Western African Ebola virus epidemic

Situation map of the outbreak, including medically evacuated cases click to enlarge
Date	December 2013 – present[1]
Casualties
Reported Cases / Deaths (as of 1 October 2014[update])[2]  Total: 7,493 / 3,439 Liberia: 3,834 / 2,069[2] Sierra Leone: 2,437 / 623[2] Guinea: 1,199 / 739[2] Nigeria: 20 / 8[2] Senegal: 1 / 0[2] United States: 1 / 0[2] Spain: 1 / 0 (as of 6 October 2014[update])[3] See notes for 1 October on Timeline Section

An epidemic of Ebola virus disease (EVD) is ongoing in West Africa. The epidemic began in Guinea in December 2013^[4] then spread to Liberia, Sierra Leone, Nigeria, Senegal, United States^[5] and Spain.^[3] As of 1 October 2014^[update], the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (CDC) and local governments reported a total of 7,493 suspected cases and 3,439 deaths (4,108 cases and 2,078 deaths having been laboratory confirmed),^[2] though many experts believe that this substantially understates the magnitude of the outbreak.^[6]

The current epidemic of EVD, caused by Ebola virus, is the most severe outbreak of Ebola since the discovery of ebolaviruses in 1976,^[7] and by September 2014 cases of EVD from this single outbreak exceeded the sum of all previously identified cases.^[8] The epidemic has caused significant mortality with a Case Fatality Rate (CFR) reported as 70%.^[9]

Affected countries have encountered many difficulties in their control efforts. The WHO has estimated that region's capacity for treating EVD is insufficient by the equivalent of 2,122 beds.^[10]. In some areas, people have become suspicious of both the government and hospitals; some hospitals have been attacked by angry protestors who believe that the disease is a hoax or that the hospitals are responsible for the disease. Many of the areas that are seriously affected with the outbreak are areas of extreme poverty with limited access to soap or running water to help control the spread of disease.^[11] Other factors include belief in traditional folk remedies, and cultural practices that involve physical contact with the deceased, especially death customs such as washing the body of the deceased.^[12][13][14] Some hospitals lack basic supplies and are understaffed. This has increased the chance of staff catching the virus themselves. In August, the WHO reported that ten percent of the dead have been health care workers.^[15]

By the end of August, the WHO reported that the loss of so many health workers was making it difficult for them to provide sufficient numbers of foreign medical staff.^[16] By September 2014, Médecins Sans Frontières, the largest NGO working in the affected regions, had grown increasingly critical of the international response. Speaking on 3 September, the international president spoke out concerning the lack of assistance from the United Nations member countries saying, "Six months into the worst Ebola epidemic in history, the world is losing the battle to contain it."^[17] A United Nations spokesperson stated "they could stop the Ebola outbreak in West Africa in 6 to 9 months, but only if a 'massive' global response is implemented."^[18] The Director-General of the WHO, Margaret Chan, called the outbreak "the largest, most complex and most severe we've ever seen" and said that it "is racing ahead of control efforts".^[18] In a 26 September statement, the WHO said, "The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long."^[19]

Epidemiology

Outbreak

Researchers believe that a 2-year-old boy was the index case of the current Ebola virus disease epidemic. He died on 6 December 2013 in the village of Meliandou, Guéckédou Prefecture, Guinea. His mother, sister, and grandmother then became ill with similar symptoms and also died. People infected by those victims spread the disease to other villages. Although Ebola represents a major public health issue in sub-Saharan Africa, no cases had ever been reported in West Africa and the early cases were diagnosed as diseases more common to the area. Thus, the disease had several months to spread before it was recognized as Ebola.^[1][20][21]

On 19 March, the Guinean Ministry of Health acknowledged a local outbreak of an undetermined viral hemorrhagic fever that had sickened at least 35 people and killed 23. "We thought it was Lassa fever or another form of cholera but this disease seems to strike like lightning. We are looking at all possibilities, including Ebola, because bushmeat is consumed in that region and Guinea is in the Ebola belt."^[22] On 25 March, the World Health Organization (WHO) reported that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts, with suspected cases in the neighbouring countries of Liberia and Sierra Leone being investigated. In Guinea, a total of 86 suspected cases, including 59 deaths (case fatality ratio: 68.5%), had been reported as of 24 March.^[23]

On 31 March, the U.S. Centers for Disease Control and Prevention (CDC) sent a five-person team to assist Guinea's Ministry of Health and the WHO to lead an international response to the Ebola outbreak. On that date, the WHO reported 112 suspected and confirmed cases including 70 deaths. Two cases were reported from Liberia of people who had recently traveled to Guinea, and suspected cases in Liberia and Sierra Leone were being investigated.^[23] On 30 April, Guinea's Ministry of Health reported 221 suspected and confirmed cases including 146 deaths. The cases included 25 health care workers with 16 deaths. By late May, the outbreak had spread to Conakry, Guinea's capital, a city of about two million inhabitants.^[23] On 28 May, the total cases reported had reached 281 with 186 deaths.^[23]

In Liberia, the disease was reported in Lofa and Nimba counties in late March.^[25] The Ministry of Health and Social Welfare recorded possible cases in Margibi and Montserrado counties in mid-April.^[26] The first cases in Liberia's capital Monrovia were reported in mid-June.^[27][28][29]

The outbreak then spread into Sierra Leone and rapidly progressed. A study of the virus genomes determined that twelve Sierra Leone residents, when attending a funeral in Guinea, became infected. They then carried the virus back home.^[30] On 25 May, the first cases in the Kailahun District, near the border with Guéckédou in Guinea, were reported.^[31] By 20 June, there were 158 suspected cases, mainly in Kailahun and the adjacent district of Kenema. Others were reported in the Kambia, Port Loko, and Western districts in the northwest of the country.^[32] By 17 July, the total number of suspected cases in the country stood at 442, and had overtaken those in Guinea and Liberia.^[33] By 20 July, cases of the disease had additionally been reported in the Bo District.^[34] The first case in Freetown, Sierra Leone's capital, was reported in late July.^[35][36]

