One year into the Ebola epidemic. January 2015
Much was learned during 2014. The epidemic in West Africa – the largest and longest in the nearly four-decade history of this disease – yielded greater clinical understanding of the pathology of Ebola virus disease and ways to improve survival rates jumped ahead. We have gained much greater understanding at the operational level: what specific packages of control interventions will have the greatest impact on getting transmission down?
Scientific research about the disease escalated dramatically, as has research and development to develop new medical products for prevention, treatment and possibly cure.
The four biggest lessons from 2014
The biggest and most obvious lessons are four-fold.
First, countries with weak health systems and few basic public health infrastructures in place cannot withstand sudden shocks, whether these come from a changing climate or a runaway virus. Under the weight of Ebola, health systems in Guinea, Liberia and Sierra Leone collapsed. People stopped receiving – or stopped seeking – health care for other disease, like malaria, that cause more deaths yearly than Ebola.
In turn, the severity of the disease, compounded by fear within and beyond the affected countries, caused schools, markets, businesses, airline and shipping routes, and borders to close. Tourism shut down, further deepening the blow to struggling economies. What began as a health crisis snowballed into a humanitarian, social, economic and security crisis. In a world of radically increased interdependence, the consequences were felt globally.
The evolution of the crisis underscored a point often made by WHO: fair and inclusive health systems are a bedrock of social stability, resilience and economic health. Failure to invest in these fundamental infrastructures leaves countries with no backbone to stand up under the weight of the shocks that this century is delivering with unprecedented frequency.
Second, preparedness, including a high level of vigilance for imported cases and a readiness to treat the first confirmed case as a national emergency, made a night-and-day difference. Countries like Nigeria, Senegal and Mali that had good surveillance and laboratory support in place and took swift action were able to defeat the virus before it gained a foothold.
Third, no single control intervention is, all by itself, sufficiently powerful to bring an Ebola epidemic of this size and complexity under control. All control measures must work together seamlessly and in unison. If one measure is weak, others will suffer.
Aggressive contact tracing will not stop transmission if contacts are left in the community for several days while test results are awaited. Good treatment may encourage more patients to seek medical care, but will not stop community-wide transmission in the absence of rapid case detection and safe burials. In turn, the powers of rapid case detection and rapid diagnostic confirmation are diminished in the absence of facilities for prompt isolation. As long as transmission occurs in the community, medical staff following strict protocols for infection prevention and control in clinics will be only partially protected.
Finally, community engagement is the one factor that underlies the success of all other control measures. It is the linchpin for successful control. Contact tracing, early reporting of symptoms, adherence to recommended protective measures, and safe burials are critically dependent on a cooperative community. Having sufficient facilities and staff in place is not enough. In several areas, communities continued to hide patients in homes and bury bodies secretly even when sufficient treatment beds and burial teams were available. Experience also showed that quarantines will be violated or dissolve into violence if affected communities are given no incentives to comply.
An epidemic with two causes
The persistence of infections throughout 2014 had two causes. The first was a lethal, tenacious and unforgiving virus. The second was the fear and misunderstanding that fuelled high-risk behaviours. As long as these high-risk beliefs and behaviours continue, the virus will have an endless source of opportunities to exploit, blunting the power of control measures and deepening its grip. Like the populations in the three countries, the virus will remain constantly on the move.
Getting to zero means fencing the virus into a shrinking number of places where all transmission chains are known and aggressively attacked until they break. It also means working within the existing context of cultural beliefs and practices and not against them. As culture always wins, it needs to be embraced, not aggravated, as WHO aimed to do with its protocol on safe and dignified burials.
A more strategic emergency response
As the new year began, a revised response that builds on accumulated experiences was mapped out by WHO. This new response plan adopts what has been shown to work but also sets out new strategies designed to seize all opportunities for getting the number of cases down to zero.
