- Mohamed F. Jalloh ,
Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing
* E-mail:[email protected]
Affiliations Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden⨯
- Reinhard Kaiser,
- Mariam Diop,
- Amara Jambai,
- John T. Redd,
- Rebecca E. Bunnell,
- Evelyn Castle,
- Charles Alpren,
- Sara Hersey,
- Anna Mia Ekström,
- Helena Nordenstedt
- Mohamed F. Jalloh,
- Reinhard Kaiser,
- Mariam Diop,
- Amara Jambai,
- John T. Redd,
- Rebecca E. Bunnell,
- Evelyn Castle,
- Charles Alpren,
- Sara Hersey,
- Anna Mia Ekström
Sierra Leone experienced the largest documented epidemic of Ebola Virus Disease in – The government implemented a national tollfree telephone line () for public reporting of illness and deaths to improve the detection of Ebola cases. Reporting of deaths declined substantially after the epidemic ended. To inform routine mortality surveillance, we aimed to describe the trends in deaths reported to the system and to quantify people’s motivations to continue reporting deaths after the epidemic.
First, we described the monthly trends in the number of deaths reported to the system between September and September Second, we conducted a telephone survey in April with a national sample of individuals who reported a death to the system between December and April We described the reported deaths and used ordered logistic regression modeling to examine the potential drivers of reporting motivations.
Analysis of the number of deaths reported to the system showed that 12% of the expected deaths were captured in compared to approximately 34% in and over % in We interviewed 1, death reporters in the survey. Family members reported 56% of the deaths. Nearly every respondent (94%) expressed that they wanted the system to continue. The most common motivation to report was to obey the government’s mandate (82%). Respondents felt more motivated to report if the decedent exhibited Ebola-like symptoms (adjusted odds ratio ; 95% confidence interval –).
Motivation to report deaths that resembled Ebola in the post-outbreak setting may have been influenced by knowledge and experiences from the prolonged epidemic. Transitioning the system to a routine mortality surveillance tool may require a robust social mobilization component to match the high reporting levels during the epidemic, which exceeded more than % of expected deaths in
By November when the World Health Organization declared the Ebola epidemic in Sierra Leone to be over, approximately 95% of the population had become aware of the risk of Ebola transmission linked to physical contact with infected corpses, especially during traditional burials. Enhanced Ebola surveillance was implemented between November and June , i.e. after the epidemic had officially ended to improve detection of possible new cases. Reporting to the system declined nationally after enhanced Ebola surveillance ended even though the Government of Sierra Leone continued to mandate that all deaths must be reported. Based on a request from the Sierra Leone Ministry of Health and Sanitation, we conducted a telephone survey with a national sample of people who had reported a death in after the end of enhanced surveillance to understand their motivations for reporting and describe the deaths that they reported. In addition, we analyzed the five-year trends (–) in the number of deaths reported through the system. Analysis of monthly summary data of deaths reported showed that on the last month of enhanced surveillance, 3, deaths were reported compared to 2, deaths in the month immediately after (July ). The monthly numbers of reported deaths continued to plummet and reached as low as 1, in January , in January , and in January In the survey, we uncovered that people who reported deaths were mainly motivated to do so in order to comply with the Government’s mandate. After adjusting for potential confounders, motivations to report were strongly associated with the presence of Ebola-like symptoms in the decedent. Additional investigations are needed to unveil reporting barriers among people who failed to report household deaths to the system to optimize reporting levels. It has been shown that during the Ebola epidemic that it is possible to reach high levels of death reporting in Sierra Leone as exemplified by the fact that in more than % of the expected deaths nationally were reported; albeit not counting potential duplicates. The post-Ebola-outbreak setting provides a unique opportunity to improve future overall mortality surveillance in Sierra Leone and contribute to the establishment of civil registration of vital statistics.
Citation: Jalloh MF, Kaiser R, Diop M, Jambai A, Redd JT, Bunnell RE, et al. () National reporting of deaths after enhanced Ebola surveillance in Sierra Leone. PLoS Negl Trop Dis 14(8): e https://doi.org//journal.pntd
Editor: Michael R. Holbrook, NIAID Integrated Research Facility, UNITED STATES
Received: February 20, ; Accepted: July 22, ; Published: August 18,
This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Data Availability: All the datasets and data files associated with the manuscript are available online at the following DOI: https://doi.org//m9.figsharev1.
Funding: Data collection for the assessment was funded by the U.S. Centers for Disease Control and Prevention (CDC) through a cooperative agreement with eHealth Africa. Several co-authors from the CDC were involved in various aspects of the assessment. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
From May to November , Sierra Leone experienced the largest epidemic of Ebola to date, which also affected neighboring Liberia and Guinea. The epidemic in Sierra Leone resulted in more than 14, cases and nearly 4, deaths of Ebola . Traditional practices involving physical contact with corpses and sick people  contributed to Ebola transmission [3–5]. It has been estimated that an average of approximately new Ebola cases resulted from every unsafe traditional burial during the epidemic in West Africa . In one extreme situation, 28 confirmed cases were epidemiologically linked to a single traditional burial of a prominent pharmacist in Moyamba district, Sierra Leone in September . Out of these 28 cases, approximately 75% of them had direct physical contact with the pharmacists’ corpse. Epidemic control efforts heavily focused on halting risky behaviors, such as washing and touching of corpses as part of traditional burial rites, and providing alternatives for safe burials by specially trained teams [6–8]. There was a need to promptly identify all deaths occurring in communities to test them for Ebola and ensure safe burial [9–11]. Community-based reporting of deaths consequently constituted an important component of responding to the epidemic [5, 12].
In August , the Government of Sierra Leone repurposed an existing national, toll-free telephone line ( system) for communities to report all deaths and suspected Ebola patients as part of the epidemic response . The system’s design, implementation and adaptations have been described elsewhere . Although the Government of Sierra Leone required communities to report deaths of all-causes to the system during the – Ebola epidemic , burial teams were not always successful in responding to all death alerts within 24 hours due to the high community demand and call volumes. This resulted in dissatisfaction among communities where families had to wait longer than 24 hours for safe burial services. Furthermore, communities were at times dissatisfied with how corpses were handled by burial teams [15, 16]. As the epidemic progressed, safe alternatives to traditional burials were made available to families such as observing the burial from a safe distance and allowing a religious leader to pray on the corpse. Religious leaders played a key role in advocating for incorporating safe alternatives that show respect for the deceased and their family . Social mobilization efforts were implemented nationwide to promote Ebola protective behaviors including community acceptance of safe burial measures and reporting of deaths to the line during the epidemic [9, 10, 18, 19]. After the outbreak ended, social mobilization and risk communication interventions that promoted the use of the line were scaled down.
Analysis of calling trends indicated that the numbers of deaths reported to the system sharply declined after the epidemic ended even though the official government policy mandated that all deaths occurring in communities must still be reported. All reported deaths that were suspected to be Ebola or otherwise ‘suspicious’ were supposed to be forwarded to district-based surveillance officers by the call center operators for screening and further investigations depending on the circumstances of the death.
Strategies for continuing death reporting in Sierra Leone or other post-Ebola-outbreak settings are scarce. Factors contributing to the decline in death reporting after the epidemic and enhanced surveillance ended are not well understood, and neither are motivating factors for those who continued to report. Moreover, the potential influence of Ebola experiences on death reporting motivations in post-Ebola-outbreak settings has not been examined. To inform routine mortality surveillance, we aimed to describe deaths reported to the system, perceptions of the reporting system, and motivations to report the deaths after the epidemic and enhanced Ebola surveillance had ended.
Methods and materials
Previous analysis of the number of sick people and deaths reported to the system has been published for the period of September to December . To establish more comprehensive trends in death reporting during a five-year period spanning September —September , we obtained monthly unadjusted aggregated data of death alerts placed to the call center managed by eHealth Africa on behalf of the Sierra Leone Ministry of Health and Sanitation . To inform strategies for improving routine surveillance of deaths, in April , we then conducted a cross-sectional, telephone-based survey with individuals aged 18 years and above who reported a death to the system after the end of enhanced Ebola surveillance in Sierra Leone. The methods and materials of the survey have been described in this paper in accordance with guidelines for Strengthening the Reporting of Observational Studies in Epidemiology .
In April we obtained a sampling frame of 7, callers who reported a death to the system. Survey respondents were randomly selected from a stratified sampling frame of all callers who reported at least one death between December and April Fewer than 5% of the records were duplicates and were removed from the sampling frame. For callers who reported multiple but non-duplicate deaths (< 10% of sample), the most recent death was kept while all others were removed to mitigate recall bias. We then stratified the sampling frame by geographic region of residence (West, North, East, South). In our sample size calculations, we assumed 70% call-success rate, 50% overall-response rate agreeing to consent, and 90% item-response rate. We aimed to obtain a final sample of approximately 1, callers, to allow for a % margin of error for national estimates and % margin of error for regional estimates of death-reporting motivations. Significance level was set to α = This resulted in a random list of 4, people to contact by telephone. Trained interviewers made up to three attempts at different times of the day to contact potential participants. A telephone number was marked as unreachable and removed from the telephone database after three unsuccessful attempts.
Data collection instruments
The questionnaire development was informed by a focus group discussion with a convenience sample of 12 respondents to assess appropriateness of item formats, respondents’ understanding and interpretation of questions, appropriate sequencing to mitigate bias, and categorization of expected responses to open-ended questions (for example, motivations to report a death). The questionnaire was subsequently revised and piloted with a convenience sample of 25 eligible respondents. Participants in the pilot were excluded from the final sample selection to avoid repeat-interview bias.
Training and data collection
A team of ten interviewers and two supervisors were trained on the proper administration of the survey including informed consent, oral translations of items from English to common local languages (Krio, Mende, Temne, and Fullah), use of the Open Data Kit (ODK) digital data collection tool , and interviewing techniques. The interviews were conducted in respondent’s preferred local language. Calls were placed by interviewers using a telephone system setup within the Call Center in Freetown. On average, interviews lasted approximately 15–20 minutes. The interviews were administered using ODK (www.opendatakit.org) installed on computer tablets pre-programmed with a digital copy of the questionnaire. Supervisors oversaw the data collection process including monitoring phone interviews, verifying data entered in ODK, and reviewing final submission of processed data to a secured, web-based hosting server. Verbal informed consent was obtained from all participants before initiating the telephone interview.
Sociodemographic variables included region of residence, sex, age, education, religion, and occupation. In addition, we collected data on circumstances surrounding the death including the nature of death (accident-related, possible stillbirth, possible maternal death), signs and symptoms, place of death, and treatment seeking history within the month prior to dying. Call history to during the Ebola epidemic was defined as anyone who responded “yes” to the question “Did you ever call during the Ebola crisis in Sierra Leone (May to November )?” It is worth noting that by the epidemic response capacity had generally improved compared to when response capacity was severely challenged as new Ebola cases peaked nationwide in November of that year . Past Ebola experience was dichotomized into “yes” and “no” such that anyone who responded by saying “yes” to one or more of the following three questions was categorized as having some past Ebola experience: (a) “Do you personally know anyone who died from Ebola?” (b) “Do you personally know anyone who survived Ebola?” and (c) “Do you personally know anyone who was quarantined due to Ebola?” Item wording and grouping for past Ebola experience was directly informed by a prior assessment in Sierra Leone .
Motivations to report a death were captured by asking an open-ended question: “What made you call to report the death?” Without prompting for any specific responses, interviewers recorded the reason(s) for calling provided by respondents into the following six categories: (a) “find out the cause of death;” (b) “protect self or others from possible infection;” (c) “obey Government policy/law;” (d) “obtain burial permit (to allow traditional burial);” (e) “obtain death certificate;” and (f) “other.” Selection of multiple reasons for calling was allowed, and data collectors probed to get an exhaustive list of motivations.
First, we described trends in reporting by plotting a bar graph (Fig 1) of the raw number of monthly deaths reported to the line during the (i) Ebola epidemic (September October ), (ii) post-outbreak enhanced surveillance (November June ), and (iii) post-outbreak routine surveillance (July September ). Given the aggregated format of the monthly data of death alerts, we could not account for potential duplicates in the descriptive analysis.
The survey data were analyzed using Stata version 15 SE (StataCorp LLC, College Station, TX). Frequencies, proportions and other descriptive statistics were generated for all variables. Responses indicating “don’t know”, “don’t remember”, and “declined to respond” were treated as missing values. A composite outcome variable was created for scoring motivations expressed by respondents. The score could range from 0 to 6 depending on the number of motivations that respondents cited. Two composite binary exposure variables were then generated. First, a binary variable was generated to indicate if Ebola-like symptoms (fever, diarrhea, vomiting) were present in the decedent (coded 0 if none and 1 if one or more symptoms). Second, a binary variable was generated for knowing someone who died from Ebola, survived Ebola or quarantined due to Ebola exposure during the – epidemic (coded 0 if none and 1 if one or more such experiences).
Given the ordered outcome for motivations using a count variable, we used ordered logistic regression modeling in our multivariate analyses to estimate odds ratios (ORs) and their 95% confidence intervals (CIs). We fitted a model to examine the possible associations between motivations to report the death and (a) experiencing Ebola-like symptoms before dying, (b) previously calling the line during the epidemic, and (c) knowing someone who died from Ebola, survived Ebola, or was quarantined due to Ebola during the epidemic in Sierra Leone. The model was adjusted for sociodemographic characteristics of the person who reported the death (region, sex, age, education, religion, health worker status) and of the deceased person (sex, age, religion). Educational attainment and occupation of the deceased persons were excluded in the models due to high frequency of missing values. The covariates in the model were assessed for collinearity. Subsequently, region of residence of the deceased persons was excluded because it was collinear with region of residence of the person who reported the death. In all models, significance level was set to α = for a two tailed Wald test.
The assessment was approved as non-research by the Sierra Leone Ministry of Health and Sanitation. Participation of U.S. Centers for Disease Control and Prevention (CDC) staff was approved as a non-research activity by CDC’s Center for Global Health (CGH-HSR# –).
Five-year death reporting trends between September and September
The monthly aggregated data of deaths reported to the system showed a sharp decline after the – Ebola epidemic ended in Sierra Leone compared to the post-outbreak enhanced mortality surveillance period. For instance, in the final month before the Ebola epidemic was declared over in Sierra Leone (October ), a total of 8, deaths were reported through the system compared to 5, in November when enhanced surveillance began. Moreover, in the last month of enhanced surveillance (June ), 3, deaths were reported through the system compared to 2, in the beginning of post-outbreak routine surveillance of deaths. The number of deaths reported to the system continued to plummet to as low as 1, in January , in January , and in January (Fig 1).