The first death in Nigeria was reported on 25 July.^[37] A Liberian-American with Ebola flew from Liberia to Nigeria and died in Lagos soon after arrival.^[38] As part of the containment efforts, 353 possible contacts were monitored in Lagos and 451 in Port Harcourt.^[39] As of 22 September, the WHO reported a total of 20 cases with 8 deaths. They continue to monitor a few contacts, but the disease appears to now be contained in Nigeria.^[40]

On 29 August, the Senegalese Health minister Awa Marie Coll Seck announced the first case in Senegal. This was subsequently identified as a Guinean national who had been exposed to the virus and had been under surveillance, but had travelled to Dakar by road and fallen ill after arriving.^[41][42][43] This case subsequently recovered and on 22 September the WHO announced that all contacts had completed a 21-day follow-up with no further cases of Ebola in Senegal.^{[39] [44]}

Countries with widespread transmission

Guinea

On 25 March, the World Health Organization (WHO) reported that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts. In Guinea, a total of 86 suspected cases, including 59 deaths (case fatality ratio: 68.5%), had been reported as of 24 March.^[23] On 31 March, the U.S. Centers for Disease Control and Prevention (CDC) sent a five-person team to assist Guinea's Ministry of Health and the WHO to lead an international response to the Ebola outbreak.^[23]

Thinking that the virus was contained, Médecins Sans Frontières closed its treatment centers in May leaving only a small skeleton staff to handle the Macenta region. However, high numbers of new cases reappeared in the region in late August. According to Marc Poncin, a coordinator for MSF, the new cases were related to persons returning to Guinea from neighbouring Liberia or Sierra Leone.^[45]

On 18 September, it was reported that the bodies of a team of Guinean health and government officials, accompanied by journalists, who had been distributing Ebola information and doing disinfection work were found in a latrine in the town of Womey near Nzérékoré.^[46] The workers had been murdered by residents of the village after they initially went missing after a riot against the presence of the health education team. Government officials said "the bodies showed signs of being attacked with machetes and clubs" and "three of them had their throats slit."^[47]

It has been reported that some people in this area believe that health workers have been purposely spreading the disease to the people, while others believe that the disease does not exist. Riots recently broke out in the regional capital, Nzérékoré, when rumors were spread that people were being contaminated when health workers were spraying a market area to decontaminate it.^[48]

WHO estimated on 21 September that Guinea's capacity to treat EVD cases falls short by the equivalent of 40 beds.^[10]

Liberia

In Liberia, the disease was reported in Lofa and Nimba counties in late March.^[25] By 23 July, the health ministry implemented measures to improve the country's response.^[49] On 27 July, Ellen Johnson Sirleaf, the Liberian president, announced that Liberia would close its borders, with the exception of a few crossing points, such as the airport, where screening centres would be established, and the worst-affected areas in the country would be placed under quarantine.^[50] Football events were banned, because large gatherings and the nature of the sport increase transmission risks.^[51] Three days after the borders were closed, Sirleaf announced the closure of all schools nationwide, including the University of Liberia,^[52] and a few communities were to be quarantined.^[53]

Sirleaf declared a state of emergency on 6 August, partly because the disease's weakening of the health care system has the potential to reduce the system's ability to treat routine diseases such as malaria; she noted that the state of emergency might require the "suspensions of certain rights and privileges".^[54] On the same day, the National Elections Commission announced that it would be unable to conduct the scheduled October 2014 senatorial election and requested postponement,^[55] one week after the leaders of various opposition parties had publicly taken different sides on the question.^[56] On 30 August, Liberia's Port Authority cancelled all "shore passes" for sailors from ships coming into the country's four seaports.^[57]

On 20 September, Liberia opened a new 150 bed treatment unit clinic in Monrovia. At the opening ceremony of the Old Island Clinic on Bushrod Island six ambulances were already waiting with potential patients. More patients were waiting by the clinic after making their way on foot with the help of relatives.^[58] Two days later 112 beds were already filled with 46 patients testing positive for Ebola, while the rest were admitted for observation.^[59]

As of 8 September, Ebola had been identified in 14 of Liberia's 15 counties.^[60] WHO estimated on 21 September that Liberia's capacity to treat EVD cases falls short by the equivalent of 1,550 beds.^[10]

On 25 September Liberia's chief medical official went on a self enforced quarantine after she was potentially exposed to the Ebola virus.^[61] By the 29th of September 2014, it was announced she tested negative for Ebola, but government officials praised her for following the self quarantine rules.^[62]

Sierra Leone

The first person reported infected in the spread to Sierra Leone was a tribal healer. She had treated one or more infected people and 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 neighboring towns.^[63] On 31 March, Sierra Leone declared a state of emergency and instituted measures to screen travelers from Guinea and Liberia.^[64] On 30 July, the government began to deploy troops to implement quarantines.^[65]

On 29 July, well-known physician Sheik Umar Khan, Sierra Leone's only expert on hemorrhagic fever, died after contacting Ebola at his clinic in Kenema. Khan had long worked with Lassa fever, a disease that kills over 5,000 a year in Africa. He had expanded his clinic to accept Ebola patients. Sierra Leone's President, Ernest Bai Koroma, celebrated Khan as a "national hero".^[63]

In August, awareness campaigns in Freetown, Sierra Leone's capital, were delivered over the radio and through loudspeakers.^[66] Also in August, Sierra Leone passed a law that subjected anyone hiding someone believed to be infected to two years in jail. At the time the law was enacted, a top parliamentarian was critical of failures by neighboring countries to stop the outbreak.^[67]