Community resistance must be tackled by all outbreak responders with the greatest urgency. Concrete guidance on ways of doing this is likely to emerge from an analysis of Sierra Leone’s Western Area Surge, which included several strategies for engaging communities and responding to their concerns. As was learned during 2014, community leaders, including religious leaders as well as tribal chiefs, can play an especially persuasive role in reducing high-risk behaviours.
Apart from low levels of community understanding and cooperation, contact tracing is considered the weakest of all control measures. Its poor performance likewise needs to be addressed with the greatest urgency. For example, in Guinea, which has the most reliable data, only around 30% of newly identified cases appear on contact lists. In all three countries, the number of registered contacts for confirmed cases is too low. In Sierra Leone, some lists of contacts include family members only, and no one from the wider community.
As the year evolved, outbreak responders learned the importance of tailoring response strategies to match distinct needs at district and sub-district levels. An understanding of transmission dynamics at the local level usually reveals which control measures are working effectively and which ones need improvement. Doing so requires better district-level data and, above all, better coordination. The outbreaks will not be contained by a host of vertical programmes operating independently. Again, all control measures must work seamlessly and in unison.
At year end, as cases flared up in new areas or moved from urban to rural settings, a clear need emerged for rapid response teams and for agile and flexible strategies that can change direction – and location – quickly. In WHO’s assessment, all three countries now have sufficient numbers of treatment beds and burial teams, but these are not always located where they are most needed. As was also learned during 2014, transporting patients over long distances for treatment does not work, either for families and communities or in terms of its impact on transmission.
As long as logistical problems persist, community confidence in the response will remain low. People cannot be expected to do as they are told if the effort leaves them visibly worse off – quarantined without food, sleeping in the same room with a corpse for days – instead of better off. These problems are compounded by poor road systems and weak telecommunications in all three countries. In Liberia, for example, health officials in rural areas are lucky if they have an hour or two of internet connectivity per week. This weakness defeats rapid communication of suspected cases, test results and calls for help, thus ensuring that response efforts continue to run behind a virus that seizes every opportunity to infect more people.
A decentralized strategy – and an ethical imperative
As the response decentralizes to the subnational level, fully functional emergency operations centres, with local government health teams integrated and playing a leadership role, must be established in each county, district and prefecture in the three countries. These centres will drive the step-change in field epidemiology capacity needed to achieve high-quality surveillance, rapid and complete case-finding, and comprehensive contact tracing – the fundamental requirements for getting to zero.
A decentralized response also demands urgent attention to well-known gaps and failures in collecting, collating, managing and rapidly sharing information on cases, laboratory results and contacts. Understanding and tackling the drivers of transmission in each area call for enhanced case investigation and analytical epidemiology. Tools for collecting and sharing this information need to be standardized and put into routine use by governments and their partners.
Another major problem is the unacceptably large difference in case fatality rates between people who receive care in affected countries (71%) and foreign medical staff (26%) who were evacuated for specialized treatment in well-resourced countries. Getting case fatality down in affected countries is an ethical imperative.
Innovation needs to be encouraged, publicized, tested and funnelled into control strategies whenever appropriate. Mali used medical students with training in epidemiology to rapidly increase the number of contact tracers. Guinea drew on its corps of young and talented doctors to strengthen its outbreak response, with training provided by WHO epidemiologists. These staff know the country and its culture best. They will still be there long after foreign medical teams leave.
In Sierra Leone, the government-run Hastings Ebola Treatment Centre, a 123-bed facility entirely operated by local staff, has defied statistics elsewhere in the country with its survival rates. Six out of every 10 patients treated there make a full recovery. As noted by an infection control specialist working on the wards, the only patients that cannot be saved are those who wait too long to seek care. After noting that Ebola virus disease has some similarities with cholera, staff at the facility made intravenous administration of replacement fluids a mainstay of the routine treatment protocol.
The pattern of transmission seen throughout 2014 makes a final conclusion obvious: cross-border coordination is essential. Given West Africa’s exceptionally mobile populations, no country can get cases down to zero as long as transmission is ongoing in its neighbours.