In the year when we conducted the survey (), a total of 11, deaths were reported to the system compared to 32, in and , in Sierra Leone has a crude death rate of per population according to the – estimates by the United Nations . Therefore, approximately 95, deaths could be expected yearly in the total estimated population of 8 million. Thus, the number of deaths reported to the system in was approximately 12% of expected total deaths in the country compared to approximately 34% in and over % in
Description of the respondents
Telephone contact was established with 1, individuals out of 4, eligible individuals in the sampling frame. Of those who were successfully reached by telephone, 1, consented to participate in the survey: (%) from the Northern region, (%) from the Western Region, (%) from the Eastern Region, and (%) from the Southern Region. Most respondents were males (%), and this was consistent across regions. Nearly half (%) of the respondents who identified as female were also health workers. The median age was 40 years (males 39 years and females 37 years). Overall, % of the respondents had no formal education. About two-thirds (%) of all respondents identified as Muslims and the rest identified as Christians (%). Family members of the deceased reported % of the deaths. Half of all respondents (%) had previously called the line at least once during the – Ebola epidemic in Sierra Leone. Of those who called during the epidemic (n = ), % reported a death. Two-thirds of all respondents (%) reported past Ebola experiences including knowing someone who died from Ebola (%), survived Ebola (%) or was quarantined due to Ebola exposure (%) (Table 1).
Description of the deaths reported
In the sample obtained, deceased persons were more frequently male (%), had no education (%), affiliated as Muslim (%), and were 50 years old or above (%) (Table 2).
Overall, (%) deaths were women of reproductive age, (%) were infants, and 59 (%) were accident-related deaths. Among deaths of women of reproductive age, 24 (%) were pregnant at the time of the death. Thirty-three of the infant deaths (%) were stillbirths. Overall, % of deceased persons reportedly received some form of treatment from one or more sources within the past month of dying, and non-exclusively cited the place of treatment as health facility (%), home (%), pharmacy or drug store (%), traditional healer (%), and other sites (<1%). The most frequently cited symptoms that the deceased persons had purportedly experienced within the past month of dying were fever (%), joint pain (%), headache (%), and abdominal pain (%). Ebola-like symptoms (fever, diarrhea, or vomiting) were reportedly experienced by % of the decedents (Table 3). Missing values were higher for the variables on occupation of the deceased person (n = ; %), education level of the deceased person (n = ; %), and treatment received before dying (n = ; %) when compared to other variables (less than 10%). Missing values were mostly due to reporting of deaths by health workers who did not know certain details about the deceased person.
Preferences for continuation of the system
Nearly all respondents (%) wanted the government to continue using the system in Sierra Leone, and to keep the current ‘’ number (%). Of those who wanted continuation of the reporting system (n = ), reporting of all deaths was the most commonly reported preference (%) (Fig 2).
Motivations to report deaths
The most frequently cited motivations were to obey government policy (%), find out the cause of death (%), obtain burial permit (%), and protect self or others from infection (%) (Fig 3). Compared to deaths that did not exhibit Ebola-like symptoms, exhibiting one or more Ebola-like symptoms was associated with a two-fold increase in the odds of being motivated to report the death (adjusted OR [aOR] CI –). Motivations to report were not associated with previously calling the line during the Ebola epidemic (aOR CI –) or knowing someone who died, survived or was quarantined due to Ebola during the epidemic (aOR CI –) (Table 4).
Our descriptive analysis of the five-year trends in the number of deaths reported to the system identified a substantial decline in reporting after the period of enhanced Ebola surveillance ended. In , the system maximally captured about 12% of the total expected deaths in the country compared to approximately 34% in and more than % (sic) in In the telephone survey we identified motivations related to death reporting that have practical implications for improving routine mortality surveillance in a post-Ebola-outbreak setting. Nearly all respondents wanted the death reporting system to continue. The leading motivation for reporting was the desire to obey the government’s reporting mandate of all deaths. Reasons for this desire to comply with reporting mandate were not directly evaluated in our assessment but may be linked to altruistic intentions to help prevent potential Ebola as documented in a prior qualitative assessment near the end of the epidemic in Sierra Leone . In fact, we found that people who reported deaths that had experienced Ebola-like symptoms were more motivated to report, which may have also been influenced by knowledge and experiences from the prolonged Ebola epidemic.
Effective mortality surveillance is an important pillar of promptly identifying and responding to deaths from notifiable diseases such as Ebola, especially in outbreak-prone areas. Recent epidemics of Ebola in sub-Saharan Africa have reinforced the need for effective surveillance systems including mechanisms to promptly detect cluster-deaths that may be tied to a possible outbreak of Ebola or other infectious diseases [4, 23, 27]. It should be noted that prior to the Ebola outbreak deaths were usually reported in-person to local city councils mainly to obtain a burial plot . Therefore, telephone reporting of deaths to the national government was a new behavior for people in Sierra Leone before the Ebola outbreak.
The context in which a death reporting system is implemented poses ethical considerations. Deaths tended to become widely publicized in communities during the epidemic in Sierra Leone. Anyone in the community could report a death to the line even without having full information about the details of the death or the approval of close relatives. Given the limited capacity to respond to all incoming death notifications, multiple reports of the same death with incomplete or contradictory information may have made it difficult to prioritize the dispatch of safe burial teams. However, during the post-outbreak period, our survey revealed that mostly family members and health workers reported deaths to the system, which likely improved the completeness and accuracy of the information provided about the death. Despite confidentiality guidelines, in both the outbreak and post-outbreak contexts it is unclear if callers to the line were assured confidentiality when they reported a death. In addition, the training guidelines of call operators stated that callers were supposed to be informed that they may receive a follow-up call to get more information about the reported death. We cannot verify whether operators informed all callers about potential follow-up calls. It is possible that concerns about confidentiality may have influenced death reporting behaviors over time, including in our assessment.
Continued implementation of the death reporting system is just one example of how Sierra Leone leveraged its Ebola response infrastructure for routine surveillance . Another example is seen in how the Government of Sierra Leone, with support from partners, transitioned from a paper-based to a web-based electronic Integrated Disease Surveillance and Response (eIDSR) system after the Ebola epidemic. Sierra Leone became the first country to have a fully functional eIDSR system in sub-Saharan Africa in . The eIDSR system is used to track 28 priority notifiable diseases in all 1, health facilities in the country . The platform was developed using the country’s existing District Health Information System. However, the system is presently not integrated into eIDSR. Going forward, if the Government maintains the system, it is critical to ensure its interoperability and integration with the eIDSR system to open the opportunity to connect case-based reporting of notifiable diseases with event-based mortality surveillance to rapidly detect outbreaks and initiate public health response.
The expectation that the system was going to be successfully converted to a routine mortality surveillance system does not seem to have been fulfilled given that the system only captured about 12% of the expected deaths in the aftermath of Ebola. The low level of death reporting to the system after the epidemic ended was likely due to several factors including the lack of continued social mobilization to promote reporting and the lack of a clearly communicated government policy for routine use of the system. Sierra Leone’s implementation of the system holds important lessons for the development and sustainability of similar telephone-based surveillance systems in sub-Saharan Africa. As reminded by the – Ebola outbreaks in the Democratic Republic of Congo and the ongoing COVID pandemic, surveillance tools such as the system when coupled with adequate public engagement can facilitate early detection of cases and deaths to curb disease spread.
Our assessment has limitations. Duplicate reporting may have been more frequent in the early stages of the epidemic in when the capacity to respond to deaths was at times unable to meet the demand for safe burial services. Improvements in response capacity in may have reduced the likelihood of families placing repeated calls for the same death in trying to ensure a safe burial. The number of duplicate reports likely stabilized starting in when response capacity improved. Duplicate records only accounted for about 5% of the total records in the database of deaths reported between December and April Assuming duplicate reporting level was similar between and , it is unlikely that duplicate reporting substantially influenced the overall reporting trends. The descriptive trends provided in the paper are meant to help lay a foundation to examine and discuss the reporting motivations in a post-Ebola-outbreak context. Additional research could consider leveraging the recently launched Sierra Leone Ebola Database , which contains deduplicated, anonymized, linked data on alerts, Ebola cases, laboratory results, Ebola Treatment Unit, Ebola Treatment Unit clinical records, and burial records, to ascertain death reporting trends using case-based data that account for duplicates.
The generalizability of the results of our telephone survey with death reporters also have limitations. For instance, the sample of respondents were mostly men. We do not know if this was because proportionally more men reported deaths to the call center or whether it was due to a systematic bias of higher unsuccessful call rates to women who reported deaths. Lastly, our assessment only targeted individuals who reported deaths to the system in order to understand their motivations for reporting. People who had deaths in their households but failed to report may be demographically different from our sample and held concerns that prohibited them from reporting. Future research should consider using qualitative approaches to better understand barriers to death reporting among household heads who fail to report deaths in their households.
Support for compliance with government death reporting policy motivated users of the system in Sierra Leone after the Ebola epidemic ended. Increased motivation to report deaths that resembled Ebola in the post-outbreak setting may have been influenced by knowledge and experiences from the prolonged epidemic. Post-Ebola-outbreak periods offer an opportunity for instituting routine mortality reporting, as people have been sensitized about the importance of reporting through the experiences of the outbreak. Transitioning the system to a routine mortality surveillance tool may require a robust social mobilization component  to match the high reporting levels during the outbreak, which exceeded more than % of the expected deaths in As global health security efforts try to strengthen surveillance systems , routine use of death reporting systems like could play an important role in early detection of clusters of deaths linked to potential infectious disease outbreaks including Ebola.
We thank the 1, Sierra Leoneans who took the time to share their experiences with reporting the deaths of their loved ones to the system. We acknowledge various contributions made by Dayo Spencer-Walters, Alex Taylor, Mohamed Kabia, and Maseray Sesay from eHealth Africa; Laura Shelby, Mitsuaki Hirai, Wenshu Li, and Erika Myer from CDC.
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- U.S. Centers for Disease Control and Prevention. Data Hosting: Sierra Leone Ebola Database (SLED) [cited June 6]. Available from: https://www.cdc.gov/rdc/b1datatype/sled.htm.
- Pedi D, Gillespie A, Bedson J, Jalloh MF, Jalloh MB, Kamara A, et al. The Development of Standard Operating Procedures for Social Mobilization and Community Engagement in Sierra Leone During the West Africa Ebola Outbreak of – J Health Commun. ;22(sup1)– pmid
- Heymann DL, Chen L, Takemi K, Fidler DP, Tappero JW, Thomas MJ, et al. Global health security: the wider lessons from the west African Ebola virus disease epidemic. Lancet. ;()– Epub /05/ pmid; PubMed Central PMCID: PMC
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Western African Ebola virus epidemic
– major disease outbreak
The – outbreak of Ebola virus disease, centered in Western Africa, was the most widespread outbreak of the disease in history and caused major loss of life and socioeconomic disruption in the region, mainly in Guinea, Liberia and Sierra Leone. The first cases were recorded in Guinea in December ; later, the disease spread to neighbouring Liberia and Sierra Leone, with minor outbreaks occurring elsewhere. It caused significant mortality, with the case fatality rate reported which was initially considerable,[note 1] while the rate among hospitalised patients was 57–59%, the final numbers 28, people, including 11, deaths, for a case-fatality rate of 40%. Small outbreaks occurred in Nigeria and Mali, and secondary infections of medical workers occurred in the United States and Spain. In addition, isolated cases were recorded in Senegal, the United Kingdom and Italy. The number of cases peaked in October and then began to decline gradually, following the commitment of substantial international resources. As of 8May[update], the World Health Organization (WHO) and respective governments reported a total of 28, suspected cases and 11, deaths (%), though the WHO believes that this substantially understates the magnitude of the outbreak.
On 8 August , a Public Health Emergency of International Concern was declared and on 29 March , the WHO terminated the Public Health Emergency of International Concern status of the outbreak. Subsequent flare-ups occurred; the epidemic was finally declared over on 9 June , 42 days after the last case tested negative on 28 April in Monrovia.
The outbreak left about 17, survivors of the disease, many of whom report post-recovery symptoms termed post-Ebola syndrome, often severe enough to require medical care for months or even years. An additional cause for concern is the apparent ability of the virus to "hide" in a recovered survivor's body for an extended period of time and then become active months or years later, either in the same individual or in a sexual partner. In December , the WHO announced that a two-year trial of the rVSV-ZEBOV vaccine appeared to offer protection from the variant of EBOV responsible for the Western Africa outbreak. The vaccine is considered to be effective and is the only prophylactic which offers protection; hence, , doses have been stockpiled. rVSV-ZEBOV received regulatory approval in 
Ebola virus disease (commonly known as "Ebola") was first described in in two simultaneous outbreaks in the Democratic Republic of the Congo and what is now South Sudan. The – outbreak, caused by Ebola virus (EBOV), was the first anywhere in the world to reach epidemic proportions. Previous outbreaks had been brought under control in a much shorter period of time. Extreme poverty, dysfunctional healthcare systems, distrust of government after years of armed conflict, and the delay in responding for several months, all contributed to the failure to control the epidemic. Other factors, per media reports, included local burial customs of washing the body and the unprecedented spread of Ebola to densely populated cities.
As the outbreak progressed, the media reports, many hospitals, short on both staff and supplies, were overwhelmed and closed down, 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". Hospital workers, who worked closely with the highly contagious body fluids of the victims, were especially vulnerable to contracting the virus; in August , the WHO reported that ten per cent of the dead had been healthcare workers. In September , it was estimated that the affected countries' capacity for treating Ebola patients was insufficient by the equivalent of 2, beds; however, by December there were enough beds to treat and isolate all reported cases, although the uneven distribution of cases was resulting in serious shortfalls in some areas.
The WHO has been widely criticised for its delay in taking action to address the epidemic. On 8 August , it declared the outbreak a public health emergency of international concern. By September , Médecins Sans Frontières/Doctors Without Borders (MSF), the non-governmental organisation with the largest working presence in the affected countries, had grown increasingly critical of the international response. Speaking on 3 September, the International President of MSF spoke out concerning the lack of assistance from United Nations (UN) member countries: "Six months into the worst Ebola epidemic in history, the world is losing the battle to contain it." In a 26 September statement, the WHO stated that "[t]he Ebola epidemic ravaging parts of Western Africa is the most severe acute public health emergency seen in modern times" and its Director-General called the outbreak "the largest, most complex and most severe we've ever seen". In March , the United Nations Development Group reported that due to a decrease in trade, closing of borders, flight cancellations, and drop in foreign investment and tourism activity fuelled by stigma, the epidemic had resulted in vast economic consequences in both the affected areas in Western Africa and even in other African nations with no cases of Ebola.
On 28 January , the WHO reported that for the first time since the week ending 29 June , there had been fewer than new confirmed cases reported in a week in the three most-affected countries. The response to the epidemic then moved to a second phase, as the focus shifted from slowing transmission to ending the epidemic. On 8 April , the WHO reported a total of only 30 confirmed cases, and the weekly update for 29 July reported only seven new cases. Cases continued to gradually dwindle and on 7 October , all three of the most seriously affected countries, per media reports, recorded their first joint week without any new cases. However, as of late , while the large-scale epidemic had ended, according to media reports, sporadic new cases were still being recorded, frustrating hopes that the epidemic could be declared over.
On 31 July , the WHO announced "an extremely promising development" in the search for an effective vaccine for Ebola virus disease. While the vaccine had shown high efficacy in individuals, more conclusive evidence was needed regarding its capacity to protect populations through herd immunity. In August , 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 optimise clinical care and social well-being. Stating that "the Ebola outbreak has decimated families, health systems, economies, and social structures", the WHO called the aftermath of the epidemic "an emergency within an emergency." Of special concern is recent research that shows some Ebola survivors experience a so-called "post-Ebola Syndrome", with symptoms so severe that survivors may require medical care for months and even years. As the main epidemic was coming to an end in December , the UN announced that 22, children had lost one or both parents to Ebola. On 29 March , the Director-General of WHO terminated the Public Health Emergency of International Concern status of the Western African Ebola virus epidemic.