In an attempt to control the disease, Sierra Leone imposed a three-day lockdown on its population from 19 to 21 September. During this period 28,500 trained community workers and volunteers went door-to-door providing information on how to prevent infection, as well as setting up community Ebola surveillance teams.^[68] On 22 September, government officials said that the three day lock down had obtained its objective and would not be extended. Eighty percent of targeted households were reached in the operation. A total of around 150 new cases were uncovered, although reports from remote locations had not yet been received.^[69]

On 25 September, the government added three more districts under "isolation," in an effort to contain the spread. The districts include Port Loko, Bombali, and Moyamba. This brings the total areas under isolation to five, including the outbreak "hot spots" Kenema and Kailahun which were already in isolation. Only deliveries and essential services were to be allowed in and out. A sharp rise in cases in these areas was noted by the WHO.^[70]

WHO estimated on 21 September that Sierra Leone's capacity to treat EVD cases falls short by the equivalent of 532 beds.^[10] There have been reports that political interference and administrative incompetence have hindered the flow of medical supplies into the country.^[71] On Oct. 4, Sierra Leone recorded 121 fatalities,^[72] the most in a single day.

Countries with local transmission

Nigeria

Nigeria Ebola areas – 2014

Nigeria Situation Map as of 5 September 2014[update][73]
Date	July 2014 – present[74]
Casualties
Cases / Deaths (as of 21 September 2014[update])  Nigeria: 20 / 8[75]

The first case in Nigeria was a Liberian-American, Patrick Sawyer, who flew from Liberia to Nigeria's former capital Lagos on 20 July. Sawyer became violently ill upon arriving at the airport and died five days later. In response, the Nigerian government observed all of Sawyer's contacts for signs of infection and increased surveillance at all entry points to the country.^[76] On 6 August, the Nigerian health minister told reporters, "Yesterday the first known Nigerian to die of Ebola was recorded. This was one of the nurses that attended to the Liberian. The other five [newly confirmed] cases are being treated at an isolation ward."^[77]

On 9 August, the Nigerian National Health Research Ethics Committee issued a statement waiving the regular administrative requirements that limit the international shipment of any biological samples out of Nigeria^[78] and supporting the use of non-validated treatments without prior review and approval by a health research ethics committee.^[78] Other than increased surveillance at the country’s borders, the Nigerian government states that they have also made attempts to control the spread of disease through an improvement in tracking, providing education to avert disinformation and increase accurate information, and the teaching of appropriate hygiene measures.^[73]

On 19 August, it was reported that the doctor who treated Sawyer, Ameyo Adadevoh, had also died of Ebola disease. Adadevoh was posthumously praised for preventing the index case (Sawyer) from leaving the hospital at the time of diagnosis, thereby playing a key role in curbing the spread of the virus in Nigeria.^[79][80]

On 19 August, the Commissioner of Health in Lagos announced that Nigeria had seen twelve confirmed cases; four died (including the index case) while another five, including two doctors and a nurse, were declared disease-free and released.^[73][81] On 22 September, the Nigeria health ministry announced "As of today, there is no case of Ebola in Nigeria. All listed contacts who were under surveillance have been followed up for 21 days."^[82][83] The WHO stated that Nigeria had not reported any new cases since 8 September and if no further cases are reported, Nigeria will be declared Ebola-free on 20 October.^[44]

Spain

On 5 August 2014, the Brothers Hospitallers of St. John of God confirmed that Brother Miguel Pajares, who had been volunteering in Liberia, had become infected. He was evacuated to Spain on 6 August 2014, and subsequently died on 12 August.^[84] On 21 September it was announced that Brother Manuel García Viejo, another Spanish citizen who was medical director at the San Juan de Dios Hospital in Lunsar, had been evacuated to Spain from Sierra Leone after being infected with the virus. His death was announced on 25 September.^[85] Both of these cases were treated at the Hospital Carlos III in Madrid.^[86]

In October 2014, a nurse who had cared for these patients at the Hospital Carlos III became unwell and on 6 October tested positive for Ebola.^[87] A second test confirmed the diagnosis,^[88] making this the first confirmed case of Ebola transmission outside Africa. There are currently 50 contacts being monitored.^[89]

Countries with an initial case or cases

Senegal

In March, the Senegal Ministry of Interior closed the southern border with Guinea,^[90] but on 29 August the Senegal health minister announced Senegal's first case, a university student from Guinea who was being treated in Dakar.^[42][43] The WHO was informed on 30 August.^[91][92] According to the WHO, the case was a native of Guinea who had traveled by road to Dakar, arriving on 20 August. On 23 August, he sought medical care for symptoms including fever, diarrhoea, and vomiting. He received treatment for malaria, but did not improve and left the facility. Still experiencing the same symptoms, on 26 August he was referred to a specialized facility for infectious diseases, and was subsequently hospitalized.^[92]

On 27 August, authorities in Guinea issued an alert informing medical services in Guinea and neighbouring countries that a person who had been in close contact with an Ebola infected patient had escaped their surveillance system. The alert prompted testing for Ebola at the Dakar laboratory, and the positive result launched an investigation and triggered urgent contact tracing.^[92] On 10 September, it was reported that the student had recovered but health officials would continue to monitor his contacts for 21 days.^[93] On 22 September, the WHO announced that all contacts had completed the 21-day follow-up with no further cases of Ebola in Senegal, however they require a 42 day waiting period before a country can be called disease-free.^[44]

United States

On 30 September, the United States Centers for Disease Control and Prevention (CDC) declared its first case of Ebola disease. A CDC spokesperson said, "The patient is a man who became infected in Liberia and traveled to Texas, where he was hospitalized with symptoms that were confirmed to be caused by Ebola."^[94] The patient arrived in Dallas on 20 September. Four days later he fell ill and sought medical treatment on 26 September. Despite telling a nurse that he had arrived in the US from West Africa, he was sent home with antibiotics. The hospital later blamed a flaw in their health records system for releasing the man.^[95] He returned to the hospital by ambulance on 28 September and was placed in isolation.^{[96][97][96][98]} The patient is currently in critical condition.^[99] The third American aid worker who contracted Ebola in West Africa was released on 25 September from a Nebraska hospital.