Prevent outbreaks in unaffected countries
With the increasing number of cases and infected prefectures in Guinea, the risk of new importations to neighbouring countries is also growing. In terms of preparedness, the most urgent need is for active surveillance in the areas bordering Mali, Senegal, Guinea-Bissau and Cote d’Ivoire, through the deployment of additional human and material resources, and the introduction of standard performance monitoring and reporting on a weekly basis.
Improvements in contact tracing and monitoring in the second phase of the response provide an opportunity to substantially enhance the efficacy of exit screening. Doing so further reduces the risk of new Ebola exportations from affected areas. As contact tracing improves, lists of active contacts could be systematically shared with border and airport authorities to link this information with exit screening.
Get health systems functioning again – on a more resilient footing
Much debate has focused on the importance of strengthening health systems, which were weak before the outbreaks started and then collapsed under their weight. In large parts of all three countries, health services have disintegrated to the point that essential care is either unavailable or not sought because of fear of Ebola contagion.
As some have argued, cases will decrease fastest when a well-functioning health system is in place. That argument also points to the need to restore public confidence – which was never high – in the public health system. Targeted drug-delivery campaigns that aimed to treat and prevent malaria were well-received by the public and are a step in the right direction, but much more needs to be done.
Although virtually no good systems for civil registration and vital statistics are still functioning in the three countries, indirect evidence suggests that childhood deaths from malaria have eclipsed Ebola deaths. Liberia, for example, had around 3500 malaria cases each month prior to the outbreak, with around half of these cases, mainly young children, dying. An immediate strengthening of health systems could reduce these and many other deaths, while also restoring confidence that health facilities can protect health and heal disease.
Others argue that efforts must stay sharply focused on outbreak containment. As this argument goes, response capacity is limited and must not be distracted. This argument favours a step-wise approach that initially concentrates on strengthening those health system capacities, like surveillance and laboratory services, that can have a direct impact on outbreak containment.
For its part, WHO sees a need to change past thinking about the way health systems are structured. As the Ebola epidemic has shown, capacities to detect emerging and epidemic-prone diseases early and mount an adequate response need to be an integral part of a well-functioning health system. Outbreak-related capacities should not be regarded as a luxury or added as an afterthought. Otherwise, the security of all health services is placed in jeopardy.
Step up research
Research aimed at introducing new medical products needs to continue at its current accelerated pace. Executives in the R&D-based pharmaceutical industry have expressed their view that all candidate vaccines must be pursued “until they fail”. They have further agreed that the world must never again be taken by surprise, left to confront a lethal disease with no modern control tools in hand.
New tools will likely be needed to get to zero. For example, vaccines to protect health care workers may make it easier to increase the numbers of foreign and national medical staff. Better therapies – and improved prospects of survival – may encourage more patients to promptly seek medical care, greatly increasing their prospects of survival.
As cases decline, robust and reliable point-of-care diagnostic tests will boost efforts to break transmission chains. Rapid diagnostic tests can support efficient patient triage and reduce the time that contacts or suspected cases are held in facilities alongside confirmed cases, where they are at risk of infection. Such tests could also facilitate the screening of patients at regular health care facilities, thus reducing the risk of transmission from undiagnosed cases to unprotected medical staff.
However, all new control tools must be introduced carefully and in ways that guard against both unrealistic public expectations and unfounded fears. For example, vaccines may not confer full protection; the duration of protection could be brief; a booster shot may be needed. Not all experimental therapies can be easily and safely administered in resource-constrained settings.
Such tools may also be needed for the future. Researchers have identified at least 22 African countries that have the ecological conditions and social behaviours that put them at risk of future outbreaks of Ebola virus disease.
Mine every success story
Operational research is needed to understand why some areas have stopped or dramatically reduced transmission while others, including some in the same vicinity and with similar population profiles, remain hotspots of intense transmission.