See also: Ebola virus epidemic in West Africa timeline
Medically evacuated cases
It is generally believed that a one or two-year-old boy, later identified as Emile Ouamouno, who died in December in the village of Méliandou, Guéckédou Prefecture, Guinea, was the index case of the Western African epidemic. Scientists have deduced that bats are involved in the spread of the virus, and, incidentally, the boy's home was in the vicinity of a large colony of Angolan free-tailed bats, according to media reports. His mother, sister, and grandmother, per media reports later became ill with similar symptoms and also died; people infected by these initial cases spread the disease to other villages. There was knowledge of Tai Forest virus in Côte d'Ivoire, which had resulted in one human transmission in Thus, these early cases were diagnosed as other conditions more common to the area and the disease had several months to spread before it became recognised as Ebola.
On 25 March , the WHO indicated that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts, and that suspected cases in the neighbouring countries of Liberia and Sierra Leone were being investigated. In Guinea, a total of 86 suspected cases, including 59 deaths, had been reported as of 24 March. By late May, the outbreak had spread to Conakry, Guinea's capital—a city of about two million people. On 28 May, the total number of reported cases had reached , with deaths.
In Liberia, the disease was reported in four counties by mid-April and cases in Liberia's capital Monrovia were reported in mid-June. The outbreak then spread to Sierra Leone and progressed rapidly. By 17 July, the total number of suspected cases in the country stood at , surpassing those in Guinea and Liberia. By 20 July, additional cases of the disease had been reported by the media in the Bo District, while the first case in Freetown, Sierra Leone's capital, was reported in late July.
As the epidemic progressed, a small outbreak occurred in Nigeria that resulted in 20 cases and another in Mali with 7cases. Four other countries (Senegal, Spain, the United Kingdom and the United States of America) also reported cases imported from Western Africa, with widespread and intense transmission.
On 31 March , one year after the first report of the outbreak, the total number of cases was in excess of 25,—with over 10,deaths.
As the epidemic waned, following international control efforts, the edition of 8 April of the WHO's Ebola Situation Reports stated that a total of 30 cases were reported and on 29 July , the WHO weekly update reported only 7 cases—the lowest in more than a year. In October , the WHO recorded its first week without any new cases, and while the large-scale epidemic appeared to have ended by late , sporadic new cases continued to be reported.
On 14 January , after all the previously infected countries had been declared Ebola-free, the WHO reported that "all known chains of transmission have been stopped in Western Africa", but cautioned that further small outbreaks of the disease could occur in the future. The following day, Sierra Leone confirmed its first new case since September 
Countries that experienced widespread transmission
Further information: Ebola virus epidemic in Guinea
On 25 March , the WHO reported an outbreak of Ebola virus disease in four southeastern districts of Guinea with a total of 86 suspected cases, including 59 deaths, and MSF assisted the Ministry of Health by establishing Ebola treatment centres in the epicentre of the outbreak. On 31 March, the U.S. Centers for Disease Control and Prevention (CDC) sent a five-person team to assist in the response to the outbreak. Thinking that spread of the virus had been contained, MSF closed its treatment centres in May, leaving only a skeleton staff to handle the Macenta region. However, in late August, according to media reports, large numbers of new cases reappeared in the region.
In February , media reported that Guinea recorded a rise in cases for the second week in a row, health authorities stated that this was related to the fact that they "were only now gaining access to faraway villages", where violence had previously prevented them from entering. On 14 February, violence erupted and an Ebola treatment centre near the centre of the country was destroyed. Guinean Red Cross teams said they had suffered an average of 10 attacks a month over the previous year; MSF reported that acceptance of Ebola education remained low and that further violence against their workers might force them to leave.
Resistance to interventions by health officials among the Guinean population remained greater than in Sierra Leone and Liberia, per media reports, raising concerns over its impact on ongoing efforts to halt the epidemic; in mid-March, there were 95 new cases and on 28 March, and a day "health emergency" was declared in 5 regions of the country. On 22 May, the WHO reported another rise in cases, per media reports, which was believed to have been due to funeral transmissions; on 25 May, six persons were placed in prison isolation after they were found travelling with the corpse of an individual who had died of the disease, 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 its workers.
In late June , the WHO reported that "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". On 29 July, a sharp decline in cases was reported, with only a single case, per media reports left by the end of the week, the number of cases eventually plateaued at 1 or 2 cases per week after the beginning of August. On 28 October, an additional 3 cases were reported in the Forécariah Prefecture by the WHO. On 6 November, a media report indicated Tana village to be the last known place with Ebola in the country, and on 11 November, WHO indicated that no Ebola cases were reported in Guinea; this was the first time since the epidemic began, that no cases had been reported in any country. On 15 November, the last quarantined individuals were released, per media reports and on 17 November, the last Ebola patient in Guinea—a 3-week-old baby—had recovered; the day countdown toward the country being declared Ebola-free started on 17 November, the day after the patient yielded a second consecutive negative blood test. The patient was discharged from the hospital on 28 November, per media reports on 29 December , upon expiration of the day waiting period, the WHO declared Guinea Ebola-free.
On 17 March , the government of Guinea reported, per the media, that 2 people had again tested positive for Ebola virus in Korokpara, it was also reported that they were from the village where members of one family had recently died from vomiting (and diarrhea). On 19 March, it was also reported by the media that another individual had died due to the virus at the treatment centre in Nzerekore, consequently, the country's government quarantined an area around the home where the cases took place. On 22 March, the media reported that medical authorities in Guinea had quarantined suspected contacts of the prior cases (more than individuals were considered high-risk); the same day, Liberia ordered its border with Guinea closed.Macenta Prefecture, kilometres (mi) from Korokpara, registered Guinea's fifth fatality due to Ebola virus disease within the same period. On 29 March, it was reported that about 1, contacts had been identified ( of them high-risk), and on 30 March 3 more confirmed cases were reported from the sub-prefecture of Koropara. On 1 April, it was reported by the media, that possible contacts, which numbered in the hundreds, had been vaccinated with an experimental vaccine using a ring vaccination approach.
On 5 April , it was reported via the media, that there had been 9 new cases of Ebola since the virus resurfaced, out of which 8 were fatal; on 1 June, after the stipulated waiting period, the WHO again declared Guinea Ebola-free, after which the country entered a day period of heightened surveillance that was concluded on 30 August
In September , findings were published suggesting that the resurgence in Guinea was caused by an Ebola survivor who, after eight months of abstinence, had sexual relations with several partners, including the first victim in the new outbreak. The disease was also spread to Liberia by a woman who went there after her husband had died of Ebola.
Further information: Ebola virus epidemic in Sierra Leone
The first person reported infected in Sierra Leone, according to media reports, was a tribal healer who had been treating Ebola patients from across the nearby border with Guinea and who died on 26 May ; according to tribal tradition, her body was washed for burial, and this appears to have led to infections in women from neighbouring towns. On 11 June Sierra Leone shut its borders for trade with Guinea and Liberia and closed some schools in an attempt to slow the spread of the virus; on 30 July the government began to deploy troops to enforce quarantines, and by 15 October the last district in Sierra Leone previously untouched by the disease had declared Ebola cases.
During the first week of November reports told of a worsening situation due to intense transmission in Freetown. According to the Disaster Emergency Committee, food shortages resulting from aggressive quarantines were making the situation worse, and on 4 November media reported that thousands had violated quarantine in search of food in the town of Kenema. With the number of cases continuing to increase, an MSF coordinator described the situation in Sierra Leone as "catastrophic", saying, "there are several villages and communities that have been basically wiped out Whole communities have disappeared but many of them are not in the statistics." In mid-November the WHO reported that, while there was some evidence that the number of cases were no longer rising in Guinea and Liberia, steep increases persisted 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. On 15 December the CDC indicated that their main concern was Sierra Leone, where the epidemic had shown no signs of abating as cases continued to rise exponentially; by the second week of December, Sierra Leone had reported nearly cases—more than three times the number reported by Guinea and Liberia combined. According to the CDC, "the risk we face now [is] that Ebola will simmer along, become native and be a problem for Africa and the world, for years to come". On 17 December President Koroma of Sierra Leone launched "Operation Western Area Surge" and workers went door-to-door in the capital city looking for possible cases. The operation led to a surge in reports of cases, with new ones reported between 14and17 December.
According to the 21 January WHO Situation Report, the case incidence was rapidly decreasing in Sierra Leone. However, in February and March reports indicated a rise again in the number of cases. The following month, the 5 April WHO report again disclosed a downward trend and the WHO weekly update for 29 July reported a total of only 3 new cases, the lowest in more than a year. On 17 August the country marked its first week with no new cases, and one week later the last patients were released. However, a new case emerged on 1 September, when a patient from Sella Kafta village in Kambia District tested positive for the disease after her death; her case eventually resulted in 3 other infections among her contacts.
On 14 September Sierra Leone's National Ebola Response Centre confirmed the death of a year-old in a village in the Bombali District. It is suspected that she contracted the disease from the semen of an Ebola survivor who had been discharged in March  On 27 September a new day countdown began to declare the country Ebola-free, which eventually occurred on 7 November ; thereafter, the country increased its vigilance on the Guinean border.
Sierra Leone had entered a day period of enhanced surveillance that was scheduled to end on 5 February , when, on 14 January, a new Ebola death was reported in the Tonkolili District. Prior to this case, the WHO had advised that "we still anticipate more flare-ups and must be prepared for them. A massive effort is underway to ensure robust prevention, surveillance and response capacity across all three countries by the end of March." On 16 January aid workers reported that a woman had died of the virus and that she may have exposed several individuals; the government later announced that people had been quarantined. Investigations indicated that the deceased was a female student from Lunsar, in Port Loko District, who had gone to Kambia District on 28 December before returning symptomatic. She had also visited Bombali District to consult a herbalist, and had later gone to a government hospital in Magburaka. The WHO indicated that there were contacts (28 of them high-risk), that there were another 3missing contacts, and that the source or route of transmission that caused the fatality was unknown. A second new case—confirmed by WHO spokesman Tarik Jasarevic to involve a year-old relative and caregiver of the aforementioned Ebola victim—had become symptomatic on 20 Jan while under observation at a quarantine centre. On 22 January it was reported that this patient was responding to treatment. On 26 January WHO Director-General, DrMargaret Chan officially confirmed that the outbreak was not yet over; that same day, it was also reported that Ebola restrictions had halted market activity in Kambia District amid protests. On 7 February 70individuals were released from quarantine, and on 8 February the last Ebola patient was also released. On 17 February the WHO indicated that 2, Ebola survivors had accessed health assessments and eye examinations.
On 4 February the last known case tested negative for a second consecutive time and Sierra Leone commenced another day countdown towards being declared Ebola-free. On 17 March the WHO announced that the Sierra Leone flare-up was over, and that no other chains of transmission were known to be active at that time. The media reported that Sierra Leone then entered a day period of heightened surveillance, which concluded on 15 June , and it was reported that by 15 July the country had discontinued testing corpses for the virus.
Further information: Ebola virus epidemic in Liberia
In Liberia, the disease was reported in both Lofa and Nimba counties in late March  On 27 July, President Ellen Johnson Sirleaf announced that Liberia would close its borders, with the exception of a few crossing points such as Roberts International Airport, where screening centres would be established. Schools and universities were closed, and the worst-affected areas in the country were placed under quarantine.
With only 50 physicians in the entire country—one for every 70,citizens—Liberia was already in a healthcare crisis. In September, the CDC reported that some hospitals had been abandoned, while those still functioning lacked basic facilities and supplies. In October, the Liberian ambassador in Washington was reported as saying that he feared that his country may be "close to collapse"; by 24 October, all 15 counties had reported Ebola cases.
By 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.Roselyn Nugba-Ballah, leader of the Safe & Diginified Burial Practices Team during the crisis, was awarded the Florence Nightingale Medal in for her work during the crisis.
In January , the MSF field coordinator reported that Liberia was down to only 5confirmed cases. In March, after two weeks of not reporting any new cases, 3new cases were confirmed. On 8 April, a new health minister was named in an effort to end Ebola in the country and on 26 April, MSF handed the Ebola treatment facility, ELWA-3, over to the government. On 30 April, the US shut down a special Ebola treatment unit in Liberia. The last known case of Ebola died on 27 March, and the country was officially declared Ebola-free on 9 May , after 42days 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." As at May , the country remained on high alert against recurrence of the disease.
After three months with no new reports of cases, on 29 June Liberia reported that the body of a 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 people, who they were following up, 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. After a third new case was confirmed on 2 July, and it was discovered that all 3 new cases had shared a meal of dog meat, researchers looked at the possibility that the meat may have been involved in the transfer of the virus. Testing of the dog's remains, however, was negative for the Ebola virus. By 9 July 3 more cases were discovered, bringing the total number of new cases to 5, all from the same area. On 14 July, a woman died of the disease in the county of Montserrado, bringing the total to 6. On 20 July, the last patients were discharged, and on 3 September , Liberia was declared Ebola-free again.
After two months of being Ebola-free, a new case was confirmed on 20 November , when a year-old boy was diagnosed with the virus and two family members subsequently tested positive as well. Health officials were concerned because the child had not recently travelled or been exposed to someone with Ebola and the WHO stated that "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 staff of the CDC were sent to the country to help ascertain the cause of the new cases. The infected boy died on 24 November, and on 3 December 2 remaining cases were released after recovering from the disease. The day countdown toward Liberia being declared Ebola-free, for the third time, started on 4 December  On 16 December, the WHO reaffirmed that the cases in Liberia were the result of re-emergence of the virus in a previously infected person, and there was 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. On 18 December, the WHO indicated that it still considered Ebola in Western Africa a public health emergency, though progress had been made.
After having completed the day time period, Liberia was declared free from the virus on 14 January , effectively ending the outbreak that had started in neighbouring Guinea 2 years earlier. Liberia began a day period of heightened surveillance, scheduled to conclude on 13 April , but on 1 April, it was reported that a new Ebola fatality had occurred, and on 3 April, a second case was reported in Monrovia. On 4 April, it was reported that 84 individuals were under observation due to contact with the 2 confirmed Ebola cases. By 7 April, Liberia had confirmed 3 new cases since the virus resurfaced and a total of 97contacts, including 15healthcare workers, were being monitored. The index case of the new flareup was reported to be the wife of a patient who died from Ebola in Guinea; she had travelled to Monrovia after the funeral but succumbed to the disease. The outbreak in Guinea, in turn, had begun when a man, who had survived Ebola, had sexual intercourse with a woman and passed the virus to her, even though he had recovered more than a year earlier.
On 29 April, WHO reported that Liberia had discharged the last patient and had begun the day countdown to be declared Ebola-free once more. According to the WHO, tests indicated that the flare-up was likely due to contact with a prior Ebola survivor's infected body fluids. On 9 June, the flare-up was declared over, and the country Ebola-free, due to the passage of the day period; Liberia then entered a day period of heightened surveillance, which ended on 7 September In early July , a trial for males with detectable Ebola RNA in semen, started.