On 1 October, the Director of Dallas County's health department confirmed that a second person is being closely monitored for Ebola. More contacts of the infected patient are under watch and will be monitored for 21 days and placed in isolation if necessary.^[100] Four relatives of the patient were placed legally under strict quarantine. Texas health officials have ordered them to stay at home and be available to undergo regular testing until 19 October, the end of the 21-day incubation period.^[101]

Countries with medically evacuated cases

A number of healthcare workers who had become infected with Ebola virus disease have been medically evacuated to treatment in isolation wards in their country of origin.

France

A French volunteer health worker, working for MSF in Liberia, contracted EVD and was flown to France on 18 September. After successful treatment at a military hospital near Paris, she was discharged on 4 October.^[102]

Germany

Germany set up an isolation ward to care for six patients at the University Medical Center Hamburg-Eppendorf. On 27 August, a Senegalese epidemiologist working for the WHO in Sierra Leone became the first patient. On 4 October he was discharged after successful treatment.^[103]

The WHO requested that a Ugandan doctor working in Sierra Leone, who contracted the disease, be treated in Germany. The request was granted by Germany and he was flown to the country on 3 October. The patient is being treated in an isolation unit at the University Hospital in Frankfurt. The doctor was working for an Italian NGO in Sierra Leone according to Stefan Gruettner, the State Health Minister of Hessen.^[104]

Norway

On 6 October, MSF announced that one of their workers, a Norwegian national, had become infected in Sierra Leone. It is understood that she will receive treatment in special facilities at Oslo University Hospital.^[105]

Switzerland

On Monday 22 September a Swiss health worker was flown by a private airline to Geneva. The nurse was bitten by an Ebola-infected child on Saturday, 20 September in Sierra Leone. The unidentified male nurse will remain in isolation for 21 days at Geneva's University Hospital. The health ministry says it is unlikely that he was infected, but are monitoring him as a potential Ebola patient until the incubation period has passed.^[106]

United Kingdom

An isolation unit at the Royal Free Hospital received its first case on 24 August. William Pooley, a British nurse, was evacuated from Sierra Leone. He was released on 3 September.^[107][108]

United States

A number of US citizens who contracted EVD while working in the affected areas have been evacuated to the US for treatment; see main article.

Democratic Republic of the Congo

Democratic Republic of Congo – 2014

DRC Ebola area as of 6 September 2014[update][109]
Casualties
Cases / Deaths (as of 23 September 2014[update])[110]  DR Congo: 70 / 42

In August 2014, the WHO reported an outbreak of Ebola Virus in the Boende District, Democratic Republic of the Congo. They confirmed that the current strain of the virus is the Zaire Ebola species, which is common in the country. The virology results and epidemiological findings indicate no connection to the current epidemic in West Africa. This is the country's seventh Ebola outbreak since 1976.^[111][112]

In August, 13 people were reported to have died of Ebola-like symptoms in the remote northern Équateur province, a province that lies about 750 miles north of the capital Kinshasa.^[112] The initial case was a woman from Ikanamongo Village who became ill with symptoms of Ebola after she had butchered a bush animal that her husband had killed. The following week, relatives of the woman, several health-care workers who had treated the woman, and individuals with whom they had been in contact came down with similar symptoms.^[112] On 26 August, the Équateur Province Ministry of Health notified the WHO of an outbreak of Ebola.^[112] As of 23 September, the WHO has confirmed the number of cases at 70 and the death toll at 42 from possible or confirmed Ebola cases. Among this group are 8 health care workers.^[110]

Virology

Ebola virus disease is caused by four of five viruses classified in the genus Ebolavirus. Of the four disease-causing viruses, Ebola virus (formerly and often still called the Zaire virus), is the most dangerous and is the strain responsible for the ongoing epidemic in West Africa.^[113][114]

Since the discovery of the viruses in 1976 when outbreaks occurred in Sudan and the Democratic Republic of Congo (then called Zaire), Ebola virus disease has been confined to areas in Central Africa, where it is endemic. With the current outbreak, it was initially thought that a new strain endemic to Guinea might be the cause, rather than being imported from central to West Africa.^[21][115] However, further studies have shown that the current outbreak is likely caused by an Ebola virus lineage that has spread from Central Africa into West Africa, with the first viral transfer to humans in Guinea.^[114][116]

In a study done by the Broad Institute and Harvard University, in partnership with the Sierra Leone Ministry of Health and Sanitation, researchers may have provided information about the origin and transmission of the Ebola virus that sets this outbreak apart from previous outbreaks. For this study, 99 Ebola virus genomes were collected and sequenced from 78 patients diagnosed with the Ebola virus during the first 24 days of the outbreak in Sierra Leone. The team found more than 300 genetic changes that make the 2014 Ebola virus distinct from previous outbreaks. It is still unclear whether these differences are related to the severity of the current outbreak.^[30][117] Five members of the research team became ill and died from Ebola before the study was published in August.^[30][118]

Transmission

It is not entirely clear how an Ebola outbreak is initially started.^[119] 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. Bats drop partially eaten fruits and pulp, then land mammals such as gorillas and duikers feed on these fallen fruits. This chain of events forms a possible indirect means of transmission from the natural host to animal populations.^[120]

