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The 2014-2016 Ebola epidemic in West Africa exposed a divide between the planning of the global health community and the reality of controlling an infectious disease outbreak. Public health planners planned, prepared, and strategized about combating emerging infectious diseases and bioterrorism attacks, yet as the reality of the containment effort set in, the infection rate climbed out of control as the disease migrated from the rural area of origin to major urban centers in West Africa. Front-line doctors and nurses did not have enough personal protective equipment (PPE), IV fluid to help rehydrate patients, or workers to move bodies to the morgue. Over the duration of what was to become the worst Ebola outbreak in history to date, Ebola Virus Disease (EVD) infected over 28,000 people, caused over 11,000 deaths, and spread to a total of 10 countries including: Guinea, Sierra Leone, Liberia, Mali, Nigeria, Senegal, Italy, Spain, the United Kingdom, and the United States (WHO 2018).
The Ebola Virus was discovered in 1976 in two nearly simultaneous, but separate outbreaks in Central and West Africa. The first outbreak was in Nzara, South Sudan and the second was in Yambuku, Democratic Republic of Congo near the Ebola River, which is where the virus gets its name (WHO 2018). The virus is a member of the family Filoviridae, of which Ebolavirus is one of three separate genera. The other two genera are Cuevavirus and Marburgvirus. Within the genus Ebolavirus, there are five different types that have been identified. They are Zaire, Bundibugyo, Sudan, Reston, and Ta?? Forest. The Bundibugyo, Zaire, and Sudan Ebolaviruses have been linked to large outbreaks in Africa. The 20142016 West African outbreak was caused by the Zaire Ebolavirus species (CDC 2018). Since 1976, the Ebola Virus has emerged several times and caused a number of outbreaks in many African countries. It is estimated that prior to the 2014-2016 outbreak, Ebola Virus had killed approximately 1,590 people between 1976 and 2012 (WHO 2018).
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On August 8, 2014, the World Health Organization (WHO) declared the situation in West Africa a Public Health Emergency of International Concern (PHEIC) (WHO 2018). A PHEIC designation is reserved for public health events with a potential risk of spreading beyond the country of origin or that require a coordinated international response. Numerous local, national, and international government agencies and militaries responded as well as international aid groups such as Doctors Without Borders and Samaritan’s Purse, which played key roles in the response. The international response to the outbreak was one of the largest and most complex emergency public health operations in history (Huber et al 2018).
This paper will examine scope of this outbreak, the reasons why this particular outbreak resulted in the unprecedented circulation of EVD, and why it was such a challenge for the public health community to control. The paper will also examine the local public health response, efforts by the WHO and United States Centers for Disease Control and Prevention (CDC) to assist in the response, and look for lessons learned during the response and present a few recommendations to improve future responses to outbreaks of infectious diseases.
The map below shows the West African region including Guinea (the country of origin), Sierra Leone, and Liberia, which were most severely affected by the outbreak. Source: CDC 2015
Public Health Response to the Outbreak
The initial patient showing signs of an unknown illness was reported in December of 2013. The first case, called the index patient, was an 18-month-old boy who lived in a small village in Guinea. An official medical alert was issued on January 24, 2014 after five cases of fatal diarrhea occurred in the same area. The virus spread to the capital city of Conakry, Guinea some time in February or March. On March 13, 2014, the Guinean Ministry of Health issued an alert for an illness that was yet unidentified. Around that time, the Pasteur Institute in France was able to confirm Zaire Ebola Virus as the pathogen and that patients were suffering and dying from EVD. As of March 23, 2014, there were 49 laboratory confirmed cases and 29 deaths from the outbreak, the WHO officially declared an outbreak of EVD (WHO 2018).
Local Public Health Response
By July 2014, the outbreak had spread to the capitals of Guinea, Liberia, and Sierra Leone. Local public health agencies and healthcare providers in all three countries were struggling to keep pace with the number of patients flooding into treatment centers and other healthcare facilities. Attempts were made at isolation and contact tracing, however local officials simply did not have the staff to successfully contain an outbreak that had already spread to urban centers with large, densely packed populations. When symptomatic people did begin seeking assistance and treatment, the local healthcare infrastructure did not have the capacity to care for the intense, sustained surge caused by the epidemic EVD.