Western African countries with limited local cases
In March , the Senegal Ministry of Interior closed its southern border with Guinea, but on 29 August, the health minister announced the country's first case – a university student from Guinea who was being treated in a Dakar hospital. The patient was a native of Guinea who had travelled to Dakar, arriving on 20 August. On 23 August, he sought medical care for symptoms including diarrhoea, and vomiting plus signs of fever. 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 specialised facility for infectious diseases, and subsequently hospitalised.
On 28 August , authorities in Guinea issued an alert informing their medical services 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, triggering urgent contact tracing. On 10 September, it was reported that the student had recovered but health officials continued to monitor his contacts for 21 days. No further cases were reported, and on 17 October , the WHO officially declared that the outbreak in Senegal had ended.
The WHO officially commended the Senegalese government, and in particular the President Macky Sall and the Minister of Health, Dr Awa Coll-Seck, for their response in quickly isolating the patient and tracing and following up 74 contacts, as well as for their public awareness campaign. This acknowledgement was also extended to MSF and the CDC for their assistance.
Further information: Ebola virus disease in 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 On 6 August , the Nigerian health minister told reporters that one of the nurses that attended to the Liberian had died from the disease. 5 newly confirmed cases were being treated at an isolation ward.
On 22 September , the Nigerian health ministry announced, "As of today, there is no case of Ebola in Nigeria." According to the WHO, 20cases and 8deaths were confirmed, including the imported case, who also died. 4 of the dead were health workers who had cared for the index case.
The WHO's representative in Nigeria officially declared the country Ebola-free on 20 October , after no new active cases were reported in the follow up contacts, stating it was a "spectacular success story". Nigeria was the first African country to be declared Ebola free. This was largely due to the early quarantine efforts of Dr. Ameyo Stella Adadevoh at First Consultants Medical Centre in Lagos.
Further information: Ebola virus disease in Mali
On 23 October , the first case of Ebola virus disease in Mali was confirmed in the city of Kayes—a two-year-old girl who had arrived with a family group from Guinea, and died the next day. Her father had worked for the Red Cross in Guinea and also in a private health clinic; he had died earlier in the month, likely from an Ebola infection contracted in the private clinic. It was later established that a number of family members had also died of Ebola. The family had returned to Mali after the father's funeral via public bus and taxi—a journey of more than 1, kilometres (mi). All contacts were followed for 21days, with no further spread of the disease reported.
On 12 November , 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 returned to Guinea for burial. A nurse and a doctor who had treated the imam subsequently fell ill with Ebola and died. The next 3cases were related to the imam as well: a man who had visited the imam while he was in hospital, his wife and his son. On 22 November, the final case related to the imam was reported—a friend of the Pasteur Clinic nurse who had died from the Ebola virus. On 12 December, the last case in treatment recovered and was discharged, "so there are no more people sick with Ebola in Mali", according to a Ministry of Health source. On 16 December, Mali released the final 13individuals who were being quarantined and 24days later (18 January ) without new cases, the country was declared Ebola-free.
Other countries with limited local cases
Further information: Ebola virus disease in the United Kingdom
On 29 December , Pauline Cafferkey, a British aid worker who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola. She was treated and declared to be free of infection and released from hospital on 24 January  On 8 October, she was readmitted for complications caused by the virus and was in "serious" condition, according to a hospital report. On 14 October, her condition was listed as "critical" and 58individuals were being monitored and 25 received an experimental vaccination, being close contacts. On 21 October, it was reported that she had been diagnosed with meningitis caused by the virus persisting in her brain. On 12 November, she was released from hospital after making a full recovery. 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.
On 12 May , 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 centre for Ebola patients. On 10 June, it was reported that he had recovered and was disease-free and he was released from hospital.
Further information: Ebola virus disease cases in Spain
On 5 August , 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. On 21 September it was announced that Brother Manuel García Viejo, another Spanish citizen who was medical director at the St John of God Hospital Sierra Leone in Lunsar, had been evacuated to Spain from Sierra Leone after being infected with the virus. His death was announced on 25 September.
In October , a nursing assistant, Teresa Romero, who had cared for these patients became unwell and on 6 October tested positive for Ebola, making this the first confirmed case of Ebola transmission outside 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.
Further information: Ebola virus cases in the United States
On 30 September , the CDC declared its first case of Ebola virus disease. It disclosed that Thomas Eric Duncan became infected in Liberia and travelled to Dallas, 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. He died on 8 October. Two cases stemmed from Duncan, when two nurses that had treated him tested positive for the virus on 10 and 14 October and ended when they were declared Ebola-free on 24 and 22 October, respectively.
A fourth case was identified on 23 October , when Craig Spencer, an American physician who had returned to the United States after treating Ebola patients in Western Africa, tested positive for the virus. This case, however, had no relation to those originating from Duncan. Spencer recovered and was released from hospital on 11 November.
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 Western Africa. With the exception of a single isolated case in Spain, no secondary infections occurred as a result of the medical evacuations. The US accepted four evacuees and three were flown to Germany. France, Italy, the Netherlands, Norway, Switzerland, and the United Kingdom received two patients (and five who were exposed).
Unrelated outbreak in the Democratic Republic of the Congo
Further information: Democratic Republic of the Congo Ebola virus outbreak
In August , the WHO reported an outbreak of Ebola virus in the Boende District, part of the northern Équateur province of the Democratic Republic of the Congo (DRC), where 13 people were reported to have died of Ebola-like symptoms. Genetic sequencing revealed that this outbreak was caused by the Zaire Ebola species, which is native to the DRC; there have been seven previous Ebola outbreaks in the country since The virology results and epidemiological findings indicated no connection to the epidemic in Western Africa.
The index case was initially reported to have been a woman from Ikanamongo Village, who became ill with symptoms of Ebola after she had butchered a bush animal. However, later findings suggested that there may have been several previous cases, and it was reported that pigs in the village may have been infected with Ebola some time before the first human case occurred. The WHO declared the outbreak over on 21 November , after a total of 66 cases and 49 deaths.
See also: Ebola virus disease §Virology, and Ebola virus
Ebola virus disease is caused by four of six viruses classified in the genus Ebolavirus. Of the four disease-causing viruses, Ebola virus (formerly and often still called the Zaire Ebola virus) is dangerous and is the virus responsible for the epidemic in Western Africa. Since the discovery of the viruses in , when outbreaks occurred in South Sudan (then Sudan) and Democratic Republic of the Congo (then Zaire), Ebola virus disease had been confined to areas in Middle Africa, where it is native. With the current outbreak, it was initially thought that a new species native to Guinea might be the cause, rather than being imported from Middle to Western Africa. However, further studies have shown that the outbreak was likely caused by an Ebola virus lineage that spread from Middle Africa via an animal host within the last decade, with the first viral transfer to humans in Guinea.
In a study done by Tulane University, the Broad Institute and Harvard University, in partnership with the Sierra Leone Ministry of Health and Sanitation, researchers provided information about the origin and transmission of the Ebola virus that set the Western African outbreak apart from previous ones, including genetic changes in the virion. Five members of the research team became ill and died from Ebola before the study was published in August 
In a report released in August , researchers tracked the spread of Ebola in Sierra Leone from the group first infected—13 women who had attended the funeral of the traditional healer, where they contracted the disease—giving them a unique opportunity to track how the virus had changed. This provided "the first time that the real evolution of the Ebola virus [could] be observed in humans." The research showed that the outbreak in Sierra Leone was sparked by at least two distinct lineages 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 one appeared.
In January , the media stated researchers in Guinea had reported mutations in the virus samples that they were looking at. According to them, "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 [become] less deadly, but more contagious and that's something we are afraid of." A study suggested that accelerating the rate of mutation of the Ebola virus could make the virus less capable of infecting humans. In this animal study, the virus became practically non-viable, consequently increasing survival.
See also: Ebola virus disease §Transmission
Animal to human transmission
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). Bats drop partially eaten fruit and pulp, then land mammals such as gorillas and duikers feed on this fallen fruit. This chain of events forms a possible indirect means of transmission from the natural host to animal populations. As primates in the area were not found to be infected and fruit bats do not live near the location of the initial zoonotic transmission event in Meliandou, Guinea, it is suspected that the index case occurred after a child had contact with an insectivorous bat from a colony of Angolan free-tailed bats near the village.
On 12 January, the journal Nature reported that the virus emergence could be found by studying how bush-meat hunters interacted with the ecosystem. The continent of Africa has experienced deforestation in several areas or regions; this may contribute to recent outbreaks, including this epidemic, as initial cases have been in the proximity of deforested lands where fruit-eating bats natural habitat may be affected, though % evidence does not as yet exist.
Human to human transmission
Prior to this outbreak, it was believed that human-to-human transmission occurred only via direct contact with blood or bodily fluids from an infected person who is showing symptoms of infection, by contact with the body of a person who had died of Ebola, or by contact with objects recently contaminated with the body fluids of an actively ill infected person. It is now known that the Ebola virus can be transmitted sexually. Over time, studies have suggested that the virus can persist in seminal fluid, with a study released in September suggesting that the virus may survive more than days after infection. EBOV RNA in semen is not the same situation as perseverance of EBOV in semen, however the "clinical significance of low levels of virus RNA in convalescent" individuals who are healthy is unknown.
In September , the WHO had reported: "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." In April , following a report that the RNA virus had been detected in a semen sample six months after a man's recovery, the WHO issued a statement: "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."
The WHO based their new recommendations on a March 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 , was diagnosed with Ebola. While no evidence of the virus was found in his blood, his semen revealed Ebola virus RNA closely matching the variant 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 testes are protected from the body's immune system to protect the developing sperm, and it is thought that this same protection may allow the virus to survive in the testes for an unknown time.
On 14 September , the body of a girl who had died in Sierra Leone tested positive for Ebola and it was suspected that she may have contracted the disease from the semen of an Ebola survivor who was discharged in March  According to some news reports, a new study to be published in the New England Journal of Medicine indicated that the RNA virus could remain in the semen of survivors for up to six months, and according to other researchers, the RNA virus could continue in semen for 82 days and maybe longer. Furthermore, Ebola RNA had been found up to days post-onset of viral symptoms.
One of the primary reasons for the spread of the disease is the low-quality, functioning health systems in the parts of Africa where the disease occurs. The risk of transmission is increased among those caring for people infected. Recommended measures when caring for those who are infected include medical isolation via the proper use of boots, gowns, gloves, masks and goggles, and sterilizing all equipment and surfaces.
One of the biggest dangers of infection faced by medical staff requires their learning how to properly suit up and remove personal protective equipment. Full training for wearing protective body clothing can take 10 to 14 days. Even with proper isolation equipment available, working conditions such as lack of running water, climate control, and flooring have made direct care difficult. Two American health workers who contracted the disease and later recovered said that to the best of their knowledge, their team of workers had been following "to the letter all of the protocols for safety that were developed by the [CDC] and WHO", including a full body coverall, several layers of gloves, and face protection including goggles. One of the two, a physician, had worked with patients, but the other was assisting workers to get in and out of their protective gear while wearing protective gear herself.
Difficulties in attempting to halt transmission have also included the multiple disease outbreaks across country borders.Dr Peter Piot, the scientist who co-discovered the Ebola virus, stated that the outbreak was not following its usual linear patterns as mapped out in earlier outbreaks—this time the virus was "hopping" all over the Western African epidemic region. Furthermore, most past epidemics had occurred in remote regions, but this outbreak spread to large urban areas, which had increased the number of contacts an infected person might have and made transmission harder to track and break. On 9 December, a study indicated that a single individual introduced the virus into Liberia, causing the most cases of the disease in that country.
Containment and control
Main article: Prevention of viral hemorrhagic fever
See also: Ebola virus disease §Prevention
In August , 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 Western Africa; the coordinated international response worked towards realising this plan.
Surveillance and contact tracing
Contact tracing is an essential method of preventing the spread of the disease, this requires effective community surveillance so that a possible case of Ebola can be registered and accurately diagnosed as soon as possible, and subsequently finding everyone who has had close contact with the case and tracking them for 21 days. However, this requires careful record-keeping by properly trained and equipped staff. WHO Assistant Director-General for Global Health Security, Keiji Fukuda, said on 3 September , "We don't have enough health workers, doctors, nurses, drivers, and contact tracers to handle the increasing number of cases." There was a massive effort to train volunteers and health workers, sponsored by United States Agency for International Development (USAID). According to WHO reports, 25, contacts from Guinea, 35, from Liberia and , from Sierra Leone were listed and traced as of 23 November  According to one study, 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.
See also: Cultural effects of the Ebola crisis
To reduce the spread, the WHO recommended raising community awareness of the risk factors for Ebola infection and the protective measures individuals can take. These include avoiding contact with infected people and regular hand washing using soap and water. A condition of extreme poverty exists in many of the areas that 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." One study showed that once people had heard of the Ebola virus disease, hand washing with soap and water improved, though socio-demographic factors influenced hygiene.
A number of organisations enrolled local people to conduct public awareness campaigns among the communities in Western Africa. "what we mean by social mobilization is to try to convey the right messages, in terms of prevention measures, adapted to the local context—adapted to the cultural practices in a specific area," said Vincent Martin, FAO's representative in Senegal.
Denial in some affected countries also made containment efforts difficult. Language barriers and the appearance of medical teams in protective suits sometimes increased fears of the virus. In Liberia, a mob attacked an Ebola isolation centre, stealing equipment and "freeing" patients while shouting "There's no Ebola." Red Cross staff were forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives. In September, in the town of Womey in Guinea, suspicious inhabitants wielding machetes murdered at least eight aid workers and dumped their bodies in a latrine.
An August 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 had died. In November, WHO released a protocol for the safe and dignified burial of people who die from Ebola virus disease. It encouraged the inclusion of family and clergy, and gave specific instructions for Muslim and Christian burials. In the 21 January WHO road map update, it was reported that % of districts in Sierra Leone and 71% of districts in Guinea had a list of key religious leaders who promoted safe and dignified burials. Speaking on 27 January , 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 practising safer burying rituals that do not compromise tradition.
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 They met with thousands of teachers and administrators to work out hygiene guidelines. Their efforts included installing hand-washing 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 had access to running water. In August , 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." Researchers presented evidence indicating that infected people that lived in low socioeconomic areas were more likely to transmit the virus to other socioeconomic status (SES) communities, in contrast to individuals in higher SES areas who were infected as well. Another study showed that, in Guinea, a satisfactory knowledge had 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 (% thought that a higher power had caused it). A study on Nigeria's success story stated that, in this case, a prompt response by the government and proactive public health measures had resulted in the quick control of the outbreak.
During the height of the crisis, Wikipedia's Ebola page received million page views per day, making Wikipedia one of the world's most highly used sources of trusted medical information regarding the disease.
Travel restrictions and quarantines
There was serious concern that the disease would spread further within Western Africa or elsewhere in the world, such as:
- Western Africa On 8 August , 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 per cent of the known cases had been found. 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.
- International Many countries considered imposing travel restrictions to or from the region. On 2 September , WHO Director-General Margaret Chan advised against this, saying that they were not justified and that they would prevent medical experts from entering the affected areas. She also stated that they were "marginalizing the affected population and potentially worsening the crisis". UN officials working on the ground also criticised the travel restrictions, saying the solution was "not in travel restrictions but in ensuring that effective preventive and curative health measures are put in place". MSF also spoke out against the closure of international borders, calling 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."
