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Residents call attention to a man lying dead on a busy street in Monrovia, Liberia. who had died three days earlier. When no burial team came, people wearing rubber gloves dragged him into the street, stopping traffic and demanding he be taken away.

Ebola 2013-2016 – how long will the memory last?

All of the three countries – Guinea, Liberia and Sierra Leone – most affected by the prolonged outbreak of Ebola virus disease have been recently declared “free of Ebola transmission” and, on March 29th the WHO Director-General declared the end of the Public Health Emergency of International Concern regarding the Ebola virus disease outbreak in West Africa.

This does not necessarily mean the outbreak is completely over; all three countries are still under enhanced surveillance from the (most recent) date that they were declared free of transmission. In Liberia, this first happened in May 2015, but a small cluster of cases occurred in June, linked to a survivor who had continued to shed Ebolavirus in his semen. After a second declaration in September there was another small outbreak (3 cases) two months later and the country was declared free of transmission a third time, in January. Sierra Leone was declared free in November but there were two related cases in January and nearly 150 contacts who had attended the “unsafe” burial of one victim remain in quarantine or under observation. Finally, Guinea, where the outbreak began, was declared free of Ebola transmission on December 29th. However, in the last 2 weeks of March, 5 confirmed and 3 probable cases were reported, most of whom were high-risk contacts of earlier cases, including 3 probable cases, who had died and not been buried safely.

The outbreak began in December 2013 when a small boy in a remote Guinean village, and three of his family members, died from a mysterious disease. By the time the Guinean government notified WHO of an outbreak, in March 2014, it had spread to neighbouring towns and the Guinean capital, Conakry; it was identified as Ebola a week later. By then about 90 cases had been identified, two thirds of them fatal and the disease had spread to neighbouring Liberia and Sierra Leone. Already the extent of the outbreak was unprecedented: all 25 previous outbreaks, since 1976, when Ebola was first identified, had been in Central or East Africa and limited to single villages or small towns. By June, Médicins sans Frontière (MSF) – one of few organisations working to contain it – described the West African outbreak as “out of control” but was accused of being alarmist, by the Guinean government and the World Health Organisation (WHO). WHO had initially sent a contingent of about 100 technical advisers to investigate, but had withdrawn them after being reassured that the outbreak in Guinea was under control.

It soon became clear that this was not the case, as more cases were reported in Liberia and Sierra Leone, including their capitals, Monrovia and Freetown, respectively. WHO remained indecisive and the rest of the world took little notice until early August, when two American aid workers with Ebola, were evacuated to the USA for treatment. On August 8th, WHO belatedly declared “a public health emergency of international concern” (PHIEC). Their only immediate action was to hastily convene an ethics committee to discuss the use of drugs with unproven efficacy and safety, after controversy had arisen when it was announced that the two Americans had been given the experimental drug, Z-Mapp. There was little other action on the ground and, in September, an increasingly frustrated MSF President, in an address to the United Nations (UN) General Assembly, criticised the “global coalition of inaction” and made an unprecedented plea for “massive deployment of military and civilian teams”… “to contain the biological disaster”.

Diagram showing the size of outbreaks of Ebola virus disease in West Africa between December 2013 and January 2014. The single case in Senegal and small outbreaks in Mali and Nigeria were directly imported from Guinea or Liberia, but that in the Democratic Republic of Congo was unrelated.

Diagram showing the size of outbreaks of Ebola virus disease in West Africa between December 2013 and January 2014. The single case in Senegal and small outbreaks in Mali and Nigeria were directly imported from Guinea or Liberia, but that in the Democratic Republic of Congo was unrelated.

Nearly three weeks later, the UN established the Mission for Ebola Emergency Response (UNMEER), with powers similar to that of a peace keeping mission and the first ever for a public health emergency. Over the next four months, international financial and human resources and government and NGO agencies were slowly mobilised and a relatively co-ordinated response established. But the disease continued to spread; by year’s end there had been around 20,000 cases and 8000 deaths, but the numbers, at last, began to fall, during 2015, as more treatment centres and laboratories were commissioned and contact tracing and safe burial teams deployed.

