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From the Archives |
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Editor's Note:
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Latest [2014] Ebola Situation Report |
In one of the most comprehensive summaries of the Ebola outbreak to date, the latest WHO situation report documents more than 13,000 cases as of early November in eight countries (Guinea, Liberia, Mali, Nigeria, Senegal, Sierra Leone, Spain, and the United States) and almost 5,000 deaths. Among the three West African countries reporting more than 99% of the cases, weekly incidence appears stable in Guinea and declining in Liberia. However, the incidence continues to rise in Sierra Leone, especially in Freetown the capital city.
The Good News
While initial reports of a decline in cases were uncertain, a recent press release from Doctors Without Borders on November 10 confirms that cases being admitted to their treatment centers are clearly down for the first time in the epidemic. Warning that case numbers could rise again as they have in Guinea, the organization says “priority should be given to a more flexible approach that allows a rapid response to new outbreaks and gets the regular health care system safely up and running again.”
Epidemiologic Variation
A closer examination of the cases reveals that while the epidemic started in Guinea, that country has surprisingly had fewer cases (13%) than neighboring Liberia and Sierra Leone. According to WHO, the geographic spread of Ebola within country has been less in Guinea than elsewhere. Liberia accounts for fully half of the cases and Sierra Leone the remaining 37%. While the data are considered incomplete because of underreporting, the case fatality rates vary dramatically between countries with cases in Guinea exhibiting an almost 3 fold greater mortality rate.
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| *Adapted from WHO, Nov 7, 2014 |
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Congo Ebola Outbreak [2019] |
An outbreak of Ebola in the Congo has persisted for a year with 2,512 probable or confirmed cases and killed at least 1,650 persons as of mid-July without showing signs of abating. An estimated 12 new cases are being reported each day or about 80 per week, and this number is believed to be an underestimate. The case fatality rate for confirmed cases is 67% and there is special concern that approximately 30% of the cases are children under 18 years. Health workers are accounting for 5% of the cases.
Expanded Risk
Now, the report of a new case in the highly populated region of Goma, a large population center in the Democratic Republic of the Congo on the border with Rwanda, has sounded alarm bells even more loudly. The World Health Organization, triggered by the case in Goma, has declared a public health emergency. The declaration means the outbreak is “an extraordinary event that poses a public health risk to other countries through international spread and that potentially requires a coordinated international response.” WHO’s assessment is that risk remains very high at national and regional levels but still low at global level. There is cause for special concern linked to the recent case in Goma because the city is a provincial capital with an airport which has international flights
Complex Environment
Because of the lessons learned from the last outbreak in West Africa five years ago and the development of an effective vaccine since then, it is puzzling to understand why the current year-old outbreak has not yet been halted. Official reports, eyewitness observations, and multiple media articles all point to a complex and uniquely challenging situation in which lessons learned from West Africa may not really apply. The major factors which have proven to be serious impediments to the control of this outbreak include the following:
Fear of unintended
consequences
Three previous meetings by the WHO Advisory Committee have not
recommended declaring an emergency out of fear of doing more harm than
good because of unintended consequences. A similar declaration five
years ago in West Africa caused travel bans, visa cancellations, trade
freezes, cancelled flights and other hardships which amplified the
negative social and economic effects of the outbreak and actually
backfired to impede control measures.
Lack of Resources
The resources needed to properly combat the outbreak have not been
provided. “Unless we get substantially more financial resources
immediately, it will not be possible to end the outbreak,” according
to Mark Lowcock, a United Nations Emergency Relief Coordinator.
Previous decisions not to declare an emergency have meant less
leverage for those arguing for more resources, which hopefully will
now be forthcoming.
Tenuous Security
Insecurity is the greatest concern, especially after two more
community health workers were killed recently. Media Express reports
“as many as 134 separate armed rebel groups have sparred for control
of the mineral-rich region in recent years, and an explosion of
ethnically motivated kidnappings, maimings, and sexual violence
displaced at least 300,000 people in June alone. There is a
humanitarian crisis underway with millions of people displaced from
their homes and on the move.