- In December , during the 8th meeting of WHO's "IHR Emergency Committee regarding Ebola", it 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." In December , the CDC indicated that it would no longer make the recommendation for US citizens going to Sierra Leone to be extra careful. However, the CDC did further indicate that individuals travelling to the country should take precaution with sick people and body fluids. Additionally, individuals travelling to the country should avoid contact with animals.
- 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 CDC, MSF, Public Health England, and Public Health Ontario.
See also: Ebola virus disease treatment research and Ebola vaccine
No proven Ebola virus-specific treatment presently exists; however, measures can be taken to improve a patient's chances of survival. Ebola symptoms may begin as early as two days or as long as 21 days after one is exposed to the virus. Symptoms usually begin with a sudden influenza-like illness characterised by feeling tired, and pain in the muscles and joints. Later symptoms may include headache, nausea, and abdominal pain; this is often followed by severe vomiting and diarrhoea. In past outbreaks, it has been noted that some patients bleed internally and/or externally; however data published in October showed that this had been a rare symptom in the Western African outbreak. Another study published in October 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 others progress to a very severe stage that includes bleeding.
Without fluid replacement, such an extreme loss of fluids leads to dehydration, which in turn 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 therapy may be instituted, but patients who are vomiting or are delirious must be hydrated with intravenous (IV) therapy. However, administration of IV 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, for which many areas did not have access to the required laboratory services.
Treatment centres were overflowing with patients while others waited to be admitted; 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 working in 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 was 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. In experts studied the mortality rates of different treatment settings, and given the wide differences in variables that affected outcomes, adequate information had not yet been gathered to make a definitive statement about what constituted optimal care in the Western African setting.Paul Farmer of Partners in Health, an NGO that only as of January had 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 lines. In , viewing the information gathered from the pandemic Farmer noted that there were almost no deaths in the U.S. and European patients because they had received optimal care.
Ebola virus disease has a high case fatality rate (CFR), which in past outbreaks varied between 25% and 90%, with an average of about 50%. The epidemic caused significant mortality, with reported CFRs of up to 70%. Care settings that have access to medical expertise may increase survival by providing good maintenance of hydration, circulatory volume, and blood pressure.
The disease affects males and females equally and the majority of those that contract Ebola disease are between 15 and 45 years of age. For those over 45 years, a fatal outcome was more likely in the Western African epidemic, as was also noted in preceding outbreaks. Only rarely do pregnant women survive—a midwife who worked with MSF in a Sierra Leone treatment centre stated that she knew of "no reported cases of pregnant mothers and unborn babies surviving Ebola in Sierra Leone." In September , the WHO issued pregnancy guidance information entitled, "Interim Guidance on Ebola Virus Disease in Pregnancy."
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 that "the additional death toll from malaria and other diseases [is] likely to exceed that of the outbreak itself". Dr 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." As the epidemic drew to a close in , a report from Sierra Leone showed that the fear and mistrust of hospitals generated by the epidemic had resulted in an 11% decline in facility-based births, and that those receiving care before or after birth fell by about a fifth. Consequently, between May and April , the deaths of women during or just after childbirth rose by almost a third and those of newborns by a quarter, compared to the previous year.
Research suggests that many Ebola infections are asymptomatic, meaning that some infected people show no symptoms of the disease. For example, two studies done on previous outbreaks showed that 71% of seropositive individuals did not have the clinical disease in one outbreak and another study reported that 46% of asymptomatic close contacts of patients with Ebola were seropositive. On 22 January, the 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 possible periarticular tenosynovitis affecting the shoulders. The WHO guidelines advise to distinguish non-inflammatory arthralgia from inflammatory arthritis. With regard to ocular problems, sensitivity to light and blurry vision have been indicated among survivors. Among the aftereffects of Ebola virus disease, uveitis and optic nerve disease could appear after an individual is discharged. Ocular problems could threaten sight in survivors, thus the need for prompt treatment. In treating such individuals, the WHO recommends urgent intervention if uveitis is suspected; this consists mainly of prednisone (a corticosteroid). Hearing loss has been reported in Ebola survivors 25% of the time. Treatment, in the case of acute labyrinthitis (inner ear disorder), should be given within 10 days of the onset of symptoms and prochlorperazine, a vestibular sedative, may be administered for vertigo.
Post-Ebola virus syndrome
See also: Post-Ebola virus syndrome
There are at least 17, people who have survived infection from the Ebola virus in Western Africa; some of them have reported lingering health effects. 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."
In February , a Sierra Leone physician said about half of the recovered patients she saw reported declining health and that she had seen survivors go blind. In May , a senior consultant to the WHO said that the reports of eye problems were especially worrying because "there are hardly any ophthalmologists in Western Africa, and only they have the skills and equipment to diagnose conditions like uveitis that affect the inner chambers of the eye."
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.
In December , 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 However, in October , 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 clinical meningitis. The woman was treated and in November it was reported that she had recovered.
In terms of medical literature that are reviews, few articles have been published, such as Shantha, et al. which discusses management of panuveitis and iris heterochromia.
Ebola survivor studies
An observational study, done roughly 29 months after the Bundibugyo outbreak in Uganda, found that long-term sequelae (i.e. consequences) persisted among survivors. 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".
From August through December , a total of 10 patients with Ebola were treated in US hospitals; of these patients, 8 survived. In March , the CDC interviewed the survivors; they all reported having had at least one adverse symptom during their recovery period. The symptoms ranged from mild (e.g. hair loss) to more severe complications requiring re-hospitalisation or treatment. The most frequently reported symptoms were lethargy or fatigue, joint pain, and hair loss. Sixty-three per cent 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.
A study published in May 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 centre in Sierra Leone. He was transported to the US and 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 obtained from his eye tested positive for Ebola. The authors of the study concluded that "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.
Another study, which was released in August looked at the health difficulties reported by survivors. Calling the set of symptoms "post-Ebolavirus disease syndrome", the research found symptoms that included "chronic joint and muscle pain, fatigue, anorexia, hearing loss, blurred vision, headache, sleep disturbances, low mood and short-term memory problems", and suggested the "implementation of specialised health services to treat and follow-up survivors".
Level of care
In June , it was reported that local authorities did not have the resources to contain the disease, with health centres closing and hospitals becoming overwhelmed. There were also reports that adequate personal protection equipment was not being provided for medical personnel. The Director-General of MSF said: "Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible."
In late August, MSF called the situation "chaotic" and the medical response "inadequate." They reported that they had expanded their operations, but 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 had left people with other health problems without any care at all. Speaking from a remote region, an MSF worker said that a shortage of protective equipment was making the medical management of the disease difficult and that they had limited capacity to safely bury bodies.
By September, treatment for Ebola patients had become unavailable in some areas. Speaking on 12 September, WHO Director-General, Margaret Chan, said: "In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centres. Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia." According to a WHO report released on 19 September, Sierra Leone was meeting only 35% of its need for patient beds, while for Liberia it was just 20%.
In early December, the WHO reported that at a national level there were enough beds in treatment facilities to treat and isolate all reported Ebola cases, although their uneven distribution was resulting in serious shortfalls in some areas. Similarly, all affected countries had sufficient and widespread capacity to bury reported deaths; however, because not all deaths were reported, it was possible that the reverse could have been the case in some areas. WHO also reported that every district had access to a laboratory to confirm cases of Ebola within 24 hours of sample collection, and that all three countries had reported that more than 80% of registered contacts associated with known cases of Ebola virus disease were being traced, although contact tracing was still a challenge in areas of intense transmission and those with community resistance.
Kerry Town Ebola Treatment Centre in Sierra Leone MOD jpg at the International Gymnastics Federation
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. In January , a new treatment and research centre was built by Rusal and Russia in the city of Kindia in Guinea. It is one of the most modern medical centres in Guinea. Also in January, MSF admitted its first patients to a new treatment centre in Kissy, an Ebola hotspot on the outskirts of Freetown, Sierra Leone. The centre has a maternity unit for pregnant women with the virus.
Although the WHO does not advise caring for Ebola patients at home, in some cases it became a necessity when no hospital treatment beds were available. For those being treated at home, the WHO advised informing the local public health authority and acquiring appropriate training and equipment. UNICEF, USAID and Samaritan's Purse began to take measures to provide support for families that were forced to care for patients at home by supplying caregiver kits intended for interim home-based interventions. The kits included protective clothing, hydration items, medicines, and disinfectant, among other items. Even where hospital beds 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. 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. Health facilities with low-quality systems for preventing infection were involved as sites of amplification during viral outbreaks.
The Ebola epidemic caused an increasing demand for protective clothing. A full set of protective clothing includes a suit, goggles, a mask, socks and boots, and an apron. Boots and aprons can be disinfected and reused, but everything else must be destroyed after use. Health workers change garments frequently, discarding gear that has barely been used. This not only takes a great deal of time but also exposes them to the virus because, for those wearing protective clothing, one of the most dangerous moments for contracting Ebola is while suits are being removed.
The protective clothing sets that MSF uses cost about $75 apiece. Staff who have returned from deployments to Western Africa say the clothing is so heavy that it can be worn for only about 40 minutes at a stretch. A physician working in Sierra Leone has said: "After about 30 or 40 minutes, your goggles have fogged up; your socks are completely drenched in sweat. You're just walking in water in your boots. And at that point, you have to exit for your own safety Here it takes 20–25 minutes to take off a protective suit and must be done with two trained supervisors who watch every step in a military manner to ensure no mistakes are made, because a slip up can easily occur and of course can be fatal." By October, there were reports that protective outfits were beginning to be in short supply and manufacturers began to increase their production, but the need to find better types of suits has also been raised.
USAID published an open competitive bidding for proposals that address the challenge of developing "new practical and cost-effective solutions to improve infection treatment and control that can be rapidly deployed; 1) to help health care workers provide better care and 2) transform our ability to combat Ebola". On 12 December , USAID announced the result of the first selection in a press release.
On 17 December , a team at Johns Hopkins University developed a prototype breakaway hazmat suit, and was awarded a grant from the USAID to develop it. 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. In March, Google developed a tablet that could be cleaned with chlorine; it is charged wirelessly and can transmit information to servers outside the working area.
The WHO recommends the use of 2 pairs of gloves, with the outer pair worn over the gown. Using 2 pairs may reduce the risk of sharp injuries; however, there is no evidence that using more than the recommended will give additional protection. WHO also recommends the use of a coverall, which is generally appraised in terms of its resistance to non-enveloped DNA virus. When a gown (or coverall) is worn, it should continue beyond the shoe covers. According to guidelines released by the CDC in August , updates were put 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 was recommended to help in this process. The order in which boot covers are removed, by these guidelines, indicates their removal after the coverall or gown. Finally, a trained observer is to read to the healthcare worker each step in donning and doffing, but must not physically assist therein.
In the hardest hit areas there have historically been only one or two doctors available to treat ,people, and these doctors are heavily concentrated in urban areas. Ebola patients' healthcare providers, as well as family and friends, are at highest risk of getting infected because they are more likely to come in direct contact with their blood or body fluids. In some places affected by the outbreak, care may have been provided in clinics with limited resources, and workers could be in these areas for several hours with a number of Ebola infected patients. According to the WHO, the high proportion of infected medical staff could be explained by a lack of adequate manpower to manage such a large outbreak, shortages of protective equipment or improper use of what was available, and "the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe". In August , healthcare workers represented nearly 10 per cent of cases and fatalities—significantly impairing the capacity to respond to an outbreak in an area already facing severe shortages. By 1 July , the WHO reported that a total of health workers had been infected, of which had died.
Among the fatalities was Samuel Brisbane, a former adviser to the Liberian Ministry of Health and Social Welfare, described as "one of Liberia's most high-profile doctors". In July , leading Ebola doctor Sheik Umar Khan from Sierra Leone also died in the outbreak. In August, a well-known Nigerian physician, Ameyo Adadevoh, died. Mbalu Fonnie, a licensed nurse-midwife and nursing supervisor at the Kenema hospital in Sierra Leone, with over 30 years of experience, died after contracting Ebola while caring for a fellow nurse who was pregnant and had the disease. Fonnie was also a co-author of a study that analysed the genetics of the Ebola virus; five others contracted Ebola and died while working on the same study.
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", the editors of Time magazine in December 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 defences, for risking, for persisting, for sacrificing and saving, the Ebola fighters are Time's Person of the Year." According to an October report by the CDC, Guinean healthcare workers had times higher Ebola infection rates than non-healthcare workers, and male healthcare workers were more affected than their female counterparts. The report indicated that 27% of Ebola infections among healthcare workers in Guinea occurred among doctors. The CDC report also stated that the Guinea Ministry of Health recorded males as representing 46% of the health workforce, and that 67% of Ebola infections among non-doctor healthcare workers occurred among males. The CDC further indicated that healthcare workers in Guinea were less likely to report contact with an infected individual than non-healthcare workers.
Experimental treatments and testing
Further information: Ebola virus disease treatment research
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. A number of experimental treatments are undergoing clinical trials. 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.
The effectiveness of potential treatments for any disease is usually assessed in a randomised controlled trial, which compares the outcome of those who received treatment to those who received a placebo (i.e. dummy treatment). However, randomised controlled trials are considered unethical when a disease is frequently fatal, as is the case with Ebola. In December , a study was released that found that the 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 suggested that this information could help to assess the efficacy of proposed treatments more accurately in non-randomised clinical trials.
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 Western Africa, this delays diagnosis. As of February [update] a number of rapid diagnostic tests were under trial.
History of Ebola Virus Disease (EVD) Outbreaks
- Species: Zaire ebolavirus
- Reported number of cases: 12
- Reported number of deaths and percentage of fatal cases: 6 (50%)
On February 7, , the Ministry of Health (MOH) in the Democratic Republic of the Congo (DRC) announced that a case of Ebola virus disease (EVD) had been confirmed in Biena Health Zone, North Kivu Province. Subsequent cases were confirmed. North Kivu was previously affected by EVD during the – Ebola outbreak, the largest in DRC’s history, which was declared over on June 25, Sequencing of samples suggests that cases in this outbreak were linked to cases in the area during the – outbreak and likely resulted from persistent infection in a survivor that led to either a relapse or sexual transmission of the virus. The outbreak was declared over on May 3,
- Species: Zaire ebolavirus
- Reported number of cases:
- Reported number of deaths and percentage of fatal cases: 55 (%)
The DRC government declared a new Ebola outbreak in Mbandaka, Équateur Province of western DRC on June 1, International partners, including CDC, provided technical assistance to the DRC government to support response efforts. This was DRC’s 11th Ebola outbreak and distinct from the 10th Ebola outbreak in eastern DRC, which was still ongoing when this one began.
Laboratory sequencing suggests that most cases in this outbreak were likely the result of a new spillover event (i.e. a new introduction of the virus into the community from an animal reservoir) followed by person-to-person spread. Sequencing efforts also identified a few cases which appeared to be linked to the prior Équateur Province outbreak in , possibly due to sexual transmission or relapse of a survivor.
On November 18, , the DRC Ministry of Health and WHO announced the outbreak was over.
