November 24, 2014
Ebola: 2014 Outbreak in West Africa
In March 2014, an outbreak of Ebola Virus Disease (EVD)
began in Guinea. It spread to Liberia in the same month and
to Sierra Leone a month later. An EVD outbreak that began
in Nigeria in July was contained in August. In that same
month, a case was detected and contained in Senegal.
Health officials are working to contain an outbreak that
began in Mali in October. As of November 20, Mali has
reported six cases, including five deaths. The current EVD
outbreak is the largest, most persistent one ever
documented, and is the first in West Africa. As of
November 21, more than 15,000 people had contracted
EVD and nearly 5,500 had died (Figure 1). Infection rates
are declining in Liberia, are stable or rising in various parts
of Guinea, and are accelerating in Sierra Leone.
Figure 1. Global Ebola Outbreaks: 1976-2014
Source: Created by Tiaji Salaam-Blyther based on WHO data.
There have been 20 medical evacuations of international
medical workers to developed countries infected in Guinea,
Liberia, or Sierra Leone (the “affected countries”), seven to
the United States and 13 to Europe. Until October, all EVD
cases outside of West Africa were among medical
evacuees. In that month, the United States and Spain
experienced their first secondary cases, which occurred in
health workers who had cared for EVD patients.
Prior human EVD outbreaks occurred primarily in rural and
forested areas of Central and East Africa. The current
outbreak is occurring in both urban and rural areas. Its
current size and rate of growth is widely viewed as a
potential threat to other African countries and the world.
Due to weak surveillance systems, there is uncertainty
about the actual number of EVD cases in West Africa. The
Centers for Disease Control and Prevention (CDC) and the
World Health Organization (WHO) both assert that EVD
cases are underreported. Actual cases could be two to four
times larger than reported, according to WHO.
Transmission. Fruit bats are the suspected natural reservoir
of EVD in West Africa, where some people consume bats
and other potentially infected forest animals. Humans can
contract EVD when exposed to bodily fluids of infected
animals and persons, or through contact with contaminated
surfaces or items (e.g., needles). Inter-human transmission
is the primary source of infection in West Africa. During
outbreaks, close associates of infected persons face a high
risk of infection, as do health care and funeral workers.
Asymptomatic patients are not contagious.
Disease. Symptoms typically include fever; weakness;
head, joint, muscle, throat, and stomach aches; vomiting;
diarrhea; and bleeding. Kidney and liver function may be
impaired; white blood cell and platelet counts may drop;
and shock and death may occur. The incubation period (the
time between infection and the onset of symptoms) ranges
between two and 21 days, but is usually 8 to 10 days. There
is no cure for EVD, but EVD treatments and vaccines are
being developed. Palliative care focuses on balancing fluids
and electrolytes; maintaining blood pressure and access to
oxygen; and treating complicating infections. Prompt
treatment can extend survival prospects, but those in early
EVD onset stages may delay seeking health care, since
symptoms are akin to those of many common illnesses.
Prevention. In clinical settings, suspected EVD cases are
isolated, health care workers (HCWs) wear personal
protective equipment (PPE), and contaminated objects are
sterilized. In communities, HCWs are working with
community leaders to develop alternatives to cultural
practices (e.g., funeral rites) that might spread EVD, as well
as training safe burial teams.
The Ebola outbreak has overwhelmed the governments of
the affected countries, where it is exacerbating preexisting
social, economic, development, and security challenges and
creating new ones. Schools and many health facilities have
been closed. Trade and other economic activity have been
disrupted by road and border closures and domestic controls
on population movements. These closures have interrupted
access to food, income, and social and health services.
Public skepticism about political leadership and state
capacity is growing. International pledges of financial and
medical support are increasing, but critics allege that the
international response to date has been inadequate.
International Response. In September, the United Nations
(U.N.) established the U.N. Mission for Ebola Emergency
Response (UNMEER) to coordinate the international
response to the outbreak. That month, the U.N. Security
Council and General Assemblies held special meetings on
Ebola at which member states were urged to expedite
support for the affected countries and a U.N. integrated
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Ebola: 2014 Outbreak in West Africa
Ebola response plan. Implementing U.N. agencies include
the WHO, which leads the U.N. health response.
The six-month, $988 million U.N. plan is designed to halt
the outbreak and mitigate related health and social impacts.
Roughly 60% the funds would fund health programs and
the balance would be used to address food insecurity,
economic disruptions, and international response supply
chain needs. As of November 14, 2014, the U.N. Office for
the Coordination of Humanitarian Affairs reported, donors
had committed more than $1.2 billion to fight the Ebola
outbreak and pledged to provide an additional $910 million.