Political
considerations
Epidemiologists and Ebola experts from CDC have been banned from full
participation. “High income countries fear a Benghazi moment: If they
let trained experts into the hot zone and they got killed—or
worse—kidnapped—it would be a political crisis,” reported Medical
Express in speaking with Georgetown University’s Larry Gostin
who directs an institute on national and global health law.
Lack of trust
Contact tracing has not been possible in a place where there is
distrust of the government and other authorities and the population is
mobile. If they can be found, families which are identified for
preventive measures hide loved ones behind closed doors for fear they
will be hauled away. Contacts who need the proven effective vaccine do
not get it.
Lack of Information
& Misinformation
Conspiracy theories and misinformation circulates on social media.
Lancet reported that a quarter of residents of North Kivu do not
believe the virus is real. Other claims are that it is a biological
attack by white Westerners or deliberate spread by the Congolese
government.
According to the latest situation report from WHO, “The continuous transmission in major hotspots and the involvement of new health areas remain a grave concern, and thus necessitates both the continuation of proven and the introduction of novel outbreak control interventions in all affected areas.”
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WHO Issues New Recommendations to Intensify Ebola Control Measures
Triggered by its Declaration of a Public Health Emergency of International Concern and citing the International Health Regulations, the WHO has issued new recommendations for officials in the Democratic Republic of the Congo and for neighboring countries. The spread of the infection to a large population of 2 million persons in Goma on the border with Rwanda has heightened regional and international risk. The recommendations include:
Temporary Recommendations
In its emergency declaration, WHO makes the following temporary recommendations under international health regulations to improve control of the outbreak.
Recommendations for the Congo
• Communication:
Continue to strengthen community awareness, engagement, and
participation, including at points of entry, with at-risk populations,
in particular to identify and address cultural norms and beliefs that
serve as barriers to their full participation in the response.
• Screening
Continue cross-border screening and screening at main internal roads
to ensure that no contacts are missed and enhance the quality of
screening through improved sharing of information with surveillance
teams.
• Security
Continue to work and enhance coordination with the UN and partners to
reduce security threats, mitigate security risks, and create an
enabling environment for public health operations as an essential
platform for accelerating disease-control efforts.
•Surveillance
Strengthen surveillance with a view towards reducing the proportion
of community deaths and the time between detection and isolation, and
implementing real-time genetic sequencing to better understand the
dynamics of disease transmission.
• Vaccination
Optimal vaccine strategies that have maximum impact on curtailing the
outbreak, as recommended by WHO’s Strategic Advisory Group of Experts
(SAGE), should be implemented rapidly.
• Nosocomial
infections
Strengthen measures to prevent nosocomial infections, including
systematic mapping of health facilities, targeting of IPC
interventions and sustain support to those facilities through
monitoring and sustained supervision.
Recommendations for neighboring countries:
• Preparedness
At-risk countries should work urgently with partners to improve their
preparedness for detecting and managing imported cases, including the
mapping of health facilities and active surveillance with zero
reporting. At-risk countries should put in place approvals for
investigational medicines and vaccines as an immediate priority for
preparedness.
• Mapping
Countries should continue to map population movements and
sociological patterns that can predict risk of disease spread.
•Communication and
Engagement
Risk communications and community engagement, especially at points of
entry, should be increased.
Recommendations for
all States:
• No
country should close its borders or place any restrictions on travel
and trade.
• National authorities should work with airlines and other transport and tourism industries to ensure that they do not exceed WHO’s advice on international traffic.
• The Committee does not consider entry screening at airports or other ports of entry outside the region to be necessary. ■
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From Containment To Crisis In 5 Minutes---Ebola “Out Of Control” In West Africa Says Doctors Without Borders [2014] Unexpected Failure To Contain The Outbreak Has Multiple Causes |
“Given that surveillance and response measures have held this [Ebola] terrifying disease in check for the past decade, why has the situation gotten so far out of hand this time?”