- Species: Zaire ebolavirus
- Reported number of cases: 3,*
- Reported number of deaths and percentage of fatal cases: 2,* (66%)
The DRC government declared its 10th Ebola outbreak on August 1, , in North Kivu province of eastern DRC. Cases were also reported in Ituri and South Kivu provinces, and in Uganda. CDC assisted the DRC government, neighboring countries, and local and international partners to coordinate activities and provide technical guidance related to laboratory testing, contact tracing, infection control, border health screening, data management, risk communication and health education, vaccination, and logistics.
The outbreak was declared over by the World Health Organization (WHO) on June 25,
*In , four cases confirmed in Uganda were attributed to cross-border movement from DRC and recorded in both countries. These cases died in DRC and are reported in the DRC death count.
- Species: Zaire ebolavirus
- Reported number of cases: 54
- Reported number of deaths and percentage of fatal cases: 33 (61%)
The DRC government declared the outbreak in the Bikoro region of Équateur Province in the northwestern part of the country on May 8 after two cases were confirmed by laboratory testing at the Institut National de Recherche Biomédicale in Kinshasa. CDC assisted the DRC government and local and international partners, including the World Health Organization (WHO), as they pursued priority areas of support, including establishing an outbreak response platform; implementing surge support for deployment of personnel, supplies, laboratory materials, operational support, logistics, and transportation; and identifying communication needs to support the partners and the response. On July 24, , WHO declared the end of the ninth outbreak of Ebola in the Democratic Republic of the Congo.
- Species: Zaire ebolavirus
- Reported number of cases: 8
- Reported number of deaths and percentage of fatal cases: 4 (50%)
On May 11, , the Ministry of Public Health of the Democratic Republic of the Congo notified international public health agencies of a cluster of suspected cases of Ebola Virus Disease (EVD) in the Likati health zone of the province of Bas Uélé. The first report mentioned eight suspected cases, including two deaths, with a third death reported on May Testing of samples was conducted by the Institut National de Recherche Biomedicale (INRB) in Kinshasa, with two samples testing positive for Ebola Zaire. Teams from international agencies, including CDC, WHO, MSF (Doctors without Borders), and others, supported the Ministry of Public Health’s epidemiologic, diagnostic, clinical, and communications efforts to respond to the outbreak. The response faced challenging logistical obstacles, including the remoteness of the area and limited services. Mobile diagnostic laboratories provided testing of samples in the affected areas. Following a period of 42 days since the second negative laboratory diagnostic test of the last confirmed patient, WHO declared an end to the outbreak on July 2,
- Species: Zaire ebolavirus
- Reported number of cases: 69
- Reported number of deaths and percentage of fatal cases: 49 (71%)
Outbreak occurred in multiple villages in the vicinity of Boende town but was limited to the Équateur province in the western part of the country. The Ebola virus variant that caused this outbreak was closely related to the one that caused the outbreak in Kikwit, indicating that this outbreak was not related to the large outbreak happening at the same time in West Africa.1
1 Maganga GD, Kapetshi J., Berthet N, et al. Ebola virus disease in the Democratic Republic of Congo [PDF – MB]external icon. New England Journal of Medicine. ;
- Species: Bundibugyo ebolavirus
- Reported number of cases: 38*
- Reported number of deaths and percentage of fatal cases: 13* (34%)
Outbreak occurred in the Orientale province in the northeast of the country. CDC and the Public Health Agency of Canada (PHAC) provided laboratory support through a field laboratory in Isiro Health Zone, as well as through the CDC/UVRI (Uganda Virus Research Institute) laboratory in Uganda. This outbreak in DRC had no epidemiologic link to the Ebola outbreak occurring in the Kibaale district of Uganda at the same time.
* Numbers reflect laboratory-confirmed cases only
- Species:Zaire ebolavirus
- Reported number of cases: 32
- Reported number of deaths and percentage of fatal cases: 15 (47%)
Outbreak occurred in the Mweka and Luebo health zones in the Kasai Occidental province. A number of international partners were involved in the response to this outbreak.1
1 World Health Organization. End of the Ebola Outbreak in the Democratic Republic of the Congoexternal icon. Global Alert and Response. 17 February
- Species: Zaire ebolavirus
- Reported number of cases:
- Reported number deaths and percentage of fatal cases: (71%)
Outbreak was declared in mid-September in Luebo and Mweke health zones in the Kasai Occidental Province. Radio broadcasts were used to deliver accurate and timely messages to the local population on EVD spread and prevention. The last confirmed case was on October 4 and the outbreak was declared over November 1
1 Declaration de son Excellence Monsieur le Ministre de la Santé Publique annonçant la fin de l’épidémie de FHV à virus Ebola dans les zones de santé de Mweka, Luebo et Bulape dans la Province du Kasai Occidental pdf icon[PDF- KB]. Mardi, le 20 novembre Dr. Victor Makwenge Kaput, Ministre de la Santé Publique.
2 World Health Organization. Ebola virus haemorrhagic fever, Democratic Republic of the Congo – Update. pdf icon[PDF- KB]external icon Weekly Epidemiological Record. ;82(40)
- Species: Zaire ebolavirus
- Reported number of cases:
- Reported number of deaths and percentage of fatal cases: (81%)
Outbreak occurred in Kikwit and surrounding areas and began with a charcoal maker in the forested areas near the city. The epidemic spread through families and hospitals. Transmission in the healthcare setting was halted almost immediately once proper protective measures were taken, such as the use of face masks, gloves and gowns for healthcare personnel, were instituted.1
1 Khan AS, Tshioko FK, Heymann DL, et al. The Reemergence of Ebola Hemorrhagic Fever, Democratic Republic of the Congo, external icon. Journal of Infectious Diseases. ;SS
- Species: Zaire ebolavirus
- Reported number of cases: 1
- Reported number of deaths and percentage of fatal cases: 1 (%)
Case was noted retrospectively in the village of Tandala. This case had no known connection to the original Ebola outbreak in , suggesting Ebola virus is enzootic in the area. 1
1 Heymann DL, Weisfeld JS, Webb PA, et al. Ebola hemorrhagic fever: Tandala, Zaire, external icon. Journal of Infectious Diseases. ;(3)
- Species: Zaire ebolavirus
- Reported number of cases:
- Reported number of deaths and percentage of fatal cases: (88%)
This outbreak was the first recognition of Ebola Virus Disease. It occurred in the Équateur province, with most cases occurring within 70 km of Yambuku village. The index case was treated at the Yambuku Mission Hospital with an injection for possible malaria. Subsequent transmission followed through use of contaminated needles and syringes at the hospital and clinics in the area and close personal contact. There were only 38 serologically confirmed survivors.1
1 World Health Organization. Ebola haemorrhagic fever in Zaire, pdf icon[PDF- MB]external icon. Report of an International Commission. Bulletin of the World Health Organization. ;56(2)
Ebola Outbreak in West Africa
The Ebola outbreak in West Africa has ended. Visit the Ebola Outbreak section for information on current Ebola outbreaks.
On March 23, , the World Health Organization (WHO) reported cases of Ebola Virus Disease (EVD) in the forested rural region of southeastern Guinea. The identification of these early cases marked the beginning of the West Africa Ebola epidemic, the largest in history.
The initial case, or index patient, was reported in December An month-old boy from a small village in Guinea is believed to have been infected by bats. After five additional cases of fatal diarrhea occurred in that area, an official medical alert was issued on January 24, , to the district health officials. The Ebola virus soon spread to Guinea’s capital city of Conakry, and on March 13, , the Ministry of Health in Guinea issued an alert for an unidentified illness. Shortly after, the Pasteur Institute in France confirmed the illness as EVD caused by Zaire ebolavirus. On March 23, , with 49 confirmed cases and 29 deaths, the WHO officially declared an outbreak of EVD.
Weak surveillance systems and poor public health infrastructure contributed to the difficulty surrounding the containment of this outbreak and it quickly spread to Guinea’s bordering countries, Liberia and Sierra Leone. By July , the outbreak spread to the capitals of all three countries. This was the first time EVD extended out from more isolated, rural areas and into densely populated urban centers, providing an unprecedented opportunity for transmission.
On August 8, , WHO declared the deteriorating situation in West Africa a Public Health Emergency of International Concern (PHEIC), which is designated only for events with a risk of potential international spread or that require a coordinated international response. Over the duration of the epidemic, EVD spread to seven more countries: Italy, Mali, Nigeria, Senegal, Spain, the United Kingdom, and the United States. Later secondary infection, mainly in a healthcare setting, occurred in Italy, Mali, Nigeria, and the United States.
The scope of this outbreak, both in terms of cases and geography, can be attributed to the unprecedented circulation of EVD into crowded urban areas, increased mobilization across borders, and conflicts between key infection control practices and prevailing cultural and traditional practices in West Africa. Engaging local leaders in prevention programs and messaging, along with careful policy implementation at the national and global level, helped to eventually contain the spread of the virus and put an end to this outbreak.
Liberia was first declared Ebola-free in May Additional cases were found and treated, and the country was again declared Ebola-free in September More cases were discovered in November On January 14, , Liberia again announced it was Ebola-free; however, cases were detected in March and April of , and Liberia made its final declaration on June 1,
After an initial declaration in November , Sierra Leone announced a new case of EVD in January and declared it was Ebola-free on March 17, In Guinea, the first end of outbreak declaration was in December , but additional cases were discovered in March and April of Guinea was finally declared Ebola-free in June  Two and a half years after the first case was discovered, the outbreak ended with more than 28, cases and 11, deaths.
Ebola in the United States
Overall, eleven people were treated for Ebola in the United States during the epidemic. On September 30, , CDC confirmed the first travel-associated case of EVD diagnosed in the United States in a man who traveled from West Africa to Dallas, Texas. The patient (the index case) died on October 8, Two healthcare workers who cared for him in Dallas tested positive for EVD. Both recovered.
On October 23, , a medical aid worker who had volunteered in Guinea was hospitalized in New York City with suspected EVD. The diagnosis was confirmed by the CDC the next day. The patient recovered.
Seven other people were cared for in the United States after they were exposed to the virus and became ill while in West Africa, the majority of whom were medical workers. They were transported by chartered aircraft from West Africa to hospitals in the United States. Six of these patients recovered, one died.
CDC activated its Emergency Operations Center in July to help coordinate technical assistance and disease control activities with partners. CDC personnel deployed to West Africa to assist with response efforts, including surveillance, contact tracing, data management, laboratory testing, and health education. CDC staff also provided support with logistics, staffing, communication, analytics, and management.
To prevent cross-border transmission, travelers leaving West Africa were screened at airports. Exit screening helped identify those at risk for EVD and prevent the spread of the disease to other countries. The United States also implemented enhanced entry screening for travelers coming from Guinea, Liberia, Sierra Leone, and Mali by routing them to designated airports better able to assess travelers for risk.
During the height of the response, CDC trained 24, healthcare workers in West Africa on infection prevention and control practices. In the United States, more than 6, people were trained during live training events throughout the response. In addition, laboratory capacity was expanded in Guinea, Liberia, and Sierra Leone with 24 laboratories able to test for Ebola virus by the end of 
On March 29, , the WHO lifted the PHEIC status on West Africa’s Ebola situation. The impact this epidemic had on the world, and particularly West Africa, is significant. A total of 28, cases of EVD and 11, deaths were reported in Guinea, Liberia, and Sierra Leone. There were an additional 36 cases and 15 deaths that occurred when the outbreak spread outside of these three countries. The table below shows the distribution of cases and deaths in countries with widespread transmission and countries affected by the epidemic.
|Country||Total Cases (Suspected, Probable, Confirmed)||Laboratory Confirmed Cases||Total Deaths|
|Countries with Widespread Transmission|
* While there were 11 patients with EVD in total treated in the United States, only four patients became ill after they arrived in the United States, either after exposure in West Africa or in a healthcare setting.
Graphs of reported cases, called epidemic curves, show the rate (incidence) of new, probable, and confirmed cases over the duration of the outbreak in the three West African countries with widespread transmission, Guinea, Liberia, and Sierra Leone.
Healthcare workers caring for patients with EVD were among those at highest risk for contracting the disease. During the epidemic, Liberia lost 8% of its doctors, nurses, and midwives to EVD. 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.
The epidemic also had a great impact on children. Nearly 20% of all EVD cases occurred in children under 15 years of age, and an estimated 30, children became orphans during this epidemic. As funding and logistics previously dedicated to child vaccination campaigns were redirected to Ebola response or postponed to avoid public gatherings, routine immunizations decreased by 30%, further putting children at risk of getting vaccine-preventable diseases.,
The epidemic has been estimated to cost a total of $ billion USD. Investments in Guinea, Liberia, and Sierra Leone dramatically decreased. Similarly, the countries experienced a substantial loss in private sector growth, decline in agricultural production leading to concerns about food security, and a decrease in cross-border trade as restrictions on movements, goods, and services increased.,,
While the spread of EVD in West Africa has been controlled, additional cases may continue to occur from time to time. However, because of ongoing surveillance and strengthened response capabilities, the affected countries now have the experience and tools to rapidly identify cases and limit the spread of the disease.
CDC no longer recommends that U.S. residents avoid nonessential travel to Guinea, Liberia, or Sierra Leone. Although there is believed to be no risk of EVD to travelers in these countries, travelers should, as usual, avoid contact with sick people, dead bodies, or blood and body fluids.
 Kaner J, Schaak S. Understanding Ebola: the Epidemic [PDF – KB]external icon. Globalization and Health ()
 Bell BP, Damon IK, Jernigan DB et al. Overview, Control Strategies, and Lessons Learned in the CDC Response to the – Ebola Epidemic. Morbidity and Mortality Weekly Report. ;65(3)
 CDC – Division of Global Migration and Quarantine – International Border Team.
 CDC – International Infection Control Team.
 Ebola labs testing in infected African countries.external icon February Accessed January 20,
 David K Evansa, Markus Goldstein, Anna Popova. “Health-care worker mortality and the legacy of the Ebola epidemicexternal icon.” The Lancet Global Health 3 (8): e–e Accessed December 22, doi/SX(15)
 Parpia, A. S., Ndeffo-Mbah, M. L., Wenzel, N. S., & Galvani, A. P. (). Effects of Response to – Ebola Outbreak on Deaths from Malaria, HIV/AIDS, and Tuberculosis, West Africaexternal icon. Emerging Infectious Diseases, 22(3),
 UNDP. “Assessing the socio-economic impacts of Ebola Virus Disease in Guinea, Liberia and Sierra Leone: The Road to Recovery” pdf icon[PDF – MB]external icon Accessed December 22,
 Kaner J, Schaak S. Understanding Ebola: the Epidemic [PDF – KB]external icon. Globalization and Health ()
 Wright S, Hanna L, Malifert M. A wake-up call: lessons from Ebola for the World Health Systems pdf icon[PDF – MB]external icon. Save the children.
 The World Bank. Summary on the Ebola Recovery Plan: Sierra Leoneexternal icon. April Accessed January 20,
 The World Bank. Summary on the Ebola Recovery Plan: Guineaexternal icon. April Accessed January 20,
 The World Bank. Summary on the Ebola Recovery Plan: Liberia – Economic Stabilization and Recovery Plan (ESRP)external icon. April Accessed January 20,
Ebola cases 2015 new
- More than 3, cases, including more than 2, deaths, have been reported to date in the ongoing Ebola outbreak in the Democratic Republic of the Congo (DRC), making it second only to the West Africa outbreak that saw nearly 29, cases and claimed more than 11, lives. The outbreak has lasted a year and a half already, having been first declared by the DRC Ministry of Health on August 1, There are ongoing concerns about cross-border spread outside the DRC.