Did the striking and robust declines in Lofa County, Liberia, and Kailahun and Kenema districts in Sierra Leone occur because devastated populations learned first-hand which behaviours carried a high risk and changed them? Or can the declines be attributed to simultaneous and seamless implementation of the full package of control measures, as happened in Lofa country? Answers to these questions will help refine control strategies.
Research is also needed to determine how areas that have achieved zero transmission can be protected from re-reinfection. Some success stories look real and robust, but these are only pockets of low or zero transmission in a broad cloak of contamination.
At every opportunity, strategies devised for the emergency response should be made to work to build basic health capacities as well. Some success stories can serve as models.
Liberia demonstrated how quickly the quality of data and reporting can improve, thus strongly supporting the strategic targeting of control measures at district and sub-district levels.
Sierra Leone showed how laboratory services can be strengthened and expanded, reducing waiting times for test results close to what is seen in countries with advanced health systems while also supporting the better clinical management of cases.
Each and every survivor is also a success story. In an effort to fight the stigma that so often haunts these people, many treatment centres hold celebratory ceremonies when survivors are released from treatment. Each is given a certificate as proof that they pose no risk to families or communities.
Get the incentives – and support – right
Both foreign and domestic medical staff have worked in the shadows of death, placing their lives at risk to save the lives of others. In many places, these staff also risked losing their standing in communities, given the fear and stigma attached to anything or anyone associated with Ebola.
These people deserve to be honoured and respected. They also deserve to be paid on time and given safe places to work. Timely and appropriate payment to national staff remains problematic. More studies are currently under way to identify the circumstances under which health care workers continue to get infected.
Special efforts are also needed to improve safety at private health facilities, in pharmacies, and among traditional healers, as evidence suggests the risk of transmission is highest in these settings. The number of hospitals that remain closed or virtually empty supports the conclusion that doctors and nurses are most likely getting infected while treating patients in community settings.
Incentives also need to be in place to ensure that foreign medical teams stay in countries long enough to understand conditions, including political and social as well as operational issues, and pass on this knowledge to replacement staff. Towards the end of the year, WHO ensured that its field coordinators stayed in countries for several months.
The “post-Ebola syndrome”
Given the fear and stigma associated with Ebola, people who survive the disease, especially women and orphaned children, need psychosocial support and counselling services as well as material support. They may need medical support as well. A number of symptoms have been documented in what is increasingly recognized as a “post-Ebola syndrome”.
Efforts are now under way to understand why these symptoms persist, how they can best be managed, whether they are caused by the disease, and whether they might be linked to treatment or the heavy use of disinfectants. WHO staff have developed an assessment tool that is being used to investigate these issues further.
Maintain unwavering commitment at national and international levels
Media coverage of the Ebola crisis peaked in August, when two American missionaries and a British nurse became infected in West Africa and were medically evacuated for treatment in their home countries. Coverage increased dramatically in October, when the USA and Spain confirmed their first locally transmitted cases.
Ominous forecasts from various agencies – including 1.4 million cases by mid-January 2015 – contributed to the deepening of concern. The most accurate forecast, of 20 000 cases, was made in the WHO Ebola response roadmap, issued in late August. WHO later also made dramatic forecasts based on the assumption that control measures were not being scaled up fast enough.
Although the situation in Liberia at year end, especially in Monrovia, looked promising, optimism must remain cautious. As experiences in Guinea made clear, this is a virus that can go into hiding for some weeks, only to return again with a vengeance. In Liberia, as caseloads declined, evidence of complacency and “Ebola fatigue” rapidly appeared in some populations even though transmission continued.
The three countries will continue to need international support for some time to come, whether in the form of direct support for response measures or assistance in rebuilding their health services. Countries and the international community must brace themselves for the long-haul.
One overarching question hangs in the air. The virus has demonstrated its tenacity time and time again. Will national and international control efforts show an equally tenacious staying power?
The above article is Chapter 14 in a GAR (Global Alert and Response) from the The World Health Organization