This is the complex
question raised by the West African Ebola outbreak in Guinea, Liberia,
and Sierra Leone and posed so clearly by Dick Thompson, a
former WHO communications official, in National Geographic News.
Several epidemiologists and health officials close to the outbreak
have shared their insights in trying to answer this question.
From Control To Crisis in 5 Minutes
“Within five minutes, everything changed.” That’s how Hilde de Clerk, a Doctors Without Borders/Medecins sans Frontieres (MSF) physician, has described the shift in thinking about the Ebola virus outbreak in Guinea. In an interview on the MSF website, de Clerk describes how MSF health officials in taking a small cluster of phone calls went from monitoring only two villages and thinking they were witnessing the end of the outbreak to having to monitor 40 villages with more than 500 potential contacts and realizing they were facing the largest epidemic of Ebola they had ever faced. MSF is now describing the Ebola outbreak in Guinea, Sierra Leone, and Liberia as “out of control”.
Epidemiologist Speaks Out
According to MSF epidemiologist Michel van Herp who spoke with the Telegraph, “I have covered six previous Ebola outbreaks and this is unprecedented. It is unique in terms of the number of cases, where they are and how they are spread, the difficulty of putting enough treatment centres where they are needed, and the fact that these people move around so much.”
WHO Update
The July 15 report from WHO covering the period July 8-12 has identified 79 new confirmed, probable, and suspect cases from all three countries with the majority coming from Sierra Leone (30 cases) and Liberia (49 cases). The cumulative total of cases as of this report is 964 with 603 deaths (63% case fatality rate). WHO has recently established an outbreak coordination center in Conakry Guinea to coordinate technical support and help to mobilize resources from a vantage point closer to the outbreaks.
Communications Expert Speaks Out
According to Thompson, the Ebola outbreak in West Africa is presenting several familiar and many new challenges. His list is daunting and helps to understand more deeply why control is so difficult to achieve. This has not been the experience in other Ebola outbreaks.
1. The disease had almost never been seen before in West Africa. Also, patients presented initially without the characteristic hemorrhaging. These two facts meant that recognition of the disease was delayed and it slowed the initial response.
2. Officials initially gave inaccurate and sometimes contradictory information. Also, they have failed to communicate the true scope of the outbreak. Trust in government communication messages is low and this is a serious limitation because mobilizing the community is a key ingredient of successful containment.
3. The outbreak is occurring now or has occurred in multiple locations over a vast area. Also, the disease is spreading to urban areas for the first time. An outbreak on this scale exceeds the current capacity of the organizations involved to respond effectively. MSF has said it can no longer send teams to new outbreak sites.
4. As Thompson reminds readers so vividly, treatment of patients is dangerous for staff, physically grueling in protective gear from head to toe, and emotionally draining because of the high death rates. It requires enormous physical and emotional stamina as well as courage to be involved in treatment and outbreak control work.
5. Rumors about sinister purposes for isolation wards cause patients to escape and hide and cause the non-ill population to hide from investigators seeking the names of close contacts of patients.
6. Some populations believe a curse is at work on Ebola patients and families, and they are often stigmatized. ■
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Global Public Health Community Takes Stock As Ebola Epidemic Ends Level Of Readiness To Tackle Next Epidemic Is In Question |
Just hours after the
WHO declared the West African Ebola epidemic had come to an end on
January 14th, the disease had reemerged with the confirmation of a new
case in Sierra Leone. This most recent case underscores the
continuing risk of new flare-ups throughout the region and the
importance of looking back on what has been learned over the last 2
years fighting the largest public health disaster in recent history.
Compiled from a series of recent meetings and articles about Ebola in
Nature and elsewhere, here are some of the key lessons
scientists and public health officials are relying on as they make
recommendations for the future (4).