- Since July , the outbreak has been considered a “public health emergency of international concern” (PHEIC) by WHO.
- Although the DRC has a history of successfully containing Ebola outbreaks and responders have access to new prevention tools such as an Ebola vaccine, multiple factors have impeded the response in the affected areas this time including violence and insecurity, community mistrust of government and external responders, funding constraints, and a complex political and socioeconomic operating environment.
- U.S. engagement has been limited compared to the West Africa outbreak where the U.S. played a leading role and mobilized an unprecedented amount of funding, and personnel. In contrast, the U.S. has chosen to play a more limited role in this outbreak due partly to concerns about security, which have led the U.S. to restrict its personnel from working in the outbreak zone. Even so, the U.S. is the largest single international donor to the Ebola response effort in the DRC.
- The U.S. Agency for International Development (USAID) and the U.S. Centers for Disease Control and Prevention (CDC), along with several other U.S. agencies, have provided technical and financial support to international response efforts in the DRC. A USAID Disaster Assistance Response Team (DART), which includes USAID and CDC staff, has been deployed to the DRC since September
- Policy questions for the U.S. government going forward include whether it will change its approach in order to allow government personnel to engage directly in frontline response activities and how it will support the transition from emergency response to longer-term support for improving health care in the affected areas.
When did the outbreak begin, and what countries are affected?
The current Ebola outbreak was first declared by the DRC Ministry of Health on August 1, (see timeline of key events below). Almost all cases of Ebola in this outbreak so far have occurred in the two northeastern DRC provinces of Ituri and North Kivu, though a few cases have recently been identified in South Kivu province. This outbreak is the tenth – and by far the largest – in the DRC’s history and the second largest Ebola outbreak ever recorded after the West Africa Ebola outbreak in that saw 28, cases, including 11, deaths, in the three most affected countries (Guinea, Liberia, and Sierra Leone).
Cross-border spread remains a concern. Uganda has reported several imported Ebola cases in areas bordering the DRC, with the most recent reported on August 26, WHO says there is a risk of further spread within the DRC and potentially across borders to Burundi, Rwanda, South Sudan, and Uganda, in particular. Several cases over the summer of in the large city of Goma, a regional and international transport hub that directly borders Rwanda, highlighted such concerns. Given the risks, neighboring countries have been preparing for possible cases for some time.
|August 1, Outbreak declared by the DRC Ministry of Health|
|Early August First U.S. CDC staff deployed to North Kivu province to assist in response efforts|
|August , Genetic tests confirm outbreak; vaccination efforts begin|
|August-September U.S. government pulls backstaff from outbreak area due to security concerns|
|September 21, USAID deployed a Disaster Assistance Response Team (DART) to the DRC|
|October 17, WHO-convened Emergency Committee recommends that “public health emergency of international concern” (PHEIC) not be declared with regard to the DRC Ebola outbreak|
|November 9, Ebola case count surpasses largest number from previous DRC outbreaks, making this the largest Ebola outbreak in the DRC’s history|
|Late November Ebola case count surpasses all but the West Africa outbreak, making this the second largest Ebola outbreak ever|
|Late December Voting in the DRC elections postponed in certain Ebola-affected areas, sparking protests|
|February 24, Ebola treatment center attacked and partially burned down, leading Medicins Sans Frontieres (MSF) to suspend services at the center; another center was attacked three days later, leading MSF to suspend its activities in the area|
|March 30, Ebola case count in this DRC outbreak surpasses 1,|
|April 12, WHO-convened Emergency Committee recommends for a second time that a PHEIC not be declared with regard to the DRC Ebola outbreak|
|April 15, The DRC Ministry of Health reports over , people have been vaccinated in this outbreak to date|
|April 19, WHO epidemiologist from Cameroon killed when a clinic was attacked in Butembo in the DRC|
|June 5, Ebola case count in the DRC outbreak surpasses 2,|
|June 11, Uganda confirmed first imported case of Ebola, with two additional cases reported the next day|
|June 14, WHO-convened Emergency Committee recommends for a third time that a PHEIC not be declared with regard to the DRC Ebola outbreak|
|July 14, The DRC government reports first case in Goma, capital of North Kivu province and a large city of million people bordering Rwanda|
|July 17, WHO-convened Emergency Committee meets for a fourth time; WHO Director-General accepts the Committee’s assessment and declares the DRC Ebola outbreak a PHEIC|
|August 16, First Ebola cases confirmed in South Kivu province, the third province to see cases in this outbreak.|
|August 29, Ebola case count in the DRC surpasses 3,; Uganda reports a fourth imported Ebola case|
|October 18, WHO Emergency Committee meets again and says the DRC outbreak remains a PHEIC.|
|November , Merck’s Ebola vaccine (Ervebo) approved by the European Commission and pre-qualified by WHO, making it the first officially licensed vaccine for Ebola.|
|November 14, Second Ebola vaccine (from Johnson & Johnson) is introduced into the Ebola response in eastern DRC, with a planned 50, people to be vaccinated in Goma.|
|November , WHO and other organizations temporarily halt operations and evacuate some staff after armed militia groups kill four people at Ebola response centers and violent protests erupt.|
|NOTES: WHO means World Health Organization. The DRC means the Democratic Republic of the Congo.|
How many cases and deaths have there been in the DRC?
As of December 16, , the DRC Ministry of Health reports the country has had 3, cases (see figure below), of which there were 2, deaths. The number of new cases reported each week has declined noticeably since the end of July , indicating progress has been made in interrupting transmission. Still, cases continue to occur, and recent violence in some Ebola-affected areas has interrupted the response, sparking concerns about this potentially leading to an increase in Ebola cases. Regardless, response activities could be needed for another several months at least, and another increase in transmission remains a concern. The crude case fatality ratio for this outbreak is high, at 66%, as of December 16,
Figure 1: DRC Ebola Outbreak: Cumulative Number of Cases, August – Dec. (to date)
Health care workers (HCWs), such as nurses and doctors, caring for Ebola patients have been at particularly high risk of infection. At least cases (about 5% of total cases) over the course of this outbreak have occurred among HCWs. This Ebola outbreak has also disproportionately affected children, with about 15 percent of all cases occurring among children under 5 and a higher proportion of the child cases dying from the disease compared with older age groups.
What are the key factors driving the outbreak in the DRC?
Multiple issues make responding to this Ebola outbreak more challenging than any prior outbreaks in the DRC. These include:
- ongoing violence from armed groups that is impeding the response efforts, including violence against Ebola responders, amid long-standing conflict;
- mistrust of the DRC government and outsiders, including Ebola responders, in affected communities;
- disbelief in Ebola (studies find that many in the affected areas believe the Ebola outbreak is not real but rather a hoax perpetrated by the government or other outside parties);
- a shortfall in funding for the Ebola response efforts in the DRC, despite increasing calls from the World Health Organization for donors to fill the gap; and
- transitions in theleadership of the DRC government, including transitions in oversight of the Ebola response.
This combination of factors has made responding to this outbreak a much more difficult challenge compared with previous outbreaks in the DRC (see KFF brief).
Role of the U.S.
U.S. engagement in the current outbreak has been limited compared to its role in the West Africa Ebola outbreak response, where the U.S. played a major leadership role, mobilizing an unprecedented amount of funding, other resources, and personnel to support the Ebola response. Since then, there have been improvements in the global capacity to respond to Ebola, particularly on the part of WHO, and the DRC has had significant experience in addressing prior Ebola outbreaks; both WHO and the DRC took the lead early on in the current outbreak (see KFF brief). In addition, insecurity in the affected areas of the DRC has prevented U.S. agencies from being more involved, as U.S. personnel have been mostly restricted from working directly in the hardest hit areas due to safety concerns. However, the U.S. has provided significant funding and technical assistance in the DRC and in neighboring countries, working in conjunction with national governments, United Nations (U.N.) agencies, and other organizations leading the response. In fact, the U.S. is the largest donor to the Ebola response effort in the country, having provided over $ million since August
While the number of Ebola cases in the DRC continues to decline from a peak over the summer, major challenges remain for the U.S. and other responders, such as: completing the task of interrupting transmission even amid ongoing violence, preventing expansion of the outbreak into other geographic areas, and effectively transitioning from an emergency response to a longer-term development effort to help stabilize and build up health systems in the affected areas.
What U.S. agencies are involved in the response?
The U.S. Agency for International Development (USAID) and U.S. Centers for Disease Control and Prevention (CDC) are the two main agencies contributing to the U.S. government response. USAID’s Office of Foreign Disaster Assistance (OFDA) coordinates U.S. emergency response efforts in the DRC, and in September , the agency deployed a Disaster Assistance Response Team (DART) to the DRC in response to the outbreak. USAID’s Bureau for Global Health provides operational and personnel support. Several CDC offices, including the Center for Global Health’s Division of Global Health Protection and the National Center for Emerging and Zoonotic Infectious Diseases’ Division of High-Consequence Pathogens and Pathology (NCEZID/DHCPP), provide technical and personnel support. CDC efforts in the DRC are coordinated through its Emergency Operations Center (EOC) in Atlanta, which was activated in June at its lowest level (level 3).
Other U.S. agencies engaged in Ebola efforts include the National Institutes of Health (NIH) (conducting research on drug and vaccine development, including Ebola treatment trials in the DRC); the U.S. Food and Drug Administration (FDA) (regulating drug and vaccine development); and the Department of State (coordinating the U.S. and international diplomatic response).
Are U.S. government personnel working in the outbreak areas in the DRC?
U.S. personnel have been assisting in the DRC since the outbreak was announced in August , but since late August/early September , no U.S. personnel have been allowed to directly engage in response activities in active transmission areas in northeastern DRC. Citing safety concerns due to ongoing violence there, U.S. officials have decided to keep CDC and other U.S. staff away from the front lines of the response. Outside experts have madecalls for the U.S. to return CDC staff to affected areas to assist more directly. So far though, there is little indication that the U.S. government will deviate from its current policy, though CDC reports working with the U.S. Department of State to “pre-position CDC staff in Goma to rapidly respond to hotspots where the security situation is permissible.”
Outside of the outbreak zone, U.S. personnel continue to assist. The DART – a “team of disaster and health experts” from USAID and CDC – continues its work in the DRC in response to the outbreak. CDC reports 34 staff working the DRC. Other CDC workers have deployed to WHO headquarters and to neighboring countries, such as Uganda, to assist in keeping the virus from crossing borders and to support countries in preparedness and response activities.
How much funding has the U.S. provided?
USAID reports providing about $ million toward the Ebola response in the DRC and surrounding countries since the outbreak began in August Of this amount, $ million is for activities in the DRC, while $14 million is for preparedness and response activities in Burundi, Rwanda, South Sudan, and Uganda. No estimate is available for the amount that CDC has spent on its Ebola response activities, though WHO reports the CDC has provided $ thousand in funding to its efforts. The funding for both USAID and CDC, as well as for other U.S. agencies, in the response is not new funding; rather, it has been drawn from unspent FY emergency Ebola supplemental appropriations provided by Congress at the time of the West Africa Ebola outbreak. For USAID, leftover funding in the International Disaster Assistance (IDA) account that was designated for “assistance for countries affected by, or at risk of being affected by,” Ebola is being utilized for this purpose, and for CDC, leftover funding that was designated for Ebola international preparedness and response is being utilized. CDC’s leftover funding expired at the end of FY on Sept. 30, and, per communication with CDC, was expected to have been entirely spent by that time. In recent months, Congress has statedthat CDC may use existing funds in the Infectious Diseases Rapid Response Reserve Fund, which was established in FY , for CDC Ebola response.
Global Response Activities
Who leads the response to the outbreak?
The DRC government, including the Ministry of Health, and agencies of the U.N. lead the outbreak response. WHO is the lead U.N. agency for the public health response; other key U.N. actors include the U.N. Office for Coordination of Humanitarian Affairs (OCHA), the U.N. Children’s Fund (UNICEF), the World Food Programme (WFP), and MONUSCO, a multinational peacekeeping force that has been assisting with security. U.N. actors are led by a U.N. Emergency Ebola Response Coordinator.
Other key actors in and supporters of the response include governments of various countries, including the U.S.; multilateral organizations, such as the World Bank and Gavi; international and national non-governmental organizations (NGOs), such as Medicins Sans Frontieres (MSF), International Medical Corps, the Alliance for International Medical Action (ALIMA), and the International Red Cross/Red Crescent; and other partners.
What is the plan for ending the outbreak in the DRC?
Current public health response efforts in the DRC are focused on interrupting chains of Ebola transmission through identifying, isolating, and caring for cases before they transmit the disease further. The goal of the response is to bring the number of cases down “to zero”. Ebola outbreaks are usually declared to be over after 42 days have passed since the last known case (equal to two incubation periods of Ebola virus disease). A national Strategic Response Plan outlines the overall strategy, objectives, and priority activities for responding to the outbreak. There have been four iterations of the plan to date, each covering a specific period of time. The current plan that focuses on the core public health “pillar” of the response covers planned activities from July through the end of December It addresses strengthening response capacities in priority areas such as: coordination, surveillance and laboratory capabilities, infection prevention and control measures, vaccination, human resources, security, and risk communication among others. Complementary humanitarian response activities are another “pillar” of the response and outlined in a broader integrated Ebola response strategy, which includes efforts addressing food assistance, employment, and economic development in Ebola-affected regions.
Has the outbreak been declared a global emergency?
On July 17, , the WHO Director-General accepted the recommendation of the Emergency Committee and declared the DRC Ebola outbreak to be a “public health emergency of international concern” (PHEIC). A PHEIC is “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response.” In its declaration, WHO released a set of recommend actions for affected countries, neighboring countries, and all states. This was the fourth time the Emergency Committee had met to discuss a potential PHEIC declaration for Ebola in the DRC; each of the prior three times the Committee recommended not to do so.
At its most recent meeting, on October 17, , the WHO Emergency Committee again recommended that the PHEIC declaration remain in place.
What has been the role of vaccination in the current outbreak?
Vaccination has been an important component of the response since it began. This outbreak marks the first time that an effective vaccine is available and being used as a core component of an Ebola response. Authorities have mostly used a “ring vaccination” approach, targeting vaccination of those who have been in contact with a case of Ebola and the contacts of those contacts, as well as other groups at potential risk of exposure such as health care workers. As of December 8, , over , people have been vaccinated in the DRC since the start of the outbreak, which has likely prevented hundreds, if not thousands, of Ebola cases already. Authorities have been primarily using a vaccine manufactured by Merck, which the company has provided free of charge to WHO and the DRC for the purposes of the response. The Merck vaccine, which was being deployed on an emergency use basis under a “compassionate use” protocol, received approval from European regulators and prequalification from WHO in November , making it the first officially licensed Ebola vaccine. It is not yet approved and licensed by the FDA (though it is under review and an FDA regulatory decision is expected in early ). Costs for vaccine distribution and management of vaccinations in the response are shared among Gavi, WHO, other donors, and the DRC government.
