Ebola: 2014 Outbreak in West Africa

Ebola: 2014 Outbreak in West Africa

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

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