Containment Actions Taken
Taking measures to keep the virus from spreading beyond the region, all Travelers leaving West Africa were screened at airports in order to prevent cross-border transmission. Exit screening of all travelers helped isolate people at risk for EVD and helped to prevent the spread of Ebola to other countries. In the U.S., the CDC and Customs and Border Patrol worked together to implement enhanced entry screening for travelers originating from or traveling to Guinea, Liberia, Mali, and Sierra Leone. Travelers from these countries were routed to designated airports that were better equipped to assess travelers for EVD risk.
The WHO declaration of a Public Health Emergency of International Concern came on August 8, 2014, but the WHO had been on site of the outbreak from the beginning. On March 23, 2014, the WHO’s African Regional Office reported an outbreak of Ebola virus disease in Guinea. The WHO response to the outbreak of the Ebola virus disease in West Africa was integral to gaining control of the epidemic. Multiple countries were affected by the outbreak, and their already strained public health and clinical infrastructure was fracturing under the extreme patient loading and exponential infection rate. The West African nations were struggling to control the epidemic in an environment of extreme poverty and local customs that make breaking the human-to-human transmission chain difficult (WHO 2015).
The WHO response team responsible for administrative support developed a strategic plan for controlling the transmission of Ebola and “”bending the curve in favor of reduced transmission. The strategic plan was designed to reach three overall objectives (WHO 2015):
- Stop all chains of transmission in the affected countries
- Prevent the spread of the disease to neighboring countries
- Safely reactivate essential health services and increase domestic resilience
In addition to these three objectives, the WHO added two more to its overall strategic plan to combat Ebola:
- Fast-track Ebola research and development
- Coordinate national and international Ebola response
When the outbreak was at its peak, public health officials were seeing exponential growth of cases each week. The WHO Ebola Response Team set a “”70/70/60 Target. This meant that the team was aiming for 70% case isolation and treatment, and 70% case isolation in 60 days. That target was achieved by the 1st of December 2014 (WHO 2015).
In July of 2014, the CDC activated its Emergency Operations Center after receiving a request for assistance from the West African countries affected by the outbreak and the WHO. The CDC was requested to help coordinate technical assistance and disease control activities with other agencies involved in the response effort. The focus of CDC efforts was on supporting the local public health infrastructure and supplementing those capabilities where possible, and when not already existing, implement the necessary service while training the local workers to perform the service (CDC 2018). This model works best in the long term because it allows the local public health workers to increase their abilities and capacity in the future. The CDC also deployed personnel to West Africa. These personnel assisted with response efforts including epidemiological expertise in:
- Disease surveillance
- Contact tracing
- Laboratory testing
- Health education
The CDC also deployed staff members to provide support in logistics, data management, staffing, communication, analytics, and management (CDC 2018).
In West Africa, the CDC trained 24,655 healthcare workers in the areas of infection prevention and control practices. In the United States, more than 6,500 people received training during live training events hosted by the CDC both on the main campus and streamed live through the web throughout the response. The CDC also worked with its West African partners to expand laboratory capacity in Guinea, Liberia, and Sierra Leone. By the end of 2015, 24 laboratories were able to test for Ebola virus (CDC 2017).
The extent of the epidemic in terms of the number of people infected and the location and spread of the infections was due to the speed with which it was spread to major urban areas. Additionally, the world had not yet to seen such prolific transmission across borders into other countries. Another major source of confounding for the public health response was the prevalence of local cultural practices that made the transmission from deceased friends and family members so easy. In the affected region, it is common practice to hold, caress, and even share a final drink with a deceased member of the family by holding the cup to their lips and then take a drink. These practices proved a ready method of transmission for Ebola virus, which is spread through bodily fluid transfer.
Eventually, with the help of all government and non-governmental agencies, the tide began to turn. Infection rates began to fall in early 2015. Critical activities in reducing infection rates included engaging local leaders in prevention programs, developing public messaging that was culturally appropriate and meaningful, and public health policy implementation at the national and global level (WHO 2018).