Human-to-human transmission can occur via direct contact with blood or bodily fluids from an infected person or by contact with objects contaminated by the virus.^[121] When adequate infection control measures are utilized, the potential for widespread Ebola infections is considered low as the disease is only spread by direct contact with the secretions from someone who is showing signs of infection.^[121] Airborne transmission has not been documented during Ebola outbreaks. The time interval from infection with the virus to onset of symptoms is 2 to 21 days. Because dead bodies are still infectious, local traditional burial rituals may spread the disease.^[122] Semen and possibly other body fluids (e.g., breast milk) may be infectious in survivors for months.^[123][124]

One of the primary reasons for spread is that the health systems in the part of Africa where the disease occurs function poorly.^[125] The risk of transmission is increased among those caring for people infected. Recommended measures when caring for those who are infected include isolating them, sterilizing equipment and surfaces, and wearing protective clothing including masks, gloves, gowns, and goggles.^[119] However, even with proper isolation equipment available, working conditions such as no running water, no climate control, and no floors, continue to make direct care dangerous. Two American health workers who had contracted the disease and later recovered said that 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 working to help workers get in and out of their protective gear, while wearing protective gear herself.^[126]

Prevention

Comparing the present Ebola outbreak to some in the past, the WHO notes that many of the most recent districts in which epidemics have occurred were in remote areas where the transmission had been easier to track and break. This outbreak is different in that large cities have been affected as well, where tracking has been difficult. Furthermore, without past Ebola experience medical staff did not suspect Ebola when they made a diagnosis, mistaking the symptoms for more familiar diseases such as malaria and typhoid fever, which are common to the area. Not aware that they were dealing with such a highly contagious disease, strict isolation and contact tracing techniques were not deemed necessary.^[16] Also, without recent past experience with the disease, some people have become intensely fearful and have denied that the disease even exists and, in some cases, attacked medical staff, believing that they cause the disease.^[16]

Contact tracing

Contact tracing is an essential method to tamp down the spread of the disease. It involves finding everyone who had close contact with an Ebola case, and tracking them for 21 days. However, this requires careful record keeping by properly trained and equipped staff.^[127] 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."^[128] This is a massive ongoing effort to volunteers and health workers. According to reports, 12,315 from Sierra Leone and 11,911 from Liberia are listed and being traced as of 23 September. Figures for Guinea are not known.^[129][130]

Travel restrictions and quarantines

Difficulties faced in attempting to contain the outbreak include the outbreak's multiple locations across country borders,^[131] Dr Peter Piot, the scientist who co-discovered the Ebola virus, has stated that the present outbreak is not following its usual linear patterns as mapped out in previous outbreaks. This time the virus is "hopping" all over the West African epidemic region.^[45] Furthermore, past epidemics have occurred in remote regions, but this outbreak has spread to large urban areas which has increased the number of contacts an infected person may have and has also made transmission harder to track and break.^[16]

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 percent of the known cases had been found.^[132] By September, the closure of borders had caused a collapse of cross-border trade and was having a devastating effect on the economies of the involved countries. A United Nations spokesperson reported that the price of some food staples had increased by as much as 150% and warned that if they continue to rise widespread food shortages can be expected.

On 2 September, WHO Director-General Margaret Chan advised against travel restrictions saying that they are not justified and that they are preventing medical experts from entering the affected areas and "marginalizing the affected population and potentially worsening [the crisis]". UN officials working on the ground have also criticized the travel restrictions saying the solution is "not in travel restrictions but in ensuring that effective preventive and curative health measures are put in place."^[15] Médecins Sans Frontières, also speaking out against the closure of international borders, called it "another layer of collective irresponsibility": "The international community must ensure that those who try to contain the outbreak can enter and leave the affected countries if need be. A functional system of medical evacuation has to be set up urgently."^[17]

Deaths of healthcare workers

In August, it was reported that healthcare workers represented nearly 10 percent of the cases and fatalities, significantly impairing the ability to respond to the outbreak in an area which already faces a severe shortage of doctors.^[133] In the hardest hit areas there have historically been only one or two doctors available to treat 100,000 people, and these doctors are heavily concentrated in urban areas.^[16] Healthcare providers caring for people with Ebola and family and friends in close contact with people with Ebola are at the highest risk of getting infected because they may come in direct contact with the blood or body fluids of the sick person. In some places affected by the current outbreak, care may be provided in clinics with limited resources, and workers could be in these areas for several hours with a number of Ebola infected patients.^[134] According to the WHO, the high proportion of infected medical staff can be explained by lack of the number of medical staff needed to manage such a large outbreak, shortages of protective equipment, or improperly using what is available, and "the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe".^[16]

Among the fatalities is Samuel Brisbane, a former advisor to the Liberian Ministry of Health and Social Welfare, described as "one of Liberia's most high-profile doctors."^[135] In July, leading Ebola doctor Sheik Umar Khan from Sierra Leone died in the outbreak. His death was followed by two more deaths in Sierra Leone: Modupe Cole, a senior physician at the country`s main referral facility,^[136] and Sahr Rogers, who worked in Kenema.^{[137][137][138][139]} In August, a well-known Nigerian physician, Ameyo Adadevoh, died. She was posthumously praised for preventing the Nigerian index case from leaving the hospital at the time of diagnosis, thereby playing a key role in curbing the spread of the virus in Nigeria.^[79]

By 1 October, the WHO reported 382 workers had been infected and 216 had died. Liberia has been especially hard hit with almost half the total cases (188 with 94 deaths) reported. Sierra Leone registered 114 cases with 82 fatalities, thus indicating a death toll of seven out of ten. Guinea reported 69 infected cases with 35 deaths. In Nigeria 11 healthcare workers were also infected and 5 deaths were recorded.^[2]