Meanwhile, the rest of the world began to fear for its own safety. In October 2015, a Liberian-American man was admitted to hospital in Dallas, Texas with Ebola, with a high fever and severe diarrhoea, a week after he had been first seen in the emergency department, with a vague flu-like illness, and sent home. He died a few days later, and then two nurses, who had cared for him, also developed Ebola. Although they recovered, this provoked acrimonious recriminations and over-reactions in the USA and elsewhere. Some countries banned – or threatened to ban – flights from West Africa, despite the likely serious adverse effects on control efforts; several US (and one Australian) states – inappropriately – mandated home quarantine of aid workers returning from Ebola-affected countries, despite warnings that it would jeopardise recruitment of volunteers. Australia temporarily blocked refugees from West Africa.

The Dallas incident also undermined reassurances from the Centers for Disease Control (CDC) that strictly applied “routine” infection control measures would prevent hospital transmission of Ebola. The CDC advice was not exactly wrong, but it failed to account for the fact that “routine” hospital infection control measures are often not properly applied, unless there is a strong suspicion of a very high-risk communicable disease.

Map showing countries in Europe and North America to where patients with Ebola virus disease were treated. Most of whom were western healthcare or other aid workers, including three nurses (one in Spain, two in the USA) infected whilst caring for patients from West Africa. Five of these 26 people died; four had been airlifted to the West relatively late in the course of illness and the fifth was a Liberian man, who became ill shortly after returning to the USA, but in whom the diagnosis was only considered after he became gravely ill.

Map showing countries in Europe and North America to where patients with Ebola virus disease were treated. Most of whom were western healthcare or other aid workers, including three nurses (one in Spain, two in the USA) infected whilst caring for patients from West Africa. Five of these 26 people died; four had been airlifted to the West relatively late in the course of illness and the fifth was a Liberian man, who became ill shortly after returning to the USA, but in whom the diagnosis was only considered after he became gravely ill.

Infections of nurses in USA and the terrible toll among healthcare workers in West Africa, focussed the attention of hospital administrators and frontline staff around he world. CDC modified their guidelines for the use of personal protective equipment (PPE) to emphasise the need for all skin, clothing and hair to be completely covered and that particular care be taken – with supervision – when removing potentially contaminated PPE. Alarming deficiencies of knowledge and standards of routine infection control practice were identified, reflecting the low priority often given to infection prevention and control. In Australia – and presumably in other countries – preparations to receive patients with Ebola were unco-ordinated and inconsistent between jurisdictions and hospitals. Fear that Ebolavirus had become more transmissible or virulent prompted suggestions for excessive precautions that were impractical, potentially dangerous and confusing. By the time nationally consistent Ebola prevention and control guidelines were published, the risk had almost passed. There were no Ebola cases in Australia and only a handful anywhere outside of Africa.

The latest WHO situation report (March 30th 2016) indicates a total of 28,646 reported confirmed, probable and suspected cases and 11,323 deaths associated with this outbreak (including 29 cases and 14 deaths in African countries, other than the three most affected, and seven cases reported in Europe and North America). Thankfully this was far fewer than the possible 500,000-1.4 million predicted in September 2014, but over 60 times more than any previous outbreak. The international ramifications have been immense.

WHO has been severely criticised for its delayed, ineffective response. But its ability to respond to infectious disease emergencies has always been limited, especially since a recent 50% budget cut. Local governments initially claimed that assistance was not needed and WHO was understandably cautious about declaring a PHEIC, after criticism that it over-reacted to the H1N1 influenza pandemic. Nevertheless, the WHO Director-General has acknowledged the shortcomings of its response and promised reforms to improve emergency response capacity, although clearly this will depend on funding from member states. There is a need to strengthen International Health Regulations, which require that member states acquire the capacity to identify and report infectious diseases of international concern and seek assistance to control them, if required. Considering their grossly inadequate healthcare and disease surveillance systems, Guinea, Liberia and Sierra Leone had neither the capacity nor, apparently, the will – at least initially – to comply.

The international community must also carry responsibility for a slow, initially inadequate, response. Many countries, including Australia, offered funds, but not the people who were desperately needed to build facilities and train local health workers. Many countries spent a fortune on their own hospital preparations, for what should be routine practice – effective infection prevention and control. We cannot predict when, or in what form, future infectious disease emergencies will occur, but that they will is inevitable. Next time we are unlikely to have the luxury of months of preparation time. If we are to avoid another devastating international or local epidemic comparable to the 2013-6 Ebola outbreak we must be better prepared and respond more quickly and effectively.

For more information, email lyn.gilbert@sydney.edu.au

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Professor Lyn Gilbert, Marie Bashir Institute for Emerging Infections and Biosecurity, University of Sydney.