The WHO lifted the PHEIC alert on March 29, 2016. By that time, the devastating human toll was becoming clear. A total of 28,616 cases were reported with 15,261 laboratory confirmed cases and 11,310 deaths were reported in the hardest hit West African countries of Guinea, Liberia, and Sierra Leone. An additional 36 cases and 15 deaths occurred when the virus spread outside of these countries (WHO 2018). The table below shows the countries affected by the outbreak and the number of cases and deaths in each of those countries.
2014-2016 Ebola Outbreak by Country Affected
|Country||Total Cases||Confirmed Cases||Deaths|
Lessons Learned and Future Recommendations
Prior to this epidemic, the public health infrastructure in the three primarily affected countries were functioning and improving, according to the WHO, however the local Guinean surveillance systems and epidemiological infrastructure simply did not have the capacity to keep pace with an outbreak that spread to urban centers so quickly. This contributed significantly to the struggle in the containment of the outbreak; as a result, the virus spread remarkably quickly to Guinea’s urban areas and neighboring countries. This was the first time an outbreak of Ebola had moved from isolated rural areas to densely populated cities, which provided an extraordinary environment for transmission (WHO 2018).
A factor that made this epidemic so difficult to control was the high infection rates among healthcare workers. Liberia lost 8% of its doctors, nurses, and midwives to Ebola during the outbreak (CDC 2017). And, according to the CDC, “”In addition to the devastating effects on the healthcare workforce in Guinea, Liberia, and Sierra Leone, the Ebola epidemic severely impacted the provision of healthcare services and caused setbacks in the treatment and control of HIV, tuberculosis, measles, and malaria in these countries.
Children were particularly impacted by the epidemic. Almost 20% of all EVD cases were in children under 15 years of age. Additionally, an estimated 30,000 children were orphaned due to the epidemic (Huber et al. 2018). In an example of indirect effects a major epidemic can have on other areas of public health, resources normally dedicated to vaccination campaigns for children were repurposed to the Ebola response or activities were postponed to avoid public gatherings. Immunization rates in Guinea, Liberia, and Sierra Leone dropped by 30% at the height of the epidemic when compared to prior immunization rates. The lower immunization rates placed children at increased risk of getting vaccine-preventable diseases further compounding the impact of the Ebola epidemic and worsening the public health situation in the region (CDC 2018). This is why it is critical to maintain public health activities during outbreaks and epidemics. Each critical service that goes unfilled can only serve to worsen the situation.
The economic cost of the epidemic in West Africa was staggering. International economic investments in the countries most affected by the epidemic, Guinea, Liberia, and Sierra Leone radically declined during and well after the outbreak. Additionally, the three countries experienced massive downturns in private sector growth, and declines in agricultural production, which lead to concerns about food security for the affected populations. Cross-border trade also decreased due to restrictions on the movement of people, goods, and services across national borders proliferated. According to the CDC, the Ebola outbreak in West Africa is estimated to have direct costs at a total of $4.3 billion (2014 USD), however Huber, Finelli, and Stevens conducted a review of the economic and social burden and place the number at a staggering $53.1 billion (2014 USD). They also place $18.8 billion in non-Ebola related deaths, contributing to the idea that significant impacts were seen in other public health impacts apart from those directly associated with the Ebola outbreak.
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Cenciarelli, Orlando, Pietropaoli, Stefano, Malizia, Andrea, et al., (2015). International Journal of Microbiology. Ebola Virus Disease 2013-2014 Outbreak in West Africa: An Analysis of the Epidemic Spread and Response, vol. 2015. Retrieved from https://doi.org/10.1155/2015/769121.
Centers for Disease Control and Prevention. (December 2017). Ebola Virus Disease. Retrieved from www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html.
Centers for Disease Control and Prevention. (November 2018).
Huber, Caroline, Finelli, Lyn, Stevens, Warren. (2018). The Economic and Social Burden of the 2014 Ebola Outbreak in West Africa. The Journal of Infectious Diseases, Volume 218, Issue suppl_5, 22 November 2018, Pages S698S704. Retrieved from https://doi.org/10.1093/infdis/jiy213
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