Community

In order to reduce the spread, the World Health Organization recommends raising community awareness of the risk factors for Ebola infection and the protective measures individuals can take.^[140] These include avoiding contact with infected people and regular hand washing using soap and water.^[141] A condition of dire poverty exists in many of the areas that have experienced a high incidence of infections. According to the director of the NGO Plan International in Guinea, "The poor living conditions and lack of water and sanitation in most districts of Conakry pose a serious risk that the epidemic escalates into a crisis. People do not think to wash their hands when they do not have enough water to drink."^[11]

Containment efforts have been hindered because there is reluctance among residents of rural areas to recognize the danger of infection related to person-to-person spread of disease, such as burial practices which include washing of the body of one who has died.^{[12][13][14][35]} A 2014 study found that nearly two thirds of cases of Ebola in Guinea are believed to be due to burial practices.^[142]

Denial in some affected countries has often made containment efforts difficult.^[143] Language barriers and the appearance of medical teams in protective suits has sometimes increased fears of the virus.^[144] There are reports that some people believe that the disease is caused by sorcery and that doctors are killing patients.^[145] In late July, the former Liberian health minister, Peter Coleman, stated that "people don't seem to believe anything the government now says."^[50]

Acting on a rumor that the virus was invented to conceal "cannibalistic rituals" (due to medical workers preventing families from viewing the dead), demonstrations were staged outside of the main hospital treating Ebola patients in Kenema, Sierra Leone. The demonstrations were broken up by the police and resulted in the need to use armed guards at the hospital.^[146] In Liberia, a mob attacked an Ebola isolation centre stealing equipment and "freeing" patients while shouting, "There's no Ebola."^[147] Red Cross staff were forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives.^[148] In the town of Womey in Guinea, at least eight aid workers were murdered by suspicious inhabitants with machetes and their bodies dumped in a latrine on September 18.^[149]

Treatment

No proven Ebola virus-specific treatment exists as of August 2014.^[151] Treatment is primarily supportive in nature and includes minimizing invasive procedures, balancing fluids and electrolytes to counter dehydration, administration of anticoagulants early in infection to prevent or control disseminated intravascular coagulation, administration of procoagulants late in infection to control bleeding, maintaining oxygen levels, pain management, and the use of medications to treat bacterial or fungal secondary infections.^{[152][153][154][155][156]} Early treatment may increase the chance of survival.^[157]

Level of care

Local authorities have not had resources to contain the disease, with health centres closing and hospitals overwhelmed.^[158] In late June, the Director-General of Médecins Sans Frontières 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."^[131] Adequate equipment has not been provided for medical personnel,^[159] with even a lack of soap and water for hand-washing and disinfection.^[160]

In late August, Médecins Sans Frontières (MSF) called the situation "chaotic" and the medical response "inadequate". They reported that they had expanded their operations but were unable to keep up with the rapidly increasing need for assistance which had forced them to reduce the level of care they were able to offer: "It is not currently possible, for example, to administer intravenous treatments." Calling the situation "an emergency within the emergency", MSF reported that many hospitals have had to shut down due to lack of staff or fears of the virus among patients and staff which has left people with other health problems without any care at all. Speaking from a remote region, a MSF worker said that a shortage of protective equipment was making the medical management of the disease difficult and that they had limited capacity to safely bury bodies.^[161]

By September, treatment for Ebola patients had become unavailable in some areas. Speaking on 12 September, WHO director-general Margaret Chan said, "In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centers. Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia."^[162] According to a WHO report released on 19 September, Sierra Leone is currently meeting only 25% of its need for patient beds, and Liberia and Guinea are meeting only 20% of their needs.^[163]

Healthcare settings

A number of Ebola Treatment Centres have been 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 & 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.^[164][165]

Although the WHO does not advise caring for Ebola patients at home, it is an option and even a necessity when no hospital treatment beds are available. For those being treated at home, the WHO advises informing the local public health authority and acquiring appropriate training and equipment.^[166] UNICEF, USAID and the NGO Samaritan's Purse have begun to take measures to provide support for families that are forced to care for patients at home by supplying caregiver kits intended for interim home-based interventions. The kits include protective clothing, hydration items, medicines, and disinfectant, among other items.^[167][168] Even where hospital beds are available, it has been debated whether conventional hospitals are the best place to care for Ebola patients, as the risk of spreading the infection is high.^[169] The WHO and non-profit partners have launched a program in Liberia to move infected people out of their homes into Ad Hoc Centers that will provide rudimentary care.^[170]

Experimental treatments

The unavailability of treatments in the most-affected regions has spurred controversy, with some calling for experimental drugs to be made more widely available in Africa on a humanitarian basis, and others warning that making unproven drugs widely available would be unethical, especially in light of past experimentation conducted in developing countries by Western drug companies.^[171][172] As a result of the controversy, on 12 August an expert panel of the WHO endorsed the use of interventions with as-yet-unknown effects for both treatment and prevention of Ebola, and also said that deciding which treatments should be used and how to distribute them equitably were matters that needed further discussion.^[173]

The WHO has recognised that transfusion of whole blood or purified serum from Ebola survivors is the therapy with the greatest potential to be implemented immediately, although there is little information its efficacy.^[174] At the end of September, WHO issued an interim guideline for this therapy.^[175] During September, there were reports of blood from survivors of the disease being offered for sale on the black market. Health professionals have warned that patients buying blood on the black market could expose themselves to a number of risks, including infection with HIV or hepatitis.^[176]

A number of experimental treatments are being considered for use in the context of this outbreak, and are currently or will soon undergo clinical trial:^[177]

