early international reporting of outbreaks by following agreed international rules. Responding to outbreaks begs strong operational capacity within the World Health Organization and within the aid system if outbreaks turn into emergencies, a politically protected system for the World Health Organization's emergency declarations, and strong mechanisms for the responsibility of all who are involved, from national governments to non-governmental organizations to United Nations agencies. Mobilization of the understanding needed to fight outbreaks will require an international structure of rules to enable access to the benefits of research, and financing to establish technology when commercial motivations are not appropriate. The article continues indicating that competent governance of this global system demands political leadership and a World Health Organization that is more focused and appropriately financed and whose integrity is restored through the application of good reforms and leadership. The west African Ebola epidemic that started in 2013 exposed problems in the national (and international) institutions responsible for protecting the public from the human consequences of infectious disease outbreaks like EVD.^{[492][493][494]}

The article mostly indicates that the committee responsible for checking the World Health Organization's actions during the EVD outbreak (the World Health Organization Ebola Interim Assessment Panel) and leaked emails suggest many reasons for the delay. These include worries about political resistance from the west African leaders, economic consequences, and a system inside the World Health Organization dissuading open debate about issues, such as emergency declarations. The World Health Organization might also have hesitated because it was criticised for creating panic by declaring a public health emergency during the mild 2009 H1N1 pandemic. The delay shows the risks in having such consequential decision making power in one individual; this risk is made worse when there is no mechanism of responsibility for such leadership failure.^[494]

Timeline of reported cases and deaths

Data sources

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 three times as many cases as officially reported.^{[20][495][496]}

Tables

Major Ebola virus outbreaks by country and by date – to most recent WHO / Gov update- 14 Jan 2016
Note: Cases include confirmed, probable and suspected per the WHO, numbers are the cumulative figures as published on the given date, and due to retrospective revisions differences between successive weekly totals are not necessarily the number of new cases that week.

Date	Total		Guinea		Liberia		Sierra Leone		Sources
	Cases	Deaths	Cases	Deaths	Cases	Deaths	Cases	Deaths
14 Jan 2016	28,542	11,299	3,806	2,535	10,675	4,809	14,061	3,955	[note 3][497]
23 Dec 2015	28,542	11,299	3,806	2,535	10,676	4,809	14,061	3,955	[498]
9 Dec 2015	28,542	11,299	3,806	2,535	10,675	4,809	14,061	3,955	[499]
25 Nov 2015	28,539	11,298	3,806	2,535	10,672	4,808	14,061	3,955	[500]
11 Nov 2015	28,539	11,298	3,806	2,535	10,672	4,808	14,061	3,955	[501]
25 Oct 2015	28,539	11,298	3,800	2,534	10,672	4,808	14,061	3,955	[502]
11 Oct 2015	28,454	11,297	3,800	2,534	10,672	4,808	13,982	3,955	[503]

Minor Ebola virus outbreaks by country and by date – 30 July 2014 to most recent WHO / Gov update 30 Aug 2015

Date	Total		Nigeria		Senegal		United States		Spain		Mali		United Kingdom		Italy		Refs
	Cases	Deaths	Cases	Deaths	Cases	Deaths	Cases	Deaths	Cases	Deaths	Cases	Deaths	Cases	Deaths	Cases	Deaths
30 Aug 2015	36	15	20	8	1	0	4	1	1	0	8	6	1	0	1	0	[note 4][504]
29 Dec 2014	35	15	20	8	1	0	4	1	1	0	8	6	1	0	–	–	[note 5][14]
14 Dec 2014	32	15	20	8	1	0	4	1	1	0	6	6	–	–	–	–	[118]
2 Nov 2014	27	10	20	8	1	0	4	1	1	0	1	1	–	–	–	–	[505]
12 Oct 2014	23	8	20	8	1	0	1	0	1	0	-	–	–	–	–	–	[506]
28 Sep 2014	22	8	20	8	1	0	1	0	-	–	-	–	–	–	–	–	[507]
30 Jul 2014	3	1	3	1	–	–	–	–	-	–	–	–	–	–	–	–	[508]

Notes:

1. The mortality rate (death/case ratio) recorded in Liberia up to 26 August 2014 was 70%.^[13] 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.
2. With the exception of the sole case of Tai Forest ebolavirus in Ivory Coast
3. 25 Oct: All governments as per WHO.
4. No change in Data from 13 May till 30 Aug
5. 29 December: All governments as per WHO. United Kingdom case dated 29 December.

• Date is the "as of" date from the reference. A single source may report statistics for multiple "as of" dates.
• Numbers with ≥ may not be consistent due to under reporting.

See also

• Health crisis

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Further reading

• "The role of training in the West Africa Ebola response" (PDF). WHO A review of the role of training in WHO Ebola emergency response (Review/ WHO). April 2016. Retrieved 24 April 2016.

External links

• "Ebola response roadmap – Situation reports". WHO. Retrieved 11 April 2015.
• "Outbreak Updates". World Health Organization (WHO). Retrieved 11 April 2015.
• "Outbreak Updates". US Centers for Disease Control and Prevention (CDC). Retrieved 11 April 2015.
• "Ebola Outbreak in West Africa Updates". Food and Agriculture Organization of the UN (FAO). Retrieved 11 April 2015.
• "2014 Ebola Outbreak – detail timeline and projection". healthmap.org. Retrieved 11 April 2015.
• "Platform to share communication materials regarding the Ebola epidemic". Ebola Communication Network. Retrieved 11 April 2015.
• "Fighting Ebola: A Grand Challenge for Development – Platform to collect and distribute ideas to stop the Ebola epidemic". USAID. Retrieved 11 April 2015.
• "Ebola outbreak in West Africa". European Centre for Disease Prevention and Control (ECDC). Retrieved 11 April 2015.
• "Ebolafacts – a simple FAQ in English & French". Retrieved 11 April 2015.

Resources

1. "Disease Outbreak News (DONs)". Global Alert and Response (GAR). WHO. Retrieved 11 April 2015.   Website content changes frequently.
2. "Disease Outbreak News". Regional Office for Africa. WHO. Retrieved 11 April 2015.   Website content changes frequently.
3. "West and Central Africa". HumanitarianResponse.info. OCHA. Retrieved 11 April 2015.