1. The world is not adequately prepared to deal with international epidemics.
There was a general failure on the part of public health officials and international organizations to respond quickly and effectively to the outbreak. Delays both in identifying initial cases of the disease and in declaring the outbreak a public health emergency allowed it to grow out of control. At the same time, the resources necessary to contain the initial spread of the disease were not deployed rapidly enough.
After the WHO received much of the blame, director-general Margaret Chan told the New York Times, “We are not the first responder…. the government has first priority to take care of their people and provide health care.” However, the Ebola outbreak has shown that the global health community cannot rely on the governments of some of the poorest countries in the world to handle outbreaks of this nature alone.
2. The true extent of the weaknesses in the health systems of some of the world’s poorest countries.
A shortage of
healthcare workers as well as a lack of proper equipment, training and
information-sharing systems in West Africa enabled the rapid spread of
Ebola. Large-scale investment in the health systems of these
countries is urgently necessary as future outbreaks of Ebola and other
diseases are likely to strike the region.
3. Support of community leaders is absolutely critical in overcoming cultural challenges
Ebola raised many unique cultural challenges related to social, traditional and religious practices in the affected regions. A lack of trust and clear communication led people to resist quarantines, travel bans and sending the sick to treatment centers. In addition, traditional funerals and burial methods involve extensive contact with family members and the bodies of victims, promoting further spread of the disease. Local religious leaders, village chiefs and elders were by far the most effective at educating communities about Ebola transmission and gaining compliance with measures that proved essential to containing and controlling the epidemic.
4. It is possible to conduct rapid clinical trials during an epidemic.
Under normal circumstances it takes years to complete all the phases of approval and testing involved in controlled trials of new drugs or vaccines. Outbreaks tend to be over too quickly for clinical trials to take place and conditions in the field have generally been thought too challenging to make quality trials possible. Despite early failures to get various clinical trials underway rapidly, a WHO-supported fast-track approach to testing an experimental Ebola vaccine was ultimately successful, finding the vaccine to be safe and highly effective within the limited scope of the study (1).
Not only are these results promising in terms of controlling further Ebola outbreaks, this study can also serve as a model for the rapid development of drugs and vaccines in future epidemics. In fact, the WHO announced in the September Ebola Newsletter the development of a “blueprint action plan” intended to “reduce the time between identification of a nascent outbreak and final testing of the most advanced products”.
5. The world must remain vigilant
As this most recent case in Sierra Leone demonstrates, there is a high-risk for continuing small outbreaks of Ebola throughout the region. Scientists are still learning to what extent the virus persists in survivors. Some evidence suggests that in rare instances the virus can be sexually transmitted by male survivors for up to a year. While the epidemic transitions to a new phase in which in which the focus shifts to controlling the risk of new infections, bolstering disease surveillance and identifying the animal reservoirs for the virus (a topic that remains controversial) (2) will be essential.
Actions Stemming From
Lessons
By
far the largest in history, this Ebola outbreak surprised the public
health community with its length and scope and in the process exposed
the weaknesses in the global health system. In November of 2015 a
joint panel of more than 20 experts from the Harvard Global Health
Institute and the London School of Hygiene and Tropical Medicine
authored an assessment of the global response to the epidemic in which
they argued that we are no better prepared to handle another epidemic
today than we were 2 years ago (3). In response to these they argued
that we are no better prepared to handle another epidemic today than
we were 2 years ago (3). In response to these shortcomings and the
lessons learned, the panel laid out what it called “10 Essential
Reforms” aimed at improving prevention, detection and response to
outbreaks in the future. In addition, panels have been convened by
other organizations including the WHO and UN to make specific
assessments and recommendations.
It appears critical that the world learns from these lessons and takes recommended actions to correct systemic shortcomings in the infrastructure and leadership of the world’s health systems before the next global health emergency strikes.
References
(1.)
https://tinyurl.com/qeyjzor
(2.)
https://tinyurl.com/jmjdau4
(3.)
https://tinyurl.com/zklsj74
(4.)
https://tinyurl.com/hm82cau
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