• ZMapp, a monoclonal antibody vaccine. The limited supply of the drug has been used to treat a small number of individuals infected with the Ebola virus. Although some of these have recovered the outcome is not considered statistically significant.^[178] ZMapp has proved highly effective in a trial involving rhesus macaque monkeys.^[179]
• TKM-Ebola, an RNA interference drug.^[180] The drug started Phase 1 trial in early 2014 and has since has received limited approval from the FDA for emergency use.^[181]
• Favipiravir (Avigan), a drug approved in Japan for stockpiling against influenza pandemics. The drug appears to be useful in a mouse model of the disease^[182][183] and a clinical trial is being planned for Ebola patients in Guinea, due November.^[184]
• BCX4430 is a broad-spectrum antiviral drug developed by BioCryst Pharmaceuticals and currently being researched as a potential treatment for Ebola by USAMRIID.^[185] The drug has been approved to progress to Phase 1 trials, expected late in 2014.^[186]
• Brincidofovir, another broad-spectrum antiviral drug, has been granted an emergency FDA approval as an investigational new drug for the treatment of Ebola, after it was found to be effective against Ebola virus in in vitro tests.^[187] It has subsequently been used to treat the first patient diagnosed with Ebola in the USA, after he had recently returned from Liberia.^[188]
• In September, an experimental vaccine, now known as the cAd3-ZEBOV vaccine, commenced simultaneous Phase 1 trials in Oxford and Bethesda. The vaccine was developed jointly by GlaxoSmithKline and the NIH. If this phase is completed successfully, the vaccine will be fast tracked for use in West Africa. In preparation for this, GSK is preparing a stockpile of 10,000 doses.^[189][190] A second vaccine candidate, rVSV-ZEBOV, developed by the Public Health Agency of Canada is about to undergo Phase 1 trials.^[191]

Prognosis

Statistical measures

Calculating an accurate case fatality rate (CFR) is difficult for an ongoing epidemic due to differences in testing policies, the inclusion of probable and suspected cases, and the inclusion of new cases that have not run their course.^[192] In late August, the WHO made an initial CFR estimate of 52%.^{[193][194][195]} However, this figure was grossly inaccurate due to their method of simply dividing the number of deaths by current cases. On 23 September, the WHO released a revised and far more accurate CFR of 70%, derived using data from patients with definitive clinical outcomes.^[9]

The basic reproduction number (BRN) is a statistical measure of the number of people who are expected to be infected by one person who has the disease in question. If the rate is less than 1, the infection will die out in the long run and if the rate is greater than 1, the infection will continue to spread in a population.^[196] A study published on 23 September found the BRN of the current outbreak to be between 1.71 and 2.02.^[4]

Projections of future cases

On 28 August, the WHO released its first estimate of the possible total cases (20,000) from the outbreak as part of its roadmap for stopping the transmission of the virus.^[197][198] The WHO roadmap states "[t]his Roadmap assumes that in many areas of intense transmission the actual number of cases may be two- to fourfold higher than that currently reported. It acknowledges that the aggregate case load of EVD could exceed 20,000 over the course of this emergency. The Roadmap assumes that a rapid escalation of the complementary strategies in intense transmission, resource-constrained areas will allow the comprehensive application of more standard containment strategies within 3 months."^[198] It includes an assumption that some country or countries will pay the required cost of their plan, estimated at half a billion dollars.^[198]

When the WHO released its first estimated projected number of cases, a number of epidemiologists presented data to show that the WHO's projection of a total of 20,000 cases was likely an underestimate. On August 31, the journal Science quoted Christian Althaus, a mathematical epidemiologist at the University of Bern in Switzerland, as saying that if the epidemic were to continue in this way until December, the cumulative number of cases would exceed 100,000 in Liberia alone.^[199] According to a research paper released in early September, in the hypothetical worst-case scenario, if a BRN of over 1.0 continues for the remainder of the year we would expect to observe a total of 77,181 to 277,124 additional cases within 2014.^[200] On 9 September, Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine controversially announced that the containment fight in Sierra Leone and Liberia has already been "lost" and that the disease would "burn itself out".^[201] Writing in the New York Times on 12 September, Bryan Lewis, an epidemiologist at the Virginia Bioinformatics Institute at Virginia Tech, said that researchers at various universities who have been using computer models to track the growth rate say that at the virus's present rate of growth, there could easily be close to 20,000 cases in one month, not in nine.^[202]

On 8 September, the WHO warned that the number of new cases in Liberia was increasing exponentially, and would increase by "many thousands" in the following three weeks. In a 23 September WHO report, the WHO revised their previous projection, stating that they expect there to be an excess of 20,000 Ebola cases in West Africa by 2 November.^[203] They further stated, that if the disease is not adequately contained it could become endemic in Guinea, Sierra Leone and Liberia,^[202] "spreading as routinely as malaria or the flu",^[204] and according to an editorial in the New England Journal of Medicine, eventually to other parts of Africa and beyond.^[205]

In a 23 September CDC report, a projection calculates a potential underreporting which is corrected by a factor of 2.5. With this correction factor, approximately 21,000 total cases are the estimate for the end of September 2014 in Liberia and Sierra Leone alone. The same report predicted that total cases, including unreported cases, could reach 1.4 million in Liberia and Sierra Leone by 20 January 2015 if no improvement in intervention or community behaviour occurred.^[206]

On 2 September, an assessment of the probability of Ebola virus disease case importation in countries across the world was published in PLOS Currents Outbreaks.^[207] The projections are based on simulations of epidemic spread worldwide. The analysis was updated with simulations based on new data on 6 October, and the updated results are available online.^[208]

Economic effects

In addition to the loss of life, the outbreak is having a number of significant economic impacts.