In addition to the vaccination efforts in the DRC, neighboring countries are also vaccinating certain people, such as health workers, in areas at risk of seeing or that have seen Ebola cases due to cross-border spread (like Uganda, with at least 5, people vaccinated thus far).
A second Ebola vaccine, manufactured by Johnson & Johnson, is also available. Following recommendations from WHO and other expert groups, the DRC government decided to introduce the second vaccine into some at-risk areas of the country that do not have active Ebola transmission. For example, DRC authorities began vaccinating 50, people in Goma with the second vaccine in November , and in December , the DRC and neighboring Rwanda initiated a new vaccination campaign using that vaccine to protect people in at-risk areas on their mutual border.
Is there an adequate supply of vaccine?
It appears there are enough doses of the Merck vaccine to meet the demands of the current WHO/DRC government’s ring vaccination approach. Currently there are enough vaccine doses to vaccinate , people, which is greater than the total number of people vaccinated in the outbreak over the first 17 months of the response. In addition, WHO reports that Merck will produce enough vaccine over the next 6 to 18 months to vaccinate an additional million people. Gavi announced in December that it will support a new global stockpile of , doses of Ebola vaccine, to be made available for emergency use as needed.
There is reportedly an adequate supply of the second (Johnson & Johnson) Ebola vaccine, with enough to vaccinate approximately 2 million people.
Are treatments available for those infected with Ebola?
There are no FDA- or other approved treatments for Ebola, though several promising treatments are under development. Four experimental treatments have been studied in a clinical trial among Ebola patients in the DRC, and in August, the U.S. NIH announced that initial results of the trial indicated two of those treatments (the monoclonal antibody mAb and the multi-antibody “cocktail” REGN-EB3) showed the most promise. Ebola patients in the DRC enrolled in the trials are offered these two treatments as investigators further evaluate them. The treatments are still under investigation and being offered on a “compassionate use” basis only in the DRC.
What has the response cost, and how much funding has been provided?
From August through early December the amount of funding directed to response activities in the DRC included under four iterations of a national Strategic Response Plan has reached $ million. This amount does not include additional DRC outbreak activities not captured under the plans, nor response costs in Uganda and preparedness costs in neighboring countries.
Funding amounts provided under each of the plans so far:
- August – October DRC government data show that the first plan was fully funded, with $ million made available to meet the $ million requested for the August to October period the plan covered.
- November – January U.N. data shows that the second plan was fully funded, with donors (largely the World Bank) providing $ million (including some funds leftover from the first phase of the response) of the $ million requested to cover the period through January
- February – July U.N. data shows the third plan has received $ million from February through July , of the $ million requested to cover the period through July This includes $40 million from the World Bank, with more promised, and $ million from USAID.
- July – December WHO data shows the current plan has received at least $ million from August through early December , of the $ million requested for the public health pillar of the response through December (U.N. data tracking donor funding toward the current plan is not yet available, but WHO is reporting the funding it has received under the plan). The plan has substantially higher funding needs than prior iterations. The broader response strategy, which includes the funding requirements of the public health pillar within its funding assessment, is requesting more than $ million for the broader DRC response through December; some donors, including the World Bank, United Kingdom, and the European Union, have already announced they will be providing additional funding for the response.
As mentioned earlier, USAID reports providing about $ million toward the Ebola response in the DRC and about $14 million for activities in neighboring countries since the outbreak began in August (this includes funding channeled through the DRC national plans as well as funding not captured under the plans). No estimate is available for the amount that CDC has spent on its Ebola response activities, though WHO reports the CDC has provided $ thousand in funding to its efforts. All U.S. funding for the current outbreak is drawn from existing funding sources (i.e., no new funding has been appropriated to agencies by Congress for this Ebola response, thus far).
See the KFF data note on donor funding for the response for further information.
Key Issues Going Forward
Now well into its second year, the Ebola outbreak in the DRC remains challenging for responders, despite having important tools (such as vaccines and new treatment options) on hand. This is because the underlying factors driving transmission of Ebola in the DRC remain. The security situation shows no sign of abating, and there is a fear that it can always worsen. Mistrust of public health authorities also remains a barrier to response efforts. While it is not possible to predict the trajectory of the outbreak, it could take at least a few more months to fully contain even under good circumstances, so given the complex set of challenges being faced, the outbreak could take even longer than that to be brought under control.
Addressing these longstanding challenges more effectively is the aim of the broader integrated response strategy being implemented in the DRC. This strategy, which includes the public health pillar’s current national plan and is designed to guide the response through the end of December , calls for greater community engagement, support for health and development interventions beyond addressing Ebola alone, a new approach to security, and more coordination among all responders.
Finally, the major questions for the U.S. government going forward include: whether or not it will change its approach and engagement in the DRC to allow U.S. government personnel to directly engage in public health activities on the frontlines of the response, how the U.S. will contribute to finally breaking all chains of transmission, and how the U.S. will support efforts to transition from an emergency response to a longer-term strategy for supporting the health care system in the affected areas to help prevent and contain any future recurrences of Ebola or other outbreaks.
WHO reports 3 new Ebola cases—all in Guinea
The number of newly confirmed Ebola infections in West Africa's outbreak region stayed at three last week for the third straight week, with Guinea the only country to report new cases, the World Health Organization (WHO) said today in its weekly snapshot of the epidemic.
Earlier this week, the WHO announced that Sierra Leone had gone a full week without reporting a new case, the first time since the outbreak began last year. However, in reporting further progress against the virus, the WHO also warned of a significant risk of transmission, because some contacts have been lost to follow-up in Guinea and in Freetown, Sierra Leone's capital.
In a related development, the WHO recently announced that a committee set up to review how the International Health Regulations (IHRs) performed during the Ebola outbreak will meet for the first time on Aug
All 3 cases among contacts
All of Guinea's three Ebola cases were among registered contacts, and the patients are all receiving care in Ebola treatment centers, according to the WHO. The high percentage of detections in known contacts is an encouraging sign that surveillance activities have identified ongoing transmission chains.
Two of the patients are from Conakry's Matam area and relatives of a single case-patient reported from the capital's Ratoma area the previous week. The country's only other case was in Forecariah district, which had been a hot spot over the past several months.
Between Guinea and Sierra Leone there are about contacts still under monitoring, about half the number of the week before. They are limited to three districts in Guinea and three in Sierra Leone. The WHO warned, though, that having a large number of people under observation still poses a risk of further transmission.
Liberia's last two Ebola patients were discharged on Jul 23 after testing negative twice, the WHO said. If the country goes until Aug 28 without another detection, it will reach Ebola-free status for the second time, Tolbert Nyenswah, who heads Liberia's incident management system, told Liberia News Agency (LINA) yesterday.
For the third straight week, no new Ebola illnesses were reported in healthcare workers, keeping the total at , including deaths.
Over the course of the outbreak, the three countries have reported 27, confirmed, probable, and suspected Ebola infections, including 11, fatalities.
Ebola IHR committee to meet
At its meeting in May the World Health Assembly asked for a committee to assess the effectiveness of the IHRs during the Ebola response. The member group will also look at links to the WHO's emergency response framework and other humanitarian responsibilities. In , a similar committee reviewed IHR performance during the H1N1 pandemic.
The IHRs have faced criticism in other reviews of the Ebola response. For example, an independent review committee appointed by the WHO found that many countries haven't met their IHR core capacities, which likely contributed to the spread of the virus and the slow response to the epidemic. Other observers have noted that the IHRs in their current form didn't prevent countries from imposing travel and trade restrictions, which were also thought to have impeded the response to the crisis.
In a recent announcement, the WHO said the committee will meet on Aug 24 and Aug 25 in Geneva and that the committee chair will hold a press conference on Aug 25 at the conclusion of the event.
Aug 19 WHO situation update
Aug 18 LINA story
WHO Ebola IHR review committee announcement
WHO Ebola IHR review committee background
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Epidemiological update: Outbreak of Ebola virus disease in West Africa, 15 January
Since the last epidemiological update on Ebola virus disease (EVD) published on 9 January , and as of 12 January , WHO has reported additional cases in the affected countries and additional deaths.
Since the last epidemiological update on Ebola virus disease (EVD) published on 9 January , and as of 12 January , WHO has reported additional cases in the affected countries and additional deaths. As of 12 January , WHO has reported 21 confirmed, probable, and suspected cases of Ebola virus disease (EVD), with 8 deaths, in four affected countries (Guinea, Liberia, Mali and Sierra Leone) and four previously affected countries (Nigeria, Senegal, Spain and the United States of America).
According to WHO, in week two of Guinea reported its lowest weekly number of new confirmed EVD cases since mid-August Case numbers remain low in Liberia, showing the lowest weekly number of confirmed cases since the first week of June Sierra Leone has now reported a decline in case incidence for the second week running, and recorded its lowest weekly number of new confirmed cases since the end of August
On 29 December , Scotland reported the first imported case of EVD to the UK that was not a medical evacuation. According to WHO, all possible contacts of the case have been investigated and no high risk contacts have been identified.
According to WHO, Mali will be declared Ebola free on 18 January
WHO Ebola Situation report, 14 January
Ebola data and statistics, Situation summary, Data published on 15 January
Distribution of cases
Countries with widespread and intense transmission:
- Guinea: 2 cases and 1 deaths (as of 12 January )
- Liberia: 8 cases and 3 deaths (as of 12 January )
- Sierra Leone: 10 cases and 3 deaths (as of 12 January )
Countries with an initial case or cases, or with localised transmission:
- United Kingdom: one confirmed case on 29 December
- United States: four cases including one death. The last case tested negative on 11 November in New York.
- Mali: eight cases, six deaths. According to WHO, Mali will be declared Ebola free on 18 January
- Nigeria, Senegal and Spain have been declared free of EVD after having cases related to the current epidemic in West Africa
Figure 1 . Distribution of cases of EVD by week of reporting in Guinea, Sierra Leone, Liberia, Nigeria, Senegal and Mali, weeks 48/ to 03/, as of 12 January
* In week 45/, the WHO carried-out a retrospective correction in the data resulting in reporting fewer cases resulting in a negative value for new cases in week 45 which is not plotted. . ** According to the WHO the marked increase in the cumulative total number of cases in week 43 is due to a more comprehensive assessment of patient databases leading to 3 additional reported cases. However, these cases have occurred throughout the epidemic period.
The green line represents the trend based on a five week moving average plotted on the fifth week of the moving average window. The figure includes cases in Nigeria (20), Senegal (1) and Mali (4). (See WHO Ebola response roadmap: Situation report, 26 November )
Situation in the affected West African countries
Quoting the latest WHO Ebola Situation Report, each of the intense-transmission countries has sufficient capacity to isolate and treat patients, with more than two treatment beds per reported confirmed and probable case. However, the uneven geographical distribution of beds and cases, and the under-reporting of cases, means that not all EVD cases are isolated in several areas.
Between 84 and 99% of registered contacts are being monitored in the three countries with intense transmission, though the number of contacts traced per EVD case remains lower than expected in many districts.
The cumulative case-fatality rate in the three intense-transmission countries among hospitalized patients is between 57 and 60%.
According to WHO, Mali will be declared Ebola-free on 18 January The last confirmed case in Mali tested negative for the second time on 6 December All identified contacts connected with both the initial case in Kayes and the outbreak in Bamako have completed the day follow-up period.
Figure 2. Distribution of cases of EVD by week of reporting, Guinea, Liberia and Sierra Leone, as of week 03/
* The marked increase in the number of cases reported in Sierra Leone (week 44) and Liberia (week 43) results from a more comprehensive assessment of patient databases. The additional 3 cases have occurred throughout the epidemic period.Source: Data are based on official information reported by ministries of health up to the end of 2 November for Guinea and Sierra Leone and 31 October for Liberia. (See WHO Ebola response roadmap: Situation report, 5 November )
** In week 45/, WHO reported fewer cases than the week before in Sierra Leone due to retrospective corrections. § In week 44/, WHO reported zero cases for Liberia.
Figure 3. Distribution of cases of EVD by week of reporting in Guinea, Sierra Leone, Liberia and Mali (as of week 02/).
Source: Data from ministries of health reports (suspected, probable and confirmed cases).
Situation among healthcare workers
Up to the end of 11 January , healthcare workers (HCWs) are known to have been infected with EVD, of whom have died. Distribution of cases: HCWs in Guinea, HCWs in Liberia, HCWs in Sierra Leone, two HCWs in Mali, 11 HCWs infected in Nigeria, one HCW infected in Spain while treating an EVD-positive patient, one HCW in the UK who became infected in Sierra Leone, and three HCWs in the USA (one HCW infected in Guinea, and two HCWs infected during the care of a patient in Texas).
Table 1. Number of Ebola cases and deaths among healthcare workers, as of 11 January
|Country||Healthcare worker cases (% of reported cases)||Healthcare worker deaths (% of reported deaths)|
|Mali||2 ()||2 ()|
|Nigeria||11 ()||5 ()|
|United States||3 ()||0|
Source: Data are based on official information reported by Ministries of Health. (See WHO Ebola Situation report, 14 January )
Situation outside West Africa
One case was reported in Scotland in a patient who travelled from Sierra Leone via Casablanca and London and arrived in Glasgow late on 28 December
Public Health England (PHE) has completed contact tracing following the confirmed case of Ebola in a healthcare worker returning from Sierra Leone. People contacted by Public Health England were made aware that a person on their flight was confirmed with Ebola after they returned to the UK, although the person would have been in the very early stages of disease and extremely unlikely to be infectious. The people sitting directly in the vicinity of the passenger (two rows adjacent, ahead and behind) were advised to take their temperature twice daily until 18 January If their temperature is °C or higher, or they begin to feel unwell in any way, they are advised to call a dedicated Public Health England contact immediately for advice.
No high-risk contacts have been identified in connection with the EVD case in the United Kingdom.
This is the largest ever documented epidemic of EVD in terms of numbers and geographical spread. The evolving epidemic of EVD increases the likelihood that EU residents and travellers to the EVD-affected countries will be exposed to infected or ill persons. The risk of infection for residents and visitors in the affected countries through exposure in the community is considered low if they adhere to the recommended precautions. Residents and visitors to the affected areas run a risk of exposure to EVD in healthcare facilities. The level of this risk is related to how well the infection control measures are being implemented in these settings and the nature of the care required. As the epidemic is still evolving and international staff are deployed to the affected countries to support the epidemic control, there remains a risk of importation of EVD cases to the EU. The risk of Ebola virus spreading from an EVD patient who arrives in the EU as result of a planned medical evacuation is considered to be low when appropriate measures are strictly adhered to, but cannot be excluded in exceptional circumstances. If a symptomatic case of EVD presents in an EU Member State, secondary transmission to caregivers in the family and in healthcare facilities cannot be excluded. The highest risk is at an early stage of the disease, before the risk of EVD has been recognised and at the late stage of the disease when patients have very high viral loads and undergo invasive therapeutic procedures.
Download the data:
• Epi-curve data
Cumulative number of cases and deaths for the West African countries with reported EVD cases. Source: WHO
• Map data
Cumulative number of cases and deaths at subnational level in the West African countries with reported EVD cases. Source: National situation report.
For those weeks without reported data, the most recent figures were used as best estimate of the number of case.
Page last updated: 16 Jun