U.S. Response. The United States is the leading funder of
the global Ebola response. As of November 21, combined
U.S. Agency for International Development (USAID),
CDC, State Department, and Department of Defense
(DOD) funding for EVD responses in Africa totaled about
$640 million. This aid supports the goals and activities in
West Africa and other areas of Africa listed below.
The U.S. Ebola strategy has four key goals: (1) control the
outbreak, (2) mitigate second order impacts, (3) establish
coherent leadership and operations, and (4) advance global
health security. U.S. efforts focus primarily on Liberia,
where U.S. investments appear to be contributing to
declines in new EVD cases. Due to improved conditions in
the country, DOD downgraded the number of ETUs to be
built in Liberia from 17 to 10, and reduced the bed capacity
of the facilities from 100 to 50.
The U.S. response to the Ebola outbreak is coordinated by
the USAID. Key agencies play the following roles:
• State Department: Coordinates U.S. responses with
affected country host governments, helps to provide
public EVD prevention and awareness messaging, and
ensures safe evacuation of U.S. government personnel.
• USAID: Oversees U.S. Ebola response, supports the
creation of ETUs, provides outbreak response
commodities (e.g., PPE), supplements affected countries
for health worker salaries, and supports training for
HCWs, burial teams, and community workers.
• CDC: Coordinates U.S. medical responses, develops
protocol and best practices for Ebola care, trains airport
screeners and HCWs, and supports Ebola control efforts,
case tracing, EVD testing, and epidemiology.
• DOD: Constructs ETUs in Liberia, trains HCWs, and
supports international and U.S supply and logistics.
Health System Constraints. Poor conditions in health
clinics, inadequate quantities of health staff and equipment,
and EVD cases among HCWs have discouraged some of
the ill from attending health clinics. Clinic closures and
HCW shortages are also leaving people without health care.
Health experts are particularly concerned about
interruptions in vaccination campaigns and services for
pregnant women. Maternal and child mortality rates in the
affected countries are among the highest in the world. Most
maternal and child deaths in these countries can be
prevented with improved access to vaccines, prenatal care,
and labor and delivery assistance.
Inadequate Laboratory Capacity. Efforts to contain the
outbreak are encumbered by weak laboratory and
surveillance systems, though the situation has improved.
Diagnosis backlogs are being eliminated, contributing to
better targeting of treatment and freeing up capacity in
ETUs. There are bed vacancies in some facilities in Liberia.
On November 14, WHO reported that roughly 40% of
suspected EVD cases in the country were scientifically
confirmed, up from roughly 20% a month earlier. In Guinea
and Sierra Leone, more than 80% of suspected EVD cases
were confirmed through laboratory diagnosis.
Local Response Challenges. Affected countries have
responded to the outbreak by pursuing the responses
discussed above, but such efforts have faced multiple
hindrances. Misinformation about EVD and mistrust of
HCWs have led some communities to resist EVD tracking
and treatment efforts and, in a few cases, to attack HCWs.
Such factors, and fear of EVD-linked stigma, have
prompted some ill persons to avoid health centers or to flee
clinics while being treated, increasing EVD transmission
risks. Social practices (e.g., familial care, socialization with
infectious patients, and local funeral practices) and local
customs have also contributed to failures to properly
medically treat EVD, and to further EVD transmission.
Containment. The ongoing small outbreak in Mali has
heightened concern that the outbreak may spread to other
countries that lack the capacity to detect and respond to
disease outbreaks. The Obama Administration has included
funds in the Ebola emergency request for its Global
Security Agenda, which aims to bolster pandemic
preparedness and other health system capacities worldwide.
Some countries are screening travelers arriving from the
affected countries to detect EVD, and others may follow
suit. Others have banned travel from the affected region.
U.S. Policy and Congressional Actions
While on an October 25-30 visit to the affected countries,
U.S. Ambassador to the U.N. Samantha Power, stressed the
strength of U.S. support for the international EVD response
and called on other countries to increase their support for
the effort. Congress has held multiple hearings on Ebola
and Members have introduced multiple Ebola-related bills
and resolutions. The bills seek to strengthen measures to
curtail EVD importation into the United States, or fund or
otherwise support U.S. and international responses in the
region. Congress has authorized several USAID and DOD
reprogramming requests, including a $750 million DOD
request, and provided $88 million to the Department of
Health and Human Services (HHS) for CDC Ebola
responses in Africa and EVD-related drug development
under the FY2015 Continuing Appropriations Resolution
(P.L 113-164). On November 5, President Obama requested
$6.2 billion in emergency FY2015 appropriations to fund
U.S. Ebola responses, of which $3.02 billion would support
overseas operations. Apart from funding matters, future
issues for Congress may include whether U.S. and
international responses in Africa are technically appropriate
and effectively coordinated.
Nicolas Cook, email@example.com, 7-0429
Tiaji Salaam-Blyther, firstname.lastname@example.org, 7-7677
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