• Markets and shops are closing, due to travel restrictions, cordon sanitaire, or fear of human contact, leading to loss of income for producers and traders.^[209]
• Movement of people away from affected areas has disturbed agricultural activities.^[210][211] The UN Food and Agriculture Organisation (FAO) has warned that the outbreak could endanger harvest and food security in West Africa.^[212]
• Tourism is directly impacted in affected countries.^[213] Other countries in Africa which are not directly affected by the virus have also reported adverse effects on tourism.^[214]
• Foreign mining companies have withdrawn non-essential personnel, deferred new investment, and cut back operations.^{[211][215][216]}
• Many airlines have experienced reduced traffic. Some airlines have suspended flights to the area.^[217]
• Forecasts of economic growth have been reduced.^[218] A 4 August World Bank-IMF assessment for Guinea projected a full percentage point fall in GDP growth from 4.5 percent to 3.5 percent^[219] and on 17 September, they reported that if the epidemic continues to grow, the affected countries could see the economic impact grow eight-fold, "dealing a potentially catastrophic blow to the already fragile states."^[220]
• The outbreak is straining the finances of governments, with Sierra Leone using Treasury bills to fund the fight against the virus.^[221]
• The IMF is considering expanding assistance to Guinea, Sierra Leone, and Liberia as their national deficits are ballooning and their economies contract sharply.^[222]

Responses

In July, the World Health Organization convened an emergency meeting with health ministers from eleven countries and announced collaboration on a strategy to co-ordinate technical support to combat the epidemic. In August they published a roadmap to guide and coordinate the international response to the outbreak, aiming to stop ongoing Ebola transmission worldwide within 6–9 months and formally designated the outbreak as a Public Health Emergency of International Concern.^[223] This is a legal designation used only twice before (for the 2009 H1N1 (swine flu) pandemic and the 2014 resurgence of polio) which invokes legal measures on disease prevention, surveillance, control, and response, by 194 signatory countries.^[224][225]

In September, the United Nations Security Council declared the Ebola virus outbreak in West Africa a "threat to international peace and security" and unanimously adopted a resolution urging UN member states to provide more resources to fight the outbreak; the WHO stated that the cost for combating the epidemic will be a minimum of $1 billion.^[226][227] The Economic Community of West African States and the World Bank Group have pledged aid money and the World Food Programme announced plans to mobilize food assistance for an estimated 1 million people living in restricted access areas. Several Non-Governmental Organizations have provided assistance in the efforts to control the spread of the disease. The humanitarian aid organisation Médecins Sans Frontières (Doctors Without Borders) is the leading organization responding to the crisis. Currently it has five treatment centers in the area.^[163] Samaritan's Purse is providing direct patient care in multiple locations in Liberia.^[228] Many nations and charitable organizations, foundations, and individuals have also pledged assistance to control the epidemic.

Popular culture

"Ebola in Town", a dance tune by a group of West African rappers warning people of the dangers of the Ebola virus and explaining how to react, became popular in Guinea and Liberia during the first quarter of 2014.^[229][230]

In August 2014, George Weah and Ghanaian musician Sidney produced a song to raise awareness about Ebola.^[231]

There are a number of Ebola-themed jokes circulating in West Africa to spread awareness.^[232]

Timeline of cases and deaths

Data comes from reports by the Centers for Disease Control and Prevention^[233] and the WHO.^[234] All numbers are correlated with United Nations Office for the Coordination of Humanitarian Affairs (OCHA) if available.^[235] The table includes suspected cases that have not yet been confirmed. The reports are sourced from official information from the affected countries' health ministries. WHO has stated the reported numbers "vastly underestimate the magnitude of the outbreak",^[236] saying there may be 2.5 times as many cases as officially reported.^[237] Cases in remote areas may also be missed.^[238]

The case numbers reported may include probable or suspected cases. Numbers are revised downward if a case is later found to be negative. (Numbers may differ from reports as per respective Government reports. See notes at the bottom for stated source file.)

• 
  Cumulative totals of cases and deaths over time
• 
  Cumulative totals in log scale
• 
  Average new cases and deaths per day (between WHO reporting dates)

• 
  Cumulative number of cases and deaths by country, using a linear scale
• 
  Cumulative number of cases and deaths by country, using a logarithmic scale
• 
  Cases and death based on population, using a linear scale
• 
  Cases and death based on population, using a logarithmic scale

Notes:

Date is the "as of" date from the reference. A single source may report statistics for multiple "as of" dates.

Total cases and deaths before 1 July 2014 are calculated.

Numbers with ± are deltas from a previous report. The deltas may not be consistent.

Numbers with a ↓ indicate cases that were eliminated.

Liberia:

29 Mar: LI data is confused. Earlier, there were 8 suspected cases and 6 deaths (no confirmed cases). Seven suspected cases were tested by 29 Mar, and five were not Ebola. That should take suspected cases to 3, but a total was not stated; it also implies deaths should be at most 3. The report states only 2 suspected deaths were tested, and one was not Ebola.^[306]

21 Apr: reduced deaths by 2: one in Guinea total and one case discarded. 26 samples negative for Ebola.^[296]

24 Apr: stated it was reviewing its 27 suspected cases and may toss all of them;^[295]

2 May: reclassification complete.^[294]

Sierra Leone: cases were reported, but by 3 May there were no cases.^[293] Early reports are marked with parens "()".

7 Apr: 2 suspected cases of EVD were confirmed as Lassa Fever.^[302]

15 Apr: Of 12 suspected cases, 11 were tested for Ebola but came up negative.^[299]

Mali: 4 possible cases were reported on 7 April,^[302][303] but they were not EVD.^[299]

References

External links

• "Outbreak Updates". World Health Organization (WHO)..
• "Outbreak Updates". US Centers for Disease Control and Prevention (CDC)..
• 2014 Ebola Outbreak Timeline Healthmap.org
• How Ebola has grown since March (Graphic)